Rage disorders – DSM-5, psychopharmacology, & rabies

I congratulate all those who put together the newest version of the Diagnostic & Statistical Manual of Mental Disorders, DSM-5.  It must be an overwhelming task.  I am particularly pleased to see a unified chapter on “Disruptive, Impulse-Control, and Conduct Disorders”.  It is a step forward in putting into one place a number of conditions in which rage is prominent.  And it is recognition that explosive disorders are fairly common. 

Then one notices a new disorder, “Disruptive Mood Dysregulation Disorder”, which is defined by frequent outbursts of rage.  Of course that goes into this new chapter, right?  Wrong!  This rage, disruptive, impulse-control, and conduct disorder, that is, lyssantic disorder is placed in with Depressive Disorders!  That’s really lame, and casts serious doubt on the DSM as a whole.

This brings to the fore that clinical psychiatric disorders are the sum of all the symptoms seen in people with behavioral disorders.  These disorders don’t fit into neat little boxes that can be defined at the didactic level.  Comorbidity is the rule for psychiatric disorders rather than the exception.  The DSM is important for giving therapists and researchers a common set of symptoms to describe what they are hearing.  And it is critical to aid in determine the symptoms most interfering with a person’s life and livelihood in order to prioritize therapy.  Therapies, be they pharmacological, cognitive-behavioral, or even psychodynamic or humanistic must focus on one aspect at a time, however much the therapist wishes to treat the ‘whole patient’.

Yet it is evident that psychiatric categories are grounded in theoretical constructs conceived by individual therapists and the schools of thought in which they were taught.  The whole point of the DSM in the first place was to find commonality in the behaviors/problems patients described and did not depend upon theoretical constructs.  This was a huge advance over the way psychiatry was carried out previous to 1950 when each therapist could uniquely define, without much regard to the thoughts of others, each patient they encountered.  However, the DSM still clumps various disorders (collections of symptoms) into categories that reflect psychoanalytic systems; systems that cannot be directly tied to testable biological events.

This must change!  One criticism of the newest DSM is the intrusion of pharmaceutical interests into its construction.  I cannot comment on this directly.  However, pharmacology must inform psychiatry!  Psychoactive drugs, to the extent that we can define their mechanism of action, act as a kind of experimental psychiatry, a way of testing schemas.  The effects of psychoactive drugs on human behavior and disorders must become a manual of its own, to be an adjunct to the DSM.  If SSRI’s, for example, reduce symptoms X, Y, & Z, then we know there is a neural circuit mediated (in some measure) by serotonergic synapses that can modulate those symptoms, those behaviors.  It may be that such an analysis of each drug’s effect on various patients will, in the short term, confuse psychiatric terms even more.  However, in the long run it will lead to strong underpinnings for categorizing disorders and lead to more selective therapies.

Beyond that, the study of the brain itself, when and how various behaviors and concepts are produced and modulated, is critical to our understanding of human beings.  I am obviously keen to explicate where rage is constructed and carried out.  But, we know that our nervous systems are built up of many layers carrying out different types of analyses on the world around us.  Rage will reveal itself in many ways in many people based on their genetics and the environment they grew up in, and the environment they operate in today.  Defensive rage is a synchronized group of behaviors designed to protect us from a threat that cannot be fully analyzed – no time to analyze it, perhaps it is just beyond comprehension (or just too immense to see how to defend against it), or presently unseen.  But even in its most basic form, it is triggered, and held at bay, by analyses of numerous parts of the nervous system.  Still, we can only understand its complexity if we know its source.  And while that source might be, for some, feelings of inferiority with regard to superhuman parental figures, it still has a specific place in the nervous system.  Together, and only together, these three analyses can write the story of human beings.

I have invented the term lyssant for someone who exhibits rage, be it normal or abnormal.  That term and its underlying neurobiology have been specifically enslaved by the rabies virus for its own purposes.  In having done so, rabies can light the way to understanding this important part of our behavior.  More important than some other aspects because it is a part of our non-conscious/subconscious nervous system that we cannot directly access by language or bring under control by learning or conditioning. 

The DSM should be seen as one aspect of the way we look at human beings.  Psychopharmacology and neurobiology form the other parts, and the intersection of all three will be the final understanding of what it means to become human.