Sunday, June 30, 2013

Changes in the DSM V (Part 1)

Folks, when I undertook to summarize the changes from DSM IV to DSM V, I was biting off more than could chew! At least, in one blog, that is. I will have to give it to you in chunks, and oversimplified chunks at that.  You are welcome to read the “not exhaustive” but exhausting (!) APA list of changes for yourself if you like. You will find them here: bit.ly12x42BU. There are far more categories than I ever realized.

But let’s start with an important victory right at the top of the document. From now on, the language of the DSM recognizes that a mental illness is a medical condition. When someone has a mental illness and a physical illness and both are mentioned, the physical illness will be referenced as “another medical condition” not a “general medical condition” as in the past. To some that may seem picky - but as anyone who’s ever worked for the equality of an underclass can tell you, language is important. The way we speak and write about things influences the way we think about them.

I’ll begin with the category “Psychotic Disorders.” There are a number of changes here. Perhaps the most signal is the elimination of the word “bizarre” in front of “delusions.” This is important, I think, as a step towards recognizing us as fellow human beings. Everybody has delusions, not just schizophrenics, and calling them names if they depart too far from the norm is not particularly helpful. Much better to rate them by whether a person can function with that particular delusion, or whether it makes life unmanageable. All this is implied by the APA’s own words: the term “bizarre” was abandoned due to “poor reliability in distinguishing bizarre from non-bizarre delusions.”

Also, two of Criterion A symptoms (delusions, hallucinations, and disorganized speech) are required now, not just one. A number of subtypes (paranoid, disorganized, catatonic) have been flat out eliminated due to “limited...stability...and poor validity,” which will no doubt please patients who dislike labels. Instead, measuring will be done on a basis of severity of core symptoms. Which goes right along with what I was saying above about judging by functionality.

A diagnosis of Schizoaffective Disorder will now require that a major mood episode be present for the majority of the disorder’s duration, “recognizing that the characterization of patients with both...symptoms...has been a clinical challenge.” Boy, you said it. I am still not sure if I am better described as Schizoaffective or, as my psychiatrist would have it, Bipolar with Psychotic Features. It kind of depends on which day you see me.

Delusional Disorder, with which I admit I am not familiar, is no longer separated from Shared Delusional Disorder, and can only be diagnosed if it is not better explained by Obsessive-Compulsive Disorder or Body Dysmorphic Disorder.

Lastly, Catatonia now has the same criteria whether it applies in a bipolar, psychotic, depressive or other medical context. All of them now require 3 catatonic symptoms.

Whew. That’s enough to digest for now, don’t you think? I’ll go on with more next time. We have yet to cover Bipolar, Depressive, Anxiety, Obsessive-Compulsive and Panic Disorders, just to name a few. It looks like a long ride from here.

Deborah is the author of Is There Room for Me, Too? 12 Steps & 12 Strategies for Coping with Mental Illness, available at Amazon and other major vendors. Visit her web page at or see her catalog at

Tuesday, June 11, 2013

So What’s All the Fuss About DSM 5? Part 1

I’m assuming you’ve heard of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, that doctors use as a handbook to help them diagnose our psychiatric conditions. Since the 1980s DSM has been the clinical ‘Bible’ and given professionals a common language. Periodically it is revised by the American Psychiatric Association. Well, DSM mach 5 is due to roll out any day now, and it is surrounded by controversy.

Controversy about DSM revisions is nothing new. But this time, the National Institute of Mental Health (NIMH) has rather spectacularly proclaimed that DSM 5 categories will no longer be used for funding research. NIMH wants to start a new system for researching and classifying studies on a scientific basis, which it is calling Research Domain Criteria (RDoC). You can read the 4/29 blog post by NIMH Director Thomas Insel here:

Basically, the idea is that rather than doing research into a chosen cluster of symptoms with a group name (e.g. ‘Schizophrenia’), they want to start diagnosing using scientific and biological markers: genetics, imaging, and other laboratory measures. A symptom could be studied no matter which DSM category it formerly fit into, to eventually be reclassified once the facts are in. The example given is anhedonia (loss of interest in formerly pleasurable things), which could now be funded and studied whether it was part of depression or an eating disorder. The goal would then be to discover how anhedonia actually worked, and possibly reclassify types of anhedonia later based on collected evidence. In other words, how about we find out what’s CAUSING these disorders, instead of just describing them?

There are two problems with this scheme. One is that it is 50 years too early; the other that it is 50 or 100 years too late.

Early because the data aren’t there. Nobody has really studied symptoms this way, and it will be a very long time before there is enough information to start collating and classifying, much less constructing an entire new diagnostic framework.

Late, because psychiatry should have been put on a strictly evidential basis a very long time ago. The mentally ill have always been prey to uninformed guesswork by doctors and society alike, since very ancient times. Long ago they were sure we were possessed by demons. At the turn of the last century, horrific water treatments and chains and other tortures were going to ‘cure’ us. Then it was psychobabble about what kind of family environment produced schizophrenia. We are certainly better off now, with drugs that actually work sometimes, but finding the right medicines - many of which were discovered quite accidentally, by the by - is still a crapshoot, a matter of blind experimentation.

I was giving a presentation in a psychiatric ward last Friday. We were over and over disrupted by a patient yelling that psych meds were bunk, that there were no biomarkers for our diseases, and that cymbalta had ruined his liver and his life. We eventually had to ask him to leave so that we could go on with the presentation. But I had a sneaking sympathy for him. Where ARE the proofs? Where is the real, objective evidence? We deserve better, and we have deserved it forever.

But meanwhile, back on the ground, who’s going to run things? How are clinicians to decide what to do with people who walk into their offices? Until we have all that good new data, we will have to use the DSM. Of course. There’s nothing else available, unless you want to go by the ancient Chinese system which blames ghosts for our disorders, or the Ayurvedic system which blames astrology. Sorry, but no.

So, what does the DSM 5 say that’s different? I’ll look into that and try to sum it up for you in my next blog.

Saturday, June 1, 2013

Just a quickie

A new blog is coming soon, I promise. Meantime, if you didn't get to attend, here is the link to my webinar as recorded by the International Bipolar Foundation: