June 17, 2013


Two weeks ago, I attended a psychiatry conference on mindfulness in cultural context. Many of the talks were about contemplative practices from cultures outside North America, and one in particular caught my attention:

The Japanese practice of Naikan (tr: inner-looking or introspection) is a structured method of reflection designed to help people broaden perspective, gain insight about themselves and their relationships, and increase appreciation of the kindnesses of others. Practicing Naikan involves sitting for long periods and reflecting on the following three questions as they relate to various significant others (e.g., parents, children, partners, friends, teachers):

What have I received from this person?
What have I given this person?
What troubles and difficulties have I caused this person?

The objective of Naikan is to generate a realistic view of our behaviour and of the give and take in our relationships. The obvious fourth question (What troubles and difficulties has this person caused me?) is purposely excluded, with the rationale that most of us are already quite adept at pinpointing and obsessing about the inconveniences caused us by others--and that our focus on this aspect of our relationships is responsible for much day-to-day stress and unhappiness. 

What happens when we practice Naikan? Research demonstrates that the practice increases our sense of connectedness with others and improves quality of life. If we once believed ourselves to be alone or to be "self-made," recognition of the kindness and contributions of others increases feelings of security, connection, and gratitude. Insight into the troubles and suffering we've caused others can create change in our behaviour and in our relationships.

In traditional Naikan retreats, practitioners sit in silent isolation for fourteen hours per day for two weeks reflecting on the three questions. This is described as a profound and life-changing experience, but when a week-long retreat isn't accessible or desirable, we can try daily Naikan. Daily Naikan practice means taking time at the end of the day to reflect on the three questions as they relate to the day’s events. What did I receive today? What did I give today? What troubles and difficulties did I cause today? Even trivial-seeming instances of give and take such as "My colleague brought me a coffee" and "I cut off a guy in traffic" are included.

Daily Naikan may not be as profound an experience as a week-long retreat, but I noticed that just keeping these questions in mind as I went about my daily life in the past two weeks changed my perspective. I was more mindful of the kindnesses I received and more aware of the hassles and difficulties I caused--with the end result that my behaviour was more flexible and more giving. I drove a friend to the airport, agreed to give a presentation as a favour to a supervisor, and offered my apartment to visiting friends so they won't have to book a hotel. I softened my stance against a colleague who gets under my skin, changed my schedule to accommodate a client, and called up friends just to see how they're doing. The first two Naikan questions helped me appreciate the love and guidance I receive and less apt to focus on the support or attention I don't receive. The third Naikan question helped me recognize times that I was needy, irritating, or rude--which will help me change my behaviour.


NB: Naikan has clear parallels to the What Went Well exercise and other positive psychology exercises such as keeping a gratitude journal--and the same reported outcome: improved quality of life. Naikan can also be considered to be a form of mindfulness practice in that it involves attention and awareness, and making an effort to see ourselves and our circumstances clearly.

June 03, 2013

DSM-5: Pathologizing versus Dismissing

After years of working groups, expert task forces, and public opinion, the American Psychiatric Association has finally published the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is the bible of mental illness, listing every diagnosable problem from autism to post-traumatic stress disorder to attention deficit/hyperactivity disorder to cocaine addiction. It's widely used by psychologists, psychiatrists, and general practitioners to categorize symptoms, differentiate between disorders, and communicate with other professionals.

Despite its widespread applications, use of the DSM is controversial because detractors fear that the manual pathologizes normal behaviour. This is a reasonable concern: for example, homosexuality was listed in the DSM up until 1986, an inclusion that effectively labelled homosexuals as mentally ill. Today, DSM-5 is criticized for new additions such as binge eating disorder, skin-picking disorder, and premenstrual dysphoric disorder (PMDD).

While concerns about pathologizing are legitimate, it's easy to go too far in the opposite direction and dismiss psychological problems that cause real and significant distress. For example, binge eating disorder (BED) is a controversial new diagnosis in DSM-5. It's the first time that binge eating has been recognized as a problem independently of more familiar eating disorders such as anorexia and bulimia. In his article about the 'worst changes in DSM-5,' psychiatrist Allen Frances dismissed the diagnosis of BED, attributing binge eating to gluttony and the wide availability of good-tasting food.

This is irritating. Not only is Frances' attitude flippant and dismissive, his statement ignores several of the diagnostic criteria for binge eating disorder. To be diagnosed with BED, you have to overeat at least once per week for a period of three months, but you also have to experience a lack of control over eating, marked feelings of distress, and three of the following: eating much more rapidly than normal; eating until uncomfortably full; eating large quantities when not physically hungry; eating alone out of embarrassment for overeating; and feeling disgusted, depressed, or guilty after binge eating.

The characterization of binge eating as gluttony or overindulgence doesn't account for the distress, isolation, and shame involved in BED. There's a difference between overeating with friends or family on a special occasion, and regularly standing in front of your fridge one hour after dinner, furtively shoving cold leftovers into your mouth and feeling helpless to stop. The criterion of 'distress or impairment in functioning' applies to most DSM diagnoses: scratching mosquito bites the week after camping is not the same thing as regularly picking at skin blemishes until they're bloody and infected (skin-picking disorder), and occasional tearfulness following ovulation is not the same thing as the monthly mood swings and deep sadness and despair that characterize PMDD.

While so-called fad diagnoses can divert attention and resources away from serious illnesses, and hastily slapping a diagnosis on anyone who reports a symptom now and then is obviously harmful, let's not go too far in the opposite direction, dismissing symptoms and denying treatment to people who are suffering. The changes introduced in DSM-5 mean that individuals who binge eat, pick their skin, or experience monthly episodes of distressing unstable mood post-ovulation may now have better luck convincing doctors that the problem is real, explaining themselves to loved ones, and getting their insurer to pay for treatment.

What's wrong with that?