Trichotillomania and other ‘manias’: A lesson in inconsistency,selective concern about stigma and political correctness

To the Editor

Examining the names of mental disorders can be illuminating. In the Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5), trichotillomania was ‘translated’ and the official diagnosis is ‘trichotillomania (hair-pulling disorder)’. This change was proposed because ‘mania’ as part of trichotillomania is considered pejorative by consumer advocates (Stein et al., 2010). The history of mania is complex (Goldney, 2012; Hermsen, 2011), and the term is not only used in the context of bipolar disorder. In fact, in popular discourse, mania usually implies madness, violent behaviour, irrational preoccupation or excessive enthusiasm (www.thefreedictionary.com/mania). Consumer advocates were apparently concerned that these negative meanings of mania might ‘increase stigmatization of hair pulling’ (Stein et al., 2010: 616). The DSM-5 diagnostic term represents a compromise, with trichotillomania kept to provide continuity with previous terminology.

The suffix ‘mania’ was popular in the 18th and 19th centuries, and most terms containing mania (e.g. monomania, nymphomania, megalomania, egomania, pyromania, trichotillomania, erotomania, dipsomania, mythomania and kleptomania) originate from that era. Admittedly, some of these terms are now considered obsolete and inadequate. Still, they teach us a valuable history lesson and remind us that psychopathology did not start with the DSM system and its terminology.

Interestingly, the suffix ‘mania’ was not completely expelled from DSM-5: the diagnostic categories of pyromania and kleptomania still exist, albeit without any ‘explanation’ in the brackets. The likely reason for this is that no one lobbied for a change in terminology or for descriptive clarifications (e.g. a ‘fire-setting disorder’ or an ‘impulsive stealing disorder’) because people with pyromania and kleptomania have no advocacy groups. Also, there seems to be no concern about the stigma associated with these diagnostic terms. Perhaps that reflects an attitude that behaviours that often have criminal consequences should carry stigmatising labels.

There are several implications of this terminological inconsistency. The first is an apparent hypocrisy when it comes to caring about the stigma associated with psychiatric diagnoses and terms. Mental health professionals may only be selectively concerned about the stigma, turning a blind eye to the stigmatisation of the psychopathological terms that frequently have criminal implications. The second controversy is the extent to which consumer and advocacy groups should influence psychiatric terminology and the attendant delicate balancing between professional allegiance, scientific rigour, terminological continuity, common sense and political correctness. In the meantime and until these issues have been resolved, should the residents of Tasmania consider resurrecting Van Diemen’s Land, the previous name of their state, to avoid possible stigmatisation?