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?
Showing posts with label DSM/DSM Diagnoses. Show all posts
Showing posts with label DSM/DSM Diagnoses. Show all posts
June 03, 2013
February 26, 2013
R.E.S.P.E.C.T.
Lately I've been feeling impressed by the courage of my patients and my friends.
Once a month at the clinic where I work, two members of the team conduct a psychological evaluation with a new patient, while a group of medical residents and psych interns observes. Each time, I'm struck by the courage of the patient who sits before the group and describes in detail the manifestations and origin of the presenting mental health problem, the distress or impairment it causes, current and past relationships, and goals for treatment. How brave is that!
I was similarly struck a few weeks ago when a colleague told me that her patient with panic disorder willingly ran up and down the stairs inside the clinic, trying to expose himself to the terrifying breathlessness that triggers his panic attacks. I feel the same respect when a patient with chronic health anxiety successfully writes, records, and listens to an exposure scenario describing himself dying of cancer, or when a painfully shy patient reports that she successfully completed her plan to initiate a conversation with one of the other parents in her son's class.
It's not just my patients who are impressive: my friends are, too. A few months ago, one of my friends was diagnosed with schizoaffective disorder, a difficult-to-diagnose mix of depression, mania, and psychosis that neatly explains symptoms he's been experiencing for years. Following the diagnosis, he took his mental health into his own hands--seeking out a support group and tirelessly navigating the overwhelming bureaucracy of the health care system until he found a doctor who understood the diagnosis, prescribed medication appropriately, and addressed his concerns about side effects. Another friend recently began psychotherapy to deal with a procrastination problem that has plagued her for years. A third friend called me up for a referral for a couples therapist so that he and his partner could address some issues they were unable to resolve on their own.
My friends' and patients' initiative touches and impresses me. There's still a stigma attached to mental health care and there are still people who believe that seeing a psychologist or psychiatrist or taking medication is a sign of weakness. I'm pretty sure that acknowledging a problem and seeking help demonstrates the precise opposite.
Think about it.
Once a month at the clinic where I work, two members of the team conduct a psychological evaluation with a new patient, while a group of medical residents and psych interns observes. Each time, I'm struck by the courage of the patient who sits before the group and describes in detail the manifestations and origin of the presenting mental health problem, the distress or impairment it causes, current and past relationships, and goals for treatment. How brave is that!
I was similarly struck a few weeks ago when a colleague told me that her patient with panic disorder willingly ran up and down the stairs inside the clinic, trying to expose himself to the terrifying breathlessness that triggers his panic attacks. I feel the same respect when a patient with chronic health anxiety successfully writes, records, and listens to an exposure scenario describing himself dying of cancer, or when a painfully shy patient reports that she successfully completed her plan to initiate a conversation with one of the other parents in her son's class.
It's not just my patients who are impressive: my friends are, too. A few months ago, one of my friends was diagnosed with schizoaffective disorder, a difficult-to-diagnose mix of depression, mania, and psychosis that neatly explains symptoms he's been experiencing for years. Following the diagnosis, he took his mental health into his own hands--seeking out a support group and tirelessly navigating the overwhelming bureaucracy of the health care system until he found a doctor who understood the diagnosis, prescribed medication appropriately, and addressed his concerns about side effects. Another friend recently began psychotherapy to deal with a procrastination problem that has plagued her for years. A third friend called me up for a referral for a couples therapist so that he and his partner could address some issues they were unable to resolve on their own.
My friends' and patients' initiative touches and impresses me. There's still a stigma attached to mental health care and there are still people who believe that seeing a psychologist or psychiatrist or taking medication is a sign of weakness. I'm pretty sure that acknowledging a problem and seeking help demonstrates the precise opposite.
Think about it.
August 21, 2012
When Panic Attacks
We use the term "panic" all the time, saying we panicked at our job interview, or had a panic attack when our child wandered into the street, but what do psychologists mean when they talk about panic attacks or panic disorder?
Panic isn't the nervousness you feel the morning of your presentation at work, the stress you feel when you're running late for an appointment, or the anxiety you feel when your partner is mad at you. A panic attack is a sudden surge of overwhelming anxiety and fear, accompanied by a flood of physiological symptoms; it develops abruptly and usually lasts no more than fifteen minutes. It may be triggered by something specific (e.g., public speaking, enclosed spaces, a stressful thought), or may come out of the blue.
The DSM defines a panic attack as a discrete period of intense fear, in which at least four of the following symptoms develop abruptly and reach a peak within ten minutes:
Physiological symptoms: palpitations, pounding heart, or increased heart rate; sweating; trembling or shaking; shortness of breath or a feeling of smothering; a feeling of choking; chest pain or discomfort; nausea; feeling dizzy, lightheaded, or faint; chills or hot flushes; and numbness or tingling, often in the extremities. Psychological symptoms: fear of dying, losing control, or going crazy; and derealization or depersonalization, i.e., feeling unreal, disembodied, or detached from your surroundings.
What does a panic attack feel like?
It feels like terror in your belly, an elephant sitting on your chest, and going crazy. Your heart feels like it's pounding out of your chest, the room seems to be closing in, and you can't breathe. Many people experiencing panic are convinced they're having a heart attack--in fact, over 40% of individuals who show up the emergency room with chest pain are actually suffering from a panic attack. On top of the discomfort of the physiological symptoms of panic, the feeling of derealization can make panic lonely and confusing because what's happening in your mind doesn't match what's happening in the external world; it's hard to understand why other people seem to be calmly and happily going about their business when, for you, the world seems to be ending.
A panic attack is not a DSM diagnosis, but panic disorder is. Panic disorder is diagnosed when recurrent panic attacks result in persistent concern about further attacks, worry about the consequences or implications of the attacks, or significant change in behaviour for fear of future attacks (e.g., refusing to give presentations at work, declining social invitations). At worst, individuals with panic disorder develop agoraphobia--the fear of being out in public, or in a place where they could panic--and begin to avoid crowded public spaces, or avoid leaving the home at all.
A panic attack can happen in the context of panic disorder, depression, or another psychological problem, or can simply be an isolated incident during a stressful period or situation. During a panic attack, it's not important to try to figure out what happened or what's wrong; instead, just focus on breathing slowly and trying to calm down. It can help to realize that you're having a panic attack and to remember that thinking you're going crazy and thinking you're having a heart attack are symptoms of panic. If you experience recurrent panic attacks, it may be time to see your doctor or consult a psychologist. Panic is eminently treatable and responds well to cognitive-behavioural therapy (CBT), among other treatments.
Panic isn't the nervousness you feel the morning of your presentation at work, the stress you feel when you're running late for an appointment, or the anxiety you feel when your partner is mad at you. A panic attack is a sudden surge of overwhelming anxiety and fear, accompanied by a flood of physiological symptoms; it develops abruptly and usually lasts no more than fifteen minutes. It may be triggered by something specific (e.g., public speaking, enclosed spaces, a stressful thought), or may come out of the blue.
The DSM defines a panic attack as a discrete period of intense fear, in which at least four of the following symptoms develop abruptly and reach a peak within ten minutes:
Physiological symptoms: palpitations, pounding heart, or increased heart rate; sweating; trembling or shaking; shortness of breath or a feeling of smothering; a feeling of choking; chest pain or discomfort; nausea; feeling dizzy, lightheaded, or faint; chills or hot flushes; and numbness or tingling, often in the extremities. Psychological symptoms: fear of dying, losing control, or going crazy; and derealization or depersonalization, i.e., feeling unreal, disembodied, or detached from your surroundings.
What does a panic attack feel like?
It feels like terror in your belly, an elephant sitting on your chest, and going crazy. Your heart feels like it's pounding out of your chest, the room seems to be closing in, and you can't breathe. Many people experiencing panic are convinced they're having a heart attack--in fact, over 40% of individuals who show up the emergency room with chest pain are actually suffering from a panic attack. On top of the discomfort of the physiological symptoms of panic, the feeling of derealization can make panic lonely and confusing because what's happening in your mind doesn't match what's happening in the external world; it's hard to understand why other people seem to be calmly and happily going about their business when, for you, the world seems to be ending.
A panic attack is not a DSM diagnosis, but panic disorder is. Panic disorder is diagnosed when recurrent panic attacks result in persistent concern about further attacks, worry about the consequences or implications of the attacks, or significant change in behaviour for fear of future attacks (e.g., refusing to give presentations at work, declining social invitations). At worst, individuals with panic disorder develop agoraphobia--the fear of being out in public, or in a place where they could panic--and begin to avoid crowded public spaces, or avoid leaving the home at all.
A panic attack can happen in the context of panic disorder, depression, or another psychological problem, or can simply be an isolated incident during a stressful period or situation. During a panic attack, it's not important to try to figure out what happened or what's wrong; instead, just focus on breathing slowly and trying to calm down. It can help to realize that you're having a panic attack and to remember that thinking you're going crazy and thinking you're having a heart attack are symptoms of panic. If you experience recurrent panic attacks, it may be time to see your doctor or consult a psychologist. Panic is eminently treatable and responds well to cognitive-behavioural therapy (CBT), among other treatments.
May 15, 2012
Personality Disorders, Part 2
A personality disorder is a recurrent and pervasive pattern of maladaptive or inappropriate behaviour that causes significant distress or causes impairment in social, interpersonal, or professional functioning. People with personality disorders repeatedly think, feel, and react in ways that cause problems, and often elicit consistent reactions from the different people in their lives. Think of someone whose friends and colleagues all take advantage of him, someone whose romantic partners always leave her because she is so dependent, or someone who keeps getting fired because he refuses to work on projects that he considers to be beneath him. These are examples of enduring and problematic behaviour patterns.
How can you tell if someone has a personality disorder? A clinical supervisor once told me that when a client inspires an unusual or strong reaction during therapy, that's a big clue. After all, what happens in the psychotherapy office reflects what happens in the client's larger world; if I have a certain intense reaction during my limited contact with a client, changes are good that other people in his or her life do too. Example:
I have a new client who has a physical injury subsequent to a car accident. The injury is minor--something that doesn't usually disturb functioning for more than a month or two--but it has taken over the client's life. He remains significantly more disabled than what is expected at this stage, and family life revolves around his disability: The client's wife and children have put their regular weekend activities on hold to accompany the client to an outpatient rehabilitation centre an hour from home every weekend; the client's wife drastically cut her hours at work in order to care for him; and the client's children and extended family wait on him hand and foot. The client reports some tension as a result of his disability, but for the most part, his family members are extremely accommodating.
In a recent session with this client, I felt myself becoming intensely frustrated as he described his resistance to his doctor's proposal of a progressive return to work. However, despite my frustration, when the client wistfully expressed the wish for our sessions to be longer than the standard fifty minutes, I extended the session an extra fifteen minutes, keeping my next client waiting. When I looked at my schedule to book our appointment for next week and the client's preferred afternoon slot was unavailable, I accepted his proposal that I stay late at work and see him at suppertime.
After the client left, I felt unsettled: I don't usually spend more than an hour with any client, nor am I in the habit of extending my workday! I took a few minutes to explore what happened: Unusual client behaviour (asking for longer appointments; asking for an evening appointment)--check! Intense emotions (frustration) and unusual reactions (prolonging the session; rearranging my schedule) on my part--check! Probably replicating the client's family's behaviour of alternating between frustration and excessive accommodation--check!
It was fascinating to observe myself and the client replicating in therapy what I suspect is his dynamic wherever he goes. The client may or may not have a personality disorder, but my reaction to him tells me that it's something to explore. Clinically, it's not that important to establish whether or not the client has a personality disorder or which one he might have. What's essential is that we identify his maladaptive behaviour patterns so that I can help him by a) addressing the pattern in therapy, and b) making sure not to continue replicating/reinforcing the behaviour.
How can you tell if someone has a personality disorder? A clinical supervisor once told me that when a client inspires an unusual or strong reaction during therapy, that's a big clue. After all, what happens in the psychotherapy office reflects what happens in the client's larger world; if I have a certain intense reaction during my limited contact with a client, changes are good that other people in his or her life do too. Example:
I have a new client who has a physical injury subsequent to a car accident. The injury is minor--something that doesn't usually disturb functioning for more than a month or two--but it has taken over the client's life. He remains significantly more disabled than what is expected at this stage, and family life revolves around his disability: The client's wife and children have put their regular weekend activities on hold to accompany the client to an outpatient rehabilitation centre an hour from home every weekend; the client's wife drastically cut her hours at work in order to care for him; and the client's children and extended family wait on him hand and foot. The client reports some tension as a result of his disability, but for the most part, his family members are extremely accommodating.
In a recent session with this client, I felt myself becoming intensely frustrated as he described his resistance to his doctor's proposal of a progressive return to work. However, despite my frustration, when the client wistfully expressed the wish for our sessions to be longer than the standard fifty minutes, I extended the session an extra fifteen minutes, keeping my next client waiting. When I looked at my schedule to book our appointment for next week and the client's preferred afternoon slot was unavailable, I accepted his proposal that I stay late at work and see him at suppertime.
After the client left, I felt unsettled: I don't usually spend more than an hour with any client, nor am I in the habit of extending my workday! I took a few minutes to explore what happened: Unusual client behaviour (asking for longer appointments; asking for an evening appointment)--check! Intense emotions (frustration) and unusual reactions (prolonging the session; rearranging my schedule) on my part--check! Probably replicating the client's family's behaviour of alternating between frustration and excessive accommodation--check!
It was fascinating to observe myself and the client replicating in therapy what I suspect is his dynamic wherever he goes. The client may or may not have a personality disorder, but my reaction to him tells me that it's something to explore. Clinically, it's not that important to establish whether or not the client has a personality disorder or which one he might have. What's essential is that we identify his maladaptive behaviour patterns so that I can help him by a) addressing the pattern in therapy, and b) making sure not to continue replicating/reinforcing the behaviour.
September 04, 2011
Trichotillomania
The DSM is full of curious and non-intuitive disorders like Dissociative Fugue (sudden, unexpected travel away from home, with inability to recall one's past), Voyeurism (recurrent, intense sexually arousing fantasies involving the act of observing an unsuspecting person in the process of disrobing or sexual activity), and Factitious Disorder (intentional production or feigning of physical or psychological signs or symptoms, with external incentives).
Trichotillomania (TTM) is another one. This DSM diagnosis is characterized by repetitive pulling out of one's own hair, accompanied by pleasure, relief, or gratification at the time of pulling, but also usually accompanied by longer term or global distress about the behaviour. This is not the cliched image of the frustrated person pulling out clumps of hair; rather, hairs are selected and plucked one by one from any area of the body, but most often from the scalp, eyebrows, eyelashes, or beard. People with TTM might pull out their hair in front of the bathroom mirror, on the phone, or on the bus; they might use their fingers or a pair of tweezers; they might do it when they are relaxed or when they feel stressed.
Why do people pull out their hair?
In some ways, hair-pulling is a bad habit akin to biting your nails or picking at your skin. You know that pain/relief/pleasure/regret you feel when you pull off a scab or yank out a hangnail? People with TTM will tell you that there's something similarly satisfying about feeling around in your hair until you find a perfect one--usually a hair with a weird colour or texture--and yanking it out of your head. It's rewarding and it feels good to fulfill the urge to pull.
In other ways, TTM is more than just a bad habit. It seems to cause more distress than do nail-biting and skin-picking--significant enough distress to land TTM a spot in the DSM, where it is currently listed as an impulse-control disorder, along with Pyromania, Kleptomania, and Pathological Gambling, among others. In the new version of the DSM (DSM-V, to be published in 2013), TTM will be listed as an Obsessive-Compulsive Spectrum Disorder instead, in recognition of the overwhelming urge that precedes hair-pulling, and the repetitive and compulsive nature of the behaviour.
Some research has found that people with TTM are most likely to pull out their hair when they're bored or during sedentary activities like watching TV or reading, while other research has shown that hair-pulling happens the most when people are anxious, depressed, stressed, or angry. Some research has shown that people with TTM are often perfectionists who have very high standards; when they fail to meet their own elevated standards, they become frustrated and impatient and that's when they pull out their hair. Still other research suggests that there are two types of hair-pulling: one that is habit-like and happens without conscious intent and one where the person with TTM consciously and deliberately grabs the tweezers and heads for the bathroom mirror. None of this research, however, explains why people start pulling out their hair in the first place.
Trichotillomania is not a trivial disorder. A lot of people with TTM feel a great deal of shame, frustration, and distress about their hair-pulling and go to great lengths to hide the behaviour and its consequences--going on pulling sprees when they're home alone, wearing a wig, and avoiding swimming, hairdressers, and windy days. TTM can create relationship issues (e.g., your partner doesn't understand and keeps frustratedly batting your hands away from your hair or demanding that you stop it) and problems at work (you can't focus because your hands drift up to your head every time you sit down at your computer).
If you suffer from TTM, know that there are treatments for this problem. Some are behavioural (i.e., they focus mostly on just plain stopping the behaviour, mostly through increasing awareness of the habit and introducing an alternative habit, kind of like gum chewing instead of smoking), and others focus on mindfully accepting the urge to pull and dealing with the difficult emotions that often precede and follow hair-pulling. These treatments help a lot of people decrease their hair-pulling or stop altogether.
Trichotillomania (TTM) is another one. This DSM diagnosis is characterized by repetitive pulling out of one's own hair, accompanied by pleasure, relief, or gratification at the time of pulling, but also usually accompanied by longer term or global distress about the behaviour. This is not the cliched image of the frustrated person pulling out clumps of hair; rather, hairs are selected and plucked one by one from any area of the body, but most often from the scalp, eyebrows, eyelashes, or beard. People with TTM might pull out their hair in front of the bathroom mirror, on the phone, or on the bus; they might use their fingers or a pair of tweezers; they might do it when they are relaxed or when they feel stressed.
Why do people pull out their hair?
In some ways, hair-pulling is a bad habit akin to biting your nails or picking at your skin. You know that pain/relief/pleasure/regret you feel when you pull off a scab or yank out a hangnail? People with TTM will tell you that there's something similarly satisfying about feeling around in your hair until you find a perfect one--usually a hair with a weird colour or texture--and yanking it out of your head. It's rewarding and it feels good to fulfill the urge to pull.
In other ways, TTM is more than just a bad habit. It seems to cause more distress than do nail-biting and skin-picking--significant enough distress to land TTM a spot in the DSM, where it is currently listed as an impulse-control disorder, along with Pyromania, Kleptomania, and Pathological Gambling, among others. In the new version of the DSM (DSM-V, to be published in 2013), TTM will be listed as an Obsessive-Compulsive Spectrum Disorder instead, in recognition of the overwhelming urge that precedes hair-pulling, and the repetitive and compulsive nature of the behaviour.
Some research has found that people with TTM are most likely to pull out their hair when they're bored or during sedentary activities like watching TV or reading, while other research has shown that hair-pulling happens the most when people are anxious, depressed, stressed, or angry. Some research has shown that people with TTM are often perfectionists who have very high standards; when they fail to meet their own elevated standards, they become frustrated and impatient and that's when they pull out their hair. Still other research suggests that there are two types of hair-pulling: one that is habit-like and happens without conscious intent and one where the person with TTM consciously and deliberately grabs the tweezers and heads for the bathroom mirror. None of this research, however, explains why people start pulling out their hair in the first place.
Trichotillomania is not a trivial disorder. A lot of people with TTM feel a great deal of shame, frustration, and distress about their hair-pulling and go to great lengths to hide the behaviour and its consequences--going on pulling sprees when they're home alone, wearing a wig, and avoiding swimming, hairdressers, and windy days. TTM can create relationship issues (e.g., your partner doesn't understand and keeps frustratedly batting your hands away from your hair or demanding that you stop it) and problems at work (you can't focus because your hands drift up to your head every time you sit down at your computer).
If you suffer from TTM, know that there are treatments for this problem. Some are behavioural (i.e., they focus mostly on just plain stopping the behaviour, mostly through increasing awareness of the habit and introducing an alternative habit, kind of like gum chewing instead of smoking), and others focus on mindfully accepting the urge to pull and dealing with the difficult emotions that often precede and follow hair-pulling. These treatments help a lot of people decrease their hair-pulling or stop altogether.
July 14, 2011
Criteria Controversy
How do you know if a given behaviour or group of symptoms constitutes a psychiatric or psychological disorder? This is an important question, and particularly relevant right now as psychiatrists work on the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), to be published in 2013.
Proposed additions to the DSM like Internet Addiction and Premenstrual Dysphoric Disorder (PMDD) are raising the ire of DSM critics who argue that the manual medicalizes and pathologizes normal behaviour. While this criticism is valid and worthy of discussion, people making this argument have the frustrating habit of selecting one symptom from the list of DSM criteria for a given disorder and using it to claim that the criteria describe normal behaviour. The most recent person to do so is Ian Brown of the Globe & Mail. In his article, Brown gives the example of one criterion for the proposed DSM-V diagnosis of compulsive hoarding: "Persistent difficult discarding or parting with possessions, regardless of the value others may attribute to those possessions."
According to Brown, this symptom describes "anyone with a basement." Such is the problem of selecting and criticizing a diagnostic criterion in isolation. Anyone wishing to make a similarly unsophisticated argument could choose "Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances" from the proposed criteria for binge eating disorder (BED) or "Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection) prior to most menstrual cycles" from the proposed criteria for PMDD. They could argue that they often overeat at dinner parties and experience mood swings before they menstruate and that the inclusion of BED and PMDD in DSM-V would unfairly pathologize their behaviour.
This argument fails to acknowledge a) the other diagnostic criteria for the respective disorders and, importantly, b) the additional criterion of significant distress. The diagnostic criteria for most of the DSM disorders include "Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." This is a key criterion: If you have a basement full of junk, but it's not bothering you or anyone else (and not causing a health or safety risk), no one is going to accuse you of being a compulsive hoarder. If you overeat at dinner parties and binge on chips during the Superbowl, but it doesn't cause you lasting distress (or health problems), no one is going to label you with binge eating disorder. Writers like Brown are advised to keep the distress criterion in mind--as well as the entirety of the criteria for a given disorder--when they're fretting about the pathologizing of normal behaviour.
NB: My endorsement of the significant distress criterion is not a defense of the singular use of the DSM to decide what is and isn't a clinical problem. If your symptoms or behaviour don't cause you distress or impairment, you probably don't have a clinical problem. But: if you experience significant distress or impairment despite having only minor symptoms, it's still a problem. That is, if you binge eat only four times per year at holidays or only experience mood swings every third time you menstruate--but it causes you significant distress or impairment--ignore the doctor telling you your symptoms are subclinical according to the DSM, and seek help elsewhere. Distress is distress.
Proposed additions to the DSM like Internet Addiction and Premenstrual Dysphoric Disorder (PMDD) are raising the ire of DSM critics who argue that the manual medicalizes and pathologizes normal behaviour. While this criticism is valid and worthy of discussion, people making this argument have the frustrating habit of selecting one symptom from the list of DSM criteria for a given disorder and using it to claim that the criteria describe normal behaviour. The most recent person to do so is Ian Brown of the Globe & Mail. In his article, Brown gives the example of one criterion for the proposed DSM-V diagnosis of compulsive hoarding: "Persistent difficult discarding or parting with possessions, regardless of the value others may attribute to those possessions."
According to Brown, this symptom describes "anyone with a basement." Such is the problem of selecting and criticizing a diagnostic criterion in isolation. Anyone wishing to make a similarly unsophisticated argument could choose "Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances" from the proposed criteria for binge eating disorder (BED) or "Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection) prior to most menstrual cycles" from the proposed criteria for PMDD. They could argue that they often overeat at dinner parties and experience mood swings before they menstruate and that the inclusion of BED and PMDD in DSM-V would unfairly pathologize their behaviour.
This argument fails to acknowledge a) the other diagnostic criteria for the respective disorders and, importantly, b) the additional criterion of significant distress. The diagnostic criteria for most of the DSM disorders include "Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." This is a key criterion: If you have a basement full of junk, but it's not bothering you or anyone else (and not causing a health or safety risk), no one is going to accuse you of being a compulsive hoarder. If you overeat at dinner parties and binge on chips during the Superbowl, but it doesn't cause you lasting distress (or health problems), no one is going to label you with binge eating disorder. Writers like Brown are advised to keep the distress criterion in mind--as well as the entirety of the criteria for a given disorder--when they're fretting about the pathologizing of normal behaviour.
NB: My endorsement of the significant distress criterion is not a defense of the singular use of the DSM to decide what is and isn't a clinical problem. If your symptoms or behaviour don't cause you distress or impairment, you probably don't have a clinical problem. But: if you experience significant distress or impairment despite having only minor symptoms, it's still a problem. That is, if you binge eat only four times per year at holidays or only experience mood swings every third time you menstruate--but it causes you significant distress or impairment--ignore the doctor telling you your symptoms are subclinical according to the DSM, and seek help elsewhere. Distress is distress.
January 02, 2011
Multiple Personalities
Dissociative Identity Disorder (DID) is pretty much the most fascinating DSM diagnosis of all. Formerly called Multiple Personality Disorder, DID is a rare disorder diagnosed when a client presents more than one discrete identity or personality state that recurrently takes control of his or her behaviour. Each identity has a distinct and enduring way of behaving, perceiving, and interacting. Correspondingly, in addition to significant memory lapses and time unaccounted for, symptoms of DID include things like being told that one behaved extremely uncharacteristically, not responding to one's name, and being frequently accused of lying.
DID is associated with early traumatic experiences, particularly childhood physical or sexual abuse, often by a parent or other trusted caregiver. The hypothesis is that dissociation is an extreme response to severe trauma: the mind splits off the memory and awareness of the abuse; the memories go into the subconscious and eventually emerge in another personality, meanwhile allowing the original identity to exist as though untraumatized.
Without forgetting the anguish and suffering inherent to DID, I can't help but be impressed by the brain's capacity to protect individuals from their own terrible experiences by creating a separate personality to whom the terrible experiences happened. Some research has even found evidence for differences between identities in handwriting, and in physiological variables like heart rate and blood pressure!
Clinical psychology doesn't get more amazing than that.
DID is associated with early traumatic experiences, particularly childhood physical or sexual abuse, often by a parent or other trusted caregiver. The hypothesis is that dissociation is an extreme response to severe trauma: the mind splits off the memory and awareness of the abuse; the memories go into the subconscious and eventually emerge in another personality, meanwhile allowing the original identity to exist as though untraumatized.
Without forgetting the anguish and suffering inherent to DID, I can't help but be impressed by the brain's capacity to protect individuals from their own terrible experiences by creating a separate personality to whom the terrible experiences happened. Some research has even found evidence for differences between identities in handwriting, and in physiological variables like heart rate and blood pressure!
Clinical psychology doesn't get more amazing than that.
December 08, 2010
Personality Disorders
DSM personality disorders are fascinating and controversial because they suggest that a person’s personality--by nature multifaceted, unique, and shaped by experience--can be maladaptive and inappropriate to the point that it constitutes a disorder. According to the DSM, a personality disorder is an enduring, inflexible, and pervasive pattern of experience and behaviour that deviates markedly from the expectations of the person’s culture; is manifested in terms of cognition, emotion, interpersonal functioning, and impulse control and leads to significant distress or impairment. The ten DSM personality disorders are divided into three clusters.
Odd or Eccentric: A person with a schizoid personality is a loner, detached or aloof, with a restricted range of emotions. A person with a paranoid personality is distrustful and suspicious, and frequently and unjustifiably perceives others as deceitful or disloyal. A person with antisocial personality disorder is popularly known as a psychopath or sociopath: manipulative and lacking in empathy or conscience. A person with a schizotypal personality is odd or eccentric, with unusual or peculiar beliefs or behaviour.
Dramatic, Emotional, or Erratic: Borderline personality disorder is characterized by emotional instability, poor self-image, dramatic shifts in mood, fear of abandonment, and tumultuous interpersonal relationships. A person with a narcissistic personality is grandiose, selfish, entitled, and intolerant, with a strong need for admiration. A person with a histrionic personality is theatrical, flashy, emotional, and uncomfortable when not the centre of attention.
Fearful or Avoidant: A person with an avoidant personality fears criticism, avoids social interaction, and is risk-adverse and sensitive to rejection. A person with a dependent personality is needy and submissive, very sensitive to criticism or disapproval, and needs a lot of reassurance and help making decisions. A person with an obsessive-compulsive personality is focused on efficiency and productivity, and may be considered a perfectionist or a workaholic.
Each personality disorder is described by 7 to 9 traits, most of which are not independently pathological. Lots of people people are, for example, impulsive and fail to plan ahead, or show restraint within intimate relationships out of fear of shame or ridicule, without having an antisocial or avoidant personality disorder, respectively. Further, a personality disorder is not necessarily immediately obvious. You could be dating someone for three months before you realize that he is intolerant of your opinions, expects special treatment from waiters and customer service representatives, and frequently and tangentially mentions his Harvard PhD in conversation with strangers–-helping explain why he has a hard time sustaining a relationship.
Therapists can use a strong or otherwise unusual personal reaction to a given client as a clue to the possibility of a personality disorder, and can convert the reaction into a therapeutic intervention by telling the client about it (e.g., “I feel personally responsible for your well-being to an unusual extent” or “I feel like nothing I could do would allow me to gain your trust”). If the client says it’s not the first time he or she has received that particular feedback, the therapist can ask something like, “What do you think it’s like for others to feel so much responsibility for you?” or “How has your difficulty with trust affected your marriage?” to help the client gain insight about how his or her personality impacts his or her relationships.
Personality disorders don’t come out of nowhere, and can constitute a valid response to a maladaptive early environment. If you were consistently misled and betrayed as a child, paranoia is a reasonable response. If you were an adored and overprotected child who was never criticized and who never faced a tough decision or problem on her own, dependence is to be expected. The emotional instability and fear of abandonment common among individuals with borderline personality disorder are the natural outcomes of alternating abuse, invalidation, and neglect. This developmental perspective on personality disorders can be validating for clients and helpful in maintaining patience and empathy in therapists who work with people with personality disorders. The therapist’s job is then to guide the client to an understanding of the impact of the behaviour pattern on the client’s current relationships and to help the client replace dysfunctional patterns with more adaptive and appropriate behaviour.
November 25, 2010
Twilight Zone
Seasonal Affective Disorder (SAD) is a mood disorder in which people whose mental health is stable for most of the year experience depressive symptoms during the winter months. But what about the short-term anxiety, disorientation, or melancholy that you feel in the winter around 4pm when the light starts to change? At first I thought it was just me, but the fleeting depressive state that occurs at dusk is a legitimate phenomenon (although not included in the DSM) and it has a name. It's called Hesperian depression, after the moment when the Greek God Hesperus, the evening star, rises in the sky.
I've discovered that the best way to combat Hesperian depression is to be doing something at that time other than staring out the window at the darkening sky. For me, the best thing is to go for a run, but a phone call to a friend, a coffee break, or some other quick and pleasant distraction will also do the trick. By the time you're done, darkness will have fallen completely, Hesperus' rise will be complete, and that uncomfortable twilight period will be over.
I've discovered that the best way to combat Hesperian depression is to be doing something at that time other than staring out the window at the darkening sky. For me, the best thing is to go for a run, but a phone call to a friend, a coffee break, or some other quick and pleasant distraction will also do the trick. By the time you're done, darkness will have fallen completely, Hesperus' rise will be complete, and that uncomfortable twilight period will be over.
November 24, 2010
The DSM
First published in 1952, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the diagnostic reference manual used by psychologists, psychiatrists, and other mental health clinicians in North America. The manual lists all the different depressive disorders, anxiety disorders, substance-related disorders, psychotic disorders, eating disorders, impulse control disorders, sexual and gender identity disorders, and personality disorders, among others. Each disorder is described by a set of diagnostic criteria.
What’s good and bad about the DSM?
Let's start with the good. First, the manual creates a common language for professionals. If I tell my client’s GP that the client has panic disorder, the doctor knows what I’m talking about. Second, a DSM diagnosis provides validation for clients; if you think you’re going crazy, it can be a relief to hear that your problem is a documented phenomenon. Third, DSM criteria are helpful in recruiting participants for psychiatric research. When you read an ad for individuals who experience recurrent and persistent intrusive thoughts or impulses and repetitive behaviours that they perform in response to an obsession, you’re reading the DSM criteria for obsessive-compulsive disorder.
What are the problems with the DSM? One of the biggest criticisms is that a DSM diagnosis is stigmatizing--a valid point. For example, if you have a major depressive episode documented in your medical file, your insurance carrier might consider you a suicide risk and raise your life insurance rate. If your file says that you have a personality disorder, some therapists may hesitate to accept you as a client. For this reason, as psychology interns, we are taught to be very careful what we write in client files.
A second criticism of the DSM is that it’s categorical and the diagnostic thresholds are arbitrary. I’ll use the diagnostic criteria for post-traumatic stress disorder (PTSD) as an example. You might have experienced a traumatic event and responded with intense fear, helplessness, or horror (criterion A). You may re-experience the event through flashbacks, nightmares, or memories (criterion B) and avoid people or places associated with the trauma (criterion C). But if you don’t experience arousal symptoms such as angry outbursts and sleep disturbances (criterion D), according to the DSM, you don't have PTSD. Without a DSM diagnosis, you may be denied access to specialized treatment, and your insurance company may decline to reimburse your therapy fees.
A final point to consider about the DSM is that the inclusion of a given condition constitutes an indicator of how that condition is viewed by society. Infamously, homosexuality was included in the DSM up until the 1980s. Today, there is heated debate about whether or not Gender Identity Disorder (the feeling that your physical gender does not match your true gender) is a real disorder and if so, whether or not the DSM should change the name to the less pejorative “Gender Incongruence.”
The edition in current use is DSM-IV-TR (text revision), published in 2000, but DSM-V is to be published in 2012. In preparation, working groups at the American Psychiatric Association are making decisions about such proposed additions as binge eating disorder, Internet addiction, and premenstrual dysphoric disorder.
Stay tuned.
Subscribe to:
Posts (Atom)