Tuesday, August 27, 2013

Changes in the DSM V - part 4

We continue our survey of the revised DSM, with Obsessive Compulsive Disorder. This is now a category in itself, not included as a subspecies under Anxiety Disorders. The description of this disorder now allows for a whole range of understanding by the patient, from “good” or “fair” insight at one end of the scale down to “absent/delusional” at the other end. It can also be specified as “tic-related” if appropriate.

Under the Obsessive Compulsive umbrella we have a number of subcategories, such as the much heralded new “Hoarding Disorder.”  Once relegated to a mere symptom of a subtitle, it is now recognized as a full fledged set of problem behaviors in its own right. In future blogs, I hope to look into this new animal and tell you what it is, and what qualifies one as a hoarder.

There are also other subcategories, for instance Body Dysmorphic Disorder, which consists of repetitive behaviors based on perceived (but not actual?) defects or flaws. I must admit I am not familiar with this one. Another aspect is the old chestnut Trichotillomania (hair-pulling) Disorder, and the new “Excoriation” (skin-picking) Disorder - another one I’ll have to look into. There is the additional choice that any of these may be “Substance Induced,” which makes sense, and an interesting entry under the title “Other Specified and Unspecified” - Obsessional Jealousy. Frankly, I have always believed that type of behavior to be an aberration, so I was intrigued to see the professional recognition.

In other news, under Dissociative Disorders we have a change in language to note that disruptions may be reported as well as directly observed, which is certainly going to help in diagnosis. It is also now clinically accepted that dissociation may occur in response to everyday events, not just those we label traumatic. And with this, I think we are running into a very basic principal in mental illness: one man’s passing moment is another man’s crisis.  It is the very definition of “abnormal” that we do not respond in the same way as others do to the same stimuli.  That is how people notice we are different in the first place! Where the average person may leave a noisy, chaotic environment with an annoyed shake of her head, the person with psychiatric issues may well leave that same environment crying and shaking, unable to cope for the rest of the day. So I think the recognition that everyday phenomena may function like trauma for some of us has larger implications for mental health treatment.

Also in the Dissociative category, Dissociative identity Disorder is now considered to include certain behaviors that other cultures might label as “possession.” Leave it to Western medicine to find a cubbyhole for everything.

Lastly we have a sort of backhanded mainstream recognition in the new diagnostic class “Gender Dysphoria.” This category recognizes many forms of “gender incongruence” rather than merely cross-gender identification and attraction. It is now a multi-category description rather than a dichotomy.

I am not so sure it is helpful that this is still included as a mental disorder; however, we have come a long way. Homosexuality was listed as a psychiatric disturbance until 1973. It is the only disorder ever removed from the DSM. It was replaced at that time with Sexual Orientation Disturbance, and now with Gender Dysphoria, which leaves room for all the different ways people can be unhappy with the boy/girl status quo. I prefer to think of it as a recognition of how uncomfortable and life-altering it is not to fit snugly into heterosexual roles. Our culture still makes this a difficult way to live, and often people could benefit from therapy as they try to find their way to personal power and personal peace.

No doubt some of you will consider it insulting that the category even exists, and I can understand that. But there will always be labels for those who don’t fit into the mainstream paradigm, and some people are always sure to consider them “wrong” or “sick.” That is the risk we take when we step out and do it our own way. Educating the world is a visionary calling that can take generations to achieve.

In my next blog I hope to address the one major change I have not dealt with yet: the new Autism Spectrum Disorder that has swallowed up other designations such as Aspergers Syndrome. What this means for those affected is a complex issue that I want to study further.

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 www.lafruche.net, or see her catalog at www.lastlaughproductions.net.

Tuesday, August 13, 2013

Changes in the DSM V: part three

On we go with our dissection of the new DSM 5. The next category up is Anxiety Disorders. Here we have some important changes.

For one thing, Obsessive-Compulsive patients are no longer in a subdivision of Anxiety, but now have a category of their own. And Post Traumatic Stress Disorder has been moved as well, to be placed under the Trauma Related Disorders rubric.

There is also a substantive recognition of our world view. It is no longer required that the Anxiety patient label their own fears as excessive and unreasonable. There is acceptance of the fact that what you are afraid of is, to you, truly dangerous. In the rest of the world’s eyes, maybe the danger is overestimated. But to you, it is quite real, and as far as you are concerned your fear is entirely rational. The requirement is now merely that the Anxiety be out of proportion to the danger - NOT that the patient agrees that her fears are ‘silly’ or ‘crazy.’ To me, this demonstrates respect for the patient’s reality.

The other new requirement is that the Anxiety be of at least 6 months’ duration, to distinguish it from passing fears.

The Panic Attack category also shows some changes. A set of previously complex terms have now been boiled down to a simple choice between “expected” and “unexpected.” This label can be added as a specifier across various disorders.

Also, Panic Disorder and Agoraphobia have now been unlinked. If a person displays both, then he gets two diagnoses.

The former “social phobia” is now renamed Social Anxiety Disorder and can be typified as “performance only” if necessary. It is no longer “generalized.”

Lastly for Anxiety Disorders, Separation Anxiety is now recognized as occurring in adults as well as children. And Selective Mutism has now come under the Anxiety Disorder heading.

Next post: Obsessive Compulsive Disorders, including the new Hoarding Disorder.

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 www.lafruche.net, or see her catalog at www.lastlaughproductions.net.