Posts tagged ‘DSM-V’

Saving Normal?

A recent opinion piece by Allen Frances for the LA Times is plainly pointing out the dangers of the new DSM’s broad strokes and the potential to paint too many “normal” people as mentally ill. It’s notable enough that mainstream press is presenting any criticism at all about psychiatry in general and the DSM in particular but Allen Frances was one of their own and no silent partner or low level underling either. He was the chairman of the committee that created the DSM-IV.

Our panel tried hard to be conservative and careful but inadvertently contributed to three false “epidemics” — attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many “patients” who might have been far better off never entering the mental health system.

The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day — despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.

Where the DSM-versus-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status — to say nothing of stigma and the individual’s sense of personal control and responsibility.

It’s interesting to see someone in psychiatry addressing the notion of false epidemics of mental disorder when a committee decision and ever changing public opinion are all that separate a “real” epidemic from a false one. That said, committee decisions and public opinion have proven quite powerful and if you look back, the release of each DSM has brought on a rash of newly mentally ill. If history proves a good indicator, there will be millions of people who are normal today and mentally ill in 2013 — all thanks to a book with the power to categorize and medicalize the human condition. How much sorrow is too much? How excited can you be about everyday things before you are manic? And now with the proposed introduction of psychotic risk syndrome, anyone who isn’t deemed mentally ill can be subject to the book’s reach simply out of fear that they may be in time.

What are some of the most egregious invasions of normality suggested for DSM-V? “Binge eating disorder” is defined as one eating binge per week for three months. (Full disclosure: I, along with more than 6% of the population, would qualify.) “Minor neurocognitive disorder” would capture many people with no more than the expected memory problems of aging. Grieving after the loss of a loved one could frequently be misread as “major depression.” “Mixed anxiety depression” is defined by commonplace symptoms difficult to distinguish from the emotional pains of everyday life.

The media seldom addresses views critical of psychiatry but for psychiatrists to come out against the new proposals in such a public way is truly indicative of what’s at stake with the new DSM. You can bet that if psychiatrists are picking sides on this, it carries huge implications worth looking at. It doesn’t take much to see the power inherent in handing over our culture’s ability to define “normal” to a small committee comprised exclusively of people with something to gain and Frances is not exaggerating when he calls it “wholesale medical imperialization.” How much control are we willing to hand over? How far are we willing to let anyone go in defining us? How widely cast will the net be before it captures you? This is not an issue of special interest only to those marked as seriously mentally ill. Every label of mental illness is serious and with an ever broadening range of perceived illness encroaching upon a shrinking concept of normal, you may not be off the hook. Frances’ article says that it may not be too late to save ‘normal’ but I question whether ‘normal’ is worth saving.

See also: Allen Frances’ Opening Pandora’s Box: The 19 Worst suggestions for DSM5 in Psychiatric Times.

March 4, 2010 at 10:24 am 3 comments

Defending a Diagnosis

When I first heard that the Asperger’s syndrome diagnosis was going to be dissolved and absorbed into the autism spectrum disorders, my first thought was that people with the Asperger’s diagnosis were not going to be pleased. As it turns out, I was right. Aspies, a name many with the diagnosis have adopted, have an identity and a community wrapped up in the diagnosis around which many rally in mutual support — a diagnosis that’s been the source of some contention as its legitimacy has been debated and now its existence as a stand-alone disorder is in question. I’m not one for labels, in large part because they tend to be divisive but I firmly believe that we should be able to define ourselves as we see fit and the Aspie community has done just that — or at least they’re trying. In a time when thousands of people are trying to shake off one label or another, Aspies are clinging to theirs. Many diagnosed with Asperger’s fear that their collective identity will suffer a hit, even be lost entirely if they are to be lumped in with the Autism spectrum.

From Lindsey Tanner for the Associated Press:

Some parents say they’d welcome the change, thinking it would eliminate confusion over autism’s variations and perhaps lead to better educational services for affected kids.

But opponents — mostly older teens and adults with Asperger’s — disagree.

Liane Holliday Willey, a Michigan author and self-described Aspie whose daughter also has Asperger’s, fears Asperger’s kids will be stigmatized by the autism label — or will go undiagnosed and get no services at all.

Grouping Aspies with people “who have language delays, need more self-care and have lower IQs, how in the world are we going to rise to what we can do?” Willey said.

With any diagnosis comes assumptions preconceptions and often stigma. You are one of these, therefore I can expect this of you and these are your limitations. That’s the power of labels and that’s why some people are fighting so hard for some measure of control over the labels attached to them. While incorporating the Asperger’s diagnosis into the autism spectrum may have some benefits that are not currently available to those with an Asperger’s label, many disagree on how to amend the situation. Do we change the label or the distribution of services?  And what, if anything, is a reasonable trade-off?

Rebecca Rubinstein, 23, a graduate student from Massapequa, N.Y., says she “vehemently” opposes the proposal and will think of herself as someone with Asperger’s no matter what.

Autism and Asperger’s “mean such different things,” she said.

Yes and no.

Both are classified as neurodevelopmental disorders. Autism has long been considered a disorder that can range from mild to severe. Asperger’s symptoms can vary, but the condition is generally thought of as a mild form and since 1994 has had a separate category in psychiatrists’ diagnostic manual. Both autism and Asperger’s involve poor social skills, repetitive behavior or interests, and problems communicating. But unlike classic autism, Asperger’s does not typically involve delays in mental development or speech.

Aperger’s revolves heavily around social differences and many who embrace the label embrace those differences not as subnormal or abnormal but as very natural and normal leanings and behaviors viewed unfavorably “neurotypicals” (those outside of the autism/Asperger’s umbrella). While some connections may be made based on the many parallels between the two diagnoses, many Aspies fear the distinction in developmental abilities will be lost in the blur created by blending the labels. The change in diagnosis may prove to be a double edged sword in some ways. We tend to see developmental delays (as with autism) as being objective, legitimate and neurologically based while the traits of Asperger’s are primarily behavioral and lend themselves to a more hazy and subjective reading. For many, there is a struggle to link Asperger’s to autism as an established diagnosis while maintaining its distinction as not meaning limited or delayed developmentally. Still for others, especially parents seeking useful services and placement in schools, the question of perception has to be weighed against very real needs which currently hinge on the little numbered code that accompanies every diagnosis in the DSM.

As I’ve said, I’m not one for labels applied by people other than the wearer and I’m inclined to think the whole situation might be better handled if we throw the book out altogether. If the DSM and it’s hairsplitting, mind measuring scales and labels didn’t exist, what choice would we have but to see people as individuals and not as representatives of their limitations — real or perceived? No one should need to take on a label to get the help they need, least of all children in schools and no one should need to cling to a diagnosis because a collective identity rests in it. Autistic people, Aspies, neurotypicals and beyond, we are who we are despite labels, not because of them.

• • •

You may also be interested in:

Psychology Today: What does this change mean? Don’t people have the symptoms of Asperger’s syndrome any more? Of course that’s not the case. But let’s look at mental health problems as they are reflected in years of DSM editions…

NPR: Right now, the diagnosis often hinges on a person’s language skills. But that’s pretty subjective and can change as a child grows up, researchers say. “The categories are just not used by clinicians in a reliable fashion,” Lord says. A single category for autism spectrum disorder will let clinicians stop agonizing over which diagnostic category to put someone in…

The image at the top is a still from Adam Elliot’s brilliant film, Mary and Max, featuring the voices of Philip Seymour Hoffman and Toni Collette. Go watch it.

February 17, 2010 at 9:39 am 7 comments

DSM-V Draft Released

A draft of the DSM-V has been released and is open to public comment. That’s news to me. I have yet to review any of it first hand but thought I’d put this out there to for anyone with the time and interest to take a look at it. There are some big changes in the works. While it’s not without its flaws, some of the more ludicrous attempts at creating new disorders have actually not made it into the draft and other labels are being revised. I may not have a chance to check it out and weigh in today but I’m definitely concerned with the implications that psychosis risk syndrome might carry. Think of how quickly you can lose your rights over a label. Putting a label aside for risks of symptoms is going to get messy. All things considered it is just a draft and the final isn’t due until 2013 so there’s still plenty of time for the wind to blow this thing in any direction. If nothing else, it’s a glimpse into the process, showing it is very much based on opinion and deliberation not objective medical discovery.

Here is a quick overview from MedPage Today and a few thoughts on it from Philip Dawdy at Furious Seasons and a brief breakdown at Beyond Meds with links to articles of interest to people following particular issues.

February 10, 2010 at 3:00 pm 2 comments

I Think I’m Coming Down With Something.

USA Today reports that Raymond DiGiuseppe, a researcher and psychology professor in Queens, NY seems to think we haven’t gone far enough in our efforts to pathologize the human condition. DiGiuseppe asserts that anger should be included in the DSM-V, which by way of its very presence in the book would classify it as a disease. That is the function of the DSM — to identify thought patterns, emotions and behaviors as diseases thus putting them within the increasingly invasive scope of psychiatry. 

“Clinical psychology really targets depression and anxiety and really leaves out many human experiences or emotions,” he says, noting that other emotions such as disgust, envy and jealousy are also ignored.

   There is the problem. There is a very urgent push, led by the APA and backed by Big Pharma to do away with any distinction between disease and emotion. In light of the fact that they’ve never had to prove the presence of disease, nothing really keeps them from reclassifying emotion as disease–so they do. If we’ve gotten clinical depression and generalized anxiety in, why not go for disgust, envy and jealousy?

   I’m not saying anger isn’t difficult for some people to manage or that choosing to have people guide them through that anger would not be a wise choice in many cases but that’s a far cry from calling it a disease. I’m calling into question the notion that there is a biological cause to that anger and a chemical cure for it. I’m calling into question any system which would pathologize all human emotion and the legal, social and economic implications that would go along with it.

   Do we honestly think anger is a disease — that it’s a biological malfunction? Of course not. We know why we’re angry. We often have good reasons to be angry. From a bad day at work to oppressive political regimes and many things in between, we have good reasons to be angry. Anger is very human and a necessary component for redirection and change.

It destroys interpersonal relationships. It impedes sexual functioning. It negatively effects marital relationships. It negatively affects goal attainment,” he says.

DiGiuseppe says research shows that angry people make less money, are less likely to be promoted, almost always have poor romantic relationships and are more likely to be in the criminal justice system.

   I refuse to accept the idea that the threshold between emotion and disease is a social one. If you are to assert that something is a disease, you must show that it is a biological malfunction, not that it can impede your job performance or disrupt your marital bliss. It is an especially dangerous road we are walking down and in the face of involuntary participation in the psychiatric system it is a dangerous road many are being corralled down. Justified anger is a very important part of free thought. It is the fight in you — and the way things are going, it looks like you may need it soon.

August 11, 2009 at 11:46 am 2 comments


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