tag:theconversation.com,2011:/ca-fr/topics/matters-of-the-mind-4117/articlesMatters of the Mind – La Conversation2012-10-26T21:31:55Ztag:theconversation.com,2011:article/103462012-10-26T21:31:55Z2012-10-26T21:31:55ZInternet use and the DSM-5’s revival of addiction<figure><img src="https://images.theconversation.com/files/16929/original/chqnx9h4-1351220221.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many of us feel that our internet use verges on problematic but this is different to addiction.</span> <span class="attribution"><span class="source">justingaynor</span></span></figcaption></figure><p><em>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em></p>
<hr>
<p>The term “addiction” is conspicuously absent from the pages of the current <a href="http://allpsych.com/disorders/dsm.html">Diagnostic and Statistical Manual of Mental Disorders</a>, the DSM-IV. That’s because in the 1980s, <a href="http://ajp.psychiatryonline.org/article.aspx?articleid=96549">the committee working on the DSM-III-R</a> were keen to avoid the cultural baggage and stigma associated with the word addiction. They hoped to provide more neutral and clinically useful terms by using “dependence” and “abuse” in the current category <a href="http://allpsych.com/disorders/substance/index.html">substance-related disorders</a>.</p>
<p>Experience proved this to be a mistake – the terms were confusing and misleading. </p>
<p>“Abuse” turned out to be highly stigmatising, with drug takers being compared with other types of abusers. This was shown clearly in <a href="http://www.ncbi.nlm.nih.gov/pubmed/20005692">one trial</a> that found patients described as “substance abusers” to health-care professionals were recommended less therapy and more punishment than when they were described as having “substance use disorders”. </p>
<p>“Dependence” too is misleading. Physical dependence occurs not only when people take addictive drugs, it can also occur with psychiatric medication. It <a href="http://ajp.psychiatryonline.org/article.aspx?articleid=96549">is possible</a> to be dependent on a substance without experiencing the full range of symptoms necessary for addiction. By confusing dependence and addiction, the DSM unfortunately added a level of stigma to an otherwise normal response to repeated doses of medication. </p>
<p>We can now happily say goodbye to two very problematic terms. The <a href="http://www.dsm5.org/Pages/Default.aspx">DSM-5</a> plans to reintroduce addiction in the new category of <a href="http://www.dsm5.org/proposedrevision/Pages/SubstanceUseandAddictiveDisorders.aspx">substance use and addictive disorders</a>. This new diagnostic category will not only revive the use of the term addiction, it will place substance use disorders and non-substance use addiction together, beginning with moving <a href="http://www.dsm5.org/proposedrevision/pages/proposedrevision.aspx?rid=210">gambling disorder</a> from <a href="http://psychiatryonline.org/content.aspx?bookid=22&sectionid=1892490">impulse-control disorders not elsewhere classified</a> to the new category.</p>
<h2>All behaviours large and small</h2>
<p>The inclusion of <a href="http://www.dsm5.org/proposedrevision/pages/proposedrevision.aspx?rid=210">gambling disorder</a> in the new category is <a href="http://www.sciencemag.org/content/327/5968/935.summary">not without critique</a>. But it seems in line with <a href="http://mitpress.mit.edu/books/midbrain-mutiny">current research</a>. </p>
<p>What’s more controversial is <a href="http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=573">an appendix</a> for further research into <a href="http://www.dsm5.org/proposedrevision/pages/proposedrevision.aspx?rid=573">internet use disorder</a>. This is not an official verification of problem internet use as disordered, but it’s a clear indication that the category is likely to include more behavioural addictions in future. </p>
<p>The question of how useful this will be is yet to be determined. <a href="http://bjp.rcpsych.org/content/199/2/87.abstract">Some argue</a> this is a change long overdue; <a href="http://www.psychiatrictimes.com/blog/frances/content/article/10168/2097033">others worry</a> it opens the door to labelling normal interests and passions as mental disorders. </p>
<p>Determining when doing something a lot is doing it <em>too</em> much is at the core of defining addiction. And despite our best efforts, this line remains unclear.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/16930/original/dv4nnqsf-1351220489.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/16930/original/dv4nnqsf-1351220489.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16930/original/dv4nnqsf-1351220489.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16930/original/dv4nnqsf-1351220489.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16930/original/dv4nnqsf-1351220489.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16930/original/dv4nnqsf-1351220489.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16930/original/dv4nnqsf-1351220489.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">How much screen time is too much?</span>
<span class="attribution"><span class="source">Ed Yourdon</span></span>
</figcaption>
</figure>
<h2>Is the internet addictive?</h2>
<p>The DSM-5 has clearly identified a class of people seeking treatment for a level of internet use that causes distress or suffering to the point of incapacitation. Without denying the reality of that suffering, does this justify a discrete category in future revisions of the DSM for internet addiction?</p>
<p>As I’ve <a href="https://theconversation.com/videogame-addiction-fact-or-fantasy-6732">discussed previously on The Conversation</a>, problem gaming does not fit neatly into our existing understanding of addiction, despite the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719452/">growing amount of research</a> in the area. The scope of games and gamers alone makes it difficult to determine whether videogames could be considered a medium for addiction in any way similar to substances or gambling. </p>
<p>Add to this category the wide array of uses of the internet – everything from text messaging, social networking, porn and blogging – and we end up with a list of behaviours so diverse that research becomes necessarily complex and clinically confusing.</p>
<p>As US psychiatrist and academic <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719452/">Ronald Pies suggests in the journal Psychiatry</a>, given the state of current research, what is being called internet addiction is a diverse and inconsistent range of symptoms most likely with multiple causes. In <a href="http://link.springer.com/article/10.1007%2Fs11469-011-9318-5">many cases</a>, it’s unclear whether an individual’s apparent addiction is the cause of behaviour, or a symptom itself of another <a href="http://oxforddictionaries.com/definition/english/co-morbid">disorder</a>. </p>
<p>The question then becomes – is the internet inherently addictive, or is the medium through which disorder is presented to blame?</p>
<p>Granted, many of us feel that our use of the internet verges on problematic. I know when I check my email before getting out of bed, or social media sites while waiting for the lights to change I sometimes wonder if this is normal behaviour. But does this classify as addictive? <a href="http://www.psychiatrictimes.com/blog/frances/content/article/10168/2097033">Not really</a>, unless it begins to cause significant distress or impairment. </p>
<p>At worst, it could indicate a maladjustment to a world where the tools for communication and sharing have changed rapidly to become necessary instruments for daily life.</p>
<h2>A behaviour by any other name</h2>
<p>Without an open mind in further research, we run the risk of only finding what we’re looking for. If it’s assumed that the internet is akin to a substance in that it can cause an addiction, we will almost certainly find evidence for this assumption. </p>
<p>But if we’re open to the idea that the internet may only be the medium through which disorder or maladjustment is presented, we leave space for research that is more comprehensive and reflective of reality.</p>
<p><strong>This is the tenth and final part of our series <em><a href="https://theconversation.com/topics/matters-of-the-mind">Matters of the Mind</a></em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Explainer: what is the DSM and how are mental disorders diagnosed?</a></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">Forget talking, just fill a script: how modern psychiatry lost its mind</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/strange-or-just-plain-weird-cultural-variation-in-mental-illness-9679">Strange or just plain weird? Cultural variation in mental illness</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/dont-pull-your-hair-out-over-trichotillomania-10163">Don’t pull your hair out over trichotillomania</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/when-stuff-gets-in-the-way-of-life-hoarding-and-the-dsm-5-10074">When stuff gets in the way of life: hoarding and the DSM-5</a></p>
<p><strong>Part six:</strong> <a href="https://theconversation.com/psychiatric-labels-and-kids-benefits-side-effects-and-confusion-9702">Psychiatric labels and kids: benefits, side-effects and confusion</a></p>
<p><strong>Part seven:</strong> <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Redefining autism in the DSM-5</a></p>
<p><strong>Part eight:</strong> <a href="https://theconversation.com/depression-drugs-and-the-dsm-a-tale-of-self-interest-and-public-outrage-9912">Depression, drugs and the DSM: a tale of self-interest and public outrage</a></p>
<p><strong>Part nine:</strong> <a href="https://theconversation.com/why-prolonged-grief-should-be-listed-as-a-mental-disorder-4262">Why prolonged grief should be listed as a mental disorder</a></p><img src="https://counter.theconversation.com/content/10346/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dominic Murphy receives funding from the ARC.</span></em></p><p class="fine-print"><em><span>Gemma Lucy Smart does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. The term “addiction” is conspicuously…Gemma Lucy Smart, MSc Candidate in History and Philosophy of Science, University of SydneyDominic Murphy, Director, Unit for History and Philosophy of Science, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/99122012-10-25T19:29:05Z2012-10-25T19:29:05ZDepression, drugs and the DSM: a tale of self-interest and public outrage<figure><img src="https://images.theconversation.com/files/16700/original/dshp5t4t-1350601474.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The cosy relationship between the psychiatry and Big Pharma has come under increasing scrutiny.</span> <span class="attribution"><span class="source">Hannah Nicole Aspire</span></span></figcaption></figure><p><em>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em></p>
<hr>
<p>In Australia, antidepressant medications <a href="http://www.aihw.gov.au/publication-detail/?id=10737422172">account for</a> 61% (13.7 million) of all mental health-related subsidised prescriptions, followed by anxiety-reducing medicines. <a href="http://www.aihw.gov.au/publication-detail/?id=10737422172">One in five Australians</a> aged 16 to 85 are afflicted by either a mood, anxiety or substance-use disorder. </p>
<p>We now know that depression <a href="http://theconversation.com/depression-can-break-your-heart-literally-1102">is not just a disorder of the mind</a>; it also increases risk for a host of conditions and diseases, and mortality. Hence the need for effective treatments.</p>
<p>The <a href="http://www.psych.org/practice/dsm">Diagnostic and Statistical Manual of Mental Disorders</a> (DSM) is the manual clinicians use to determine mental health diagnoses and whether medication should be prescribed. The preparation for and development of the latest edition, the <a href="http://www.dsm5.org/">DSM-5</a>, has generated an extraordinary amount of public and media debate. </p>
<p>Criticism of the DSM-5 is also coming from within the profession of psychiatry itself. An outspoken critic of the DSM-V is Allen Francis, a psychiatrist and chair of the task force that produced the DSM-IV in 1994. He has <a href="http://www.nytimes.com/2012/05/12/opinion/break-up-the-psychiatric-monopoly.html?_r=1">warned</a> that if the DSM is published unamended, it will lead to medicalisation of normal human emotions. Francis <a href="http://www.psychologytoday.com/blog/dsm5-in-distress/201206/my-debate-the-dsm-5-chair">argues</a> that the DSM-5 changes will raise the prevalence of mood and anxiety disorders. </p>
<p>Specific concerns over the proposed changes to the DSM-5 criteria of these disorders relate to <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1201794">removing the bereavement exclusion</a> to major depressive disorder and <a href="http://blog.oup.com/2012/03/dsm-5-proposals-for-generalized-anxiety-disorder/">lowering thresholds</a> for generalised anxiety disorder. </p>
<p>The idea that depression is a disease has already opened up huge opportunities for the pharmaceutical industry, argues Gary Greenberg, psychotherapist and author of <a href="http://www.garygreenbergonline.com/pages/currentbook.php">Manufacturing Depression</a>. People are now asking themselves whether their unhappiness is a disease that can be treated by medication. Given the ease with which antidepressants are <a href="http://content.healthaffairs.org/content/30/8/1434.abstract">prescribed</a>, this is a problem. Further lowering the criteria by which we are diagnosed with these disorders may serve to further perpetuate this problem.</p>
<p>Daniel Carlat, psychiatrist and author of <a href="http://www.danielcarlat.com/dcarlat-unhinged-overview.htm">Unhinged</a>, however, has criticised the discipline for embracing medication-based treatment when there is no evidence to support the idea that depression is caused by a “neurochemical imbalance”.</p>
<p>But our understanding of the biological basis of depression has come a long way since the “neurochemical imbalance” was first proposed in 1965. While the immediate effects of antidepressants are to increase the availability of serotonin and norepinephrine in the brain’s synapse, the patent’s symptoms may not improve until three to four weeks of treatment. Clearly, then, depression is a little more complicated than a “neurochemical imbalance”. </p>
<p>The biological basis of depression is now understood to be underpinned by a complex interplay between life stress, genetics and brain function.</p>
<p>Unfortunately, the unfounded belief that depression is caused by too little of a certain neurotransmitter is alive and well. <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020392">Direct-to-consumer campaigns</a> have largely revolved around the claim that the selective serotonin reuptake inhibitors (antidepressants known as SSRIs) correct a chemical imbalance caused by a lack of serotonin. </p>
<p>In this regard, psychiatrist, psychopharmacologist, scientist and author <a href="http://davidhealy.org/">David Healy</a> argues in <a href="http://www.amazon.com/dp/0674039580/ref=as_li_tf_til?tag=davhea-20&camp=14573&creative=327641&linkCode=as1&creativeASIN=0674039580&adid=17VCRGHF8KCH8E5821N9&&ref-refURL=http%3A%2F%2Fdavidhealy.org%2Fbooks%2F">The Antidepressant Era</a> that pharmaceutical companies are as much in the business of selling the “depression” diagnosis as they are in selling antidepressants.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/16729/original/ttkk5268-1350623596.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/16729/original/ttkk5268-1350623596.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16729/original/ttkk5268-1350623596.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16729/original/ttkk5268-1350623596.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16729/original/ttkk5268-1350623596.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16729/original/ttkk5268-1350623596.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16729/original/ttkk5268-1350623596.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Depression isn’t just a disorder of the mind, it also increases risk for a host of other conditions.</span>
<span class="attribution"><span class="source">Kalexanderson</span></span>
</figcaption>
</figure>
<p>So what are some of the possible consequences of treating the “worried well” with antidepressants?</p>
<p>While some have labelled antidepressant medications as “<a href="http://blogs.scientificamerican.com/cross-check/2011/07/12/are-antidepressants-just-placebos-with-side-effects/">placebos with side effects</a>”, the possibility that pharmacological treatments may have adverse long-term consequences has attracted increasing attention.</p>
<p>Take the disturbing documentary, <a href="http://www.numbdocumentary.com/">Numb</a>. This doco features a successful suburban dad who comes to the conclusion that his emotions have become blunted over the years. He decides to stop taking his medication after long-term use… with rather disturbing consequences. (He is alive today, but remains on antidepressants.)</p>
<p>But doesn’t this just indicate that some depressions require long-term treatment with antidepressant medication?</p>
<p>This is certainly the consensus amongst clinicians. However, Robert Whitaker - a journalist and author of <a href="http://www.madinamerica.com/2011/11/anatomy-of-an-epidemic/">Anatomy of an Epidemic</a> - claims that long-term use of psychiatric drugs may actually contribute to the very conditions they are prescribed to treat.</p>
<p>An important counter-point to this rather heretical claim is that [correlation does not imply causation](<a href="http://carlatpsychiatry.blogspot.com.au/2011/01/robert-whitakers-anatomy-of-epidemic.html">http://carlatpsychiatry.blogspot.com.au/2011/01/robert-whitakers-anatomy-of-epidemic.html</a>. Just because certain events – such as increasing prescription of SSRI antidepressants and the increase in psychiatric disability – appear to be related in time, one event does not necessarily <em>cause</em> the other.</p>
<p>Indeed, <a href="http://carlatpsychiatry.blogspot.com.au/2011/01/robert-whitakers-anatomy-of-epidemic.html">Carlat</a> attributes increased psychiatric disability to three major factors: </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/16731/original/3qwz2pmt-1350624004.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/16731/original/3qwz2pmt-1350624004.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16731/original/3qwz2pmt-1350624004.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16731/original/3qwz2pmt-1350624004.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16731/original/3qwz2pmt-1350624004.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16731/original/3qwz2pmt-1350624004.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16731/original/3qwz2pmt-1350624004.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Our understanding of the biological basis of depression has come a long way since the ‘neurochemical’ imbalance was first proposed.</span>
<span class="attribution"><span class="source">Carlos Smith</span></span>
</figcaption>
</figure>
<ol>
<li><p>The number of official DSM diagnoses has increased from 130 (in the first version of the DSM) to 886 (in the DSM-IV-TR, the current version). </p></li>
<li><p>There are more treatments available to clinicians, motivating them to look for newly treatable diseases.</p></li>
<li><p>Expansion of social security schemes to include psychiatric disorders such as ADHD and PTSD that are difficult to diagnose and easily faked. </p></li>
</ol>
<p>But the road to DSM-5 has been a little murkier than simply concerns over the boundary between normal sadness and clinical depression. It involves tales of <a href="http://www.forbes.com/sites/paulthacker/2011/09/13/how-an-ethically-challenged-researcher-found-a-home-at-the-university-of-miami/">scandal</a> and <a href="http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001190">conflicts of interest</a>.</p>
<p>The cosy relationship between the psychiatry and Big Pharma has come under increasing scrutiny, as have undisclosed financial dealings, commercialisation of “science” and ghostwriting.</p>
<p>David Healy argues in his recent book, <a href="http://davidhealy.org/books/pharmageddon-is-the-story-of-a-tragedy/">Pharmageddon</a>, that far from making drugs safer, clinical trials actually conceal risk; a consequence of private companies running clinical trials and the publication of ghost-written articles in leading peer-reviewed journals.</p>
<p>Here lies our primary reason for writing the present article: the research community is crying out for increased government funding allowing us to carry out unbiased research. Let’s not throw the baby out with the bath water – we need the pharmaceutical industry – but we also urgently need more government support for high-quality research to better understand depression and its treatment.</p>
<p><strong>This is the eighth part of our series <em><a href="https://theconversation.com/topics/matters-of-the-mind">Matters of the Mind</a></em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Explainer: what is the DSM and how are mental disorders diagnosed?</a></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">Forget talking, just fill a script: how modern psychiatry lost its mind</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/strange-or-just-plain-weird-cultural-variation-in-mental-illness-9679">Strange or just plain weird? Cultural variation in mental illness</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/dont-pull-your-hair-out-over-trichotillomania-10163">Don’t pull your hair out over trichotillomania</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/when-stuff-gets-in-the-way-of-life-hoarding-and-the-dsm-5-10074">When stuff gets in the way of life: hoarding and the DSM-5</a></p>
<p><strong>Part six:</strong> <a href="https://theconversation.com/psychiatric-labels-and-kids-benefits-side-effects-and-confusion-9702">Psychiatric labels and kids: benefits, side-effects and confusion</a></p>
<p><strong>Part seven:</strong> <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Redefining autism in the DSM-5</a></p>
<p><strong>Part nine:</strong> <a href="https://theconversation.com/why-prolonged-grief-should-be-listed-as-a-mental-disorder-4262">Why prolonged grief should be listed as a mental disorder</a></p>
<p><strong>Part ten:</strong> <a href="https://theconversation.com/internet-use-and-the-dsm-5s-revival-of-addiction-10346">Internet use and the DSM-5’s revival of addiction</a></p><img src="https://counter.theconversation.com/content/9912/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Kemp receives funding from the National Health & Medical Research Council and the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Andre Brunoni does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. In Australia, antidepressant…Andrew H Kemp, Associate Professor, University of SydneyAndre Brunoni, Psychiatrist and researcher, Universidade de São Paulo (USP)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/42622012-10-25T19:27:03Z2012-10-25T19:27:03ZWhy prolonged grief should be listed as a mental disorder<figure><img src="https://images.theconversation.com/files/16810/original/8pr3ry4y-1350964899.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's normal to have recurring waves of grief after the loss of a loved one but prolonged, severe grief requires treatment.</span> <span class="attribution"><span class="source">white ribbons</span></span></figcaption></figure><p><em>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em></p>
<hr>
<p>Grief is one of the most universal and distressing experiences that humans suffer. </p>
<p>For most people, the emotional pain of losing someone close to them lasts for a relatively brief period. Many <a href="http://www.ncbi.nlm.nih.gov/pubmed/21284063">studies indicate</a> that by six months after bereavement, most people begin to experience remission of the severe grief response. Waves of grief may come and go for months or years afterwards but these reactions don’t impair or limit a person’s capacity to engage in life’s activities.</p>
<p>In contrast, a proportion of bereaved people (approximately 10% to 15%) suffer persistent grief that can last for many years. Many <a href="http://www.plosmedicine.org/article/metrics/info%3Adoi%2F10.1371%2Fjournal.pmed.1000121">studies</a> from different countries and cultural settings have documented that severe yearning for the deceased that persists beyond six months is associated with marked impairment and difficulty in engaging with people and in activities. </p>
<p>This is why the DSM-5 has proposed a new diagnosis to represent this condition, known as <a href="http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=367">adjustment disorder related to bereavement</a>. The persistent yearning can be associated with difficulty accepting the death, feelings of loss of a part of oneself, anger about the loss, guilt or blame over the death, or difficulty in engaging with new social or other activities due to the loss. To meet diagnostic criteria, the symptoms must persist beyond six months after the death and affect the person’s ability to function in day-to-day life. </p>
<p>The World Health Organization’s proposed <a href="http://www.who.int/classifications/icd/revision/en/index.html">International Classification of Diseases 11th Revision</a> (ICD-11) also includes a new diagnosis, termed prolonged grief disorder, which is defined similarly.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/16819/original/x4338sfw-1350970203.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/16819/original/x4338sfw-1350970203.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16819/original/x4338sfw-1350970203.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16819/original/x4338sfw-1350970203.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16819/original/x4338sfw-1350970203.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16819/original/x4338sfw-1350970203.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16819/original/x4338sfw-1350970203.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Around 10% to 15% of bereaved people suffer persistent grief that may last for years.</span>
<span class="attribution"><span class="source">NicoleAbalde</span></span>
</figcaption>
</figure>
<p>There has been enormous and emotive debate over the extent to which prolonged grief should be recognised as a mental disorder. </p>
<p>Traditionally, the DSM has <a href="http://allpsych.com/disorders/dsm.html">precluded grief</a> as a diagnostic disorder on the basis that it “an expectable and culturally sanctioned response to a particular event”. Supporting this line, opponents of the new diagnosis argue that grief is: </p>
<ul>
<li>a ubiquitous condition insofar as death and loss is part of being human, and so emotional pain that is felt following bereavement should not be medicalised</li>
<li>managed differently across cultures and so a single diagnostic system cannot apply to all cultures</li>
<li>unlike most other psychological responses in that it is closely interwoven into religious practices </li>
<li>adequately described by existing anxiety and depression reactions so there’s no need to identify it as a distinct construct.</li>
</ul>
<p>Supporting the introduction of the new diagnosis is compelling data that counters these criticisms. First, <a href="http://www.ncbi.nlm.nih.gov/pubmed/20189657">factor analytic studies</a> demonstrate that the key feature of the grief response (yearning for the deceased) is distinct from anxiety and depression, and they contribute uniquely to the impairment suffered by these individuals. </p>
<p>Second, the 10% to 15% of bereaved people who suffer persistent severe grief reactions experience marked psychological, social, health, or occupational impairment. This can include other psychological problems (such as depression, suicidality, substance abuse), poor health behaviours (increased tobacco use), medical disorders (high blood pressure, elevated cancer rates, increased cardiovascular disorder), and functional disability. </p>
<p>Third, prolonged grief has been shown across a wide range of cultures, including non-western settings, as well as across the lifespan. </p>
<p>Fourth, and importantly, whereas bereavement-related depression responds to antidepressants, grief reactions do not. In contrast, treatments specifically targeted towards the core symptoms of prolonged grief are effective in alleviating the condition, and more effective than treatments that target depression. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/16820/original/xd7d4cb8-1350970723.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/16820/original/xd7d4cb8-1350970723.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=904&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16820/original/xd7d4cb8-1350970723.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=904&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16820/original/xd7d4cb8-1350970723.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=904&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16820/original/xd7d4cb8-1350970723.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1135&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16820/original/xd7d4cb8-1350970723.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1135&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16820/original/xd7d4cb8-1350970723.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1135&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A specific diagnosis of prolonged grief means sufferers can get timely access to the right treatment.</span>
<span class="attribution"><span class="source">sparktography</span></span>
</figcaption>
</figure>
<p>A major issue influencing the introduction of the new diagnosis is the requirement to identify bereaved people in need of appropriate mental health care and to ensure they receive appropriate treatment. </p>
<p>Studies have <a href="http://bjp.rcpsych.org/content/201/1/9">repeatedly shown</a> that leaving this condition untreated will result in the affected people suffering marked psychological, medical, and social problems. On the premise that up to 15% of bereaved people experience complicated grief, there are over 70,000 new cases of prolonged grief in the United States each year, representing a very significant public health issue. </p>
<p>A common concern is that many people presenting to health providers with grief are misdiagnosed with depression, and prescribed antidepressants. The <a href="http://jama.jamanetwork.com/article.aspx?articleid=200995">available evidence</a> indicates this will not assist recovery from prolonged grief. </p>
<p>Several <a href="http://jama.jamanetwork.com/article.aspx?articleid=200995">studies</a> have shown that <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Cognitive_behaviour_therapy">cognitive behaviour therapy</a> (CBT) is an effective intervention for prolonged grief. Cognitive behaviour therapy is a talking therapy that typically gets the person to focus on memories of the death and the relationship in a structured way. They learn more adaptive ways of appraising the loss and their relationship with the deceased, and then develop strategies for re-engaging with other people and activities. </p>
<p>Although CBT does not alleviate all prolonged grief cases, it is the best treatment we currently have available.</p>
<p>The concerns about potentially medicalising grief reactions and over-diagnosis are justified, however the proposed criteria have sufficient safe-guards built in. By limiting the diagnosis to persistent severe reactions that extend beyond 12 months after the bereavement, only a minority of bereaved people will receive this new diagnosis.</p>
<p>Hopefully, people suffering this potentially debilitating condition will now be able to receive the right treatment to allow them to move on with their life. </p>
<p><strong>This is the ninth part of our series <em><a href="https://theconversation.com/topics/matters-of-the-mind">Matters of the Mind</a></em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Explainer: what is the DSM and how are mental disorders diagnosed?</a></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">Forget talking, just fill a script: how modern psychiatry lost its mind</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/strange-or-just-plain-weird-cultural-variation-in-mental-illness-9679">Strange or just plain weird? Cultural variation in mental illness</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/dont-pull-your-hair-out-over-trichotillomania-10163">Don’t pull your hair out over trichotillomania</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/when-stuff-gets-in-the-way-of-life-hoarding-and-the-dsm-5-10074">When stuff gets in the way of life: hoarding and the DSM-5</a></p>
<p><strong>Part six:</strong> <a href="https://theconversation.com/psychiatric-labels-and-kids-benefits-side-effects-and-confusion-9702">Psychiatric labels and kids: benefits, side-effects and confusion</a></p>
<p><strong>Part seven:</strong> <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Redefining autism in the DSM-5</a></p>
<p><strong>Part eight:</strong> <a href="https://theconversation.com/depression-drugs-and-the-dsm-a-tale-of-self-interest-and-public-outrage-9912">Depression, drugs and the DSM: a tale of self-interest and public outrage</a></p>
<p><strong>Part ten::</strong> <a href="https://theconversation.com/internet-use-and-the-dsm-5s-revival-of-addiction-10346">Internet use and the DSM-5’s revival of addiction</a></p><img src="https://counter.theconversation.com/content/4262/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Bryant serves on the DSM-5 PTSD/Trauma/Dissociative Work Group and the ICD-11 WOrk Group for Traumatic Stress Disorder. These comments reflect the opinions of the author and not necessarily those of the DSM-5 or ICD-11 Work Groups.</span></em></p>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. Grief is one of the most universal…Richard Bryant, Professor & Director of Traumatic Stress Clinic, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/97022012-10-24T19:34:47Z2012-10-24T19:34:47ZPsychiatric labels and kids: benefits, side-effects and confusion<figure><img src="https://images.theconversation.com/files/16574/original/bwpvfhyb-1350359143.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As an adolescent and child psychiatrist, I dispense all sorts of labels – but what do they mean?</span> <span class="attribution"><span class="source">emildom</span></span></figcaption></figure><p><em>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em></p>
<hr>
<p>As a child and adolescent psychiatrist my daily work involves diagnosing children and young people with various mental disorders. There are diagnostic manuals to guide me: the <a href="http://www.psychiatry.org/practice/dsm/dsm-iv-tr">Diagnostic and Statistical Manual of Mental Disorders</a> (DSM-IV) and the mental disorders section of the the <a href="http://www.who.int/classifications/icd/en/">International Classification of Diseases of the World Health Organisation, 10th Edition</a> (ICD-10).</p>
<p>These manuals give algorithms and criteria by which diagnoses can be made. Since its <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">third edition</a> in 1980, the DSM has mostly followed the “medical model” of diagnosing by checking off lists of symptoms with little reference to past or present life stressors or the person’s coping or personality style. And ICD-10 followed the same post-DSM-III model.</p>
<p>Thus I dispense labels such as <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Attention_deficit_hyperactivity_disorder">ADHD</a> (attention-deficit hyperactivity disorder) for mainly boys with hyperactive or inattentive behaviour; if they’re particularly naughty they get the label <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Oppositional_defiant_disorder">ODD</a> (oppositional defiant disorder) and if they’re being seriously nasty then <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Conduct_disorder">CD</a> (conduct disorder). </p>
<p>With troubled teenagers who are down in the dumps with disturbances of appetite, sleep, loss of interest in life then <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/781C84612938D1CDCA25727D0014932D/$File/whatdep.pdf">MDD</a> (major depressive disorder) or if it’s less severe, <a href="http://www.health.harvard.edu/newsweek/Dysthymia.htm">dysthymia</a> may apply. </p>
<p>Nervous children may get a number of overlapping anxiety labels – <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Obsessive_compulsive_disorder_explained">OCD</a> (obsessive compulsive disorder), <a href="http://www.nimh.nih.gov/health/publications/panic-disorder-when-fear-overwhelms/what-is-panic-disorder.shtml">panic disorder</a>, <a href="http://www.anxietyonline.org.au/anxiety-disorder-types/generalised-anxiety-disorder">GAD</a> (generalised anxiety disorder), social phobia, separation anxiety disorder, or a number of other labels. </p>
<p>Some disorders such as <a href="http://thebutterflyfoundation.org.au/Uploaded_Files/CMS_Image/file/Anorexia%20Nervosa%20Fact%20Sheet(1).pdf">anorexia nervosa</a> or <a href="http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001924/">bipolar I disorder</a> (once called manic-depressive psychosis) define more discrete and serious mental illness. But others such as <a href="http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml">bipolar II disorder</a> (with milder manic symptoms), and all the NOS (not otherwise specified) disorders can blur with other labels. </p>
<p>Although <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960532-6/fulltext">schizophrenia</a> is a very serious illness, transient psychotic symptoms are very common, even among the so-called normal young people who are under significant stress and of course under the influence of drugs.</p>
<p>Every few years an epidemic sweeps the nation’s schoolyards. In the mid-1990s it was ADHD; a few years ago an American epidemic of so-called <a href="http://www.tandfonline.com/doi/pdf/10.1080/15299732.2011.597826">PBD</a> (pediatric bipolar disorder) touched a few here. Since then it seems a plague of <a href="http://raisingchildren.net.au/articles/aspergers_disorder_signs_and_symptoms.html">Asperger’s disorder</a> or <a href="http://www.cddh.monash.org/assets/fs-autism.pdf">ASD</a> (autistic spectrum disorder) has struck many. </p>
<p>The DSM-5, due out next year, is likely to unleash a <a href="http://dsm5-reform.com/the-open-letter-to-dsm-5-task-force/">new epidemic</a> – <a href="http://www.dsm5.org/proposedrevision/pages/proposedrevision.aspx?rid=397#">DMDD</a> (disruptive mood dysregulation disorder), which has been <a href="http://www.psychologytoday.com/blog/dsm5-in-distress/201110/should-temper-tantrums-be-made-dsm-5-diagnosis">strongly criticised</a> by the former DSM-IV task force head <a href="http://www.psychologytoday.com/blog/dsm5-in-distress">Professor Allen Frances</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/16566/original/cyd3tfct-1350357007.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/16566/original/cyd3tfct-1350357007.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16566/original/cyd3tfct-1350357007.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16566/original/cyd3tfct-1350357007.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16566/original/cyd3tfct-1350357007.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16566/original/cyd3tfct-1350357007.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16566/original/cyd3tfct-1350357007.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Child psychiatry is not a cookbook discipline of simplistic labels with drugs ready for each label.</span>
<span class="attribution"><span class="source">theloushe</span></span>
</figcaption>
</figure>
<p>The question is what do the labels mean? They are rarely complete explanations in themselves; they label surface symptoms but not underlying causes. </p>
<p>Labels are useful in research where simplification is necessary. In clinical practice they sometimes are useful too, but almost as often they can distract or obscure the real issues rather than point to the right treatment options.</p>
<p>In psychiatric training, we learn that what really counts is a <a href="http://en.wikipedia.org/wiki/Biopsychosocial_model">biopsychosocial</a> (biological, psychological and social) formulation. This is a few paragraphs which accompanies the diagnosis, summarising the main relationships, genetic inheritance, stressful events, temperament and psychological coping style of the person. The biopsychosocial formulation seeks to uncover and put in perspective all the causes of their symptoms and point to what help is needed, even if not readily available.</p>
<p>Child psychiatry is not a cookbook discipline of simplistic labels with drugs ready for each label on some shelf. At worst, DSM labels totally obscure the real underlying causes by making everyone think they have an answer. University of Adelaide psychiatry professor <a href="https://theconversation.com/profiles/jon-jureidini-1609">Jon Jureidini</a> has referred to such use of diagnostic labels to explain people’s predicaments as “<a href="https://theconversation.com/time-to-go-back-to-the-drawing-board-on-mental-health-reform-5041">unexplanations</a>”. </p>
<p>This sentiment has been echoed elsewhere in the profession. In an <a href="http://informahealthcare.com/doi/abs/10.1080/j.1440-1665.2006.02241.x">address</a> to the Royal Australian and New Zealand College of Psychiatrists, University of Sydney Professor of Psychiatry <a href="https://theconversation.com/profiles/philip-boyce-1146">Philip Boyce</a> commented:</p>
<blockquote>
<p>“The current paradigm seems to be that if a patient suffers from a specific DSM disorder, then there is a specific medication for this. If that medication does not work, try some other medication… a number of trends have contributed to this: increased service demand, the deification of DSM, the influence of the pharmaceutical industry, a misunderstanding of evidence-based medicine (EBM), managerialism and the influence of consumerism. … The (simplistic) DSM approach is exemplified by …treating DSM disorders rather than individuals.”</p>
</blockquote>
<p>Oxford Professor <a href="http://sociology.ucsd.edu/faculty/bio/scull.shtml">Andrew Scull</a> summed the issue up in a <a>Lancet article</a> where he described the DSM-III as “an anti-intellectual system published in book form: a check-list approach to psychiatric diagnosis and treatment” by which “Patients and their families learned to attribute mental illness to faulty brain biochemistry”.</p>
<p>To be fair, three DSM diagnoses do relate to stress and trauma: </p>
<ul>
<li><a href="http://www.mayoclinic.com/health/reactive-attachment-disorder/DS00988">RAD</a> (reactive attachment disorder) in young children due to highly disturbed relationships with their primary caregivers;</li>
<li>PTSD (post-traumatic stress disorder) but criteria are restricted to mainly life threatening events; and </li>
<li>Adjustment disorder, where someone has more trouble than usual coping with a serious stress. </li>
</ul>
<p>But stress weaves in through everyone’s life. In particular, complex childhood trauma and long-term outcomes of attachment problems are <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1601-5215.2010.00478.x/abstract;jsessionid=03A07A008355A88D7337D13DC78FE1F7.d02t04">under-represented</a> in the DSM.</p>
<p>One remedy would be the inclusion of <a href="http://www.traumacenter.org/products/pdf_files/preprint_dev_trauma_disorder.pdf">DTD</a> (developmental trauma disorder) into the DSM-5. But DTD seems to have lacked sufficient support in the APA’s DSM-5 committee. Most child psychiatrists find this a grave pity as DTD would add increased focus on the ongoing need for good child protection services.</p>
<p>In the end I’m glad my daily work involves broader, deeper and more commonsense thinking than simply dispensing <a href="http://www.clinicalpsychiatrynews.com/index.php?id=2407&cHash=071010&tx_ttnews%5Btt_news%5D=95430">diagnostic labels</a>. </p>
<p>Taking the time to engage with young people, their families, and sometimes school counsellors and others, to explore and understand all the interacting causes and meanings of the troubling symptoms is rewarding. And it’s often successful, as natural healing mechanisms are unleashed when real causes are addressed.</p>
<p><strong>This is the sixth part of our series <em><a href="https://theconversation.com/topics/matters-of-the-mind">Matters of the Mind</a></em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Explainer: what is the DSM and how are mental disorders diagnosed?</a></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">Forget talking, just fill a script: how modern psychiatry lost its mind</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/strange-or-just-plain-weird-cultural-variation-in-mental-illness-9679">Strange or just plain weird? Cultural variation in mental illness</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/dont-pull-your-hair-out-over-trichotillomania-10163">Don’t pull your hair out over trichotillomania</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/when-stuff-gets-in-the-way-of-life-hoarding-and-the-dsm-5-10074">When stuff gets in the way of life: hoarding and the DSM-5</a></p>
<p><strong>Part seven:</strong> <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Redefining autism in the DSM-5</a></p>
<p><strong>Part eight:</strong> <a href="https://theconversation.com/depression-drugs-and-the-dsm-a-tale-of-self-interest-and-public-outrage-9912">Depression, drugs and the DSM: a tale of self-interest and public outrage</a></p>
<p><strong>Part nine:</strong> <a>Why prolonged grief should be listed as a mental disorder</a>)</p>
<p><strong>Part ten:</strong> <a href="https://theconversation.com/internet-use-and-the-dsm-5s-revival-of-addiction-10346">Internet use and the DSM-5’s revival of addiction</a></p><img src="https://counter.theconversation.com/content/9702/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Parry is affiliated with Healthy Scepticism <a href="http://www.healthyscepticism.org">www.healthyscepticism.org</a> .</span></em></p>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. As a child and adolescent psychiatrist…Peter Parry, Child and adolescent psychiatrist & senior lecturer, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/63852012-10-24T19:34:35Z2012-10-24T19:34:35ZRedefining autism in the DSM-5<figure><img src="https://images.theconversation.com/files/16680/original/tj5cmhdm-1350533985.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Overall, there will be fewer symptoms and disorders listed in the new psychiatry manual.</span> <span class="attribution"><span class="source">Axel Buhrmann</span></span></figcaption></figure><p><em>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em></p>
<hr>
<p>For autistic people and their families, getting an autism diagnosis is just the first step in a long struggle to access much-needed intervention, support, and appropriate education.</p>
<p>In Australia, as in many countries, autism diagnoses are made according to criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The latest update to the manual, the [DSM-5](<a href="http://www.dsm5.org/Pages/Default.aspx">http://www.dsm5.org/Pages/Default.aspx</a>, is due for publication in May 2013 and will bring <a href="http://www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=94">significant changes</a> to the definition and diagnosis of autism.</p>
<p>These changes reflect a continually <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2012.02587.x/full">evolving understanding</a> of autism, as well as a desire to make autism diagnosis simpler and more reliable. </p>
<p>But the DSM-5 remains highly controversial. In a recent letter to the Journal of Autism and Developmental Disorders, a group of 30 autism researchers called for the changes to be <a href="http://www.usautism.org/content/PDF_files_newsletters/080612_newsletter_postponing_DSM5.pdf">postponed</a> until their real world implications are better understood.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/KeCQXuWKD8A?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">An overview of DSM 5 changes to autism diagnosis from Dr Giacomo Vivanti.</span></figcaption>
</figure>
<h2>DSM-IV</h2>
<p>The current edition of the diagnostic rules, the DSM-IV, has been in force since 1994 and is certainly ripe for an overhaul.</p>
<p>Under the DSM-IV, autism diagnosis involves a complex and confusing “<a href="http://crackingtheenigma.blogspot.com.au/2011/02/exactly-how-many-ways-are-there-to-get.html">pick'n'mix</a>” process. The manual describes 12 autistic “symptoms” divided into three broad categories: social interaction, communication, and repetitive and restricted behaviours. Depending on the particular combination of symptoms present, a person may be given a diagnosis of autistic disorder, <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Asperger's_syndrome">Asperger’s disorder</a>, or <a href="http://childstudycenter.yale.edu/autism/information/pddnos.aspx">PDD-NOS</a> (pervasive developmental disorder not otherwise specified).</p>
<p>But these diagnoses are not applied consistently in clinical practice. A <a href="http://archpsyc.ama-assn.org/cgi/content/abstract/archgenpsychiatry.2011.148">recent study</a> found that the clinic where a child goes to be diagnosed is one of the best predictors of the diagnosis they ultimately receive.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/16675/original/sh4brg5s-1350533568.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/16675/original/sh4brg5s-1350533568.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16675/original/sh4brg5s-1350533568.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16675/original/sh4brg5s-1350533568.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16675/original/sh4brg5s-1350533568.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16675/original/sh4brg5s-1350533568.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16675/original/sh4brg5s-1350533568.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Three different clincians can give three different autism-related diagnoses to the same child.</span>
<span class="attribution"><span class="source">Flickr/esti</span></span>
</figcaption>
</figure>
<h2>DSM-5</h2>
<p>The DSM-5 brings two major simplifications: the three diagnoses will be rolled into a <a href="http://sfari.org/news-and-opinion/viewpoint/2011/why-fold-asperger-syndrome-into-autism-spectrum-disorder-in-the-dsm-5">single diagnosis</a>, <a href="http://www.dsm5.org/proposedrevision/pages/proposedrevision.aspx?rid=94">autism spectrum disorder</a>; and social and communication difficulties will be merged into a single category.</p>
<p>Most researchers agree the changes <a href="https://theconversation.com/dsm-v-and-the-changing-fortunes-of-autism-and-related-disorders-5071">make sense</a>, at least in theory. But there are genuine concerns that some people, particularly those with Asperger’s or PDD-NOS, may miss out on a diagnosis - and access to the support they need.</p>
<p>In a 2011 [study](<a href="http://crackingtheenigma.blogspot.com.au/2011/05/what-is-pdd-nos.html">http://crackingtheenigma.blogspot.com.au/2011/05/what-is-pdd-nos.html</a>, Will Mandy and colleagues at University College London identified a subgroup of children who experience serious social and communication difficulties but don’t show repetitive or restricted behaviours. Under the DSM-IV, they qualify for a diagnosis of PDD-NOS. Under the DSM-5, they would probably miss out. They might qualify for a new diagnosis, <a href="http://crackingtheenigma.blogspot.com.au/2011/06/social-communication-disorder-new.html">social communication disorder</a>, but there are currently no guarantees that assistance will be available for people with this diagnosis.</p>
<h2>Effects of the DSM-5 on autism rates</h2>
<p>These fears appeared to be confirmed by a <a href="http://crackingtheenigma.blogspot.com.au/2012/03/how-will-dsm-5-affect-autism-rates-yale.html">study</a> published earlier this year by James McPartland and colleagues at Yale University. By recoding data collected during the development of the DSM-IV, they determined that many kids diagnosed with Asperger’s or PDD-NOS would <em>not</em> meet the new DSM-5 criteria. </p>
<p>However, the Yale study’s recoding is problematic because the items in the new DSM-5 criteria don’t neatly map onto the questions that were asked during development of the DSM-IV.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/1J3iHCkpj4I?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A/Prof James McPartland discusses autism prevalence, what’s known about causes and changes to the DSM.</span></figcaption>
</figure>
<p>More recently, a <a href="http://www.forbes.com/sites/emilywillingham/2012/10/11/new-dsm-5-criteria-for-autism-who-will-be-left-behind/">paper published</a> by Marisela Huerta and colleagues at Cornell University reached very different conclusions. The Cornell group recoded information from two “gold standard” diagnostic tools and, in contrast to the Yale study, found that 96% of children originally diagnosed with Asperger’s or PDD-NOS would meet DSM-5 criteria for autism spectrum disorder. </p>
<p>But again there are <a href="http://crackingtheenigma.blogspot.com.au/2012/10/more-dsm-5-confusion.html">concerns</a>. The same recoding process also gave the majority of non-autistic children an autism spectrum disorder diagnosis. </p>
<p>Perhaps the clearest evidence to date comes from a relatively small <a href="http://www.ncbi.nlm.nih.gov/pubmed/22677932">study</a>, conducted by Vicki Gibbs and colleagues at <a href="http://www.autismspectrum.org.au/a2i1i1l445l487/welcome.htm">Autism Spectrum Australia</a>. Rather than recoding old data, they used DSM-IV and DSM-5 criteria to assess 132 children referred to their diagnostic team. Thirty-four of the children received a DSM-IV diagnosis of PDD-NOS, but only half of these met criteria for Autism Spectrum Disorder in the DSM-5.</p>
<h2>DSM 5.x</h2>
<p>Clearly, the issues surrounding autism and the DSM-5 are far from settled. Official “[field trials](http://dsmfacts.org/issue-accuracy/wall-street-journal-gets-it-right/](http://dsmfacts.org/issue-accuracy/wall-street-journal-gets-it-right/)” of the DSM-5 are currently underway. However, the true consequences may not become apparent until after the manual comes into force. A welcome change from previous editions is that DSM-5 will be regularly updated, so we can look forward to bug-fixes in DSM-5.1.</p>
<p>And despite all the fuss, it’s possible that nothing much will change. As a number of practising clinicians have told me, their main objective is to address the person’s needs. Diagnosis is a means to an end and the proposed changes still allow a lot of <a href="http://crackingtheenigma.blogspot.com.au/2012/03/how-will-dsm-5-affect-autism-rates-yale.html?showComment=1333077020032#c7830367770598328532">flexibility in interpretation</a>.</p>
<p>More than anything, the DSM-5 debate highlights the subjective and somewhat arbitrary nature of autism diagnosis and definitions. In a revealing <a href="http://www.jaacap.com/article/S0890-8567(12)00101-3/abstract">commentary</a>, the DSM-5 <a href="http://www.dsm5.org/meetus/pages/neurodevelopmental%20disorders.aspx">neurodevelopmental disorders work</a> group wrote of the need to evaluate DSM-5 against “the true gold standard of expert clinical diagnoses”. For now at least, autism diagnosis remains an art rather than a science.</p>
<p><strong>This is the seventh part of our series <em><a href="https://theconversation.com/topics/matters-of-the-mind">Matters of the Mind</a></em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Explainer: what is the DSM and how are mental disorders diagnosed?</a></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">Forget talking, just fill a script: how modern psychiatry lost its mind</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/strange-or-just-plain-weird-cultural-variation-in-mental-illness-9679">Strange or just plain weird? Cultural variation in mental illness</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/dont-pull-your-hair-out-over-trichotillomania-10163">Don’t pull your hair out over trichotillomania</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/when-stuff-gets-in-the-way-of-life-hoarding-and-the-dsm-5-10074">When stuff gets in the way of life: hoarding and the DSM-5</a></p>
<p><strong>Part six:</strong> <a href="https://theconversation.com/psychiatric-labels-and-kids-benefits-side-effects-and-confusion-9702">Psychiatric labels and kids: benefits, side-effects and confusion</a></p>
<p><strong>Part eight:</strong> <a href="https://theconversation.com/depression-drugs-and-the-dsm-a-tale-of-self-interest-and-public-outrage-9912">Depression, drugs and the DSM: a tale of self-interest and public outrage</a></p>
<p><strong>Part nine:</strong> <a>Why prolonged grief should be listed as a mental disorder</a>)</p>
<p><strong>Part ten:</strong> <a href="https://theconversation.com/internet-use-and-the-dsm-5s-revival-of-addiction-10346">Internet use and the DSM-5’s revival of addiction</a></p><img src="https://counter.theconversation.com/content/6385/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jon Brock receives funding from the Australian Research Council.</span></em></p>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. For autistic people and their…Jon Brock, ARC Australian Research Fellow in Cognitive Science, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/101632012-10-23T19:32:28Z2012-10-23T19:32:28ZDon’t pull your hair out over trichotillomania<figure><img src="https://images.theconversation.com/files/16793/original/psrp8zbh-1350954982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Trichotillomania, where individuals pull out their hair, has long been considered a mental disorder, but where does it fit in the DSM-5?</span> <span class="attribution"><span class="source">Tigresblanco</span></span></figcaption></figure><p><em>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em></p>
<hr>
<p>Trichotillomania is a psychological disorder where individuals feel the urge to remove their bodily hair, to the point of obvious hair loss. </p>
<p>While the general community remains largely unaware of the condition, psychiatric cases date back to 1889, when the French physician <a href="http://books.google.com.au/books?id=T9JLudtXgIQC&printsec=frontcover#v=onepage&q&f=false">Francois Hallopeau</a> described a male patient who “manically” pulled out his scalp hair, resulting in bald patches. </p>
<p>This manic feature of the disorder refers to the individual impulsively pulling their hair in response to an irresistible urge or craving. They know that once they give in to an urge to pull they are likely to create further hair loss. But they still feel compelled to, in order to feel pleasure, gratification or relief. This leads to great <a href="http://www.ncbi.nlm.nih.gov/pubmed/11011830">shame, distress and embarrassment</a>. </p>
<p>People with trichotillomania regret their self-inflicted hair loss, and devote energy and time into hiding the pulling and the hair loss from their family and the public. This very secrecy and lack of public awareness means that many individuals with trichotillomania believe they are the only person in the world with the problem. </p>
<p>Trichotillomania has a <a href="http://www.ncbi.nlm.nih.gov/pubmed/17194265">devastating impact on</a> those affected. As <a href="http://www.arcvic.org.au/component/docman/doc_view/75-trichotillomania-and-me">one individual</a> explained:</p>
<blockquote>
<p>“Pulling out my eyelashes impacted on my whole life. It shaped the person I was and how I presented to the world, I was affected by it when I was pulling and it was present even in the moments I wasn’t pulling. That is, I got through the day with the knowledge that I would have relief by night, pulling my eyelashes out.”</p>
</blockquote>
<h2>Growing understanding</h2>
<p>Despite the profound impact trichotillomania can have on those afflicted, it was not formally recognised as a psychiatric disorder until its inclusion in the diagnostic handbook - the DSM - in 1987. Since this time, our knowledge has improved exponentially. </p>
<p>We now know how people “pull” - with hair typically removed from the scalp, eyebrows, and eyelashes, although hair anywhere on the body can be a target. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19926375">We know</a> that most people affected are women, with the problem arising during early childhood or adolescence. And we know that without help, the hair pulling tends to be chronic. </p>
<p>While initially believed to be rare, we now understand that <a href="http://www.ncbi.nlm.nih.gov/pubmed/1938977">2%</a> to <a href="http://www.ncbi.nlm.nih.gov/pubmed/20694115">4%</a> of the population experience the disorder, making it at least as common as schizophrenia - although the lengths that people go to hide their problem makes it much less visible. </p>
<p>We have and are developing treatments that work. Having traditionally been viewed as a <a href="http://www.sciencedirect.com/science/article/pii/0005791680900452">simple habit</a>, the “gold-standard” treatment for trichotillomania has for many decades been <a href="http://ocd.about.com/od/treatment/a/Habitreversal.htm">habit-reversal therapy</a> (HRT). But with our expanding knowledge of the nature of trichotillomania, <a href="http://www.sciencedirect.com/science/article/pii/S1077722912000375">researchers</a> have found that a blend of HRT with acceptance and commitment therapy – a form of cognitive therapy – is far more effective. </p>
<p>As with all mental illnesses, treatments still have scope for improvement.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/16796/original/bpxhzgj4-1350957308.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/16796/original/bpxhzgj4-1350957308.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16796/original/bpxhzgj4-1350957308.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16796/original/bpxhzgj4-1350957308.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16796/original/bpxhzgj4-1350957308.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16796/original/bpxhzgj4-1350957308.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16796/original/bpxhzgj4-1350957308.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Between 2% and 4% of the population suffer from trichotillomania.</span>
<span class="attribution"><span class="source">Chapendra</span></span>
</figcaption>
</figure>
<h2>Classifying trichotillomania</h2>
<p>There are still great limits to our knowledge; more so than for common mental conditions. Given how common trichotillomania is, it’s under-researched, under-recognised, under-treated and misunderstood. </p>
<p>One current issue among researchers and clinicians is defining what “kind” of mental illness it is. Within the DSM disorders are placed into categories, such as mood disorders and eating disorders. These categories are important because they influence how we form ideas about the core features of problems, and influence both medical and psychological research into treatment. If a treatment “works” for one anxiety disorder, it is likely to be tried in some form for others. </p>
<p>But trichotillomania has had trouble finding a suitable “home”. Since its first listing, it has been categorised as an <a href="http://www.dsm5.org/PROPOSEDREVISIONS/Pages/Impulse-ControlDisordersNotElsewhereClassified.aspx">impulse-control disorder not elsewhere classified</a>. Although its inclusion itself was important, this category - which contains everything from pathological gambling to pyromania - is a residual category with <a href="http://www.ncbi.nlm.nih.gov/pubmed/19811840">limited acceptance and validity</a>. </p>
<p>Recently, studies have found that <a href="http://www.ncbi.nlm.nih.gov/pubmed/19467648">hair pulling also reduces unpleasant emotions</a> such as anxiety. Indeed, our own ongoing research, interviewing individuals with trichotillomania about their experience and beliefs, highlights the role of both pleasure and relief from psychological pain that occurs when individuals pull. </p>
<p>In this sense, trichotillomania is similar to <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Obsessive_compulsive_disorder_explained">obsessive-compulsive disorder</a> (OCD), where people feel relief after they’ve washed their hands, following obsessive thoughts that they may have been contaminated. As such, the forthcoming DSM-5 proposes to <a href="http://www.dsm5.org/proposedrevision/Pages/Obsessive-CompulsiveandRelatedDisorders.aspx">reclassify trichotillomania</a> as an OCD-related disorder. </p>
<p>While time will tell whether this change actually leads to improved treatment for trichotillomania, it should at least serve to better highlight the problem and encourage new avenues for research.</p>
<p>In the meantime, our research aims to improve the understanding of the problem and encourage individuals suffering in secrecy to seek and find help.</p>
<p><em>Support groups are available through <a href="http://www.arcvic.org.au/support-a-referral-options/259">ARCVic</a>.</em></p>
<p><em>If you have trichotillomania and are interested in sharing your experiences, please <a href="mailto:irehm@swin.edu.au">contact us</a>.</em> </p>
<p><strong>This is the fourth part of our series <em><a href="https://theconversation.com/topics/matters-of-the-mind">Matters of the Mind</a></em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Explainer: what is the DSM and how are mental disorders diagnosed?</a></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">Forget talking, just fill a script: how modern psychiatry lost its mind</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/strange-or-just-plain-weird-cultural-variation-in-mental-illness-9679">Strange or just plain weird? Cultural variation in mental illness</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/when-stuff-gets-in-the-way-of-life-hoarding-and-the-dsm-5-10074">When stuff gets in the way of life: hoarding and the DSM-5</a></p>
<p><strong>Part six:</strong> <a href="https://theconversation.com/psychiatric-labels-and-kids-benefits-side-effects-and-confusion-9702">Psychiatric labels and kids: benefits, side-effects and confusion</a></p>
<p><strong>Part seven:</strong> <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Redefining autism in the DSM-5</a></p>
<p><strong>Part eight:</strong> <a href="https://theconversation.com/depression-drugs-and-the-dsm-a-tale-of-self-interest-and-public-outrage-9912">Depression, drugs and the DSM: a tale of self-interest and public outrage</a></p>
<p><strong>Part nine:</strong> <a>Why prolonged grief should be listed as a mental disorder</a>)</p>
<p><strong>Part ten:</strong> <a href="https://theconversation.com/internet-use-and-the-dsm-5s-revival-of-addiction-10346">Internet use and the DSM-5’s revival of addiction</a></p><img src="https://counter.theconversation.com/content/10163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Moulding receives funding from the National Health & Medical Research Council. He is affiliated with the Anxiety Recovery Centre (ARCVic) as a volunteer committee member.</span></em></p><p class="fine-print"><em><span>Imogen Rehm does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. Trichotillomania is a psychological…Imogen Rehm, PhD Candidate, Swinburne University of TechnologyRichard Moulding, Lecturer, Clinical Psychologist, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/100742012-10-23T19:32:22Z2012-10-23T19:32:22ZWhen stuff gets in the way of life: hoarding and the DSM-5<figure><img src="https://images.theconversation.com/files/16752/original/2sg6t227-1350869533.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The inclusion of hoarding on the DSM-5 will drive an integrated response to this complex problem.</span> <span class="attribution"><span class="source">Hoarding Grap Wikimedia Commons</span></span></figcaption></figure><p><em>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em></p>
<hr>
<p>We’ve all got boxes of old letters, clothes and other keepsakes we’ve collected over our lifetime. Sometimes these boxes or shelves seem to take over spare rooms and garages. But while we might joke that we’re “a bit of a hoarder”, there’s a big difference between holding onto important mementos and compulsive hoarding. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/8871366">Hoarding</a> is the persistent difficulty discarding or parting with possessions and their ultimate stockpiling – regardless of their value. Possessions may include <a href="http://www.sciencedirect.com/science/article/pii/S2211364912000760">objects or animals</a>, with the resulting clutter rendering living spaces unusable, unsafe or <a href="http://www.ncbi.nlm.nih.gov/pubmed/21608085">unhygienic</a>. </p>
<p>Aside from problems discarding objects, people with hoarding difficulties report <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2735347/">excessive acquisition</a>, whether through compulsive buying or free procurement.</p>
<p>With <a href="http://www.ncbi.nlm.nih.gov/pubmed/20189280">prevalence estimates</a> of around 2% to 5% of the population, somewhere between 400,000 and 1 million Australians are likely to have hoarding problems that cause them or others significant distress and conflict. Hoarding problems most commonly <a href="http://www.ncbi.nlm.nih.gov/pubmed/20189280">begin</a> before early adulthood, although they most commonly present to services when affected individuals are much older. </p>
<p>Hoarding affects people from all social classes and educational backgrounds, though it <a href="http://www.ncbi.nlm.nih.gov/pubmed/21770000">commonly presents</a> alongside depression, obsessive compulsive disorder (OCD), attention deficit disorder, other anxiety problems, compulsive buying, other impulse control problems, and other serious mental health problems. </p>
<p>The <a href="http://www.sciencedirect.com/science/article/pii/S107772291000088X">degree of self-awareness</a> in individuals with hoarding problems varies, and is generally poorer than that in those with OCD. </p>
<h2>Hoarding in the DSM-5</h2>
<p>The <a href="http://www.psych.org/">American Psychiatric Association</a> will likely recognise <a href="http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=398">hoarding disorder</a> as a separate diagnosis in its forthcoming fifth revision of the <a href="http://www.dsm5.org/Pages/Default.aspx">Diagnostic and Statistical Manual of Mental Disorders</a> (DSM), placing hoarding within the <a href="http://www.dsm5.org/Documents/Anxiety,%20OC%20Spectrum,%20PTSD,%20and%20DD%20Group/OC%20Spectrum%20Disorders/DMC_Hoarding%20Disorder.pdf">obsessive-compulsive and related disorders</a> (OCRD).</p>
<p>Current diagnostic manuals don’t account for compulsive hoarding or excessive acquisition as separate entities. In fact, the fourth edition of the DSM hardly mentions hoarding, except in the context of obsessive-compulsive personality disorder (OCPD), even though clinically it has been regarded as a subtype of OCD.</p>
<p>The DSM-5’s OCRD category brings together a range of complex disorders, such as anxiety, impulsive-compulsive and somatoform, a mental disorder that manifests in physical symptoms; inclusion of hoarding disorder within the OCRD diagnosis recognises its distinctiveness from related disorders.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/16771/original/yw2jqmwz-1350881160.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/16771/original/yw2jqmwz-1350881160.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16771/original/yw2jqmwz-1350881160.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16771/original/yw2jqmwz-1350881160.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16771/original/yw2jqmwz-1350881160.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16771/original/yw2jqmwz-1350881160.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16771/original/yw2jqmwz-1350881160.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Between 400,000 and one million Australians have a problem with hoarding.</span>
<span class="attribution"><span class="source">Aric McKeown</span></span>
</figcaption>
</figure>
<h2>Causes</h2>
<p>Researchers have proposed <a href="http://www.ncbi.nlm.nih.gov/pubmed/20189280">a number of causes</a> of excessive hoarding, including biases in how information is processed, insecurities in attachment patterns, problems in regulating emotions, and unhelpful thinking styles, particularly as they relate to objects and possessions. There is evidence implicating <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1307558">genetic factors</a>, cognitive and <a href="http://www.sciencedirect.com/science/article/pii/S0005796706000271">brain functions</a>. </p>
<p>Our own <a href="http://link.springer.com/article/10.1023%2FA%3A1025428631552?LI=true">research</a> has focused on thinking styles, early developmental influences, and insecure attachment patterns, adding to <a href="http://www.ncbi.nlm.nih.gov/pubmed/17673166">research findings</a> linking hoarding to trauma. People with hoarding problems often report that amassing possessions helps them experience rewards and feel more secure, compensating for early emotional and material deprivation.</p>
<h2>Treatment</h2>
<p>Historically, hoarding has been considered resistant to treatment and had been dealt with through enforced clean outs – the style you see on reality television programs about hoarding. But these are generally <a href="http://www.sciencedirect.com/science/article/pii/S0887618510001842">ineffective</a> and lead to unnecessary distress.</p>
<p>More recently, compulsive hoarding has <a href="http://link.springer.com/article/10.1007%2Fs10615-010-0311-4?LI=true">been shown to be amenable</a> to talk-based cognitive-behaviour therapy (CBT). <a href="http://www.ncbi.nlm.nih.gov/pubmed/20336804">CBT for hoarding</a> involves helping affected people to: </p>
<ul>
<li>understand hoarding and thinking styles that maintain hoarding behaviours </li>
<li>become more motivated to change unhelpful behaviours and thinking styles</li>
<li>develop strategies that change unhelpful thinking </li>
<li>build skills related to sorting, organising, and decision making </li>
<li>increase control over impulses to acquire possessions and the inability to discard unnecessary clutter </li>
<li>overcome anxiety and depression </li>
<li>feel more confident within themselves and other people </li>
<li>maintain their gains. </li>
</ul>
<p>While there is <a href="http://link.springer.com/article/10.1007%2Fs10615-010-0311-4?LI=true">consistent evidence</a> that a specific CBT approach to the treatment of hoarding disorder can be effective, outcomes vary considerably. Such variance in outcomes is likely due to diversity in the disorder, although we have little understanding of what predicts outcomes.</p>
<p>While specialised CBT-based hoarding treatments are not yet generally available in Australia, we run a group and individual CBT program through the <a href="http://www.swinburne.edu.au/lss/psychology/pc/compulsive-hoarding-group.html">Swinburne University Psychology Clinic</a>. Based on the <a href="http://www.oup.com/us/catalog/general/subject/Psychology/PractitionerClientGuides/?view=usa&ci=9780195300581">approach of US researchers</a> Randy Frost, Gail Steketee and David Tolin, our program has <a href="http://www.ncbi.nlm.nih.gov/pubmed/20336804">outcomes</a> consistent with their published data.</p>
<p>We know that online treatments for related disorders, <a href="http://www.ocdstop.org.au">such as OCD</a>, can be very <a href="http://www.jmir.org/2011/4/e89/">effective</a>, so we are currently in the process of developing an online version of our treatment. We are also developing alternative models of treatment, including groups moderated by previously affected individuals who have overcome their hoarding problems.</p>
<p>In the meantime, we’re working with government, local councils, and community organisations and services to develop preventative, early intervention, and support programs for people with hoarding problems.</p>
<h2>Effective responses</h2>
<p>The inclusion of hoarding in the DSM-5, the associated increased research and clinical interest, and media coverage of people with hoarding problems have been important determinants in activating governments and local councils to develop an integrated response to this complex problem. </p>
<p>Policies are being developed by various <a href="http://www.health.vic.gov.au/agedcare/publications/hoarding.htm">state governments</a> that bring together social, health, mental health and aged services, police and fire brigade services, animal welfare, public and private housing agencies, local government and non-government organisations, and other bodies. Along with a well-trained and informed workforce, service coordination is essential to effective responses to those affected by hoarding.</p>
<p><strong>This is the fifth part of our series <em><a href="https://theconversation.com/topics/matters-of-the-mind">Matters of the Mind</a></em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Explainer: what is the DSM and how are mental disorders diagnosed?</a></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">Forget talking, just fill a script: how modern psychiatry lost its mind</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/strange-or-just-plain-weird-cultural-variation-in-mental-illness-9679">Strange or just plain weird? Cultural variation in mental illness</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/dont-pull-your-hair-out-over-trichotillomania-10163">Don’t pull your hair out over trichotillomania</a></p>
<p><strong>Part six:</strong> <a href="https://theconversation.com/psychiatric-labels-and-kids-benefits-side-effects-and-confusion-9702">Psychiatric labels and kids: benefits, side-effects and confusion</a></p>
<p><strong>Part seven:</strong> <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Redefining autism in the DSM-5</a></p>
<p><strong>Part eight:</strong> <a href="https://theconversation.com/depression-drugs-and-the-dsm-a-tale-of-self-interest-and-public-outrage-9912">Depression, drugs and the DSM: a tale of self-interest and public outrage</a></p>
<p><strong>Part nine:</strong> <a>Why prolonged grief should be listed as a mental disorder</a>)</p>
<p><strong>Part ten:</strong> <a href="https://theconversation.com/internet-use-and-the-dsm-5s-revival-of-addiction-10346">Internet use and the DSM-5’s revival of addiction</a></p><img src="https://counter.theconversation.com/content/10074/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Kyrios is a director of the Australian Psychological Society and receives funding from NHMRC, ARC, and the Victorian Centre of Excellence in Depression and Related Disorders.</span></em></p>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. We’ve all got boxes of old letters…Michael Kyrios, Professor of Clinical Psychology & Director, Brain & Psychological Sciences Research Centre, Swinburne University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/96792012-10-22T19:30:47Z2012-10-22T19:30:47ZStrange or just plain weird? Cultural variation in mental illness<figure><img src="https://images.theconversation.com/files/16687/original/vbk2wx84-1350538252.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many non-western cultures recognise states of mind that look like mental illness but don't fit DSM categories.</span> <span class="attribution"><span class="source">Todd Huffman</span></span></figcaption></figure><p><em>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em></p>
<hr>
<p>There’s an old saying that psychology has two model organisms: the rat and the American college student. As research subjects rats are fine, the problem is that that Americans are, as evolutionary psychologist <a href="http://www.psych.ubc.ca/faculty/profile/index.psy?fullname=Henrich,%20Joseph&area=Social/Personality&designation=core">Joe Henrich</a> and his colleagues recently pointed out, <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=7825833">WEIRD</a>. That is, they’re Western, Educated, Industrialised, Rich and Democratic. In fact, most westerners are WEIRD, but Americans are the WEIRDest of all. </p>
<p>People in western countries have values and minds that are not like those of the rest of humanity. These differences should not be overstated, but they are real, and they have implications for the cognitive sciences that we are only just beginning to explore.</p>
<p>Many non-western cultures recognise states of mind that look like mental illness but which do not fit the categories of the Diagnostic and Statistical Manual of Mental Disorders (the DSM). </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/1137026">Wacinko</a> is one such illness, found only among the <a href="http://www.oglalalakotanation.org/oln/Home.html">Oglala Lakota</a> people (who are part of the <a href="http://en.wikipedia.org/wiki/Sioux#Reserves_and_First_Nations">Sioux nation</a>). Wacinko is a state of withdrawn, mute anger, directed at someone else, which may last for years. The Oglala live in the United States, but their culture is not shared with most Americans, and neither is wacinko. </p>
<p>Harvard anthropologist <a href="http://www.fas.harvard.edu/%7Eanthro/social_faculty_pages/social_pages_kleinman.html">Arthur Kleinman</a> has <a href="http://bjp.rcpsych.org/content/151/4/447.abstract">argued for decades</a> that depression takes different forms around the world. In the Chinese culture, it is likely to manifest as physical aches and pains. The experience of lower back pain and the experience of guilty despair are so different, he says, that Chinese and American subjects might as well have different diagnoses.</p>
<h2>What’s in store for the DSM-5?</h2>
<p>The <a href="http://www.dsm5.org/about/Pages/Default.aspx">DSM-5</a> looks set to follow its predecessors in coping with cross-cultural variety in two ways. </p>
<p>Some conditions, such as depression and anxiety, are treated as universal – found in every culture. The challenge here is to widen the scope of the diagnosis. It has been suggested that anxiety disorders, for example, should have their “worry domains” expanded because people in other cultures may worry about things that Americans don’t fret over. </p>
<p>We might also want to recognise the greater variety of symptoms among sufferers from anxiety, many of whom, like the Lakota, live in western cultures but don’t show the typical symptoms of a westerner.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/16692/original/yxrbbvwn-1350539374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/16692/original/yxrbbvwn-1350539374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16692/original/yxrbbvwn-1350539374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16692/original/yxrbbvwn-1350539374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16692/original/yxrbbvwn-1350539374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16692/original/yxrbbvwn-1350539374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16692/original/yxrbbvwn-1350539374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In China, depression often manifests as physical aches and pains.</span>
<span class="attribution"><span class="source">kiyoshi.be</span></span>
</figcaption>
</figure>
<p>The DSM-5 will also follow its earlier versions in devoting a section to “culture-bound syndromes”. These are conditions such as Wacinko, which occur in one culture and do not fit the diagnostic criteria of a recognised mental disorder. The <a href="http://www.psychiatry.org/practice/dsm/dsm-iv-tr">DSM-IV-TR</a> (the current diagnostic manual) called them “recurrent, locality-specific patterns of aberrant behaviour and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category”. </p>
<p>Some entries for culture-bound syndromes offer a possible DSM diagnosis that would fit the condition. There are a number of possibilities offered, for example, for <a href="http://en.wikipedia.org/wiki/Susto">susto</a>, a Latino condition with several distressing psychological and physical symptoms, including troubled sleep, disturbed appetite, headaches and diarrhoea.</p>
<p>The condition is attributed to the soul leaving the body, and ritual healing concentrates on getting it to return. The American Psychiatric Association does not embrace that explanation, but offers a choice of major depression, post-traumatic stress disorder (PTSD) and <a href="http://www.dsm5.org/PROPOSEDREVISIONS/Pages/SomatoformDisorders.aspx">somatoform</a> (a mental disorder characterised by physical illness) diagnoses. </p>
<p>On the other hand, there is no suggested DSM diagnosis to deal with [koro](http://en.wikipedia.org/wiki/Koro_(medicine), a South and East Asian syndrome marked by the fear that your penis, vulva or nipples will retract into your body and cause you to die.</p>
<h2>Small steps to progress</h2>
<p>The DSM-IV-TR dedicated a six-page appendix to cultural variation, in a 900 page book, concentrating on conditions that American psychiatrists might see. The DSM-5 is set to make one significant change, adding an interview in the cultural formulation section of the appendix, which aims to help psychiatrists see things from the patient’s point of view, and get more of a sense of cultural context. </p>
<p>This is to be welcomed, but it is difficult to avoid the suspicion that the American Psychiatric Association thinks that Americans are the template for humanity, and departures from US ways of being mentally ill represent odd bits of noise and strange local customs rather than proper scientific categories.</p>
<p>American journalist <a href="http://authors.simonandschuster.com/Ethan-Watters/1070600">Ethan Watters</a>, in his book <a href="http://books.google.com.au/books/about/Crazy_Like_Us.html?id=82OWbwAACAAJ">Crazy Like Us</a>, argues that American psychiatry is launched on a campaign of world domination, as cultures all over the world have their mental lives distorted and traditional ways of coping eroded by the spread of DSM categories, and the conceptual and clinical repertoire that comes with it. </p>
<p>Maybe we should start wondering if the western way of being mentally ill is just one culturally distinctive way among others, or even if we are odd ones out. The more we look at depression globally, the more it seems that the culturally-specific East Asian form that Kleinman studied is the human norm, and that the guilty despair that you or I might suffer from is the culture-bound variety.</p>
<p>Perhaps WEIRD people get WEIRD mental disorders, and the DSM is a valuable piece of western anthropology rather than a guide to universal human frailty.</p>
<p><strong>This is the third part of our series <em>Matters of the Mind</em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Explainer: what is the DSM and how are mental disorders diagnosed?</a></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">Forget talking, just fill a script: how modern psychiatry lost its mind</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/dont-pull-your-hair-out-over-trichotillomania-10163">Don’t pull your hair out over trichotillomania</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/when-stuff-gets-in-the-way-of-life-hoarding-and-the-dsm-5-10074">When stuff gets in the way of life: hoarding and the DSM-5</a></p>
<p><strong>Part six:</strong> <a href="https://theconversation.com/psychiatric-labels-and-kids-benefits-side-effects-and-confusion-9702">Psychiatric labels and kids: benefits, side-effects and confusion</a></p>
<p><strong>Part seven:</strong> <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Redefining autism in the DSM-5</a></p>
<p><strong>Part eight:</strong> <a href="https://theconversation.com/depression-drugs-and-the-dsm-a-tale-of-self-interest-and-public-outrage-9912">Depression, drugs and the DSM: a tale of self-interest and public outrage</a></p>
<p><strong>Part nine:</strong> <a>Why prolonged grief should be listed as a mental disorder</a>)</p>
<p><strong>Part ten:</strong> <a href="https://theconversation.com/internet-use-and-the-dsm-5s-revival-of-addiction-10346">Internet use and the DSM-5’s revival of addiction</a></p><img src="https://counter.theconversation.com/content/9679/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dominic Murphy receives funding from the ARC.</span></em></p>MATTERS OF THE MIND – a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. There’s an old saying that psychology…Dominic Murphy, Director, Unit for History and Philosophy of Science, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/95682012-10-21T19:23:51Z2012-10-21T19:23:51ZExplainer: what is the DSM and how are mental disorders diagnosed?<figure><img src="https://images.theconversation.com/files/16563/original/55x29w2z-1350355298.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Criteria for mental health disorders have been formulated by expert committees. But are they right?</span> <span class="attribution"><span class="source">Psychiatry image from shutterstock</span></span></figcaption></figure><p><em>Welcome to Matters of the Mind, a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em> </p>
<hr>
<p>The <a href="http://www.psych.org/practice/dsm">Diagnostic and Statistical Manual of Mental Disorders</a> (DSM) is a publication of the <a href="http://www.psych.org/">American Psychiatric Association</a>. It was originally published in 1952 to provide a standardised means for making and coding psychiatric diagnoses.</p>
<p>The DSM is currently undergoing its fifth revision, planning for which has been underway since 1999. This process has generated world-wide debate which has escalated as we approach its publication date. The DSM-5 is due to hit psychiatrists’ shelves in May 2013. </p>
<h2>Why we need a diagnostic manual</h2>
<p>Even in this age of brain scans and genetic analysis, we lack the capacity to diagnose psychiatric illness with objective tests. Therefore, psychiatrists rely on the symptoms reported by patients and their own observations to make a diagnosis. Clinicians can compare the patent’s symptoms with the standardised lists of symptoms and criteria contained in diagnostic manuals such as the DSM.</p>
<p>The DSM’s symptom-based criteria have been formulated by expert committees and then tested in studies to see how well they define distinct groups of patients. But clearly, the evidence base for the criteria for any particular disorder will change over time. This necessitates the process of ongoing review and revision of the make-up of the DSM.</p>
<p>The DSM provides an important standardisation of diagnostic categories for psychiatric research and treatment. Prior to the this system, there were substantial variations in the way certain diagnoses were applied. This made clinical diagnosis inconsistent and substantial advances in psychiatric research impossible. </p>
<p>But the DSM has been used more broadly than just by clinicians and researchers. Insurance companies, for instance, can require diagnoses made using specific criteria such as those in the DSM to match to reimbursement categories.</p>
<h2>Why the DSM is controversial</h2>
<p>The DSM itself states that the application of its diagnostic criteria requires extensive clinical training and judgement to make appropriate diagnoses. But many clinicians argue that the complexity of patients’ presentations cannot be adequately summarised by these limited diagnostic codes.</p>
<p>Another common concern is that the categories don’t reflect natural disease boundaries. Many patients present with symptoms meeting criteria for more than one disorder – there is major overlap between depression and anxiety disorders, for instance. This has considerable potential to undermine research: a new medication may not appear to work in drug trials if it’s being tested in what is actually a mixed group of illnesses, which all fall within one DSM diagnosis.</p>
<p>Despite these controversies, the DSM has been widely used for many years. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/16712/original/skf5d6c2-1350607587.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/16712/original/skf5d6c2-1350607587.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16712/original/skf5d6c2-1350607587.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16712/original/skf5d6c2-1350607587.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16712/original/skf5d6c2-1350607587.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16712/original/skf5d6c2-1350607587.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16712/original/skf5d6c2-1350607587.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">To make a diagnosis, clinicians compare the patent’s symptoms with the criteria on the DSM.</span>
<span class="attribution"><span class="source">Joe Houghton</span></span>
</figcaption>
</figure>
<h2>The DSM-5: confidentiality and conflicts</h2>
<p>At the start of the DSM-5 revision process, [concerns were raised](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2802599/](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2802599/) about the manner in which members of the task force were bound by confidentiality agreements from discussing the process. </p>
<p>The potential for conflicts of interest between task force members and the pharmaceutical industry have also been the focus of attention, after it <a href="http://www.psychiatrictimes.com/dsm-v/article/10168/1364672?pageNumber=1">emerged</a> that a greater percentage of task force members had current or previous ties to industry than in past revisions.</p>
<p>In terms of content, many clinicians have been anxious about the proposed changes excessively expanding diagnostic boundaries beyond the support of current evidence. This could, in some cases, “medicalise” normal aspects of human behaviour or experience. </p>
<p>It’s <a href="http://www.psychiatrictimes.com/display/article/10168/1425378?verify=0A">alleged</a> that psychiatrists, and especially those acting in the interests of pharmaceutical companies, are attempting to expand the boundaries of psychiatric diagnosis to expand the potential scope of psychiatric treatment. </p>
<p>In contrast, proponents for the DSM have argued the process was necessary to refine and potentially expand psychiatric diagnoses over time. This reflects a growing understanding of mental illness and ensures treatments are available to those who are suffering. These individuals may not be able to access services, or insurance payments, for treatment if they don’t meet the existing criteria for DSM-defined disorders.</p>
<p>An example of this is the possible inclusion of a new <a href="http://www.dsm5.org/proposedrevision/pages/proposedrevision.aspx?rid=412#">risk syndrome for first psychosis</a>. Criteria have been developed and evaluated in recent years that define a group of individuals who have a relatively high risk – 50% – of developing a DSM-diagnosable psychotic disorder such as schizophrenia.</p>
<p>It has been proposed that this syndrome would provide criteria for the diagnosis for these individuals whose psychotic symptoms aren’t sufficient to meet criteria for schizophrenia. </p>
<p>This is potentially problematic if it results in the treatment of individuals who would not develop these psychotic illnesses with interventions or medications that come with significant side-effects. However, if the criteria are applied to individuals who are actually suffering and seeking help, it will facilitate access to treatment that may otherwise be denied.</p>
<h2>Far-reaching consequences</h2>
<p>The revision of the DSM has substantive implications well beyond the narrow scope of psychiatric practice. It influences how as a society we view and define normal and abnormal behaviour as well as how we finance and reimburse medical care and compensation. </p>
<p>As there are many groups with a substantial interest in its content, we are unlikely to ever achieve perfect consensus. However, we must hope that the coming version is being developed with these broad interests and implications in mind.</p>
<p><strong>This is the first part of our series <em>Matters of the Mind</em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/forget-talking-just-fill-a-script-how-modern-psychiatry-lost-its-mind-9569">Forget talking, just fill a script: how modern psychiatry lost its mind</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/strange-or-just-plain-weird-cultural-variation-in-mental-illness-9679">Strange or just plain weird? Cultural variation in mental illness</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/dont-pull-your-hair-out-over-trichotillomania-10163">Don’t pull your hair out over trichotillomania</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/when-stuff-gets-in-the-way-of-life-hoarding-and-the-dsm-5-10074">When stuff gets in the way of life: hoarding and the DSM-5</a></p>
<p><strong>Part six:</strong> <a href="https://theconversation.com/psychiatric-labels-and-kids-benefits-side-effects-and-confusion-9702">Psychiatric labels and kids: benefits, side-effects and confusion</a></p>
<p><strong>Part seven:</strong> <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Redefining autism in the DSM-5</a></p>
<p><strong>Part eight:</strong> <a href="https://theconversation.com/depression-drugs-and-the-dsm-a-tale-of-self-interest-and-public-outrage-9912">Depression, drugs and the DSM: a tale of self-interest and public outrage</a></p>
<p><strong>Part nine:</strong> <a>Why prolonged grief should be listed as a mental disorder</a>)</p>
<p><strong>Part ten:</strong> <a href="https://theconversation.com/internet-use-and-the-dsm-5s-revival-of-addiction-10346">Internet use and the DSM-5’s revival of addiction</a></p><img src="https://counter.theconversation.com/content/9568/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>PBF is supported by an NHMRC Practitioner Fellowship. In the last two years PBF has received equipment for research from Brainsway Ltd, Medtronic Ltd and MagVenture A/S and funding for research from Cervel Neurotech. He has received consultancy fees as a scientific advisor for Bionomics Ltd. He has no other affiliations or financial involvement with organisations related to the subject matter of the manuscript including employment, consultancies, honoraria, stock ownership or options, grants, patents or royalties.
</span></em></p>Welcome to Matters of the Mind, a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. The Diagnostic and…Paul B. Fitzgerald, Director School of Medicine and Psychology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/95692012-10-21T19:23:50Z2012-10-21T19:23:50ZForget talking, just fill a script: how modern psychiatry lost its mind<figure><img src="https://images.theconversation.com/files/16606/original/td2vzgnb-1350431255.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The symptom-based approach of the current DSM does not take life events into account.</span> <span class="attribution"><span class="source">Woman image from shutterstock.com</span></span></figcaption></figure><p><em>Welcome to Matters of the Mind, a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.</em> </p>
<hr>
<p>You’re feeling down. But do you have a low mood because you’re dealing with the loss of a loved one, a break-up or divorce, or abusive co-workers? Or are you suffering from a depressive disorder: a recognised mental illness caused by an imbalance in the neurotransmitters in the brain, for which a variety of effective medical treatments are available? </p>
<p>Modern psychiatry no longer views our low moods as misguided reactions to life’s challenges. Instead, negative emotions are seen as biomedical problems which often require a prescription. This fundamental change in psychiatry occurred in the 1980s, when we shifted from the second to the third edition of the <a href="http://www.psych.org/practice/dsm">Diagnostic and Statistical Manual of Mental Disorders</a> of the American Psychiatric Association (the DSM).</p>
<h2>DSM-I and II</h2>
<p>After World War II, there were two kinds of psychiatrists: some ran large mental hospitals which housed great numbers of individuals with severe and persistent forms of mental illness; others were psychotherapists, supporting relatively well individuals who were facing unusual challenges or who were stuck for one reason or another. Psychiatrists thought the problems of this second group were related to what was happening in their lives — or their misguided, exaggerated, or misinformed reaction to that. </p>
<p>The DSM-I and II addressed the needs of both groups. There was a section on severe forms of mental illness (useful for mental hospital psychiatrists) and a section on the disorders of normal people containing a fair amount of psychodynamic jargon (for the worried well). The DSM was useful for collecting statistics and for standardising approaches. At the time, psychotherapy was considered an art — and diagnosis was only one element of that art.</p>
<h2>DSM-III</h2>
<p>Everything changed with the third edition of the DSM. The authors felt it was time to clean up the manual: out with psychoanalytic mumbo jumbo, in with scientifically proven diagnostic categories. </p>
<p>Because the cause of most mental illnesses was still shrouded in mystery, the aim was to present neutral descriptions of symptom patterns as the basis for psychiatric diagnosis. (This, by the way, made psychiatric diagnosis different from diagnosis in all other medical specialities, where physicians rely on objective physical findings and medical tests, and not only on the observation of symptoms.) </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/16614/original/rttqg3y2-1350435463.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/16614/original/rttqg3y2-1350435463.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16614/original/rttqg3y2-1350435463.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16614/original/rttqg3y2-1350435463.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16614/original/rttqg3y2-1350435463.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16614/original/rttqg3y2-1350435463.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16614/original/rttqg3y2-1350435463.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Mental health issues are seen as biomedical problems which often require a prescription.</span>
<span class="attribution"><span class="source">Sarah G</span></span>
</figcaption>
</figure>
<p>The categorical view embodied in DSM-III assumed that mental disorders are discrete entities that can be defined by specific sets of symptoms. And that, of course, is still an open question.</p>
<p>In clinical practice, DSM-III led to a “Chinese menu” approach to psychiatric diagnosis: a specific mental illness can be diagnosed if a sufficient number of boxes can be ticked. This is only of limited value in clinical practice.</p>
<h2>Blurry boundaries</h2>
<p>Psychiatric research indicates that things are more complicated than the manual leads us to believe. In reality, many diagnostic categories overlap. Over the years, many new diagnostic categories have been proposed. As a consequence, many individuals now fit several diagnostic labels. Should their different disorders all be treated separately, or at the same time?</p>
<p>Because every individual patient tends to present a unique constellation of symptoms, many practising psychiatrists use an “escape category” and diagnose their patients with a particular disorder <em>not otherwise specified</em>. This sub-category is unusually popular in clinical practice, indicating that all the other sub-categories do not fit the bill. </p>
<p>Clinical experience indicates that most presentations of mental illness can be located on a spectrum. So a dimensional rather than a categorical approach might be more useful. But unfortunately, it is much more difficult to write a dimensional manual.</p>
<h2>Research classifications</h2>
<p>One reason to reorganise the psychiatrists’ bible so thoroughly was to facilitate pharmacological research for mental disorders. In 1954, <a href="http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682040.html">chlorpromazine</a> was introduced for the treatment of schizophrenia. To investigate its effectiveness, it was necessary to standardise diagnostic practices across mental hospitals. </p>
<p>According to psychiatric statistics at the time, the prevalence of schizophrenia was three times higher in the United States than it was in United Kingdom, where patients were diagnosed with manic-depressive illness much more often. Clearly, something was amiss.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/16642/original/s667hfjr-1350452805.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/16642/original/s667hfjr-1350452805.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/16642/original/s667hfjr-1350452805.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/16642/original/s667hfjr-1350452805.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/16642/original/s667hfjr-1350452805.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/16642/original/s667hfjr-1350452805.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/16642/original/s667hfjr-1350452805.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">DSM proponents say standardised psychiatric practices were needed for research to progress.</span>
<span class="attribution"><span class="source">Ars Electronica</span></span>
</figcaption>
</figure>
<p>DSM-III contained a promise: once reliable diagnostic categories were adopted, fruitful medical research into the nature of mental illness could be conducted. To the proponents of DSM-5 (to be released in May 2013), this promise has been more than fulfilled. A great number of new diagnostic categories have been defined while many others have been refined or discarded. </p>
<p>To the critics, things appear much more problematic. According to them, psychiatric research is tainted because it is paid for by multinational pharmaceutical companies to create a market for their drugs.</p>
<h2>Widening the net</h2>
<p>The number of individuals who meet the diagnostic criteria of the latest edition of the manual is growing steadily. Biological psychiatrists have increased the number of diagnostic categories that cover behaviours and emotions which, until recently, were considered to be normal. The number of fidgety or dreamy kids on <a href="http://www.drugs.com/ritalin.html">Ritalin</a> and the number of moody adults on antidepressants has never been higher.</p>
<p>Despite its many promises, the biological approach to mental illness has only achieved a limited amount of success. Critics have argued that the symptom-based approach of the current DSM does not take life events into account. It could be that helping individuals to deal with the circumstances of life is more fruitful than medicalising human distress.</p>
<p><strong>This is the first part of our series <em>Matters of the Mind</em>. To read the other instalments, follow the links below:</strong></p>
<p><strong>Part one:</strong> <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Explainer: what is the DSM and how are mental disorders diagnosed?</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/strange-or-just-plain-weird-cultural-variation-in-mental-illness-9679">Strange or just plain weird? Cultural variation in mental illness</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/dont-pull-your-hair-out-over-trichotillomania-10163">Don’t pull your hair out over trichotillomania</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/when-stuff-gets-in-the-way-of-life-hoarding-and-the-dsm-5-10074">When stuff gets in the way of life: hoarding and the DSM-5</a></p>
<p><strong>Part six:</strong> <a href="https://theconversation.com/psychiatric-labels-and-kids-benefits-side-effects-and-confusion-9702">Psychiatric labels and kids: benefits, side-effects and confusion</a></p>
<p><strong>Part seven:</strong> <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Redefining autism in the DSM-5</a></p>
<p><strong>Part eight:</strong> <a href="https://theconversation.com/depression-drugs-and-the-dsm-a-tale-of-self-interest-and-public-outrage-9912">Depression, drugs and the DSM: a tale of self-interest and public outrage</a></p>
<p><strong>Part nine:</strong> <a>Why prolonged grief should be listed as a mental disorder</a>)</p>
<p><strong>Part ten:</strong> <a href="https://theconversation.com/internet-use-and-the-dsm-5s-revival-of-addiction-10346">Internet use and the DSM-5’s revival of addiction</a></p><img src="https://counter.theconversation.com/content/9569/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hans Pols receives funding from the Australian Research Council. </span></em></p>Welcome to Matters of the Mind, a series which examines the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition. You’re feeling down…Hans Pols, Associate Professor, History and Philosophy of Science, University of SydneyLicensed as Creative Commons – attribution, no derivatives.