The new DSM-5 draft is out (and it appears the APA is finally dropping the silly roman numeral designations). Analysis is starting to pour in from around the country about the ramifications …
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Thanks for your article. I’m glad to know that this public process is taking place.
I know that when I worked in an outpatient addiction treatment center we made frequent use of the distinction between alcohol (or substance) abuse versus dependence in the DSM IV, chiefly when it came to diagnosing adolescents. Our director at the time felt strongly that to diagnose an adolescent as drug or alcohol dependent at the age of 13 or 14 (or even 18) was terribly premature, yet there clearly were signs of abuse. To us, at least, the differentiation between these diagnoses was not confusing, on the contrary it was helpful.
I look forward to reading the new (?) criteria for Substance Use Disorder.
“There’s no good diagnosis for a person today who has self-injury behavior, but few other symptoms.”
What is the rationale for turning this symptom into a diagnosis? I understand that this group may be hard to diagnose, but it seems to me that you’re suggesting the solution is to basically abandon or put off diagnosis by substituting this non-diagnosis.
With all due respect, Dr. Grohol, if you’re going to defend this proposed revision, i think you’ve got to do better than, “Self-injurers are hard to diagnose [not an actual quote]” and the following…
“The inclusion of self-injury as its own disorder is likely to help people who currently do this to seek out help.”
I’m pretty sure that most people who self-injure on a regular basis already know there’s something wrong with that. But anyway, that’s not the point. The issue in self-injury not the actual injury. The issue is that (1) the person has some distress that they are (2) unable to cope with in a healthier manner. I really think it does a disservice to self-injurers to focus so much on the act itself, when clinicians should be focusing on resolving the underlying distress and developing healthier coping skills.
“Temper Dysfunctional Disorder with Dysphoria… So, in other words, a temper tantrum.”
I have plenty of issues with this “diagnosis” as well, but i find it disheartening to see a mental health professional such as yourself simplifying the issue in this way. Although i’m sure there are plenty of disingenuous psychiatrists out there who would glibly stick your average tired whiny child in this category, that’s not what it’s intended for, and i suspect you know that. There are children whose behavior goes far beyond the occasional temper tantrum, who are in serious need of some kind of intervention, and the parents are usually at their wits’ end.
Now, whether these children ought to be labeled with a diagnosis of ANY sort should be up for debate in my opinion; kids’ symptoms tend to be kind of vague, and i don’t understand the rush to diagnose. (Probably an insurance thing, but payment for services shouldn’t really be the concern of a _diagnostic_ manual.)
I don’t see why the inclusion of “Paraphilic Coercive Disorder” would cause “lighter” sentences. The point is for it to be used with Sexually Violent Predator laws that 20 states have permitting the “civil committment” of “sexually dangerous predators/persons” AFTER the completion of their sentences. The civil commitment process requires that people have a mental disorder, and these “disorder” are being manufactured to deprive people of due process rights and enable indefinite confinement without all of the constitutional safeguards involved in criminal cases.
I don’t see what’s wrong with including behavioral addictions in the DSM-5. Research supports the existence of behavioral addictions, and I know a number of people who have very clearly suffered from them. It’s also well known that there does seem to be such a thing as an “addictive personality,” and that while some “addictive personalities” get addicted to drugs, others get addicted to food, gambling, or other behaviors. I have also heard that when people lose one addiction (drugs, for instance) they often replace that with another addiction, such as food.
So since behavioral addictions are clearly a problem, why leave them out? Not having a diagnostic code simply means that those suffering from behavioral addictions will not be able to get insurance coverage for the therapy that will help them deal with those addictions. So Dr. Grohol, what’s your point in leaving these problems out of the DSM-5, effectively preventing these people from getting the help they need?
Obviously, gambling addiction doesn’t help people with other types of behavioral addiction, but at least it’s a start – hopefully more will be included in the next revision.
Fear of unintended acceleration for Toyota owners should be a valid diagnoses. This is dysfunction where the customer has been told his vehicle is fine but he still has a fear of losing control of his/her vehicle.
As a clinician, I’LL NEVER LIKE THE DSM and I think I’m going to be that way until something changes! The DSM has many flaws; many flaws due to the politically and socially controversial diagnostic categories such as gender identity disorder; the various disagreements on what should be listed as a mental disorder and what should not; what should be listed as a syndrome vs. a disorder; what is a true mental disorder/illness and what isn’t; establishing a meaningful boundary between abnormal and normal psychological functioning; how to incorporate other cultures; the list goes on and on and on.
I think Dr. Grohol said it best “…the DSM has always been a slave to the politics and realities of the world it tries to accurately reflect.” And might I add…these [current] changes [are] poorly conceived.
According to the American Psychiatric Association the “DSM-IV is a categorical classification that divides mental disorders into types based on criterion sets with defining features.” The purpose of the DSM is to help clinicians determine which particular disorder may or may not be present. It is evident, especially with the various revisions of the DSM (starting in 1968, maybe later), that it fails to guide the clinician to the presence of a particular disorder or multiple disorders (i.e., co-morbidity or co-occurrence).
Many current like the categorical view of the DSM, while others would prefer the dimensional view.
A dimensional model of the DSM would include abnormality and normality lying along a continuum (similar to a spectrum); it is not concerned with classifying people, but rather identifying or measuring individual differences. In other words, psychopathology would not be a category of its own, it would be an extreme variant of normal behavior or normal ways of living along a continuum.
Research on the dimensional approach has focused more on personality disorders.
I’m not quite sure I like the dimensional approach either; it is indeed more confusing and sort of undermines the presence of psychopathology by claiming a behavior is an extreme variant of normal behavior.
The DSM just continues to become more convoluted, more political, and more focused on insurance payments than the correct diagnosis of clients. Although the DSM was created and continues to be revised in order to help clinicians make sound decisions, it sometimes appears to add more diagnostic and treatment difficulties than the disorders themselves. At times, we’d probably do much better not to use it as though it were a “Bible.”
Mark my words, this effort to create more “Spectrum Disorders” categories is just a covert effort to overdiagnose further. Bipolar Disorder was not overdiagnosed by 300% as the authors of DSM 4 would have the general public believe, and I am genuinely concerned about this intent to over diagnose Autistic Disorders if DSM 5 has its way (note I do not treat Child Disorders, so this is not an expertise comment specifically here).
DSM has its place, I am not bashing my field entirely, but, the question I hope my colleagues as a whole are asking themselves and each other is, why are we tolerating other professions who do NOT have our expertise acting like they do? And even more so, why are patients accepting of outsiders practicing irresponsibly?! This whole debate about overprescribing of medication is not by psychiatry’s doing alone, but what general medical docs/nurse practitioners/and if psychologists get their way them as well, this is the majority of prescription access these days.
It ain’t about better living through chemistry, folks. It is about change, coping, and caring.
Put that in a pill and swallow it!
So now people on the Autism spectrum are mentally ill as well as diseased and in need of a cure? I’m sick and tired of people trying to “cure” me because I’m “ill” in their minds. I’m far from ill and I would refuse to be treated as such.
Remove the Autism Spectrum from the MENTAL ILLNESS MANUAL since it is a GENETIC VARIATION THAT ALL SPECIES HAVE AND NEED TO SURVIVE THE EVER CHANGING PLANET.
It seems the creators of this “manual” are just lookin for an excuse to shove more pills down more people’s throats.
Autism has been a part of the mental disorder manual for decades, so that is nothing new.
I think the use of “spectrum disorders” is to acknowledge that mental disorders are often not “black and white” — that they occur on a spectrum of behavior, some of which may be milder than others — but still troubling and life-altering.
People don’t need a new disorder to over-prescribe; that’s happening quite nicely right now. So I’m not sure the new version can accelerate an already-significant trend.
There is a report circulating which says that Poul Thorsen, who worked on and/or contributed to DSM revisions, has been lying about his academic affiliations and has (apparently) absconded with a substantial amount of money, grant funding.
Have you seen these reports? (Try http://www.ageofautism.com, if not.) Can you comment, or do you know if this is true or not true?
Thanks.
now everything a person does is a disorder……….a kid cannot run around and act out because he might be diagnosed with A.D.D AND GIVEN A PILL THAT SITS NEXT TO OPIUM AND COCAINE….what is wrong with the world?
This is a great move on the part of the APA, long overdue, but I agree about that “slippery slope” of behavior addictions – nearly any activity done beyond moderation could qualify! And why is pathological gambling the only behavior included? I agree that is a valid addiction, but why is it the only one?
-Ryan Harris
I for one am please to see the inclusion of self-injury as its own disorder. It’s about time it be recognized that self-injury may not be a symptom in some cases, but may actually be an illness in itself. Self-injury is such a compex issue that goes unseen, and maybe this will help clinicians better recognize and properly treat the problem. It will at least create a road map for clinicians to navigate when coming up with a proper diagnosis and treatment plan.
I do think, however, that self-injury should classified as part of the Impulse Control disorders rather than be given the label Non-suicidal Self-injury; a label that will only create a worse stigma that is already out there and will deter people from seeking help.
Recognizing self-injury as a disorder is an important break through, and this is a step in the right direction, but I think more research needs to be conducted to ensure that the acknowledments of the disorder are correct. Will someone who hurts or thinks about hurting his or herself almost everyday seek help if they may be told they suffer from NSSI, or will they benefit more positively if they explain to a clinician that they’re urges are unctrollable and they hurt themselves in order to provide relief which may suggest to the clinician that he or she suffers from Impulse Control Disorder Self Injury type?
It will be interesting to see in a few years what the outcome will be.
now that most of Europe has dropped the mental illness label from the wish to change sex shoudl the homosexual penophilics at The Clarke/CAMH such as Blanchard and Cantor be told to forget the idea that transsexualism is a mental illness and is really just a simple intersex problem?
In the UK a transsexual can transition from living male to female and get a certificate from the Government to that effect and then get a new birth certificate showing they are recognised at being the opposite sex at birth – which is only logical once the reality of transsexualism is grasped.
The DSM will thus be unworkable in the UK and other European countries that allow for this new birth certificate process.
Blanchard’s continuing insistence of pathalogising transsexalism is just ego protective smokescreening to make sure that no-one coudl imagine a tall guy like him is really a classic closet homosexual with extreme penophilia.
looked in vain for Penophilia – an extreme and unhealthy interest in other men’s penises – but surely it should be in DSM5 to explain the tearoom culture and the desire many men have for contact with a penis but cannot bring themselves to be openly active in the homosexual milieu of the gay bars.
I’m really curious – quite a few of the proposed changes impact on my current diagnoses. There’s a considerable reorganisation of dissociative disorders and the new trauma and stressor related disorders category. I’m curious where I might end up (complex post traumatic stress and dissociative disorder not otherwise specified).
In regard to the substance abuse vs. dependence issue, my comment about those under twenty-one with whom I dealt always had an “abuse” problem for they were breaking the law. This dichotomy has always been vague to me when dealing with adults as well as younger patients. I agree it should be dropped.
I have some disagreements and agreements with Dr. Grohol’s review and the DSM-V revisions.
First, I disagree that inclusion of paraphilic coercive disorders will lead to lighter sentences. Although Dr. Grohol is correct that offenders can claim this as an excuse, lawyers and judges are going to thoroughly question it each time it is brought up because it labels the behaviour but doesn’t indicate the person is not/less guilty. If this were so, many criminals who have anti-social personality disorder would have lighter sentences simply due to their psychiatric illness. It also won’t lead someone to being deemed, “not criminally responsible due to mental disorder” (NCRMD, as used in Canada) or “not criminally responsible due to insanity” (term used in parts of Europe).
Second, I disagree with Dr. Grohol’s view on paraphilic coercive disorders because it doesn’t exclude someone from going on the sex offender registry, which is criticized as being punitive on its own.
Third, I disagree with DSM-V’s inclusion of self-injury as a psychiatric illness. It seems to just clutter the diagnosis up because people who self-injure likely already have a mental illness. I feel it should be replaced by being a specifier for mental illnesses instead of its own mental illness. I feel that if someone were given this diagnosis, their GAF score would be lower.
I also disagree with the DSM-V’s “mild neurocognitive disorder”. While Dr. Grohol presented a good argument, my reasoning is a bit different. Particularly, the DSM-V seems to be pushing itself into the field of neurology because these neurocognitive disorders have a purely biological basis and cannot be remedied by psychotherapy. For example, “Minor/Major Neurocognitive Disorder Associated With Prion Disease” cannot be remedied at all by psychotherapy. It’s like saying Creutzfeldt-Jakob Disease can be remedied by psychology and psychiatry, when the onset, progression and treatment is purely biological at the brain level. The DSM-V is extending its arms into areas psychologists and psychiatrists are not trained in.
On the other hand, I do favour the inclusion of behavioural addictions. There is considerable research to indicate they exist. There is also a good deal of social experiences with it, however, I do wonder whether it will justify medications for such disorders.
Regarding your take on “behavioral” addictions, I would disagree. I prefer the word “process” addictions, since I see this as more descriptive of the problem. This from someone who began treatment for substance abuse back in the 80s when behavioral addiction was a relatively new idea. When recovery from alcoholism didn’t do the trick, I eventually had to explore my other addictions. I learned the most from my inquiry into issues around money, which isn’t even mentioned. Workaholism is endemic, and that particular manifestation just scratches the surface. In recent years I’ve had to acknowledge my overuse of the internet and insatiable appetite for knowledge. Really, it’s about time the DSM recognized what we in recovery have known for decades.
The American Psychiatric Association has never shown such ignorance in any subject than autism. For example, in the DSM-5, they acutally put flapping hands and complex body movements into ASPERGER diagnosis, as if this is joke or a major mistake, because any sane person knows that this is a hallmark trait of AUTISM, not Asperger’s disorder. How stupid are these people? And then you don’t even find behavioral issues in the autism diagnosis, which is a major, major hallmark trait of moderate to severely autistic people’s struggles.