tag:theconversation.com,2011:/id/topics/dsm-5-2189/articlesDSM-5 – The Conversation2023-06-20T20:13:34Ztag:theconversation.com,2011:article/2053042023-06-20T20:13:34Z2023-06-20T20:13:34ZIs it anxiety or ADHD, or both? How to tell the difference and why it matters<figure><img src="https://images.theconversation.com/files/531037/original/file-20230608-13385-suqccx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5593%2C3717&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/close-up-shot-of-a-stressed-woman-8810553/">Pexels/Los Muertos Crew</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>“Cassie” is an anxious adult. She stresses and puts off tasks that should be simple. Seeing others succeed makes her feel inadequate. It’s easier to avoid challenges than risk failing again. She has taken anxiety medication but it didn’t help much.</p>
<p>This hypothetical example illustrates a situation many people have faced. Social media abounds with stories of people who have, without success, taken medication for anxiety and are now wondering about possible undiagnosed ADHD. </p>
<p>So, how can you tell if it’s anxiety or ADHD, or both? And why does it matter?</p>
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<a href="https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531039/original/file-20230608-27-r1mlll.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"></a>
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<span class="caption">Both anxiety and depression can mimic ADHD.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/upset-black-woman-on-bed-in-house-5700165/">Pexels/Alex Green</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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Read more:
<a href="https://theconversation.com/myths-and-stigma-about-adhd-contribute-to-poorer-mental-health-for-those-affected-161591">Myths and stigma about ADHD contribute to poorer mental health for those affected</a>
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<h2>ADHD and anxiety can go hand-in-hand</h2>
<p>Anxiety and depression can mimic ADHD. Either can be <a href="https://pubmed.ncbi.nlm.nih.gov/22498754/">associated</a> with lack of motivation and difficulty focusing the attention. </p>
<p>On the other hand, a pattern of being late, missing deadlines and forgetting appointments due to ADHD may <em>lead</em> to anxiety and a sense of failure.</p>
<p>Anxiety and depression are both commonly associated with ADHD, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976041/">particularly in women</a>. Anxiety tends to be more severe and persistent and with a <a href="https://pubmed.ncbi.nlm.nih.gov/28830387/">younger age of onset</a> in people with ADHD.</p>
<p>Generalised anxiety features <a href="https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t15/">symptoms</a> such as frequent and excessive worry about different aspects of life (such as work, school and family). The worry can be difficult to control. Restlessness, fatigue, irritability and sleep problems are common.</p>
<p>For some, anxiety can be controlled through therapy, mindfulness techniques, a change in life or at work and/or medication.</p>
<p>For others, no amount of anxiety treatment seems to help. The problems persist. For these people, it could be worth investigating whether undiagnosed ADHD is a factor.</p>
<p>Successful treatment of co-existing ADHD may, for some, be the best way of getting relief from chronic anxiety. </p>
<h2>Could ADHD be a factor?</h2>
<p>ADHD is often subtle in girls and women, who are <a href="https://pubmed.ncbi.nlm.nih.gov/20591126/">less likely</a> to show the disruptive hyperactive behaviour that draws attention to ADHD in men and boys.</p>
<p>This matters because women with ADHD have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976041/">higher rates</a> of depression, anxiety, <a href="https://pubmed.ncbi.nlm.nih.gov/22498754/">eating and sleep disorders</a>.</p>
<p>Old school reports may give telling clues, such as:</p>
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<p>Cassie spends more time socialising than working. She is capable, but is frequently distracted and is not achieving her potential.</p>
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<p>“Cassie’s” parents may recall hearing such comments from teachers. She may remember feeling bored in class and looking out the window instead of listening and concentrating. </p>
<p>However, <a href="https://www.ncbi.nlm.nih.gov/pubmed/25998281">not all adults</a> with ADHD showed signs of it in childhood.</p>
<h2>ADHD in adulthood</h2>
<p>ADHD is generally diagnosed according to the <a href="https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596">criteria</a> of the American Psychiatric Association.</p>
<p>Problematically, these criteria require that to be diagnosed with ADHD, an adult should have experienced difficulties before the age of 12. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/25998281">Studies</a> have identified ADHD in adults who didn’t show evidence of it when previously assessed in childhood.</p>
<p>And ADHD is generally assessed in adults as if it were a continuation of the childhood condition. The diagnostic criteria – such as interrupting, fidgeting, not completing tasks, losing things, forgetting things – are derived from observations of children.</p>
<p>When applied to adults, these criteria still relate to behaviour seen from the outside by an observer. They miss the depth and insight an <a href="https://pubmed.ncbi.nlm.nih.gov/36981985/">adult can provide</a> about their inner world and mind.</p>
<p>A woman with no history of ADHD-related problems in childhood and no overt signs of restlessness or hyperactivity may have had her ADHD missed, particularly if she’s developed coping skills to seemingly stay on track. </p>
<p>She may feel <a href="https://pubmed.ncbi.nlm.nih.gov/33769111/">stigmatised</a> by those who believe ADHD is being self-diagnosed in treatment-seeking adults who are over-influenced by social media.</p>
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<a href="https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531058/original/file-20230609-29-ixpw6g.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"></a>
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<span class="caption">Only consider a diagnosis of ADHD if you’re facing significant difficulties in life.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/young-annoyed-female-freelancer-using-laptop-at-home-3808008/">Pexels/Andrea Piacquadio</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<h2>If I suspect ADHD, what now?</h2>
<p>If you suspect ADHD but are able to get on fine in life, you probably don’t need a diagnosis. You should only consider a diagnosis of ADHD if you’re facing <a href="https://www1.racgp.org.au/ajgp/2021/march/recognising-attention-deficit-hyperactivity-disord/">significant difficulties</a>. </p>
<p>This could <a href="https://www1.racgp.org.au/ajgp/2021/march/recognising-attention-deficit-hyperactivity-disord/">mean</a> <a href="https://pubmed.ncbi.nlm.nih.gov/20591126/">disorganisation, inefficiency, difficulty with relationships</a> at work or in the family, or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8552915/">depression</a> or anxiety so severe it affects your ability to function. </p>
<p>To be assessed for ADHD, you’ll need a GP referral to a psychiatrist. However, many people who outwardly appear to be coping well may find it difficult to convince a GP an assessment is necessary. </p>
<p>You could bring copies of school reports if they suggest ADHD. <a href="https://novopsych.com.au/assessments/diagnosis/adult-adhd-self-report-scale-asrs/">Checklists</a> with ADHD criteria can help, but <a href="https://adhdguideline.aadpa.com.au">cannot</a> reliably either diagnose or exclude ADHD.</p>
<p>Clear descriptions of difficulties you experience when attempting mentally demanding task can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10049217/">help</a>.</p>
<p>These may <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10049217/">include</a> repeated lapses in attention, or having to multitask to provide sufficient stimulation to keep working. </p>
<p>You might detail, for example, the average number of minutes per hour of your working day you are actually working productively or how long you can focus on a hard task before losing concentration. How often do you get distracted? How long does it take to get back on task? What strategies have you tried?</p>
<p>An ADHD diagnosis can be a relief for some, who may find treatment helps alleviate problems they’d previously blamed on anxiety. It can also provide an <a href="https://pubmed.ncbi.nlm.nih.gov/22498754/">explanation</a> for past difficulties attributed to personal inadequacy.</p>
<p>ADHD <a href="https://pubmed.ncbi.nlm.nih.gov/22498754/">treatments</a> can include medication, learning more about it, developing new strategies, counselling and having an ADHD coach.</p>
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Read more:
<a href="https://theconversation.com/adhd-claims-were-diagnosing-immature-behaviour-make-it-worse-for-those-affected-72180">ADHD: claims we're diagnosing immature behaviour make it worse for those affected</a>
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<img src="https://counter.theconversation.com/content/205304/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alison Poulton is affiliated with the Australian ADHD Professionals Association (AADPA). Dr Poulton discloses personal fees and non-financial support from Shire/Takeda, and royalties from Disruptive Publishing for her book: ADHD Made Simple.</span></em></p>For some people, successful treatment of co-existing ADHD may be the best way of getting relief from chronic anxiety.Alison Poulton, Senior Lecturer, Brain Mind Centre Nepean, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1815122022-05-06T15:39:29Z2022-05-06T15:39:29ZComplex post-traumatic stress disorder explained<p>Stephanie Foo, an award-winning radio producer, suffers from complex post-traumatic stress disorder, a disorder that in her country (the US) “doesn’t officially exist”. In her new book, <a href="http://www.randomhousebooks.com/books/658389/">What My Bones Know</a>, Foo writes movingly about what it’s like to live with complex PTSD and her long journey to getting a diagnosis.</p>
<p>Earlier this year, the American Psychiatric Association released the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM – the so-called psychiatrists’ bible. The manual, first published in 1952, is used worldwide to diagnose, treat and research mental health conditions. But it does not recognise complex PTSD as a distinct diagnosis. Many experts, however, do recognise that complex PTSD is a disorder in its own right. </p>
<p>Before we talk about complex PTSD, let’s look at what “standard” PTSD is.</p>
<p>PTSD is a mental health disorder that is the result of a traumatic event. People often associate it with war veterans – someone flashing back to the Afghan conflict because they were triggered by a car backfiring, for example. But, really, anyone who has suffered trauma is at risk of PTSD. And, according to the World Health Organization, around <a href="https://www.tandfonline.com/doi/full/10.1080/20008198.2017.1353383">70%</a> of people experience at least one traumatic event in their life. Research shows that just under <a href="https://www.cambridge.org/core/journals/psychological-medicine/article/posttraumatic-stress-disorder-in-the-world-mental-health-surveys/7DB941D95BB33FCC18BF52DFB3F78197">6%</a> of those people will develop PTSD. </p>
<p>Everyone’s experience of PTSD is different, but people with the condition may have reoccurring memories or nightmares related to the traumatic event, they may have distressing and intrusive thoughts about it, and they can be jumpy and easily startled. “Avoidance” is part of the condition, too. People with PTSD may avoid people or places that remind them of the trauma. Or they may try to avoid the memory by using drugs or alcohol.</p>
<p>The condition can seriously affect a person’s relationships and is often associated with <a href="https://journals.lww.com/co-psychiatry/Abstract/2019/11000/Eating_disorders_and_posttraumatic_stress_disorder.8.aspx">eating disorders</a>, substance abuse, <a href="https://link.springer.com/article/10.1007/s10880-016-9449-8">depression and suicidal behaviour</a>.</p>
<h2>How complex PTSD is different</h2>
<p>In complex PTSD, the trauma is not a one-off event, but something repeated and sustained, such as torture, domestic violence or childhood abuse.</p>
<p>Complex PTSD includes the same symptoms of PTSD, plus additional symptoms called <a href="https://www.sciencedirect.com/science/article/pii/S0272735817301460?casa_token=XupdJYp_U4AAAAAA:KJUbKMYYvk0dAoCpz-egTJfXgalBty3bIHf_s-PcgXCLkOl3qp3vaqeVPAbrprFe8_qT1ke8vvRL">disturbance in self-organisation</a>. Disturbance in self-organisation refers to problems in regulating emotions (for example, feeling numb or having sudden anger outbursts), feeling distant from others, and having extremely negative views about yourself. </p>
<p>Complex PTSD is not as common as PTSD, but it seems particularly widespread among specific groups of people, such as <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/acps.12973?casa_token=kBM6npfaVScAAAAA%3A0GL6A6TRiDUPznwi0IAf1LCQgBbWc1xkn4KFeVIlXb-ZM7k0YLzOJfubmpYmPDgEUCfRwo9WJTqo1cdl">refugees</a> and people who <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/acps.13161">experience psychosis</a>.</p>
<p>While the DSM does not recognise complex PTSD as a diagnosis, the term has been around since <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/jts.2490050305?casa_token=fBW8Z1ZD_3sAAAAA:oKtcIZeVakVaxSTLpNJqlHcNxd8NENPFvIAmGDV5scF0hty-r6_3Mkywf625ZvWXzrMlEpO8uySmy_RJ">1992</a>. And in 2019, it was officially recognised as a diagnosis in the World Health Organization’s diagnostic bible, the <a href="https://icd.who.int/browse11/l-m/en#/http%253a%252f%252fid.who.int%252ficd%252fentity%252f585833559">International Classification of Diseases</a> (ICD-11). (Both the DSM and the ICD are officially recognised diagnostic manuals, the main difference being that the DSM is more popular in the US, while the ICD is more commonly adopted in Europe.)</p>
<p>The <a href="https://www.phoenixheroes.co.uk/_webedit/uploaded-files/All%20Files/ITQ%20Overview%20and%20Scoring%20Final%209%20September%202018%20%281%29.pdf">international trauma questionnaire</a> has been developed as a self-report measure specifically designed to capture the additional symptoms of complex PTSD. The difference between PTSD and complex PTSD has been shown in <a href="https://www.tandfonline.com/doi/full/10.1080/20008198.2020.1739873">over 40 studies and across 15 different countries</a>. A <a href="https://www.sciencedirect.com/science/article/pii/S169726001500085X?via%3Dihub#sec0085">study</a> involving nearly 1,700 doctors from 76 countries found that, despite differences in ethnicity and nationality, doctors were able to accurately diagnose and distinguish between PTSD and complex PTSD. </p>
<p>In the UK, complex PTSD is officially recognised by both the <a href="https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/complex/">NHS</a> and the <a href="https://thepsychologist.bps.org.uk/what-complex-ptsd">British Psychological Society</a>, and popular mental health charities, such as <a href="https://www.mind.org.uk/information-support/types-of-mental-health-problems/post-traumatic-stress-disorder-ptsd-and-complex-ptsd/complex-ptsd/#.XIkykij7SUl">Mind</a>, strive to inform people about this new diagnosis.</p>
<p>The National Institute for Health and Care Excellence, which in England is in charge of publishing national guidelines and advice to improve health and social care, has not yet developed recommendations specifically for complex PTSD. But several treatments (still in their early stages) are being developed. </p>
<h2>How it’s treated</h2>
<p>In the meantime, people who experience complex PTSD are being offered the usual treatments for PTSD. While such treatments have shown to be effective to an extent, they need to be offered for a longer period, should be accompanied by more intensive support and supplemented with extra therapies focusing particularly on the disturbance in self-organisation symptoms.</p>
<p>Usual treatments for PTSD that the NHS offers in England include trauma-focused cognitive behavioural therapy (<a href="https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/treatment/">CBT</a>) and eye-movement desensitisation and reprocessing (<a href="https://www.nhs.uk/mental-health/conditions/post-traumatic-stress-disorder-ptsd/treatment/">EMDR</a>). </p>
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<img alt="Woman having therapy." src="https://images.theconversation.com/files/461768/original/file-20220506-22-l9yrgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461768/original/file-20220506-22-l9yrgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461768/original/file-20220506-22-l9yrgm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461768/original/file-20220506-22-l9yrgm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461768/original/file-20220506-22-l9yrgm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461768/original/file-20220506-22-l9yrgm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461768/original/file-20220506-22-l9yrgm.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">
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<span class="caption">Trauma-focused CBT can help people manage their complex PTSD.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mental-health-patient-psychotherapist-talking-therapy-1611463261">Microgen/Shutterstock</a></span>
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<p>Trauma-focused CBT involves eight to 12 weekly sessions where you learn how trauma can affect your body and which techniques are useful to deal with symptoms, such as flashbacks. EMDR is also offered as a course of eight to 12 sessions, where you will try to think about details of the trauma while making eye movements, usually by following the movement of your therapist’s finger. Both these treatments, while effective, involve thinking about the trauma and so can be quite distressing.</p>
<p>Treatments that have more than one component are the ones that are <a href="https://www.tandfonline.com/doi/full/10.1080/20008198.2020.1866423">more promising</a> for managing complex PTSD symptoms. For example, a <a href="https://www.tandfonline.com/doi/full/10.1080/20008198.2020.1783955">study</a> conducted in the Netherlands found that an intensive eight-day treatment programme combining different techniques including EMDR and physical activity significantly decreased symptoms of both PTSD and complex PTSD.</p>
<p>If you feel you might benefit from trauma-focused therapy, or would like to discuss any symptoms that you might be experiencing, you can talk to your doctor or, in the UK, refer yourself for assessment to an NHS psychological therapies service (<a href="https://www.nhs.uk/service-search/mental-health/find-a-psychological-therapies-service/">IAPT</a>) without a referral from a GP.</p><img src="https://counter.theconversation.com/content/181512/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carolina Campodonico 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>Complex PTSD was left out of the latest version of the ‘psychiatrists’ bible’, but that doesn’t make it any less real for those who live with it.Carolina Campodonico, Lecturer in Clinical Psychology, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1195402019-09-10T20:05:06Z2019-09-10T20:05:06ZWe need to stop perpetuating the myth that children grow out of autism<figure><img src="https://images.theconversation.com/files/290620/original/file-20190903-175710-137r8wx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3478%2C2086&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Autism is a lifelong condition, though some people who weren't accurately diagnosed may lose their diagnosis. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/boy-headphones-260857394?src=-1-38">Dubova/Shutterstock</a></span></figcaption></figure><p>Around 1% of the population has an autism spectrum disorder, with estimates <a href="https://www.aihw.gov.au/reports/disability/autism-in-australia/contents/autism">ranging from one in 150</a> <a href="https://www.autismspectrum.org.au/news/autism-prevalence-rate-up-by-an-estimated-40-to-1-in-70-people-11-07-2018">to one in 70</a>.</p>
<p>While people differ in the range and severity of their symptoms, common features include difficulties with communication and social interaction, <a href="https://theconversation.com/why-do-some-people-with-autism-have-restricted-interests-and-repetitive-movements-94401">restrictive and repetitive behaviours and interests</a>, and sensory sensitivities. </p>
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Read more:
<a href="https://theconversation.com/what-causes-autism-what-we-know-dont-know-and-suspect-53977">What causes autism? What we know, don’t know and suspect</a>
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<p>According to the <a href="https://www.aihw.gov.au/reports/disability/autism-in-australia/contents/autism">2017 Autism in Australia</a> report, autism is most prevalent among children aged five to 14, with 83% of Australians with an autism diagnosis aged under 25.</p>
<p>But while children are more likely to have a diagnosis of autism than adults, this doesn’t mean children “<a href="http://www.onethingforautism.com.au/wp-content/uploads/2018/05/Autism-research-report-General-awareness-knowledge-and-understanding-of-autism-and-social-isolation-1.pdf">grow out</a>” of autism. </p>
<h2>Why are rates higher among children?</h2>
<p>There are a number of reasons why the prevalence of autism is higher among school-aged children than adults, starting with the measurement. </p>
<p>“Prevalence” refers to the rate of diagnosis and/or self-reports, not the rate of actually having autism. As autism is a lifelong condition, it’s more likely the rates of actually having autism are stable across adults and children. </p>
<p><a href="https://www.sciencedirect.com/science/article/pii/S0736574815000519">Diagnostic techniques and awareness of autism</a> have improved dramatically in recent times. Many autistic adults would not have been given a formal diagnosis, but rather misdiagnosed or just seen as “weird”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-more-children-have-autism-now-than-before-4497">Do more children have autism now than before? </a>
</strong>
</em>
</p>
<hr>
<p>These days, there are clear benefits of having and reporting a diagnosis for school-aged children; including <a href="https://www.autismawareness.com.au/financial-support/">access to funding</a> and educational support. This means parents who suspect their child has autism may seek out a diagnosis when in previous generations they would not.</p>
<p>There are far fewer benefits to having and reporting a diagnosis for adults, and many more barriers, including <a href="https://www.tandfonline.com/doi/full/10.1080/09687590802535345">stigma and discrimination</a>.</p>
<h2>Some children lose their diagnosis</h2>
<p>Autism is a lifelong condition. However, a small number of studies suggest a minority of children may “lose” their autism diagnosis.</p>
<p>A <a href="https://journals.sagepub.com/doi/pdf/10.1177/1362361315607724">2011 analysis of American national survey data</a> found 13% of children diagnosed with autism (187 of the 1,576 whose parents responded to the question) had “lost” their diagnosis. </p>
<p>The most common reason was “new information”, such as being diagnosed with another developmental, learning, emotional, or mental health condition. </p>
<p>Only 21% of the 187 parents reported their child had lost their diagnosis due to treatment or maturation; and only 4% (eight children) had a doctor or other professional confirm the child did not have ASD and did not have any other developmental, learning, emotional, or mental health condition.</p>
<p>A recent study in the <a href="https://journals.sagepub.com/doi/10.1177/0883073819834428">Journal of Child Neurology</a> examined the records of 569 children diagnosed with autism between 2003 and 2013. It found 7% (38 of the 569) no longer met the diagnostic criteria. </p>
<p>However, most were diagnosed with another behaviour disorder (such as attention-deficit hyperactivity disorder) or a mental health condition (such as anxiety disorder). </p>
<p>Just three children out of 569 did not “warrant” any alternative diagnosis.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/290822/original/file-20190904-175663-1oo2fiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290822/original/file-20190904-175663-1oo2fiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290822/original/file-20190904-175663-1oo2fiy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290822/original/file-20190904-175663-1oo2fiy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290822/original/file-20190904-175663-1oo2fiy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290822/original/file-20190904-175663-1oo2fiy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290822/original/file-20190904-175663-1oo2fiy.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">Many autistic children learn to mask their symptoms and act like their neurotypical peers.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/219008878?src=-1-15&size=huge_jpg">Pressmaster/Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/five-myths-about-autism-4203">Five myths about autism</a>
</strong>
</em>
</p>
<hr>
<p>The few studies that report on children who no longer met the criteria for a diagnosis of either autism or another condition are typically small-scale <a href="https://www.ctu.mrc.ac.uk/patients-public/about-clinical-trials/what-is-an-observational-study/">observational studies</a>. </p>
<p>In 2014, for example, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547539/">US psychiatry researchers</a> studied 34 people aged eight to 21 years who were diagnosed with autism before the age of five but no longer met the criteria for a diagnosis. This was defined as the “optimal outcome”. </p>
<p>The researchers found the “optimal outcome” group did not differ from “typically developing” children on socialisation, communication, most language sub-scales and only three had below-average scores on face recognition.</p>
<p>So, a very very small number of children lose their diagnosis and appear to function normally. But these small-scale studies don’t have the capacity to differentiate between “growing out of” and “learning to mask” autism-related behaviours.</p>
<h2>Masking symptoms</h2>
<p>The diagnostic and statistical manual (DSM-5) used to classify mental health disorders states <a href="https://www.autismspeaks.org/autism-diagnosis-criteria-dsm5">symptoms of autism</a> start early and continue throughout life, though adults may be able to “mask” their symptoms – at least in some situations. </p>
<p>One of the unexpected findings of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547539/">2014 study of people who lost their autism diagnosis</a> is they tended to have high IQs. The researchers suggest high levels of cognition allowed this group of autistic people to identify and compensate for their social differences. </p>
<p>Many autistic people learn to <a href="https://link.springer.com/article/10.1007/s10803-017-3166-5">mask their behaviours</a> and thought patterns from a young age; and this is particularly <a href="https://journals.sagepub.com/doi/full/10.1177/1362361316671845">common with girls</a>. They learn that to fit in and be accepted by their peers they need to act and speak like neurotypical people. </p>
<p>Masking is physically and emotionally draining, and leads to a <a href="https://www.neurologyadvisor.com/topics/autism-spectrum-disorder/the-consequences-of-compensation-in-autism/">range of negative outcomes</a> such as exhaustion, burnout, anxiety, and depression – as well as negative self-perception and low self-esteem.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/autistic-people-arent-really-accepted-and-its-impacting-their-mental-health-86817">Autistic people aren't really accepted – and it’s impacting their mental health</a>
</strong>
</em>
</p>
<hr>
<h2>Why are these myths so harmful?</h2>
<p>Many parents <a href="https://www.questia.com/library/journal/1G1-537853432/mother-s-reaction-to-autism-diagnosis-a-qualitative">struggle with their child’s diagnosis of autism</a>, as they face the realisation their child’s life may be very different from the one they imagined. </p>
<p>The myth that children can grow out of autism – if their parents do a good enough job of educating or changing them – is harmful for the whole family. </p>
<p>It can prevent parents from seeing and accepting their child as the wonderful human being they are and recognising their strengths. </p>
<p>Sadly, it can also lead to a lifetime of the autistic person perceiving themselves to be a <a href="https://link.springer.com/article/10.1007/s10803-017-3342-7">failed neurotypical person</a> rather than a <a href="http://dsq-sds.org/article/view/5053/4412">successful autistic person</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/290824/original/file-20190904-175705-h6ekyx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/290824/original/file-20190904-175705-h6ekyx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/290824/original/file-20190904-175705-h6ekyx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/290824/original/file-20190904-175705-h6ekyx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/290824/original/file-20190904-175705-h6ekyx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/290824/original/file-20190904-175705-h6ekyx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/290824/original/file-20190904-175705-h6ekyx.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">Parents of children newly diagnosed with autism have to adjust to the idea their child’s life may be different from what they imagined.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1402275035?src=-2-1&size=huge_jpg">Natalia Lebedinskaia/Shutterstock</a></span>
</figcaption>
</figure>
<p>Australia, like many countries, has made great strides in the provision of educational supports for these students in primary and secondary school. Then we stop. </p>
<p>Of those who complete secondary school, <a href="https://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/4428.0Main%20Features52012?opendocument&tabname=Summary&prodno=4428.0&issue=2012&num=&view=">only 19% receive a post-school qualification</a>. This compares with 59% of those with any form of disability and 68% of those without a disability. </p>
<p>In terms of work, ABS data from 2015 shows the <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4430.0Main%20Features752015">unemployment rate for people with an autism diagnosis</a> was 31.6%; more than three times the rate for people with any disability (10%) and almost six times the rate of people without disability (5.3%). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/expecting-autistic-people-to-fit-in-is-cruel-and-unproductive-value-us-for-our-strengths-103888">Expecting autistic people to 'fit in' is cruel and unproductive; value us for our strengths</a>
</strong>
</em>
</p>
<hr>
<p>Autistic children don’t grow into neurotypical adults, they grow into autistic adults who are <a href="https://www.ncbi.nlm.nih.gov/pubmed/22914775">under-serviced</a>, isolated and stigmatised. </p>
<p>Until our employers, educational institutions, governments and communities fully understand this, we will continue to fail to provide them with appropriate educational and employment opportunities.</p>
<p>So, will your child grow out of their autism? Probably not, but with the right support, encouragement and understanding they might grow into it.</p><img src="https://counter.theconversation.com/content/119540/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sandra Jones 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>The myth that children grow out of autism can prevent parents from seeing and accepting their child as the wonderful human being they are and recognising their strengths.Sandra Jones, Pro Vice-Chancellor, Engagement, Australian Catholic UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1029432018-10-10T09:12:01Z2018-10-10T09:12:01ZDiagnostic labels for mental health conditions are not always useful<figure><img src="https://images.theconversation.com/files/239165/original/file-20181003-52666-7rp8mq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/758549185?src=qd_CBlIQIbRl7Kwo4ae31A-1-2&size=huge_jpg">Olivier Le Moal/Shutterstock.com</a></span></figcaption></figure><p>The number of people diagnosed with a mental health condition is <a href="https://ourworldindata.org/mental-health">increasing, globally</a>. Diagnostic labels can act as passports to accessing public services and help create communities of individuals with the same label. But are these reasons enough to justify their continued use? Getting a diagnostic label is no guarantee of getting the right treatment and it is often associated with <a href="http://psycnet.apa.org/buy/2004-19091-003">worry and stigma</a>.</p>
<p>Some say that they’re necessary for research. Scientists hope that diagnostic labels for mental health conditions will neatly correspond with specific physiological markers. But a definitive blood test or MRI-based brain marker for conditions such as autism and depression continues to elude scientists. </p>
<p>Also, mental health conditions have highly variable symptoms. They are not clear cut like other medical conditions, such as bone fractures or tooth decay. And a broken bone today is the same as a broken bone in ancient Greece. However, diagnostic criteria for mental health conditions keep shifting, even over relatively short periods of time.</p>
<p>A recent report showed that <a href="https://link.springer.com/article/10.1007/s10803-013-1799-6">over a fifth</a> of people diagnosed of autism spectrum disorder (ASD), using diagnostic criteria from 2004, would not receive the same diagnosis based on the latest criteria, published in 2013. To add to the confusion, many people can have more than one diagnostic label – a phenomenon known as “comorbidity”. </p>
<p>The inherent lack of precision in defining the diagnostic label, the changing criteria with time and the rarity of pure examples of a specific mental health condition vastly reduce the usefulness of diagnostic labels in guiding research. Indeed, the National Institute of Health in the US recognised this problem some years ago and called for a new approach to researching mental health conditions. This approach, called the <a href="https://www.nimh.nih.gov/research-priorities/rdoc/constructs/rdoc-snapshot-version-4-saved-5-30-18.shtml">research domain criteria</a> (RDoC), focuses on studying traits across the general population and their underlying biology, rather than on specific diagnostic labels. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/OyGt8-ddacA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">RDoC explained.</span></figcaption>
</figure>
<p>From a treatment point of view, knowing the diagnostic label alone is hardly ever enough information to decide the best course of action. For example, a person with a diagnosis of ASD might have significant sensory issues, while another might struggle more with language. These two people will benefit from very different interventions. It’s not an overstatement to say there is no one-size-fits-all intervention for <em>any</em> mental health diagnostic label. So the usefulness of a diagnostic label for choosing the right treatment is limited. </p>
<p>The approach of focusing on the person rather than the label is known as <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0849-x">precision psychiatry</a>. This customised approach seeks to target the specific symptoms experienced by the individual in light of his or her genetic, social and cultural background. Hippocrates echoed a similar sentiment over two millennia ago when he stated: </p>
<blockquote>
<p>It’s far more important to know what person the disease has than what disease the person has. </p>
</blockquote>
<h2>Public health</h2>
<p>A significant part of my work is in developing countries where there is a shortage of specialists who can provide a diagnosis. For most mental health conditions, early intervention is critical – <a href="https://www.rcpsych.ac.uk/pdf/Bettermentalhealthoutcomesforchildrenandyoungpeo.pdf">it is associated with the best outcomes</a>. Delays in getting a diagnostic label lead to delays in getting treatment in these countries and so can result in a reduced chance to benefit from the intervention. </p>
<p>If getting support for mental health issues did not have to rely heavily on the diagnostic label, then access to treatment could be accelerated by involving non-specialists from the <a href="http://research.bmh.manchester.ac.uk/pact/PASS/">community and families</a>. Health workers with little or no clinical training, such as those involved in vaccination drives, could be trained to identify people at risk of having or developing mental health conditions, as is being done in <a href="https://startproject.bhismalab.org">our current project</a> in India. </p>
<p>Families of people identified of being at risk of a mental health condition can then be trained to apply simple behavioural interventions that have been <a href="https://www.sciencedirect.com/science/article/pii/S0140673610605879">shown to be effective</a>. This approach of identifying at-risk people early and using simple non-specialist behavioural interventions is associated with <a href="https://onlinelibrary.wiley.com/doi/abs/10.1023/A:1024654026646">significantly better mental health outcomes</a> in children and adolescents. Crucially, this approach does not rely on getting a formal diagnostic label.</p>
<p>At a time when rates of diagnosis for mental health conditions keep spiralling upward, it is worth imagining a world without diagnostic labels: one where an individual is assessed on his or her functional needs and receives care based on the specific needs rather than a somewhat arbitrary label. A world without stigma due to these labels. And a world where scientists focus their search on understanding the biology of behaviour across the entire population, rather than create arbitrary groups of people defined by their labels as “cases” and “controls”.</p><img src="https://counter.theconversation.com/content/102943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bhismadev Chakrabarti receives funding from Medical Research Council UK, and the Leverhulme Trust.</span></em></p>Bipolar disorder, autism, schizophrenia, borderline personality disorder – how useful are mental health labels?Bhismadev Chakrabarti, Professor of Neuroscience & Mental Health, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/875672017-11-20T14:55:26Z2017-11-20T14:55:26ZPostnatal depression: men get it too<figure><img src="https://images.theconversation.com/files/195309/original/file-20171119-11454-19vuqwm.jpg?ixlib=rb-1.1.0&rect=0%2C379%2C5760%2C3311&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/682828864?src=xQo83GVWX7g5wGA_HY9ZFg-1-0&size=huge_jpg">Antonio Guillem/Shutterstock</a></span></figcaption></figure><p>Over the past few years, there has been an increase in media reports about postnatal depression and other maternal mental illnesses, and campaigns have led to greater understanding about the need for more specialist services. Although this is encouraging, very little is said about fathers. But men can get postnatal depression, too.</p>
<p>Currently, only mothers can be diagnosed with postnatal depression. The psychiatrists’ “bible”, the <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">Diagnostic and Statistical Manual of Mental Disorders (DSM-5)</a>, includes a diagnosis of “peripartum depression”. Peripartum depression is a form of clinical depression that is present at any time during pregnancy, or within the four weeks after giving birth, although experts working in perinatal mental health tend to be more flexible, extending that period to the first year after giving birth. </p>
<p>In many ways, postnatal depression varies little from traditional depression. It, too, includes a period of at least two weeks where the person experiences low mood or a lack of motivation, or both. Other symptoms include poor sleep, agitation, weight changes, guilt, feelings of worthlessness, and thoughts of death and dying. But the biggest difference is that a depression at this time involves a significant additional person: the child. </p>
<p>Evidence suggests that the long-term consequences of postnatal depression on the child can be damaging, including <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8624.1996.tb01871.x/abstract;jsessionid=F4C1DF2A61E537190E3CA659EF74EF41.f03t02">developmental problems, poor social interaction</a>, <a href="http://online.liebertpub.com/doi/abs/10.1089/jwh.2008.1050">partner-relationship problems</a> and <a href="http://everyonesbusiness.org.uk/wp-content/uploads/2014/12/Embargoed-20th-Oct-Final-Economic-Report-costs-of-perinatal-mental-health-problems.pdf">greater use of health services (including mental health services)</a>. </p>
<p>Around 7-20% of new mothers <a href="http://onlinelibrary.wiley.com/doi/10.1002/jclp.20644/epdf">experience postnatal depression</a>. A common view is that it is caused by hormonal changes. Although this is partly true, it is far more likely that <a href="http://onlinelibrary.wiley.com/doi/10.1002/jclp.20644/abstract">life factors are responsible</a>, such as poverty, being younger, lack of support and birth trauma. Another potential cause is the sudden overwhelming responsibility of having a baby to care for, and the life changes that it entails.</p>
<p>Depressed mothers also feel intensely guilty about the way they feel about their baby, and fear shame and stigma from society. As a result, at least <a href="https://link.springer.com/article/10.1007%2Fs00737-017-0767-0">50% of mothers</a> will not report a mental health problem. Other mothers will not tell their health provider out of fear of having their child taken away by social services. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/195429/original/file-20171120-18574-lmi2ij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/195429/original/file-20171120-18574-lmi2ij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/195429/original/file-20171120-18574-lmi2ij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/195429/original/file-20171120-18574-lmi2ij.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/195429/original/file-20171120-18574-lmi2ij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/195429/original/file-20171120-18574-lmi2ij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/195429/original/file-20171120-18574-lmi2ij.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">Prevalence of postnatal depression in men could be as high as 10%.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/504159763?src=aqcikNPVV-nS8vUh-bFeAA-1-74&size=huge_jpg">Pushish Images/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Mounting evidence</h2>
<p>All of the above factors can equally apply to fathers. But there is no formal diagnosis of postnatal depression for fathers. Yet evidence from several countries, including <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.2005.00708.x/abstract;jsessionid=22398CA428A1F2EEC3FB3699ED02C594.f03t03">Brazil</a>, the <a href="http://pediatrics.aappublications.org/content/118/2/659.long?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token">US</a> and the <a href="http://www.sciencedirect.com/science/article/pii/S0140673605667785?via%3Dihub">UK</a>, suggests that around 4-5% of fathers experience significant depressive symptoms after their child is born. Some other studies claim that prevalence may be <a href="https://jamanetwork.com/journals/jama/article-abstract/185905">as high as 10%</a>. </p>
<p>The cause of these feelings in fathers is similar to what we see with mothers, but there are extra complications. Men are much less likely to seek help for mental health problems, generally. </p>
<p>Societal norms in many nations suggest men should suppress emotion. This is probably even more a factor for fathers, who may perceive their role as being practical and providing for the family. Fathers – especially first-time fathers – might experience many sudden changes, including significant reduction in family income and altered relationships with their wife or partner. These are major risk factors for depression in fathers. </p>
<p>The importance for supporting fathers at this time is as vital as it is for mother. Evidence suggests that a father’s depression can have a <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1469-7610.2008.02000.x/abstract">damaging effect</a> on their child’s development. Despite this, it has been shown that fathers are also <a href="http://psycnet.apa.org/record/2003-02034-001">less likely than mothers</a> to seek help, and that <a href="https://gupea.ub.gu.se/bitstream/2077/32509/1/gupea_2077_32509_1.pdf">health professionals</a> are less likely to consider that fathers need support, compared with mothers. More evidence is needed to build a case that fathers need support as much as mothers. </p>
<h2>Poorly equipped</h2>
<p>It has been argued that, until recently, health professionals have been poorly equipped to recognise and treat mental illnesses associated with the birth of a child. Recent campaigns in the UK have led to changes in policy, funding and <a href="https://www.nice.org.uk/guidance/cg192">health guidelines</a>. However, the recent revision of the National Institute for Health and Care Excellence (NICE) guideline on perinatal mental health does not address fathers’ needs. <a href="http://www.bbc.co.uk/news/uk-wales-41726067">Despite a campaign to address this</a> having support from several professionals and academics, a NICE spokesperson told the BBC that guidelines are unlikely to be changed as there is no evidence that men experience postnatal depression. However, if we discount hormonal factors in new mothers, the remaining risk factors for postnatal depression also apply to fathers. And we need support that recognises that.</p><img src="https://counter.theconversation.com/content/87567/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Mayers is a member of the Liberal Democrats party in the UK </span></em></p>Postnatal depression in men is starting to be recognised, but mental health services aren’t geared up to help this group.Andrew Mayers, Principal Academic in Psychology, Bournemouth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/749112017-04-04T00:44:28Z2017-04-04T00:44:28ZFrom shell-shock to PTSD, a century of invisible war trauma<figure><img src="https://images.theconversation.com/files/163561/original/image-20170403-27251-14zcqdy.jpg?ixlib=rb-1.1.0&rect=0%2C311%2C2389%2C1544&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some soldiers' wounds in WWI were more mental than physical.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/taybot/14565207240">George Metcalf Archival Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>In the wake of World War I, some veterans returned wounded, but not with obvious physical injuries. Instead, their symptoms were similar to those that had previously been <a href="https://www.valas.fr/IMG/pdf/Freud-Oeuvre-traduction-anglaise.pdf">associated with hysterical women</a> – most commonly amnesia, or some kind of paralysis or inability to communicate with no clear physical cause.</p>
<p>English physician Charles Myers, who wrote the first paper on “shell-shock” in 1915, theorized that these symptoms actually did stem from a physical injury. He posited that repetitive exposure to concussive blasts caused brain trauma that resulted in this strange grouping of symptoms. But once put to the test, his hypothesis didn’t hold up. There were plenty of veterans who had not been exposed to the concussive blasts of trench warfare, for example, who were still experiencing the symptoms of shell-shock. (And certainly not all veterans who had seen this kind of battle returned with symptoms.)</p>
<p>We now know that what these combat veterans were facing was likely what today we call <a href="https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml">post-traumatic stress disorder, or PTSD</a>. We are now better able to recognize it, and treatments have certainly advanced, but we still don’t have a full understanding of just what PTSD is.</p>
<p>The medical community and society at large are accustomed to looking for the most simple cause and cure for any given ailment. This results in a system where symptoms are discovered and cataloged and then matched with therapies that will alleviate them. Though this method works in many cases, for the past 100 years, PTSD has been resisting.</p>
<p>We are three scholars in the humanities who have individually studied PTSD – the framework through which people conceptualize it, the ways researchers investigate it, the therapies the medical community devises for it. Through our research, each of us has seen how the medical model alone fails to adequately account for the ever-changing nature of PTSD. </p>
<p>What’s been missing is a cohesive explanation of trauma that allows us to explain the various ways its symptoms have manifested over time and can differ in different people.</p>
<h2>Nonphysical repercussions of the Great War</h2>
<p>Once it became clear that not everyone who suffered from shell-shock in the wake of WWI had experienced brain injuries, the British Medical Journal provided alternate nonphysical explanations for its prevalence. </p>
<blockquote>
<p>A poor morale and a defective training are one of the most important, if not the most important etiological factors: also that shell-shock was a “catching” complaint. – (<a href="http://www.jstor.org/stable/20420866">The British Medical Journal, 1922</a>)</p>
</blockquote>
<p>Shell-shock went from being considered a legitimate physical injury to being a sign of weakness, of both the battalion and the soldiers within it. <a href="https://doi.org/10.1017/CHO9780511675669">One historian estimates</a> <a href="http://www.telegraph.co.uk/history/world-war-one/10577200/WW1-dead-and-shell-shock-figures-significantly-underestimated.html">at least 20 percent</a> of men developed shell-shock, though the figures are murky due to physician reluctance at the time to brand veterans with a psychological diagnosis that could affect disability compensation.</p>
<p>Soldiers were archetypically heroic and strong. When they came home unable to speak, walk or remember, with no physical reason for those shortcomings, the only possible explanation was personal weakness. Treatment methods were based on the idea that the soldier who had entered into war as a hero was now behaving as a coward and needed to be snapped out of it.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163558/original/image-20170402-27259-1c361ss.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163558/original/image-20170402-27259-1c361ss.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163558/original/image-20170402-27259-1c361ss.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=425&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163558/original/image-20170402-27259-1c361ss.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=425&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163558/original/image-20170402-27259-1c361ss.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=425&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163558/original/image-20170402-27259-1c361ss.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=534&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163558/original/image-20170402-27259-1c361ss.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=534&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163558/original/image-20170402-27259-1c361ss.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=534&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Electric treatments were prescribed in psychoneurotic cases post-WWI.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/27337026@N03/2653489628">Otis Historical Archives National Museum of Health and Medicine</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Lewis Yealland, a British clinician, described in his 1918 “<a href="https://archive.org/details/hystericaldisord00yealuoft">Hysterical Disorders of Warfare</a>” the kind of brutal treatment that follows from thinking about shell-shock as a personal failure. After nine months of unsuccessfully treating patient A1, including electric shocks to the neck, cigarettes put out on his tongue and hot plates placed at the back of his throat, Yealland boasted of telling the patient, “You will not leave this room until you are talking as well as you ever did; no, not before… you must behave as the hero I expect you to be.”</p>
<p>Yealland then applied an electric shock to the throat so strong that it sent the patient reeling backwards, unhooking the battery from the machine. Undeterred, Yealland strapped the patient down to avoid the battery problem and continued to apply shock for an hour, at which point patient A1 finally whispered “Ah.” After another hour, the patient began to cry and whispered, “I want a drink of water.”</p>
<p>Yealland reported this encounter triumphantly – the breakthrough meant his theory was correct and his method worked. Shell-shock was a disease of manhood rather than an illness that came from witnessing, being subjected to and partaking in incredible violence.</p>
<h2>Evolution away from shell-shock</h2>
<p>The next wave of the study of trauma came when the Second World War saw another influx of soldiers dealing with similar symptoms.</p>
<p>It was Abram Kardiner, a clinician working in the psychiatric clinic of the United States Veterans’ Bureau, who rethought combat trauma in a much more empathetic light. In his influential book, “<a href="https://books.google.com/books/about/The_Traumatic_Neuroses_of_War.html?id=B2tmMQEACAAJ">The Traumatic Neuroses of War</a>,” Kardiner speculated that these symptoms stemmed from psychological injury, rather than a soldier’s flawed character.</p>
<p>Work from other clinicians after WWII and the Korean War suggested that post-war symptoms could be lasting. Longitudinal studies showed that <a href="https://doi.org/10.1001/archpsyc.1965.01720350043006">symptoms could persist anywhere from six to 20 years</a>, if they disappeared at all. These studies returned some legitimacy to the concept of combat trauma that had been stripped away after the First World War. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163582/original/image-20170403-19462-27tbqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163582/original/image-20170403-19462-27tbqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163582/original/image-20170403-19462-27tbqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=479&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163582/original/image-20170403-19462-27tbqc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=479&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163582/original/image-20170403-19462-27tbqc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=479&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163582/original/image-20170403-19462-27tbqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=602&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163582/original/image-20170403-19462-27tbqc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=602&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163582/original/image-20170403-19462-27tbqc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=602&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As veterans returned home from the war in Vietnam, combat trauma became less stigmatized.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/13476480@N07/24594442566">manhhai</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Vietnam was another watershed moment for combat-related PTSD because veterans began to advocate for themselves in an unprecedented way. Beginning with a small march in New York in the summer of 1967, veterans themselves began to become <a href="https://doi.org/10.2307/800744">activists for their own mental health care</a>. They worked to redefine “post-Vietnam syndrome” not as a sign of weakness, but rather a normal response to the experience of atrocity. Public understanding of war itself had begun to shift, too, as the widely televised accounts of the My Lai massacre brought the <a href="http://www.ucpress.edu/book.php?isbn=9780520065437">horror of war into American living rooms</a> for the first time. The veterans’ campaign helped get PTSD included in the third edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-III), <a href="https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm">the major American diagnostic resource</a> for psychiatrists and other mental health clinicians.</p>
<p>The authors of the DSM-III deliberately avoided talking about the causes of mental disorders. Their aim was to develop a manual that could simultaneously be used by psychiatrists adhering to radically different theories, including Freudian approaches and what is now known as “biological psychiatry.” These groups of psychiatrists would not agree on how to explain disorders, but they could – and did – come to agree on which patients had similar symptoms. So the DSM-III defined disorders, including PTSD, solely on the basis of clusters of symptoms, an approach that has been retained ever since.</p>
<p>This tendency to agnosticism about the physiology of PTSD is also reflected in contemporary evidence-based approaches to medicine. Modern medicine focuses on using clinical trials to demonstrate that a therapy works, but is skeptical about attempts to link treatment effectiveness to the biology underlying a disease.</p>
<h2>Today’s medicalized PTSD</h2>
<p>People can develop PTSD for a number of different reasons, not just in combat. Sexual assault, a traumatic loss, a terrible accident – each might lead to PTSD. The U.S. Department of Veterans Affairs estimates about <a href="https://www.ptsd.va.gov/professional/PTSD-overview/epidemiological-facts-ptsd.asp">13.8 percent of the veterans</a> returning from the wars in Iraq and Afghanistan currently have PTSD. For comparison, a male veteran of those wars is four times more likely to develop PTSD than a man in the civilian population is. PTSD is probably at least partially at the root of an <a href="https://www.mentalhealth.va.gov/docs/Suicide_Data_Report_Update_January_2014.pdf">even more alarming statistic</a>: Upwards of <a href="https://www.va.gov/opa/docs/Suicide-Data-Report-2012-final.pdf">22 veterans commit suicide</a> every day.</p>
<p>Therapies for PTSD today tend to be a mixed bag. Practically speaking, when veterans seek PTSD treatment in the VA system, policy requires they be <a href="https://www.healthquality.va.gov/guidelines/MH/ptsd/cpg_PTSD-full-201011612.PDF">offered either exposure or cognitive therapy</a>. Exposure therapies are based on the idea that the fear response that gives rise to many of the traumatic symptoms can be dampened through <a href="https://www.ptsd.va.gov/public/treatment/therapy-med/prolonged-exposure-therapy.asp">repeated exposures to the traumatic event</a>. Cognitive therapies work on developing personal coping methods and <a href="https://www.ptsd.va.gov/public/treatment/therapy-med/cognitive_processing_therapy.asp">slowly changing unhelpful or destructive thought patterns</a> that are contributing to symptoms (for example, the shame one might feel at not successfully completing a mission or saving a comrade). The most common treatment a veteran will likely receive will include psychopharmaceuticals – especially the class of drugs called SSRIs. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163578/original/image-20170403-19423-b8aw4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163578/original/image-20170403-19423-b8aw4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163578/original/image-20170403-19423-b8aw4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163578/original/image-20170403-19423-b8aw4p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163578/original/image-20170403-19423-b8aw4p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163578/original/image-20170403-19423-b8aw4p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163578/original/image-20170403-19423-b8aw4p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163578/original/image-20170403-19423-b8aw4p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The military is working on incorporating virtual reality with exposure therapy for PTSD sufferers.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/lancecheungmedia/3553753011">Lance Cheung</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Mindfulness therapies, based on becoming aware of mental states, thoughts and feelings and accepting them rather than trying to fight them or push them away, are <a href="https://www.ptsd.va.gov/professional/treatment/overview/mindful-ptsd.asp">another option</a>. There are also more <a href="https://books.google.com/books?hl=en&lr=&id=MFyEg007YEIC&oi=fnd&pg=PR1&dq=hypnosis+and+creative+therapy+for+PTSD&ots=ctUJrwZsSw&sig=NeEiWA7JXZROLxCClei_FB8U-f0#v=onepage&q=hypnosis%20and%20creative%20therapy%20for%20PTSD&f=false">alternative methods being studied</a> such as eye movement desensitization and reprocessing or EMDR therapy, therapies using controlled doses of MDMA (Ecstasy), <a href="http://dx.doi.org/10.1037/ccp0000134">virtual reality-graded exposure therapy</a>, hypnosis and creative therapies. The military funds a wealth of research on new technologies to address PTSD; these include <a href="http://www.darpa.mil/program/our-research/darpa-and-the-brain-initiative">neurotechnological innovations like transcranial stimulation and neural chips</a> as well as <a href="https://doi.org/10.1038/npp.2013.317">novel drugs</a>.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=Zoellner%20LA%5BAuthor%5D&cauthor=true&cauthor_uid=19577224">Several studies</a> have shown that patients improve most when they’ve chosen their own therapy. But even if they narrow their choices to the ones backed by the weight of the National Center for PTSD by using the center’s online <a href="https://www.ptsd.va.gov/apps/decisionaid/">Treatment Decision Aid</a>, patients would still find themselves weighing five options, each of which is evidence-based but entails a different psychomedical model of trauma and healing.</p>
<p>This buffet of treatment options lets us set aside our lack of understanding of why people experience trauma and respond to interventions so differently. It also relieves the pressure for psychomedicine to develop a complete model of PTSD. We reframe the problem as a consumer issue instead of a scientific one.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/163580/original/image-20170403-19459-2ufn6w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163580/original/image-20170403-19459-2ufn6w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/163580/original/image-20170403-19459-2ufn6w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=873&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163580/original/image-20170403-19459-2ufn6w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=873&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163580/original/image-20170403-19459-2ufn6w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=873&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163580/original/image-20170403-19459-2ufn6w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1097&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163580/original/image-20170403-19459-2ufn6w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1097&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163580/original/image-20170403-19459-2ufn6w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1097&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Whereas shell-shock was a weakness, PTSD is understood more sympathetically.</span>
<span class="attribution"><a class="source" href="http://www.loc.gov/pictures/item/2017674898/">Library of Congress, Prints & Photographs Division, American National Red Cross Collection, LC-A6196- 6839-Bx</a></span>
</figcaption>
</figure>
<p>Thus, while WWI was about soldiers and punishing them for their weakness, in the contemporary era, the ideal veteran PTSD patient is a health care consumer who has an obligation to play an active role in figuring out and optimizing his own therapy. </p>
<p>As we stand here with the strange benefit of the hindsight that comes with over 100 years of studying combat-related trauma, we must be careful in celebrating our progress. What is still missing is an explanation of why people have different responses to trauma, and why different responses occur in different historical periods. For instance, the paraylsis and amnesia that epitomized WWI shell-shock cases are now so rare that they don’t even appear as symptoms in the DSM entry for PTSD. We still don’t know enough about how soldiers’ own experiences and understandings of PTSD are shaped by the broader social and cultural views of trauma, war and gender. Though we have made incredible strides in the century since World War I, PTSD remains a chameleon, and demands our continued study.</p><img src="https://counter.theconversation.com/content/74911/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mental health trauma has always been a part of war. Treatments have come a long way over the last century, but we still don’t understand why the responses change for different people and times.MaryCatherine McDonald, Assistant Professor of Philosophy and Religious Studies, Old Dominion UniversityMarisa Brandt, Assistant Professor of Practice, Michigan State UniversityRobyn Bluhm, Associate Professor of Philosophy, Michigan State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/664952016-10-10T03:25:02Z2016-10-10T03:25:02ZFactCheck Q&A: do eating disorders have the highest mortality rate of all mental illnesses?<figure><img src="https://images.theconversation.com/files/141019/original/image-20161009-2652-mlk4.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Labor MP Mark Butler, speaking on Q&A.</span> <span class="attribution"><span class="source">Q&A</span></span></figcaption></figure><p><strong>The Conversation is fact-checking claims made on Q&A, broadcast Mondays on the ABC at 9:35pm. Thank you to everyone who sent us quotes for checking via <a href="http://www.twitter.com/conversationEDU">Twitter</a> using hashtags #FactCheck and #QandA, on <a href="http://www.facebook.com/conversationEDU">Facebook</a> or by <a href="mailto:checkit@theconversation.edu.au">email</a>.</strong></p>
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<figcaption><span class="caption">Excerpt from Q&A, October 3, 2016.</span></figcaption>
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<blockquote>
<p>At the less serious end, in terms of loss of self-esteem and self-confidence, but more serious end, poor diet and so on, and at the very serious end, eating disorders, which are the mental illness type which has the highest mortality rate. – Shadow Minister for Climate Change and Energy, Mark Butler, <a href="http://www.abc.net.au/tv/qanda/txt/s4528828.htm">speaking</a> on Q&A, October 3, 2016.</p>
</blockquote>
<p>Shadow Minister for Climate Change and Energy, Mark Butler, told Q&A that “eating disorders … are the mental illness type which has the highest mortality rate”. </p>
<p>Is that true?</p>
<h2>Checking the source</h2>
<p>When asked to provide sources to support his statement, a spokesperson for Mark Butler pointed The Conversation to the <a href="http://www.nedc.com.au/eating-disorders-in-australia">National Eating Disorders Collaboration</a> website, which says:</p>
<blockquote>
<p>The mortality rate for people with eating disorders is the highest of all psychiatric illnesses and over 12 times that seen in people without eating disorders. </p>
</blockquote>
<p>The National Eating Disorders Collaboration is linked to the federal Department of Health, and brings together people and organisations with an expertise and/or interest in eating disorders. So it is quite a reliable source.</p>
<p>However, we can also test his statement against publicly available research.</p>
<h2>Do eating disorders have the highest mortality rate of all mental illness types?</h2>
<p>Many <a href="http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.09020247">studies</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">meta-reviews</a> and <a href="http://jamanetwork.com/journals/jamapsychiatry/article-abstract/1107207">meta-analyses</a> reveal the <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1107207&version=meter+at+null&module=meter-Links&pgtype=article&contentId=&mediaId=&referrer=&priority=true&action=click&contentCollection=meter-links-click">high mortality rates</a> for eating disorders, <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=207163">in particular anorexia nervosa</a>. (Meta-analyses and meta-reviews involve researchers reading and compiling the results from many studies and use complex statistics to identify bigger trends).</p>
<p>Is it the highest? It depends a bit on what you mean by “mental illness type”. It’s definitely among the highest.</p>
<p>The <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">most recent meta-review</a> published in 2014 found that while the mortality ratio for eating disorders is higher than for most other psychiatric disorders, some <a href="https://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics">substance use disorders</a> had higher mortality ratios.</p>
<p>The <a href="http://www.dsm5.org/Pages/Default.aspx">Diagnostic and Statistical Manual of Mental Disorders</a> (DSM) published by the <a href="https://www.psychiatry.org/">American Psychiatric Association</a> and used internationally to classify and diagnose mental disorders, defines <a href="http://www.dsm5.org/documents/substance%20use%20disorder%20fact%20sheet.pdf">substance use disorders</a> as psychiatric condition. It <a href="http://dsm.psychiatryonline.org/doi/abs/10.1176/appi.books.9780890425596.dsm10">defines</a> eating disorders as:</p>
<blockquote>
<p>… characterised by a persistent disturbance of eating or eating-related behaviour that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. </p>
</blockquote>
<p>Eating disorders defined in the DSM-5 include anorexia nervosa, bulimia nervosa and binge-eating disorder, <a href="http://www.dsm5.org/Documents/Eating%20Disorders%20Fact%20Sheet.pdf">among</a> <a href="http://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425596.dsm10">others</a>. Eating disorders affect <a href="http://www.eatingdisorders.org.au/key-research-a-statistics">men and women of all ages</a>, with the highest incidence among girls and women. <a href="http://www.nedc.com.au/eating-disorders-in-australia">Many cases</a> emerge in adolescence. </p>
<p>It’s worth noting that there are some overlaps between eating disorders and <a href="http://onlinelibrary.wiley.com/doi/10.1002/1098-108X(199407)16:1%3C1::AID-EAT2260160102%3E3.0.CO;2-T/full"> substance use disorders</a> as well as <a href="https://books.google.com.au/books?hl=en&lr=&id=mM7SAgAAQBAJ&oi=fnd&pg=PA193&dq=depression+eating+disorders+comorbidity&ots=GyajwIogyV&sig=1kKOybyI4Rf093oztj9bOVJmhUw#v=onepage&q=depression%20eating%20disorders%20comorbidity&f=false">anxiety and depression</a>. It’s not always clear what caused what, or what the cause of death was because a person may have <a href="https://www.researchgate.net/profile/Dara_Greenwood/publication/12517510_Mortality_in_eating_disorders_A_descriptive_study/links/0deec52496fbc86eb0000000.pdf">many physical and psychological conditions</a>. </p>
<h2>What does the research show?</h2>
<p><a href="https://thebutterflyfoundation.org.au/assets/Uploads/Butterfly-report-Paying-the-Price-Executive-Summary.pdf">A report</a> written by <a href="http://www.deloitteaccesseconomics.com.au/">Deloitte Access Economics</a> for the <a href="https://thebutterflyfoundation.org.au/about-us/">Butterfly Foundation</a> estimated that there were 913,986 people in Australia with eating disorders in 2012. That’s 4% of the population. The report estimated that 1,829 people died from eating disorders in Australia in 2012. </p>
<p>A number of international reviews and meta-analyses comparing mortality rates of psychiatric disorders show that substance use disorders and eating disorders have the highest risk of death.</p>
<p>The <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">most recent meta-review</a>, published in 2014, summarised data and findings from research of over 1.7 million patients. The authors estimated (in Table 1 of the study <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">here</a>) that the mortality risk is higher for opioid use, cocaine use, and amphetamine use than for anorexia nervosa. The authors said that:</p>
<blockquote>
<p>All disorders had an increased risk of all-cause mortality compared with the general population, and many had mortality risks larger than or comparable to heavy smoking. Those with the highest all-cause mortality ratios were substance use disorders and anorexia nervosa.</p>
</blockquote>
<p><a href="http://bjp.rcpsych.org/content/173/1/11.full-text.pdf+html">A systematic review</a> published by British researchers in 1998 compared the mortality rates of 27 mental disorders. It also found that eating disorders had among the highest risks of premature death among both genders, but prescription and legal drug abuse, opioid abuse were higher in some analyses. </p>
<p>A <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1107207&version=meter+at+null&module=meter-Links&pgtype=article&contentId=&mediaId=&referrer=&priority=true&action=click&contentCollection=meter-links-click">meta-analysis</a> of mortality rates in eating disorders published in 2011 reported that anorexia nervosa had a significantly higher mortality ratio than <a href="http://www.sciencedirect.com/science/article/pii/S0920996499001917">schizophrenia</a> and <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=481814">bipolar disorder</a>.</p>
<p>A <a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.462.2442&rep=rep1&type=pdf">1995 meta-analysis</a> of 42 studies of eating disorder case reports noted that:</p>
<blockquote>
<p>The aggregate annual mortality rate associated with anorexia nervosa is more than 12 times higher than the annual death rate due to all causes of
death for females 15-24 years old in the general population (0.00045 deaths per year) and more than 200 times greater than the suicide rate in the general population (0.00002 suicides per year).</p>
</blockquote>
<h2>What are people with eating disorders dying from?</h2>
<p>Deaths associated with eating disorders are typically caused by medical complications (such as cardiovascular issues and multiple organ failure), suicide or complications relating to substance use. </p>
<p>A <a href="http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.09020247">United States study</a> reported on the causes of death in a group of eating disorder patients between 1979 and 1997. Of the 52 deceased patients, 20 died from medical causes, 13 died from suicide, 10 died from causes related to substance use, and nine died from “traumatic causes” (which was not further defined in that study). <a href="https://www.researchgate.net/profile/Dara_Greenwood/publication/12517510_Mortality_in_eating_disorders_A_descriptive_study/links/0deec52496fbc86eb0000000.pdf">Examples</a> of deaths from medical causes include acute alcohol intoxication, cardiorespiratory issues, issues with the liver and other major organs, and pneumonia.</p>
<p>Although high rates of mortality are reported for eating disorder patients, there are a large proportion of people with these conditions who go on to engage in successful treatment, and recover. Inpatient or outpatient treatment <a href="http://www.indianjpsychiatry.org/article.asp?issn=0019-5545;year=2010;volume=52;issue=2;spage=174;epage=186;aulast=Chakraborty">usually involves</a> a combination of nutritional management, psychotherapy, and medication.</p>
<h2>Verdict</h2>
<p>Mark Butler was broadly correct. Many studies show that eating disorders are among the mental illness types with the highest mortality rate. </p>
<p>Is it the highest? It’s hard to say for sure. <a href="http://onlinelibrary.wiley.com/doi/10.1002/wps.20128/full">Two</a> <a href="http://bjp.rcpsych.org/content/173/1/11.full-text.pdf+html">studies</a> that compile much of the research in this area confirm that substance use disorders and eating disorders have the highest mortality risk of all psychiatric conditions. </p>
<p>Some patients may experience more than one psychiatric disorder. It’s not always clear what role an eating disorder may have had in a person’s death, as there may be many influencing factors. </p>
<p>So it is hard to make a clear statement about which psychiatric conditions have the highest mortality rate of all. <strong>– Zali Yager.</strong></p>
<hr>
<h2>Review</h2>
<p>This is a sound analysis. It is worth noting that <em>all</em> eating disorders are associated with elevated mortality and suicide, as sometimes the general public fixate on anorexia nervosa. <strong>– Tracey Wade.</strong></p>
<hr>
<p><em>If this article has raised concerns about eating disorders, please contact the Butterfly Foundation national hotline on 1800 33 4673; or visit <a href="https://thebutterflyfoundation.org.au/">their website</a> for support and resources for eating disorder sufferers and their families and carers.</em></p>
<p><em>If this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p>
<hr>
<p><div class="callout"> Have you ever seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at checkit@theconversation.edu.au. Please include the statement you would like us to check, the date it was made, and a link if possible.</div></p><img src="https://counter.theconversation.com/content/66495/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zali Yager receives funding from the Australian Research Council, Australian Anti-Doping Association, and Oregon Health and Science University. She is a member of the Academy for Eating Disorders and has previously collaborated with the Butterfly Foundation on research projects.
</span></em></p><p class="fine-print"><em><span>Tracey Wade 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>Shadow Minister for Climate Change and Energy Mark Butler told Q&A that eating disorders “are the mental illness type which has the highest mortality rate”. We check the research.Zali Yager, Associate Professor in Health and Physical Education, Victoria UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/560232016-05-13T03:46:15Z2016-05-13T03:46:15ZSeparation anxiety disorder: not just for kids<figure><img src="https://images.theconversation.com/files/119207/original/image-20160419-5284-1vuqerx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When many doctors went through training they would not have learnt adults could suffer from separation anxiety.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Until 2013, separation anxiety disorder was confined to literature on juvenile anxiety disorders. It was omitted from the diagnostics and statistical manual on adult anxiety disorders. The disorder was reluctantly acknowledged to occur in young adults but only if they had a history of separation anxiety as a child. </p>
<p>To further complicate matters, doctors and researchers previously thought childhood separation anxiety was closely related to the development of adult panic disorder and agoraphobia (fear of public places), rather than an adult form of separation anxiety. </p>
<p>It is now known that not only can adults of all ages suffer from separation anxiety, but almost <a href="http://www.ncbi.nlm.nih.gov/pubmed/26046337">45% of lifetime separation anxiety</a> first manifests in adulthood without a history of juvenile separation anxiety. Based on research over the last 20 years, the fifth diagnostics and statistical manual (DSM-5) has broadened the range of adult anxiety disorders to include separation anxiety. </p>
<p>This has also meant overlapping features with other disorders (most commonly panic disorder, agoraphobia and generalised anxiety disorder) may have been previously misdiagnosed. These need to be better assessed to determine whether separation anxiety is a more likely diagnosis.</p>
<h2>What is separation anxiety?</h2>
<p>Separation anxiety is characterised by irrational fears of separation and abandonment by close attachment figures such as parents, partners and even pets. </p>
<p>Many people with separation anxiety also experience a reluctance to leave their homes. This may be accompanied by feelings of dread or anxiety. In children, separation anxiety can manifest as “clingy” behaviours towards parents and vague physical symptoms such as stomach aches and nausea. </p>
<p>Adults with separation anxiety often find it difficult to leave their partners even for a short time. They may experience symptoms when work commitments delay their return home. Severe separation anxiety can lead to panic attacks when separated from close attachments or when ruminating about possible separations. </p>
<p>If unchecked, these anxieties can result in avoidance of places associated with previous experiences of anxiety symptoms and panic attacks. This may also lead to social isolation and difficulties in shopping or leaving home (agoraphobia).</p>
<p>Underlying separation anxiety can be “hidden” by excessive technology-based social interaction such as texting and Instagramming. It may only become evident when these activities are restricted or curtailed.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/119208/original/image-20160419-5312-jwsmo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/119208/original/image-20160419-5312-jwsmo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/119208/original/image-20160419-5312-jwsmo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/119208/original/image-20160419-5312-jwsmo4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/119208/original/image-20160419-5312-jwsmo4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/119208/original/image-20160419-5312-jwsmo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/119208/original/image-20160419-5312-jwsmo4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/119208/original/image-20160419-5312-jwsmo4.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"></a>
<figcaption>
<span class="caption">People can become anxious when separated from loved ones, including pets.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>When these fears begin to affect people’s lives this is <a href="http://www.dsm5.org/Pages/Default.aspx">classified</a> as an anxiety disorder. This may mean they experience difficulties in going to work or to school, or feel the need to “shadow” their close attachments either by maintaining close physical proximity or by having to contact them frequently throughout the day. </p>
<p>Although separation anxiety can affect people of all ages, it is more prevalent among children. In anxiety clinics that specialise in the treatment of children, these rates can be <a href="http://www.jaacap.com/article/S0890-8567(09)65731-2/abstract">as high as 47%</a>. </p>
<p>However, separation anxiety is not a rare disorder among adults. A <a href="http://www.ncbi.nlm.nih.gov/pubmed/26046337">recent cross-national study</a> of disorders in 18 countries found lifetime rates of separation anxiety ranging from 0.2% to 9.8%, with an average of 4.8% across countries. Rates were higher in women than men.</p>
<h2>Diagnosis</h2>
<p>Despite its recent inclusion in the DSM-5 and high prevalence in clinical practice, most doctors tend to be reluctant to diagnose adult patients with separation anxiety. </p>
<p>Part of the reluctance may be due to their earlier training, which would have said adults do not, in general, suffer from this form of anxiety. Instead, they may be diagnosed with other “adult” anxiety disorders that share some common features with separation anxiety (most notably panic attacks and avoidance behaviours).</p>
<p>Separation anxiety in adults also frequently occurs with other psychiatric conditions, such as depression, which can mask subtle symptoms of separation anxiety. Sufferers are not always open about directly discussing their irrational fears of abandonment with doctors due to embarrassment or lack of awareness of these underlying issues.</p>
<p>Nevertheless, accurate recognition and diagnosis of separation anxiety is important. <a href="http://www.ncbi.nlm.nih.gov/pubmed/24129927">Studies</a> have shown most people with this disorder aren’t properly treated. Misdiagnoses result in people with separation anxiety frequently being treated for the wrong conditions.</p>
<p>Many adults with the disorder can recount therapy experiences where their specific separation fears were not addressed, or were dealt with in a cursory way, as they were treated for another disorder. Therapists have also noted that adults with co-occurring anxiety disorders and separation anxiety do not respond as well to standard treatments. The presence of separation anxiety adds a high degree of complexity to treatment decisions.</p>
<p>Adult separation anxiety, especially in the absence of a history of childhood separation anxiety, is a relatively new concept. There are, as yet, no published evidence-based treatments for the condition.</p>
<p>However, there are indications that therapies focusing specifically on fears of separation from close attachments and on strategies to internalise the emotional support provided by others could be beneficial – for example, by being able to self-soothe or better process distressing emotions.</p>
<p>It’s positive that separation anxiety has finally been formally recognised as a “legitimate” adult anxiety disorder. However, further work needs to be done to break down reluctance among doctors and researchers in diagnosing and developing effective treatments for this debilitating condition.</p><img src="https://counter.theconversation.com/content/56023/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vijaya Manicavasagar receives funding from the Department of Health and Ageing (Australia</span></em></p>Adult separation anxiety is a relatively new concept. There are, as yet, no published evidence-based treatments for the condition.Vijaya Manicavasagar, Director of Psychological Services, Black Dog Institute; Associate Professor, School of Psychiatry, Faculty of Medicine, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/473102015-09-21T09:33:26Z2015-09-21T09:33:26ZIs the changing definition of autism narrowing what we think of as ‘normal’?<figure><img src="https://images.theconversation.com/files/95464/original/image-20150920-11714-la6m1y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Is normal behavior being pathologized?</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/elizabeth_albert/4998473663/in/photolist-8BGu5p-H8xJC-f3rcu5-5G7o4F-arV7hJ-5iZgJv-caoR2A-5rEdVV-pzpQiy-pEA2Vt-5u92mx-ucGjpD-mDn41E-dcJXao-o6B3RD-5zRiDT-K1uNX-eSFyXE-e938qa-aySbxo-mgRRzB-aqWeX-a9Va4u-TuwUY-bkiYKy-a9V9PA-yEu7-9QkofD-rq2SNj-jwazH-5R4hBA-pPQwYf-8W2Jft-7QrxNC-nocAat-rycrA6-nHK8LR-5xx4KY-bsp6S5-nWLxNS-cmLwXh-8Gze6T-hBpyoD-8qGjPp-9E5Z8H-cSbPZ-9yuSeF-8MFJU7-wT6w23-p9NkG7">Elizabeth Albert/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>I first learned about autism in 1997 in my high school psychology course. It was relegated to a small paragraph in a chapter on childhood disorders. The film Rainman had come out a decade earlier, publicizing the condition to a degree. But autism still wasn’t well-known – or well-understood, at the time.</p>
<p>That certainly isn’t the case today. </p>
<p>Since then I have been a special educator, an autism consultant, and, most recently, an autism advocate and researcher. I explore how both culture and ethics influence autism as a concept, diagnosis and lived experience. One thing that is clear is that the way we think about autism has changed.</p>
<p>As the power and recognition of modern psychiatry as a medical field have expanded, so has the way we think about and define different conditions, including autism. The diagnostic criteria for autism have gotten broader, helping it go from a rare disorder to one that affects <a href="http://www.cdc.gov/ncbddd/autism/data.html">one in 68 children</a> in just a few decades. </p>
<p>And this shift isn’t unique to autism. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) – the book psychiatrists use to determine diagnoses – was criticized for lowering the diagnostic thresholds for many conditions. As these broader concepts for psychiatric disorders rapidly gain public recognition and influence, our concept of what is “normal” becomes increasingly narrow. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95260/original/image-20150917-7494-1hhhc79.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95260/original/image-20150917-7494-1hhhc79.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95260/original/image-20150917-7494-1hhhc79.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95260/original/image-20150917-7494-1hhhc79.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95260/original/image-20150917-7494-1hhhc79.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95260/original/image-20150917-7494-1hhhc79.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95260/original/image-20150917-7494-1hhhc79.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">A shifting definition.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-179060576/stock-photo-fake-dictionary-dictionary-definition-of-the-word-autism.html?src=6HKnlb94QtStXAF5D2B-Cw-2-45">Dictionary page via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>How autism has changed from DSM to DSM</h2>
<p>The first edition of the DSM was published in 1952. It was 130 pages and contained 106 diagnostic descriptions. The most recent edition, the <a href="http://www.dsm5.org/Pages/Default.aspx">DSM-5</a>, published in 2013, is 947 pages and covers roughly 300 disorders. As the DSM has gotten bigger and broader, so too has the definition of autism. </p>
<p>Before 1980, the word “autistic” appeared in the DSM only as a trait to describe schizophrenia. But that doesn’t mean diagnostic criteria for autism didn’t exist. A <a href="http://dx.doi.org/http://dx.doi.org/10.1111/j.1939-0025.1956.tb06202.x">1956 article</a> by Leo Kanner (who is credited with “discovering” autism) and Leon Eisenberg focused on two criteria: aloofness and a significant resistance to changes in routines, noticeable in a child by 24 months of age. These traits are still present in diagnostic criteria today, and are sometimes called classic autism or Kanner’s autism. </p>
<p>The DSM-III, released in 1980, introduced “infantile autism,” officially creating a separate diagnosis for autism for the first time. Seven years later, a revised edition, the DSM-III-R, changed the name to “autistic disorder” and placed it in the category of <a href="http://www.ninds.nih.gov/disorders/pdd/pdd.htm">Pervasive Developmental Disorders</a> along with other related conditions like Asperger’s Disorder and Pervasive Developmental Disorders - Not Otherwise Defined (PDD-NOS).</p>
<p>The DSM-III-R marks the first expansion of the diagnostic criteria for autism. Criteria were broken up into three categories: social interaction, communication and behavior, covering about 16 traits. At least eight of the 16 traits were required for a diagnosis. The manual covered behaviors that occurred outside the psychiatrist’s office, such as “absence of imaginative activity,” making parental input necessary. The manual also included examples of each of these traits to guide diagnosticians. </p>
<p>The 1994 DSM-IV dropped the number of required traits for a diagnosis from eight to six. And the majority of behavioral examples included in earlier versions of the manual were removed, meaning that physicians had to interpret behavioral descriptions with less guidance.</p>
<p>These changes, along with better educational services and public awareness (thanks in large part to the film Rainman), marked a dramatic rise in autism prevalence, jumping from one in 2,500 in the 1980s to one in 250 in the late 1990s. These criteria remained in place for almost 20 years when the DSM-5 was released in 2013.</p>
<p>The DSM-5 changed the diagnostic criteria yet again. Autism and related conditions like Asperger’s and PDD-NOS were collapsed into a single diagnosis: “autism spectrum disorder.” Three categories of diagnostic traits became two: social interaction and social communication became one category and the behavior category remained. No required number of traits are needed from the social interaction category for a diagnosis, but two are required from the behavior category. </p>
<p>These changes were initially criticized due to concern that the shift to “autism spectrum disorder” could reduce diagnoses, and possibly result in fewer children getting needed services. But this diagnostic reorganization seems to me like an even broader diagnostic process. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95390/original/image-20150918-17686-1k7o4z5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95390/original/image-20150918-17686-1k7o4z5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95390/original/image-20150918-17686-1k7o4z5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95390/original/image-20150918-17686-1k7o4z5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95390/original/image-20150918-17686-1k7o4z5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95390/original/image-20150918-17686-1k7o4z5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95390/original/image-20150918-17686-1k7o4z5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A diagnosis can result in fairly good educational services.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-310231568/stock-photo-happy-schoolchildren-at-primary-school-raising-hand-in-elementary-multi-ethnic-classroom.html?src=AoYMCo0h3i812apm0k5tyg-4-34">Classroom via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<h2>Despite broader criteria, diagnostic disparities persist</h2>
<p>In the case of autism, there is a <a href="http://www.ncbi.nlm.nih.gov/pubmed/12216059">higher demand</a> for the diagnosis. Having an autism diagnosis can result in fairly good education services these days, such as smaller class sizes, in-school therapies, and one-on-one teacher attention for children with the diagnosis. Psychiatrist and researcher Judy Rappaport is <a href="http://www.pbs.org/newshour/bb/health-jan-june11-grinkerext_04-19/">quoted</a> as saying: </p>
<blockquote>
<p>…We’ll call that kid a zebra if he needs to be called a zebra to get the educational and other services that he needs and deserves.</p>
</blockquote>
<p>Even though the criteria for an autism diagnosis have gotten broader, many children who could and should be diagnosed aren’t. Studies have shown that many minority children, especially African-American kids, are misdiagnosed with conditions such as <a href="http://dx.doi.org/10.2105/AJPH.2007.131243">ADD or oppositional defiant</a> disorder, which are suggestive of defiant emotional problems resulting from poor or neglectful environments. These discrepancies hold remnants of early claims from the mid-1900s that autism is a disorder of the white upper and middle class. </p>
<p>This discrepancy <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6302a1.htm?s_cid=ss6302a1_w">has continued</a>: 12.3 per 1,000 African American kids are diagnosed with autism and 10.8 per 1,000 Hispanic children, compared to 15.8 per 1,000 among white children. </p>
<p>There are many reasons these racial disparities exist. Persistently vague diagnostic criteria allow for subjectivity in diagnostic practices for autism. And it is also a question of access. Minority children are more likely to come from <a href="http://www.urban.org/research/publication/racial-and-ethnic-disparities-among-low-income-families">lower-income families</a> who simply do not have the time or money to get a diagnosis. And psychiatric and development disorders are more stigmatized in many <a href="http://dx.doi.org/10.1016/j.chc.2010.07.005">nonwhite communities</a>, meaning families are less likely to <a href="http://dx.doi.org/10.1080/19371918.2011.579499">seek</a> a diagnosis.</p>
<h2>Broad diagnoses change our concept of ‘normal’</h2>
<p>When the DSM-5 was released, it sparked <a href="http://www.ipetitions.com/petition/dsm5/">a petition</a> signed by over 15,000 psychologists. The petition argued that the manual placed the diagnostic threshold for many conditions too low, making it easier to apply a psychiatric label to a wider range of people. That also means the DSM has the power to make people more eligible for treatment with drugs whose effects, <a href="http://dx.doi.org/10.1136/bmj.h2435">especially long-term</a>, are not fully studied. </p>
<p>Allen Frances, the chair of the DSM-IV task force, <a href="http://www.harpercollins.com/9780062229250/saving-normal">has highlighted</a> the risk that “normal” people are being diagnosed with mental conditions they do not have, thanks to overly broad diagnostic criteria in the DSM-5. This almost exactly mirrors criticisms over the broadening definition of autism. </p>
<p>And as the definition of autism get broader, it narrows what is considered “normal.” People who would not previously have had a diagnosis are now being pathologized. We are constructing a new reality of the disorder that does not accurately represent the most affected population. This could divert attention and resources from the people who need it the most – the significantly disabled.</p>
<p>Rates of people with less significant forms of autism will rise and become the autistic norm, as we see in media portrayals in TV shows like Parenthood and or books like The Curious Incident of the Dog in Nighttime. When this becomes the autistic norm, people who are more significantly autistic appear super-disabled, and then become super-stigmatized.</p><img src="https://counter.theconversation.com/content/47310/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Sarrett does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Autism has gone from a rare disorder to one that affects one in 68 children in a few decades.Jennifer Sarrett, Lecturer, Center for Study of Human Health, Emory UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/299232014-08-06T16:44:35Z2014-08-06T16:44:35ZHoarding hundreds of pets is not just unhygienic, it’s a psychological disorder<figure><img src="https://images.theconversation.com/files/55876/original/27wwjbkd-1407330598.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">More than a pet problem.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/ikayama/5538051784">Ikayama</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>The broad category of hoarding has only recently been recognised as a psychiatric disorder. It first made an appearance in the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders, the <a href="http://dsm.psychiatryonline.org/book.aspx?bookid=556">global reference book of mental health</a>. But while society seems to be aware of the problem of hoarding objects, animal hoarding, where dozens or hundreds of animals can be kept under bad and unsanitary conditions, remains under-recognised.</p>
<p>However, this is not because it is uncommon. Up to 2,000 new cases are <a href="http://vet.tufts.edu/hoarding/pubs/pubhlthrep.pdf">estimated to appear every year</a> in the US. And this is likely to be an underestimate, because there is a lack of public awareness that it is a condition and only very severe cases are identified.</p>
<p>This also means that very little research has been done on animal hoarding. Most has been done in the US by a group of experts called the Hoarding of Animals Research Consortium. But interest in researching animal hoarding has been increasing, including two new studies published this year; <a href="http://www.imim.es/news/180/animal-hoarding-a-lesser-known-problem-for-public-health-and-welfare">one by myself and colleagues in Spain</a> and <a href="http://michiganpaw.org/tag/linda-marston">another in Australia</a>.</p>
<p>From this research, it is clear that this condition appears and has similarities across different cultures, but there are still many aspects of animal hoarding to uncover.</p>
<h2>The symptoms</h2>
<p>There are a number of symptoms, which when combined constitute an animal hoarding disorder. A prerequisite is having a large number of animals at home – we have seen cases of only ten animals, to people hoarding more than 500 in their homes. Sufferers are unable to provide the minimum standards of care for those animals and will deny or downplay the deplorable conditions they and their animals are living in. </p>
<p>This being such a new area of study, this is a very practical and descriptive definition of the disorder, which could change in the future when we know more about it. For example, the boundaries between functional and dysfunctional pet ownership are still not completely defined. Discovering these boundaries could lead to a different kind of definition and understanding of the problem.</p>
<h2>Negative effects</h2>
<p>However, if we take into account the current definition of animal hoarding, there are some key negative consequences of this psychiatric disorder. From the perspective of the animals, there can be severe welfare issues. Most of the animals found in animal hoarding cases are in deplorable conditions: sick, dirty, full of parasites and many dead animals can even be found when you enter an animal hoarder’s home.</p>
<p>Cases of animal hoarding can also lead to several public health issues in the surrounding environment including infestations of parasites, such as fleas and ticks, or environment toxicity, such as dangerous levels of ammonia from animal urine, in the air that people breath.</p>
<p>Then there are the hoarders themselves to think about. Animal hoarders live in the same unsanitary environment as their animals, maybe without being able to have a functional kitchen or even a clean bed to sleep.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/55878/original/2rhpsz9k-1407331028.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/55878/original/2rhpsz9k-1407331028.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/55878/original/2rhpsz9k-1407331028.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/55878/original/2rhpsz9k-1407331028.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/55878/original/2rhpsz9k-1407331028.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/55878/original/2rhpsz9k-1407331028.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/55878/original/2rhpsz9k-1407331028.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">Pining for freedom?</span>
<span class="attribution"><span class="source">Julicath</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>The most common profile of an animal hoarder is a socially isolated, middle-aged or old woman who hoards cats or dogs – or both. However, men or even whole families, with children or other dependent relatives, can be animal hoarders or live in a hoarding situation. And not only dogs and cats are hoarded – other species that have been found include farm animals and reptiles.</p>
<p>From a health perspective, there is a way to go to understand what leads a person into these hopeless situations, where they are surrounded by dozens or even hundreds of animals and their faeces and urine. Early research shows that animal hoarding is often associated with attachment problems to other people, which leads to an excessive attachment to animals. This could be due to being a victim of neglect or abuse during childhood, as many of the known animal hoarders’ <a href="http://www.imim.es/news/180/animal-hoarding-a-lesser-known-problem-for-public-health-and-welfare">investigations indicated</a>.</p>
<p>Animal hoarding sometimes appears alongside other mental disorders, like object hoarding or dementia. A common trait is the lack of insight or awareness in hoarders of their situation, and there can also be certain lack of empathy with other creatures. </p>
<h2>Tackling the problem</h2>
<p>Even though the exact cause of animal hoarding needs more analysis, the first steps for tackling this problem are broadly agreed on by those researching it. Earlier detection of cases could come from increasing public awareness of the problem, and a simple change in society’s perception of animal hoarding could save many animals’ lives and prevent severe human and public health consequences.</p>
<p>There also needs to be standardised policies for effective interventions when animal hoarding is identified. These need to respond to both the animals and the hoarder’s needs. Currently, only a few states in the US have policies in place to deal with the disorder.</p>
<p>It’s also important that those found hoarding animals are taken care of. At present, when a case is detected, the animals are removed but no attention is given to the person suffering. More often than not this person doesn’t realise that their animals are in poor health and are likely to soon start hoarding again. They need individual mental health treatment, as soon as possible, to prevent the usual evolution of a terrible and long-term condition.</p><img src="https://counter.theconversation.com/content/29923/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paula Calvo Soler consults to and receives funding from Affinity Foundation.</span></em></p>The broad category of hoarding has only recently been recognised as a psychiatric disorder. It first made an appearance in the 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders…Paula Calvo Soler, PhD in Anthrozoology- Researcher at Chair Affinity Foundation Animals and Health. Department of Psychiatry, Universitat Autònoma de BarcelonaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/166072013-08-19T20:30:19Z2013-08-19T20:30:19ZDisordered gambling: focusing on more than just ‘problem gamblers’<figure><img src="https://images.theconversation.com/files/29056/original/s3d93cs2-1376285919.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The psychiatrists' bible, the DSM-5, recently added 'gambling disorder' to its list of 'behavioural addictions'. But how true is its definition, and should it be changed?</span> <span class="attribution"><span class="source">AAP/Mick Tsikas</span></span></figcaption></figure><p>Since the issue of problem gambling was placed under the national spotlight by the <a href="http://www.pc.gov.au/projects/inquiry/gambling">Productivity Commission in 1999</a>, we have witnessed ongoing public debate about Australia’s gambling industries. The commission estimated the prevalence of problem gambling to be 2.1% of the adult population, translating at the time to approximately 290,000 people.</p>
<p>However, the debate about problem gambling is plagued by shifting definitions and understandings. Earlier this year, the American Psychiatric Association (APA) released the fifth edition of its keystone Diagnostic and Statistical Manual of Mental Disorders <a href="http://www.dsm5.org/">(DSM-5)</a>, an update on the DSM-IV that:</p>
<blockquote>
<p>…marked the end of more than a decade’s journey in revising the criteria for the diagnosis and classification of mental disorders.</p>
</blockquote>
<p>The DSM is the psychiatrists’ bible, providing the diagnostic criteria for all forms of mental disorders. It is designed to enable psychiatrists to better identify the symptoms of mental illness and diagnose them accurately, with a view towards effective treatments and interventions.</p>
<p>One of the new additions to the DSM-5 is <a href="http://www.dsm5.org/Documents/Substance%20Use%20Disorder%20Fact%20Sheet.pdf">“gambling disorder”</a>, the only entry in a new “behavioural addictions” category. It reflects <a href="http://dx.doi.org/10.1146/annurev-clinpsy-040510-143928">research findings</a> that gambling shares certain similarities with substance-specific addictions (such as alcohol and stimulant use) in terms of clinical expression, neurobiology, comorbidity and treatment.</p>
<p>This gives “disordered gambling” a somewhat unique position as the sole behavioural addiction, separating it from its previous categorisation (APA DSM-IV) as an <a href="http://allpsych.com/disorders/impulse_control/gambling.html">impulse control disorder</a>, alongside such conditions as the plucking of body hair, pyromania, explosive anger, kleptomania, sexual compulsion, skin picking, internet addiction and compulsive shopping. The shifting classification of pathological gambling - or disordered gambling as it is now known - belies the inevitably arbitrary nature of these psychiatric categories.</p>
<p>Surely a better definition of gambling disorders is a good thing? In the words of the <a href="http://www.dsm5.org/Documents/Substance%20Use%20Disorder%20Fact%20Sheet.pdf">APA</a>:</p>
<blockquote>
<p>Recognition of these commonalities will help people with gambling disorder get the treatment and services they need, and others may better understand the challenges that individuals face in overcoming this disorder.</p>
</blockquote>
<p>Well, to a point. As British sociologist <a href="http://books.google.co.uk/books?id=4O0d3Wxj0sUC">Nikolas Rose</a> points out, part of the answer depends on how the labels created by the “psy sciences” to describe aberrant consumers such as <a href="http://www.sfu.ca/media-lab/426/readings/consumptionaddiction.pdf">pathological gamblers, kleptomaniacs, anorexics, bulimics, and shopaholics</a> actually get used in our society. These are powerful terms, and while they can be used for diagnosis and treatment, they can also be subverted to the interests of powerful players.</p>
<p>To take a step back, there have been negative consequences for individuals and families ever since gambling has existed. However, it has only been relatively recently that we have started to consider the problems with gambling as a form of individual pathology. “Pathological gambling” emerged as a fully-fledged mental disorder in the DSM-III in 1980, although attempts to study the deviant anatomy of those suffering “gambling mania” date back to the 19th century.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/28464/original/7bqwz6q3-1375318820.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/28464/original/7bqwz6q3-1375318820.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/28464/original/7bqwz6q3-1375318820.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=743&fit=crop&dpr=1 600w, https://images.theconversation.com/files/28464/original/7bqwz6q3-1375318820.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=743&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/28464/original/7bqwz6q3-1375318820.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=743&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/28464/original/7bqwz6q3-1375318820.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=933&fit=crop&dpr=1 754w, https://images.theconversation.com/files/28464/original/7bqwz6q3-1375318820.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=933&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/28464/original/7bqwz6q3-1375318820.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=933&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The disordered gambler, as seen through the lens of 19th century proto-psychiatry, Théodore Géricault, The Woman with Gambling Mania, c.1820.</span>
</figcaption>
</figure>
<p>While in Australia the term “problem gambling” is preferred to pathological gambling in <a href="http://www.pc.gov.au/projects/inquiry/gambling-2009/report">policy circles</a>, the psychometric tools used in prevalence studies largely are based on the <a href="http://dx.doi.org/10.4309/jgi.2008.22.2">pathological gambling definition</a>. The key point here, one also made by gambling researcher <a href="http://theconversation.com/responsible-gambling-and-the-spectacle-of-the-problem-gambler-13579">Charles Livingstone</a>, is that this process takes a complex social problem and locates responsibility for it firmly within the mind of the aberrant individual. Moved back into the public arena, the implication is that if we had none of these irksome and maladjusted problem gamblers all would be well.</p>
<p>To this end, nearly every Australian state and territory has collectively spent millions trying to address problem gambling over the past two decades. One of their primary responses has been to conduct numerous and expensive prevalence studies to measure the numbers of problem gamblers in each jurisdiction. However, based our own research experience over the ten years, including the running of a prevalence survey and as advisor to others, we argue that problem gambling prevalence studies are virtually useless for public policy. </p>
<p>If prevalence estimates fall over time it is tempting to assume that somehow policy has made a difference. Conversely, rising estimates may be attributed to increased gambling availability. Simply put, unless we have identified a direct causal mechanism linking a particular policy or harm-minimisation measure to pathological gambling levels, then these associations may be spurious. Prevalence studies simply do not help governments to know if what they do makes any difference.</p>
<p>To make matters worse, the measurement error involved in estimating the number of problem gamblers is so great that identifying any trends in problem gambling rates with any degree of precision is nigh on impossible. For example, we were simplifying matters earlier when we stated that the Productivity Commission’s 1999 survey found that 2.1% of adults were problem gamblers. More accurately, the commission found that, had it repeated its survey 20 times, it would expect that on 19 of these hypothetical occasions it would have pegged the problem gambling rate somewhere between 1.6% and 2.4%. </p>
<p>The uncertainty inherent in this estimate – and the unfortunate fact that subsequent surveys have typically used modified methods that are not directly comparable – makes demonstrating trends or the real world effect of any policy change unfeasible.</p>
<p>So why do we keep doing them? The <a href="http://informahealthcare.com/doi/abs/10.3109/16066359.2012.680079">simple answer</a> is that the state-industry gambling complex actually needs the pathological gambler category, not just in an economic sense, but to rationalise their support of the gambling industries. </p>
<p>By locating the source of “the problem” in a pathologised minority, we transfer responsibility from the producers to the consumers of harmful products (and coincidentally keep a small niche of consultants and academic researchers like ourselves in employment). In this way, blame may be tied to the actions of a few unfortunates as opposed to the broader institutions of society (that is, the government and the market).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/29104/original/4xpxb2y8-1376353135.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/29104/original/4xpxb2y8-1376353135.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/29104/original/4xpxb2y8-1376353135.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/29104/original/4xpxb2y8-1376353135.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/29104/original/4xpxb2y8-1376353135.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/29104/original/4xpxb2y8-1376353135.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/29104/original/4xpxb2y8-1376353135.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Gambling remains pervasive in Australian society despite wide research on its social and psychological harms.</span>
<span class="attribution"><span class="source">AAP/Dean Lewins</span></span>
</figcaption>
</figure>
<p>As James Packer - Australia’s multibillionaire gambling magnate - <a href="http://www.theglobalmail.org/feature/empire-under-the-son/542/">recently noted</a>, gambling is “a fun business, as long as you’re not hurting people”. It is this fantasy of a gambling industry without harmful consequences that is offered by the precisely-defined category of the problem gambler. </p>
<p>The haunted figure of the pathological gambler reproduced by prevalence studies is a convenient way for the industry and government to absolve themselves of at least some responsibility. The failure to effectively regulate a dangerous product in the form of the pokies has been dressed up as a failure of the individual. And the DSM-5 provides the objective and scientific psychiatric respectability that can be misused to justify this switch.</p>
<p>This is not to argue that gambling problems do not exist, or that people and their families do not experience shocking harms – of course they do. But blaming an aberrant individual through a discourse of pathology just allows for industry and governments to take on less responsibility than they should. Researchers, including ourselves, who have conducted prevalence surveys are complicit in frantically doing nothing about the problem, except reinforcing its location in the individual gambler.</p>
<p>The real gambling pathology lies with the political-economic system of gambling. There are vulnerable people in any society. A civil society is not one that exploits them mercilessly. We support any move that will help the victims of the gambling industries, including counselling and pre-commitment. But it is more important to stop producing gambling harm in the first place. </p>
<p>This means we need to revisit how many pokies we license, how they are configured, and where we put them. Otherwise, we do little other than lament the collateral damage of an industry that puts profits in front of people.</p>
<hr>
<p><em>A <a href="http://dx.doi.org/10.3109/16066359.2012.680079">longer version of this essay</a>, responses by <a href="http://dx.doi.org/10.3109/16066359.2012.715223">two</a> <a href="http://dx.doi.org/10.3109/16066359.2012.715222">proponents</a> of problem gambling prevalence research, and a <a href="http://dx.doi.org/10.3109/16066359.2012.719053">rejoinder</a> were recently published in Addiction Research and Theory, volume 21, no. 1.</em></p><img src="https://counter.theconversation.com/content/16607/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Martin Young is the lead investigator on ARC Linkages Project LP0990584: Gambling-Related Harm in Northern Australia. In addition to his SCU position, he is an Honorary Fellow at the Menzies School of Health Research, Darwin, and a Visiting Fellow, Fenner School of Environment and Society, ANU. </span></em></p><p class="fine-print"><em><span>Francis Markham 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>Since the issue of problem gambling was placed under the national spotlight by the Productivity Commission in 1999, we have witnessed ongoing public debate about Australia’s gambling industries. The commission…Martin Young, Senior Lecturer, Centre for Gambling Education and Research, Southern Cross UniversityFrancis Markham, PhD candidate, The Fenner School of Environment and Society, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/139762013-07-01T05:42:43Z2013-07-01T05:42:43Z‘Mental illness’ isn’t all about brain chemistry: it’s about life<figure><img src="https://images.theconversation.com/files/26458/original/ghrv6w3m-1372434463.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are many pieces to the mental health puzzle: and it isn't all about the brain.</span> <span class="attribution"><span class="source">stephenphampshire</span></span></figcaption></figure><p>Do you believe ‘mental illness’ is all about brain chemistry? It wouldn’t be surprising if you did, because this is the message we regularly receive about various forms of troublesome feelings, thoughts and behaviour. </p>
<p>The publication of the latest Diagnostic and Statistical Manual (DSM-5) reinforced this picture. David Kupfer, chair of the manual’s taskforce, <a href="https://www.madinamerica.com/2013/05/chair-of-dsm-5-task-force-admits-lack-of-validity/">declared</a>:</p>
<blockquote>
<p>In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. </p>
</blockquote>
<p>The fact the US National Institute of Mental Health (NIMH) <a href="http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml">recently announced</a> that it would be steering research away from DSM categories doesn’t change the overall picture. It has stated that “mental disorders are biological disorders involving brain circuits”. </p>
<p>What may be surprising is how limited the evidence for this assumption is. Kupfer also said that the promise of the science of mental disorders was disappointingly distant. “We’ve been telling patients for several decades that we are waiting for biomarkers,” he said. “We’re still waiting.” And the NIMH admitted that it could not design a new diagnostic system based on biomarkers because it lacked the data.</p>
<p>Does this mean we’ve made no progress in understanding mental and emotional problems? Far from it. Researchers have produced a <a href="http://www.ncbi.nlm.nih.gov/pubmed/22297585">great deal</a> of <a href="http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf">evidence</a> that what we think of as mental disorders are strongly, consistently and meaningfully related to our life circumstances, especially loss and bereavement, ill-health, loneliness, child abuse, domestic violence, bullying, unemployment, poverty, discrimination and family conflict. This is true even for the most serious problems such as <a href="http://www.ncbi.nlm.nih.gov/pubmed/16223421">psychosis</a>. </p>
<p>Why do we hear more about the promise of brain research than about the reality of what research tells us about how people’s lives affect mental health? Partly because brain research seems to offer a simple, good news solution to complex and troubling problems. It flatters our belief in the power of technology while seeming to avoid difficult questions of blame and responsibility. </p>
<p>But it also silences us, so its limitations remain hidden. Which of us knows the important questions to ask about genetic linkage or brain imaging research? And there’s a great deal of money at stake - presenting mental distress as illness suggests drugs as a treatment. By contrast, social and psychological research can make us feel helpless and is unwelcome to governments whose policies are implicated. This has also led to accusations of “blaming families”, which can make researchers uncomfortable about discussing their findings.</p>
<p>This emphasis on brains rather than lives matters because it creates a kind of institutionalised ignorance about how our social and personal contexts relate to how we feel, think and act. Psychologist David Smail has <a href="http://www.davidsmail.info/illusion.htm">described</a> how people’s distress is compounded when they can’t understand how it relates to what’s happening in their lives. John Read and colleagues have shown that focusing on supposed brain malfunction can <a href="http://www.dbdouble.freeuk.com/actastigma.pdf">increase stigma</a>. It can also limit thinking about intervention and prevention.</p>
<p>Perhaps this is too pessimistic. Perhaps the promise of brain research will be fulfilled and we will soon understand the fundamental causes of mental suffering. </p>
<p>But it doesn’t work like that. Take just two examples. Hearing voices is often seen as a symptom of schizophrenia. But it’s quite a common experience, related to bereavement, prolonged solitude, and personal crises and also to intense religious experiences. Most voice hearers never seek help and some find the voices positive, offering comfort and guidance. But voice hearing is also related to child sexual and physical abuse, when voices may be more distressing, negative and hostile. Research suggests that the content of voices and people’s reaction to them can tell us about their relationships with others, for example about feelings of powerlessness. Certainly, the content of voices often reflects people’s actual experiences. </p>
<p>Similarly, in research for her book, Women and depression: recovery and resistance, psychologist Michelle Lafrance found that many women’s feelings of depression were inseparable from their struggles to be “a good woman”, focused on others, while their recovery was inseparable from their eventual rejection of idealised notions of femininity.</p>
<p>None of this is revealed by people’s biology or by a diagnostic label, yet all of it is vital to understanding distress and getting appropriate help.</p>
<p>The British Psychological Society’s Division of Clinical Psychology has <a href="http://tiny.cc/dcp-statement">issued a statement</a> calling for a paradigm shift in the way we think about distress, away from the notion of mental distress as similar to physical illness. This doesn’t mean ignoring biology. We are, after all, social and biological creatures. </p>
<p>It does mean not assuming that biological research can provide fundamental answers to mental suffering. Certainly, it seems time to refocus our attention to the abundant evidence that mental and emotional problems and their solutions are inextricably linked with the conditions of our lives.</p><img src="https://counter.theconversation.com/content/13976/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mary Boyle is a member of the British Psychological Society’s Division of Clinical Psychology.</span></em></p>Do you believe ‘mental illness’ is all about brain chemistry? It wouldn’t be surprising if you did, because this is the message we regularly receive about various forms of troublesome feelings, thoughts…Mary Boyle, Emeritus Professor of Clinical Psychology, University of East LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/138862013-05-23T20:35:17Z2013-05-23T20:35:17ZDSM-5 won’t increase mental health work claims – here’s why<figure><img src="https://images.theconversation.com/files/24004/original/2tmp23xz-1368757299.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The majority of diagnoses for depression, anxiety and PTSD are made by GPs who don’t use the DSM criteria.</span> </figcaption></figure><p>The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (<a href="https://theconversation.com/topics/dsm-v">DSM-5</a>) has copped the predicted criticisms since its release on the weekend. Most centre on the idea that <a href="https://theconversation.com/under-new-psychiatric-guidebook-we-might-all-be-labelled-mad-14132">more of us will be diagnosed with mental disorders</a>, as the diagnostic thresholds are lowered.</p>
<p>Critics have also argued these thresholds will <a href="http://www.smh.com.au/national/health/mental-health-revision-tipped-to-cause-rise-in-work-claims-20130426-2ijz8.html">lead to an increase</a> in claims for work-related disability or compensation, allowing more people to take extended sick leave. These claims could range from short periods of psychological distress or “not coping”, to serious and impairing illnesses such as recurrent depression or psychosis. Many systems provide income during this time off work, through tax payer-funded or organisational or personal insurance compensation. </p>
<p>However the DSM-5 is unlikely to increase such claims. Diagnostic thresholds for some mental disorders may be marginally lower in the new manual, but clinicians rarely rigorously apply the diagnostic criteria.</p>
<h2>What’s changing under the DSM-5?</h2>
<p>The DSM-5 includes small changes to the diagnosis of schizophrenia and bipolar disorder. These will have no significant effect on the workforce, as these conditions are <a href="http://anp.sagepub.com/content/early/2013/02/08/0004867413476351.full?maxtoshow=&HITS=10&hits=1&RESULTFORMAT=&author1=Glozier%252C+N&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&usestrictdates=yes&resourcetype=HWCIT&ct">rarely claimed to be caused by work </a> in any compensation system.</p>
<p>The changes that may have significant effects on the working population are in depression and anxiety disorders, including <a href="https://theconversation.com/topics/ptsd">post-traumatic stress disorder</a> (PTSD). Contrary to popular belief, the majority of people with these disorders are employed. </p>
<p>The new manual includes a diagnosis for <a href="https://theconversation.com/why-prolonged-grief-should-be-listed-as-a-mental-disorder-4262">prolonged grief</a> (depressive symptoms related to bereavement) and has a lowered threshold for PTSD. To be diagnosed with PTSD one no longer has to have experienced “fear, helplessness or horror… right after the traumatic event”. There are also some minor changes around symptom profiles – reckless or self-destructive behaviour, for instance, is now a symptom of PTSD. </p>
<h2>How are work-related illnesses diagnosed?</h2>
<p>The vast majority of diagnoses and treatment plans for depression, anxiety and PTSD are made by general practitioners who don’t use the DSM-5 criteria. </p>
<p>If anything, GPs use the <a href="https://theconversation.com/two-visions-for-understanding-illness-dsm-and-the-international-classification-of-diseases-14167">World Health Organisation’s International Classification of Diseases</a> criteria for primary care, or more commonly, rely on individuals scoring highly on the <a href="http://www.beyondblue.org.au/the-facts/depression/signs-and-symptoms/anxiety-and-depression-checklist-k10">K10</a>, which measures depressive and anxious symptoms. This measure is mandated as part of accessing a range of treatments, most notably Medicare-funded psychotherapy under the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba-fact-transfac">Better Access Scheme</a>.</p>
<p>The psychologists they are referred to most often use another measure, the <a href="http://www2.psy.unsw.edu.au/dass/">Depression Anxiety Stress Scales</a> (DASS), to determine symptom severity. </p>
<p>Perhaps the most common diagnosis given to people seeking worker’s compensation for mental illness is an “adjustment disorder.” This diagnosis is incredibly easy to make, requiring an unspecified number of symptoms “such as anxiety, depression, worry, tensions and anger” which must merely be “more severe than expected” – although who decides this is moot. The DSM-5 equivalent is “mixed anxiety-depressive disorder” and is just as easy to diagnose. </p>
<p>More importantly, a review of WorkCover certificates shows doctors are most likely to use labels such as “stress”, “anxiety”, “burnout”, “bullying and harassment”, none of which are diagnoses. The DSM-5 will do nothing to change these labels or whether a doctor thinks a condition is or isn’t work related.</p>
<h2>Rise in disability</h2>
<p>For an increasing number of people, the end point of sick leave is a move onto longer-term government disability pensions. Access to these systems is generally the purview of doctors who have to determine whether the person meets a number of eligibility criteria: severity of illness, likelihood of returning to work, and so on. </p>
<p>Every country in the OECD has seen a <a href="http://www.oecd.org/health/theoecdmentalhealthandworkproject.htm">gradual rise</a> in the proportion of disability support payments attributable to mental illness, not because of any diagnostic changes but through changing patterns of work and who is working (fewer physical jobs, more women and older workers), lower levels of back pain claims (which many suggested were really “stress”), and greater recognition of depression by clinicians compared to a few decades ago.</p>
<p>The greatest determinants of the total numbers of disability claims are likely to be social and financial, which “push” people out of the workforce and “pull” them into benefits. </p>
<p>In the mid-1980s when then-UK prime minister Maggie Thatcher noted that disabled people received lower benefits than the unemployed, her right-wing government engineered a reversal of this. At the time, the UK had just over one million citizens on disability benefits and just over three million unemployed. </p>
<p>Following the <a href="http://www.parliament.uk/briefing-papers/sn01420.pdf">payment changes</a> there was a rapid rise to a peak of 2.8 million people claiming disability benefits in 2003-4 and 1.4 million unemployed; the same number of people were out of work but they were called something different and paid more. Australia had a similar change a few years later: people were “pulled” into benefits.</p>
<p>The likelihood that a disabled person would be unemployed compared to a healthy person has also been increasing, “pushing” disabled people <a href="http://wes.sagepub.com/content/22/1/129.full.pdf">out of the workforce</a>. This “disability penalty” is highest for those with mental disorders and the trend towards short-term contracting and precarious employment has worsened this.</p>
<p>Last year, eligibility for disability support pensions for mental illness, which costs the Australian government some A$3.8 billion a year was <a href="http://www.pc.gov.au/__data/assets/pdf_file/0007/111310/35-disability-support-appendixk.pdf">changed</a> to a new threshold. This is based on the presence of both a diagnosis, but more importantly, upon a certain percentage of whole body impairment through the use of the <a href="http://www.cmspecialists.com.au/PIRS.pdf">Psychiatric Impairment Rating Scale</a>. </p>
<p>The only <a href="http://www.fahcsia.gov.au/sites/default/files/documents/05_2012/taylor_fry_final_report.pdf">publicly available testing</a> of these new scales, which impact hundreds of thousands of people, suggest that “41% of formerly eligible applicants became ineligible”. For people with psychiatric impairment there was “a comparatively high rate of downward movements” – in other words, even fewer people were eligible.</p>
<p>In terms of how we should weight our concerns about changes to workplace disability eligibility and claims, the actions of lawmakers and policy administrators in Australia have a far greater influence than a small group of psychiatrists across the Pacific who produced the DSM-5.</p><img src="https://counter.theconversation.com/content/13886/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Glozier has received funding from the NHMRC and ARC. Nick is on the medical appeal panel of the NSW Worker's Compensation Commission.</span></em></p>The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) has copped the predicted criticisms since its release on the weekend. Most centre on the idea that more of us will…Nick Glozier, Professor of Psychological Medicine, BMRI & Disciplne of Psychiatry, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141672013-05-22T20:42:29Z2013-05-22T20:42:29ZTwo visions for understanding illness: DSM and the International Classification of Diseases<figure><img src="https://images.theconversation.com/files/24244/original/n4ybcmmh-1369189681.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The DSM-5 is not the only system of classification of mental illness.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>The new Diagnostic and Statistical Manual (DSM-5) is the latest instalment in the long-running saga over the classification, nature and dimensions of mental illness. But it’s not the only system of classification of mental illness. </p>
<p>Since 1948, the World Health Organization has produced a section on mental diagnoses in its International Classification of Diseases (ICD). To understand why the DSM is such a controversial document, we need a sense of its historical relationship to the ICD.</p>
<h2>Initial harmony</h2>
<p>Between 1948 and 1965, the World Health Organisation produced three editions of the International Classification of Diseases. The release of ICD-6 in 1948 prompted the American Psychiatric Association (APA) to produce DSM-I in 1952. The American Psychiatric Association had lofty ambitions for its new manual.</p>
<p>Following the Second World War, the American Psychiatric Association was taken over by a group of young practitioners influenced by the Freudian model, with its emphasis upon neurotic illnesses. They met with some resistance from older psychiatrists, but their promise to extend psychiatry’s reach out of the mental hospitals and into society at large guaranteed them a 20-year dominance of the organisation. </p>
<p>Using ICD-6 as the foundation, they built their own classification system that served the interests of their profession. Between the ICD-6 and ICD-8, the World Health Organization’s classification was more or less harmonised with the DSM. And ICD-8 (1965) was very close to DSM-II (1968) in organisation, categories and description.</p>
<h2>DSM’s misstep</h2>
<p>To its detriment, however, DSM-II included homosexuality as a psychiatric condition. The gay liberation movement had emerged alongside the wider civil rights and women’s liberation movements, and forcefully challenged the APA’s pathologisation of homosexuality.</p>
<p>Following protests in the early 1970s, US psychiatrist and chair of DSM-III’s task force Robert Spitzer was given the task of defusing the situation. He redefined mental illness to exclude homosexuality from the DSM, replacing it with “sexual orientation disturbance”, which was supposedly experienced by those uncomfortable with their sexuality.</p>
<p>Although this was retrospectively celebrated as a milestone of psychiatric progressiveness, at the time many argued this decision was unscientific. How could something that had long been regarded as a disease be removed from a classificatory system as a result of political pressure?</p>
<h2>Change of direction</h2>
<p>Other criticisms were levelled against the APA on the back of this move. Insurance companies insisted they would only pay to treat “real” diseases, while an anti-psychiatry movement had become almost mainstream in many US universities. Something had to be done.</p>
<p>Spitzer was a long-term critic of post-war Freudian psychiatry and, along with a few like-minded colleagues, was deeply influenced by Emil Kraepelin, who had developed a method of descriptive psychiatry in the late 1890s. </p>
<p>Kraepelin’s system had no underlying theory of causation. Instead, he focused a detailed picture of the symptoms experienced by each of his patients. Collating these, he identified the twin-pillars of the psychoses: dementia praecox (later renamed schizophrenia) and manic depression (rebranded as bipolar).</p>
<p>Kraepelin’s method was not to many people’s liking in the early 1970s. But for Spitzer and his allies, it was a means to the end of transforming psychiatry. The psychobabble of the Freudian couch would be replaced by Kraepelin-style lists of symptoms that had to be observed before a categorical diagnosis could be made.</p>
<h2>A transformation</h2>
<p>The neo-Kraepelinians transformed the DSM to fit this model. DSM-III (1980) was, therefore, a radical departure from previous incarnations of the DSM and the ICD. The WHO responded by incorporating DSM-III’s innovations into ICD-10.</p>
<p>Nevertheless, there were significant differences between the two classifications. Nomenclature, diagnostic criteria and categories did not map one-to-one. What’s more, the DSM remained culture-bound and unable to cope with the complexities of gender and ethnicity in a multicultural world. </p>
<p>Harmonisation between the ICD and the DSM has remained an expressed goal of both the APA and the WHO. Currently, the APA is trumpeting the fact that ICD-11 will be very close to DSM-5. Whether this happens remains to be seen. And whether it is desirable is questionable.</p>
<h2>Divergent aims</h2>
<p>The DSM and the ICD serve similar but distinct purposes. While both can broadly be described as classifications that aid the collection and analysis of morbidity data, there has always been considerable scope to the ambitions of the DSM.</p>
<p>The ICD can be used for research while providing a tool for understanding patterns of mental illnesses. It may even contribute to diagnosis. But the DSM clearly wants to shape the wider practice of psychiatry.</p>
<p>There is no ICD equivalent of the DSM casebook, which shows how the DSM can be used in diagnosis and treatment. Neither is the ICD implicated in the jostling between pharmaceutical companies, the health insurance industry and the psychiatry profession, as each haggles with the other over the existence or the extension of particular illness categories. </p>
<p>Nor is the ICD a cash-cow for the WHO, unlike the DSM, which is a highly profitable enterprise. Indeed, the DSM is most certainly <em>not</em> disinterested.</p>
<h2>International impact</h2>
<p>For the majority of psychiatric practitioners outside of the United States, the DSM is one tool among many. Outside the US, it doesn’t possess the same power or authority. In Australia, for example, psychiatrists might be trained using the diagnostic criteria of the DSM to help them pass their exams, but in general they rely on clinical literature that is more detailed and, above all, relevant to their day-to-day practice. </p>
<p>Equally, the diagnoses of most clinicians, in the US and elsewhere, is coded using the ICD classification, which remains the principal means of statistically detailing the incidence of categories of mental illnesses.</p>
<p>The DSM-5 will probably be the most controversial book of 2013, provoking discussions about the reality, or otherwise, of particular diagnoses. But we shouldn’t get carried away with its influence over psychiatry worldwide. Outside of the US, psychiatrists are more concerned, on the one hand, with the wider clinical literature, and, on the other, using the ICD as a superior cross-cultural classification.</p><img src="https://counter.theconversation.com/content/14167/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James Bradley 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>The new Diagnostic and Statistical Manual (DSM-5) is the latest instalment in the long-running saga over the classification, nature and dimensions of mental illness. But it’s not the only system of classification…James Bradley, Lecturer in History of Medicine/Life Science, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/145082013-05-21T20:37:20Z2013-05-21T20:37:20ZDSM-5 helps perpetuate the myth of women’s madness<figure><img src="https://images.theconversation.com/files/24175/original/rq4mfvzt-1369103257.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We now put women in chemical straitjackets and prescribe psychotropic medication instead of locking them up for unfeminine behaviour or marital discontent.</span> <span class="attribution"><span class="source">Vineus/Flickr</span></span></figcaption></figure><p>The newly released edition of the Diagnostic and Statistical Manual for Mental Disorders (<a href="http://www.dsm5.org/Pages/Default.aspx">DSM-5</a>) may be heralded as the “bible of psychiatry”, but it is not an objective scientific document outlining the truth about madness as its proponents claim. Rather, it’s a manual that has been used to propagate the misdiagnosis and maltreatment of vulnerable women.</p>
<p><a href="http://www.routledge.com/books/details/9780415339285/">Women</a> are significantly more likely than men to be diagnosed with a range of psychiatric illnesses. This includes depression, anxiety, eating disorders, borderline personality disorder, somatoform disorder, sleep disorders and dissociative identity or depersonalisation disorder. </p>
<p>Those who experience mood change once a month can be diagnosed with premenstrual dysphoric disorder (<a href="http://connection.ebscohost.com/c/articles/84944753/pms-as-gendered-illness-linked-construction-relational-experience-hetero-femininity">PMDD</a>).</p>
<h2>Labelling discontent</h2>
<p>Women are also significantly more likely than men to be prescribed psychotropic medication known as selective serotonin reuptake inhibitors (<a href="http://www.naturopath4you.com/PDFs/Depression.pdf">SSRIs</a>), such as Prozac, given electroconvulsive therapy (<a href="https://pi.library.yorku.ca/ojs/index.php/cws/article/viewFile/5967/5156">ECT</a>), or hospitalised for psychiatric illness.</p>
<p>But this doesn’t mean that women are more mad than men. They are simply more likely to be labelled as such when they express discontent or distress with everyday life. Or when they fail to live up to the <a href="http://books.google.com.au/books?hl=en&lr=&id=bif4oDEuGAwC&oi=fnd&pg=PR15&dq=The+depression+epidemic:+International+Perspectives+on+Women%27s+Self-silencing+and+psychological+distress.&ots=VA7FEO2w0S&sig=EKTToswT8nFawKBtqt-TFCaiT5g#v=onepage&q&f=false">unrealistic ideals</a> of the perfect wife and mother. </p>
<p>These ideals change over time. In the <a href="http://www.routledge.com/books/details/9780415339285/">19th century</a>, women were committed to mental asylums for using foul language, having sex outside of marriage, or wanting to leave their husbands. Today, we don’t lock women up for unfeminine behaviour or marital discontent. Instead, we put them in a chemical straitjacket and prescribe psychotropic medication.</p>
<p>This phenomenon is illustrated in a <a href="http://www.psych.med.umich.edu/faculty/metzl/ImpactofSSRI.pdf">2004 study</a> that examined advertisements for SSRI antidepressants from 1985 to 2000. It showed a clear shift in recent years toward positioning women’s normal reactions to difficulties associated with marriage, motherhood, menstruation, or menopause, as psychiatric illnesses that warrant SSRI medication. </p>
<p>Emotional experiences such as “being overwhelmed with sadness”, or “never feeling happy” started to be positioned as depression or anxiety, rather than understandable reactions to life.</p>
<h2>Increasing drug use</h2>
<p>The same researchers also analysed <a href="http://www.med.umich.edu/psych/faculty/metzl/Metzl_flyer.pdf">media articles</a> on depression from 1985 to 2000. They concluded that there was evidence of “gendered diagnostic bracket creep” – a widening of gender-specific criteria for depression – which legitimated the use of SSRIs for women. </p>
<p>Stories in the press portrayed Prozac as a miracle drug, which can help women to feel “normal”, “grounded” and “better than well”, (<a href="http://www.jstor.org/discover/10.2307/3175785?uid=3737536&uid=2129&uid=2&uid=70&uid=4&sid=21102242881011">Prozac Nation</a>), or providing “chemical help to be a supermom” (<a href="http://www.jstor.org/discover/10.2307/4149402?uid=3737536&uid=2129&uid=2&uid=70&uid=4&sid=21102242881011">Time</a>). </p>
<p>Who wouldn’t take SSRIs if this were true? But it isn’t. </p>
<p>The original U.S. Food and Drug Administration (FDA) <a href="http://www.amazon.com/Listening-Prozac-Landmark-Antidepressants-Remaking/dp/0140266712">testing of SSRIs</a> was conducted on small groups of men with diagnoses of major depression. Yet the major market for these drugs today are <a href="http://www.critpsynet.freeuk.com/Gardner.pdf">women</a> with minor or “shadow” depression.</p>
<p>We also know that SSRIs have serious <a href="http://www.biomedsearch.com/article/didnt-just-cross-line-tripped/182976462.html">side effects</a>, including <a href="http://www.bmj.com/content/330/7488/385">suicide</a>, aggression, muscle spasm, sexual dysfunction, inner agitation, stomach or skin problems, and “out of character” behaviour. </p>
<p><a href="http://www.naturopath4you.com/PDFs/Depression.pdf">Over-prescription</a> of such drugs to women is clearly a matter of serious concern. And this over-prescription can be directly linked to the DSM.</p>
<h2>Dubious links</h2>
<p>In a <a href="http://www.tufts.edu/%7Eskrimsky/PDF/DSM%20COI.PDF">study</a> of the 170 panel members who produced the diagnostic criteria for DSM-IV (published in 1994), 56% had financial ties to drug companies. This included research funding, consultancies and speaker fees. </p>
<p>Some panels appeared more closely linked to Big Pharma than others. In the mood disorders and schizophrenia panels, 100% of experts had pharmaceutical connections. </p>
<p>Premenstrual dysphoric disorder had 83%, eating disorders 83%, and anxiety disorders 81%. With the exception of schizophrenia, these are all disorders more commonly attributed to women. </p>
<p>When we look to the <a href="http://www.bostonneuropsa.net/PDF%20Files/Burstzajn/Pychiatric%20Times%20Point%20&%20Counterpoint%202009.01.pdf">panel members</a> convened for DSM-5, this interest and influence appears to have increased. Around 70% of task force members reported an industry relationship – an increase of 14% on DSM-IV. </p>
<p>Psychiatric diagnosis and prescription of medication to women has also increased over this 20-year period. </p>
<p>The pharmaceutical industry is one of the most profitable industries in the world – with global sales topping <a href="http://www.nejm.org/doi/full/10.1056/NEJM200410073511522">US$400 billion</a> a year. Psychotropic medication plays a key role in these profits, with the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1079538/">top five SSRIs</a> earning between US$1 billion and US$3 billion each annually, despite the drugs being almost identical. This amounts to total profits of over US$10 billion a year. </p>
<p>The industry is driven by the economic imperative to keep profits high through retaining and continuously <a href="http://www.naturopath4you.com/PDFs/Depression.pdf">expanding their market</a>. And the DSM serves a key function in this by expanding the list of diagnostic categories with every new edition. </p>
<p>This allows psychiatrists to diagnose unhappiness as <a href="http://www.routledge.com/books/details/9780415339285/">madness</a>, and prescribe drugs to increasing numbers of unhappy or vulnerable women.</p>
<p>We need to take the distress reported by women – and men – seriously. Sometimes therapeutic or medical help is necessary. But we also need to challenge the increasing pathologisation of everyday unhappiness. It provides a market for the pharmaceutical industry and legitimates psychiatric control. And it reinforces the myth that women are more mad than men.</p><img src="https://counter.theconversation.com/content/14508/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Ussher receives funding from the Australian Research Council for research on gender and mental health. She is author of 'The Madness of Women: Myth and Experience' (Routledge, 2011). </span></em></p>The newly released edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) may be heralded as the “bible of psychiatry”, but it is not an objective scientific document outlining the…Jane Ussher, Professor of Women's Health Psychology, Centre for Health Research, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/135452013-05-20T20:36:31Z2013-05-20T20:36:31ZDSM’s approach overlooks effective therapies for children<figure><img src="https://images.theconversation.com/files/24088/original/g8kmzwkb-1368938819.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The last ten years have seen the rise of therapies for young people that focus on family and wider social systems.</span> <span class="attribution"><span class="source">Choo Yut Shing</span></span></figcaption></figure><p>The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), a classification system for mental disorders produced by the American Psychiatric Association for the past 60 years, was released on Saturday. </p>
<p>The manual has attracted criticism from across the board, from the <a href="http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health?INTCMP=SRCH">British Psychological Society</a> to the chair of the previous edition’s taskforce, <a href="http://www.huffingtonpost.com/allen-frances/dsm-5_b_2227626.html">Allen Frances</a> and the <a href="http://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html?nl=todaysheadlines&emc=edit_th_20130507&_r=0">director</a> of the US National Institute of Mental Health. </p>
<p>Some of these criticisms centre around claims that psychiatry more generally is moving away from psychological theories and pursuing an increasingly <a href="http://www.nimh.nih.gov/about/director/publications/psychiatry-as-a-clinical-neuroscience-discipline.shtml">neuroscientific approach</a> to mental disorders. And that this approach is crowding out the central role of therapy in mental health. </p>
<p>Some have gone as far to say that we are risking the bio-psycho-social model of mental illness in favour of a “<a href="http://www.ncbi.nlm.nih.gov/pubmed/20170043">bio-bio-bio</a>” model that relegates human despair to physiological functioning.</p>
<p>Australian researchers have also come under similar criticism in the past few years, particularly for former Australian of the year Patrick McGorry’s proposed “<a href="http://www.abc.net.au/worldtoday/content/2012/s3511017.htm">psychosis risk syndrome</a>” for adolescents. </p>
<p>While there is value in McGorry’s vision for early intervention to prevent serious mental health problems in young people, there are concerns about the dangers of mis-identification, and the effect that a mistaken diagnosis and resulting stigma might have on young people. </p>
<p>Concerns have also been raised, despite McGorry’s insistence that antipsychotics are not the first resort for young people, that we are witnessing a gradual creep towards the medicalising of children and young people in this country.</p>
<p>Australia is the third-highest user of stimulants for attention deficit hyperactivity disorder (ADHD) and there has been a significant increase in the use of <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2011.02200.x/abstract;jsessionid=9D4AEA442FB9BC80AACCDF585D303A20.d01t01">Risperidone</a>, traditionally an antipsychotic, for conduct or behavioural disorders.</p>
<p>These developments have significant implications for young people for a variety of reasons. </p>
<p>First, there are the potential effects of diagnosis on an adolescent or child’s developing identity. Adolescents diagnosed with a range of psychiatric disorders are more likely to experience depression and a lower sense of control over their life.</p>
<p>Adolescents who self-label refer to their illness as an organic part of themselves, <a href="http://steinhardt.nyu.edu/opus/issues/2011/spring/stigma">merging their identity</a> with that of a psychiatric disorder. This phenomenon requires more investigation but has the potential to mediate against the process of full recovery.</p>
<p>Second, there’s a risk that these developments will marginalise innovative and effective contextual treatments, especially given that medication is a quick fix compared to the demanding work of child and adolescent therapies.</p>
<p>But other, less reductive ways of understanding mental illness in young people are possible. US psychiatrist <a href="http://drdansiegel.com/">Daniel J Seigel</a>, for instance, advocates for the developing brain to be understood in the context of patterns of attachment and emphasises the critical importance of an interdisciplinary approach to understanding the cause of mental health problems.</p>
<p>For Seigel, insights from neuroscience, developmental theory, evolutionary psychology, systems theory, psychiatry, medicine, and psychotherapy are all needed if you are to truly understand the life of the child. </p>
<p>The past ten years has also witnessed the rise of a range of evidence-based integrative therapies that have demonstrated remarkable effectiveness when tackling young people most most severely affected by mental illness. These treatments take the best from established models of therapy and apply them together in a way that can tackle seemingly intractable problems. </p>
<p>Each of these therapies are grounded in the field of family therapy and incorporate family and wider social systems in intervention, rather than just focusing on the illness in the individual child.</p>
<p><a href="http://www.maudsleyparents.org/whatismaudsley.html">The Maudsley model</a> is one such therapy pitting a unified parenting team against anorexia, which takes adolescents hostage. The parents are supported to “supernanny” eating behaviours at home while the sibling and other family members support the distressed and sometimes resistant adolescent.</p>
<p>This is the first model to effectively respond to the challenge of paediatric anorexia nervosa by breaking the reliance on hospitals and building parental responsibility for eating at home. </p>
<p>Multisystemic therapy is one of the few treatments to have success with juvenile offenders. It is a highly effective intensive family- and community-based treatment program that focuses on addressing all environmental systems that impact chronic and violent juvenile offenders, including their homes and families, schools and teachers, neighbourhoods and friends.</p>
<p>Multidimensional family therapy is a similar approach for substance-abusing adolescents and adolescents with co-occurring substance use and mental disorders. It has achieved similar impressive results.</p>
<p>These developments are built on high-quality research and represent the coming-of-age of innovative, contextual therapies. </p>
<p>There’s even growing evidence for community-based treatment of acute psychosis in Finland. This “<a href="http://beyondmeds.com/2010/01/04/alternative-for-psychosis/">open dialogue</a>” approach is proposed as an alternative to traditional mental health services. It mobilises the patient’s social networks, promoting agency through dialogue rather than simply relying on psychopharmacological intervention.</p>
<p>The publication of the DSM-5 represents the field of psychiatry at the crossroads. Will we allow this trend towards reductionism to continue until there’s no need for therapy or family and community-based solutions? Will be be driven by the dollar and the delusion of the quick fix? Or, can we stand up for the rights of children, adolescent and adults, and embrace the realities of a complex and difficult world?</p><img src="https://counter.theconversation.com/content/13545/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Rhodes receives funding from the NHMRC </span></em></p>The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), a classification system for mental disorders produced by the American Psychiatric Association for the past 60 years…Paul Rhodes, Senior Lecturer in Psychology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141922013-05-20T13:07:31Z2013-05-20T13:07:31ZFive new mental disorders you could have under DSM-5<figure><img src="https://images.theconversation.com/files/24079/original/g5vr75t5-1368797027.jpg?ixlib=rb-1.1.0&rect=3%2C13%2C1020%2C645&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sufferers of internet disorder might find it starts to impose on real life, such as causing difficulties in socialising.</span> <span class="attribution"><span class="source">Flickr/Fle</span></span></figcaption></figure><p>Since it was first published in 1952, the DSM has been the has been the diagnostic bible for many psychiatrists. Each time the manual is updated, new conditions are introduced, often amid much controversy. DSM-5, the latest edition published on Saturday, is one of the most controversial yet.</p>
<p>Many conditions we’re now familiar with were codified in the DSM, including body dismorphic disorder, schizophrenia and bipolar disorder.</p>
<p>Inclusions and removals can be hugely controversial. Autism is in the manual, for example, but Asperger’s isn’t. Homosexuality was only removed in 1974.</p>
<p>Below, five experts explain some of the most noteworthy new additions, and why they’ve been included.</p>
<hr>
<h2><strong>Hoarding disorder</strong></h2>
<p><strong>David Mataix-Cols:</strong> Most children have collections at some point and <a href="http://www.ncbi.nlm.nih.gov/pubmed/22322013">approximately 30% of British adults define themselves as collectors</a>. This is a pleasurable, highly social and benign activity, which contrasts with another disabling form of object accumulation: hoarding disorder. </p>
<p>The symptoms include persistent difficulty in discarding possessions due to a strong perceived need to save items and distress in discarding them. This results in the accumulation of a large number of possessions that fill up and clutter key living areas of the home, to the extent that their intended use is no longer possible. </p>
<p>Symptoms are often accompanied by excessive acquiring, buying or even stealing of items that are not needed or for which there is no available space. </p>
<p>Using DSM-5, hoarding disorder can only be diagnosed once other mental disorders have been ruled out. </p>
<p>With a prevalence of at least <a href="http://www.ncbi.nlm.nih.gov/pubmed/20189280">1.5% of the UK population</a>, the disorder is associated with substantial functional disability, family conflict, social isolation, risk of falls and fires, evictions and homelessness.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/24077/original/cwf7wf9x-1368796075.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hoarding syndrome can leave key living areas unable to be used.</span>
<span class="attribution"><span class="source">Shadwwulf </span></span>
</figcaption>
</figure>
<h2>Binge eating disorder</h2>
<p><strong>Christopher Fairburn:</strong> The inclusion of binge eating disorder in the DSM-5 was expected and uncontroversial for the deciding committee. It’s already listed as a provisional diagnosis in the DSM-4.</p>
<p>The disorder is characterised by recurrent over-eating episodes and a sense of loss of control at the time. Sufferers don’t have the extreme dieting, vomiting and laxative misuse seen in people who have bulimia. It is the loss of control over eating that is the distressing feature of binge eating disorder, or BED.</p>
<p>BED is very different from anorexia nervosa and bulimia nervosa. These disorders are <a href="http://www.rcpsych.ac.uk/expertadvice/problemsdisorders/anorexiaandbulimia.aspx">largely confined to young women</a> and they share many features including highly distinctive concerns about shape and weight and extreme weight control behaviour, such as dieting. None of this is present in people with BED.</p>
<p>BED is typically seen among those who are middle aged. Men <a href="http://www.namedinc.org/statistics.asp">make up about a third of cases</a>. The disorders also differ in their response to treatment. Unlike anorexia and bulimia, people who suffer from binge eating disorder respond well <a href="http://www.nimh.nih.gov/health/publications/eating-disorders/complete-index.shtml">to a variety of treatments</a>.</p>
<h2>Skin picking disorder</h2>
<p><strong>Jon Grant:</strong> Skin picking has been documented in medical literature since the 19th century but only now has it been recognised in the DSM-5.</p>
<p>Skin picking disorder affects around <a href="http://www.trich.org/dnld/ExpertGuidelines_000.pdf">2-5% of people in the US</a>. It is not simply a harmless habit nor merely a symptom of another disorder. Skin picking may result in significant tissue damage and often leads to medical complications such as local infections and septicemia. </p>
<p>Sufferers of the disorder are diagnosed according to five criteria including recurrent skin picking that causes skin lesions; repeated attempts to cut down or stop, and that the skin picking causes significant distress or problems in social situations, work, or other important areas in life. </p>
<p>Skin picking also can’t exist due to the physical effects of a substance or a medical condition, or be linked to another mental disorder - for example because someone has body dysmorphic disorder. These criteria separate people who only pick their skin occasionally. </p>
<p>Data from multiple researchers around the world consistently show that skin-picking disorder has distinct characteristics, important neurobiological links, and documented responsiveness to treatments - both <a href="http://bmo.sagepub.com/content/26/3/361.short">Cognitive Behaviour Therapy</a> and <a href="http://www.trich.org/treatment/article-medications-grant.html">medication</a> can work.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/24081/original/t5sgpm9v-1368798279.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Skin picking disorder can cause significant distress or problems in social situations.</span>
<span class="attribution"><span class="source">Flickr/Chris@APL</span></span>
</figcaption>
</figure>
<h2>Somatic symptom disorder</h2>
<p><strong>Christopher Lane:</strong> Somatic comes from the Greek word for “of the body”, the focus of the disorder. DSM’s earlier family of medically unexplained ailments grouped together problems as different as hypochondria and body dysmorphia and so the <a href="http://bit.ly/12GAijJ">American Psychiatric Association proposed somatic symptom disorder</a>. </p>
<p>It’s a new, stand-alone disorder for people who experience a “disproportionate” sense of anxiety about their health and at least one physical symptom, such as a persistent headache. </p>
<p>People can be diagnosed with the new disorder if their physical symptoms are distressing and/or disruptive to their daily life for at least six months, and they also have one of the following: disproportionate thoughts about the seriousness of their symptoms; or a high level of anxiety about their symptoms or health; or they devote excessive time and energy to their symptoms or health concerns. </p>
<p>There have been concerns because the threshold of “disproportionate” and “excessive” is difficult to quantify and the disorder could be used as a catch-all for many people.</p>
<h2>Internet addiction</h2>
<p><strong>Karen M. von Deneen, Jie Tian:</strong> While not yet officially codified within a psychopathological framework, internet addiction is growing in prevalence and has attracted the attention of psychiatrists, educators, and the public. </p>
<p>Internet addiction is a newly identified condition associated with loss of control over internet use. It leads to negative psychosocial and physical results, such as impairment of academic failure, social deficits, criminal activities and even death. This consists of three main subtypes: excessive gaming, sexual preoccupations, and e-mail/text messaging.</p>
<p>The DSM-5 now includes a newly-created <a href="http://www.dsm5.org/Newsroom/Documents/Addiction%20release%20FINAL%202.05.pdf">category of behavioural addictions</a>, in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual’s appendix instead, with the goal of encouraging additional study.</p>
<p>Present treatment has included <a href="http://www.guardian.co.uk/world/2009/jul/14/china-internet-electric-shock-treatment">electric shock therapy</a> and <a href="http://www.telegraph.co.uk/health/children_shealth/7467200/Rehab-clinic-for-children-internet-and-technology-addicts-founded.html">internet rehab</a>, but these have not been satisfactory. More research needs to be done to understand the underlying mechanisms of this addiction.</p><img src="https://counter.theconversation.com/content/14192/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Fairburn receives funding from the Wellcome Trust and National Insitutes of Mental Health. He receives no commercial funding. In 1995, he wrote the book Overcoming Binge Eating</span></em></p><p class="fine-print"><em><span>Christopher Lane is the author of five books on literature and psychology including Shyness: How Normal Behavior Became a Sickness.</span></em></p><p class="fine-print"><em><span>David Mataix-Cols, Jie Tian, Jon Grant, and Karen M. von Deneen do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Since it was first published in 1952, the DSM has been the has been the diagnostic bible for many psychiatrists. Each time the manual is updated, new conditions are introduced, often amid much controversy…Christopher Fairburn, Professor of Psychiatry, University of OxfordChristopher Lane, Professor of English, Northwestern UniversityDavid Mataix-Cols, Professor and Honorary Consultant Clinical Psychologist, King's College LondonJie Tian, Professor of Automation, Chinese Academy of SciencesJon Grant, Professor of Psychiatry and Behavioral Neuroscience , University of ChicagoKaren M. von Deneen, Associate Professor, Xidian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141362013-05-19T23:11:23Z2013-05-19T23:11:23ZDSM-5 tells us more about psychiatry than psychiatrists<figure><img src="https://images.theconversation.com/files/23517/original/z6db8w96-1368198808.jpg?ixlib=rb-1.1.0&rect=0%2C2%2C1576%2C1002&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">DSM-5 has been described as the bible of psychiatry but the assumption that professionals use it for their own gain is far fetched.</span> <span class="attribution"><span class="source">PA</span></span></figcaption></figure><p>DSM-5, the latest version of the Diagnostic and Statistical Manual of the American Psychiatric Association, was published in the US at the weekend.</p>
<p>Given that not even its most passionate supporters would call it a good read, it had already attracted unusual levels of attention. There has already been an avalanche of serious comment pieces, magazine articles, <a href="http://boycott5committee.com/">blogs</a> and the <a href="http://www.dailymail.co.uk/news/article-2268791/Binge-drinkers-reclassified-mild-alcoholics-argue-scientists.html">occasional sensationalist Daily Mail headline</a>.</p>
<p>Why is it proving so controversial? The DSM is nothing more than a list of psychiatric disorders, accompanied by descriptions and explicit criteria for their diagnosis. It’s also not new – it’s the fifth such revision – although given the propensity of the association to trot out revisions on a regular basis, there have been at least eight since 1952.</p>
<p>The DSM is important in the US – unless your disorder is in the manual you won’t be treated. Or more accurately, you can be treated but your therapist won’t be reimbursed by your insurance company, which amounts to the same thing.</p>
<p>But the manual also important because it tells us something about the state of psychiatry.</p>
<h2>Mission creep?</h2>
<p>Early versions of the DSM did not attract much attention or controversy. Much of American psychiatry was dominated by psychoanalysis, which doesn’t give central importance to diagnostic categories as every patient is considered a unique individual. It was not until DSM III came along in 1980 that people really started to take notice – and to complain.</p>
<p>The first problem was the increasing number of diagnoses. In 1917, the APA recognised 59 psychiatric disorders. When DSM-I was published in 1952 it had 128. By 1987 there were 253. DSM-IV has 347.</p>
<p>We are promised that DSM-5 (now designated by digits rather than Roman numerals to make revisions easier) will reduce the total for the first time. I’m not holding my breath.</p>
<p>Given that the real number of mental disorders, whatever that may be, is unlikely to be increasing at a similar exponential rate, it’s not surprising that the cry has gone up <a href="http://dsm5response.com/">that this represents psychiatric mission creep</a> – a dastardly plot by the profession to extend its influence into more and more aspects of our daily lives and thoughts.</p>
<p>Indeed, there is evidence for a medicalisation of the normal, the eccentric and the odd. It seems increasingly difficult to find shy children anymore – instead it’s now a social phobia. Who these days is called bookish or eccentric, as opposed to someone suffering from Asperger’s?</p>
<p>When you bring big pharmaceutical companies into the picture – who have occasionally been caught colluding in the creation or expansion of psychiatric disorders in order to create new markets for their drugs – it’s not surprising that the new DSM is being greeted with a storm of criticism.</p>
<h2>The difficulty of classification</h2>
<p>But the reality is a little different. Psychiatric classification is difficult because we are restricted to largely symptomatic descriptions of disorders, as opposed to leukaemias or endocrine disorders, for example, which are based on very detailed knowledge of the actual pathological processes that underlie clinical symptoms.</p>
<p>Psychiatry is not at that stage yet, and as Gary Greenberg<a href="http://www.newyorker.com/online/blogs/elements/2013/04/psychiatry-dsm-melancholia-science-controversy.html?mbid=social_retweet&mobify=0">pointed out recently</a> in the New Yorker, things have not changed much since the superintendent of a Massachusetts asylum wrote in 1886: “in the present state of our knowledge no classification of insanity can be erected on a pathological basis.”</p>
<p>We are on the brink of new discoveries that will transform our understanding of major mental disorders such as schizophrenia and bipolar and <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)62129-1/abstract">a recent Lancet paper reported</a> common genetic markers linking five major disorders. But until that point it’s not surprising that when it comes to classification, a hundred flowers still bloom.</p>
<p>One common assumption is that it is the psychiatrists that are seeking to extend the boundaries. But you can argue that teachers also have an incentive to promote the growth of psychiatric labels – children with ADHD or Asperger’s are likely to make you eligible for more classroom assistants than difficult or unruly children. Some parents will prefer to put their child’s problematic behaviours down to genes or disordered development than inconsistent or absent parenting.</p>
<p>When Allen Frances, one of the architects of DSM-IV but now the leading critic of DSM-5, started to repudiate his own contribution to expanded diagnostic boundaries in autism, he was greeted with open hostility <a href="http://www.nytimes.com/2012/01/20/health/research/new-autism-definition-would-exclude-many-study-suggests.html?_r=0">from many parents of children who had been diagnosed</a> with one of its looser definitions.</p>
<p>The raging arguments over DSM have been more muted in the UK. Unlike the US, it isn’t necessary to be a perfect fit with a DSM category to be treated. A GP may decide to treat unhappiness as a case of depression, but it won’t involve consulting the APA’s latest bible.</p>
<p>Many mental health professionals will also be shaking their heads at the outrage that DSM-5 has generated, in particular the claim that it’s all an underhanded plot by the professionals.</p>
<p>For psychiatrists, the biggest threat is the opposite. Far from extending our empire, most of us are faced with the biggest reductions in funding and services we can remember.</p>
<p>In a recession, mental health services suffer first and foremost compared to acute care.</p>
<p>For most psychiatrists the current reality is trying desperately to protect services to ensure that those whose mental disorders are indisputable – in any classification system – do not lose out. The idea that we are looking for new markets seems far fetched.</p>
<p><em>A <a href="http://www.kcl.ac.uk/iop/news/events/2013/june/DSM-5-Conference.aspx">two-day conference into DSM takes place at the Institute of Psychiatry</a> from June 4th-5th.</em></p><img src="https://counter.theconversation.com/content/14136/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Wessely is a member of the ICD-11 Stress Disorders working party</span></em></p>DSM-5, the latest version of the Diagnostic and Statistical Manual of the American Psychiatric Association, was published in the US at the weekend. Given that not even its most passionate supporters would…Simon Wessely, Professor of Psychological Medicine, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141272013-05-19T23:11:19Z2013-05-19T23:11:19ZExplainer: what is the DSM?<figure><img src="https://images.theconversation.com/files/23539/original/8dnxvjpz-1368351346.jpg?ixlib=rb-1.1.0&rect=432%2C198%2C2203%2C1401&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Psychiatric diagnosis relies on identifying a patient's signs and symptoms rather than clinical tests.</span> <span class="attribution"><span class="source">PA/Ben Birchall</span></span></figcaption></figure><p>Traditional psychiatry uses the approaches of medicine to try to understand mental health problems and guide treatment. This means relying on diagnosis – identifying what are believed to be mental illnesses from their signs and symptoms, in the same way that doctors in other branches of medicine diagnose physical health problems.</p>
<p>There are two widely used systems in psychiatry: the World Health Organization’s International Standard Classification of Diseases, Injuries and Causes of Death - <a href="http://www.who.int/classifications/icd/en/">or ICD</a> - and the American Psychiatric Association’s Diagnostic and Statistical Manual - <a href="http://www.dsm5.org/Pages/Default.aspx">or DSM</a>. The latest edition of the DSM was published this weekend.</p>
<p>Both ICD and DSM were first published immediately after the World War II and have been revised extensively over the years. But there hasn’t been a new edition of DSM since DSM-IV was published in 1994 - almost 20 years ago.</p>
<p>ICD is technically the international standard classification system and forms the basis for NHS procedures in the UK. But the American DSM is also extremely influential and is widely used in research and academic fields and for planners, for example keeping hospital records. That’s why the publication of its fifth edition is important.</p>
<h2>The nature of psychiatric diagnosis</h2>
<p>The diagnosis of mental health problems is extraordinarily complex – and controversial. The basic aim of diagnostic manuals is to explain the underlying nature and structure of mental health problems. They attempt to describe patterns observed in nature, for example how a patient behaves, without (the authors claim) making assumptions about why. </p>
<p>However, the complexity of mental health problems can lead to difficult decisions. It also means the manuals themselves are also complex: what criteria are included; the rules about which disorders are included and which aren’t; and the relationships between different families in the manuals, for example between obsessive compulsive disorder and impulse control disorder. This also leads to significant differences in opinion.</p>
<h2>Families of illnesses</h2>
<p>The manuals are designed to group similar types of diagnoses together. For instance, diagnoses that are all concerned with anxiety of various kinds are listed together. And they are generally seen as separate from problems such as learning disabilities. </p>
<p>Including problems such as children’s learning disabilities, relationship and personality difficulties, emotional problems and problems of later life such as dementia, can be problematic. DSM-5 has come under critcism for changes in some of these areas. One example discussed widely is that idea that it might be possible to receive a diagnosis of “major depressive episode” when one is still grieving for the death of a loved-one. Bereavement was specifically excluded from previous versions.</p>
<p>The ICD and DSM are different, and to an extent are rival systems, but there is huge overlap. This allows researchers and clinicians to translate diagnoses from one system to another - a bit like cross-referencing between two dictionaries.</p>
<p>DSM uses what is called a “multi-axial” scheme to classify diagnoses. Psychiatrists use multiple axes to diagnose and treat patients. Primary diagnoses form a first tier called Axis I and includes depression and schizophrenia. So-called developmental and personality disorders lie in Axis II and includes autism. Related issues such as the degree of disruption caused to a person’s life are assessed on remaining axes. In practice, Axes I and II diagnoses tend to be used in a similar way.</p>
<p>Psychiatric diagnosis echoes and resembles conventional medical diagnosis, but there are no useful biological markers or tests for illnesses like you might get if you were treating someone with diabetes – which makes many people sceptical of biological explanations per se. </p>
<p>Diagnosis of a person’s problems is inevitably based on their descriptions of their feelings, thoughts and behaviour and on the observations of the person trying to make the diagnosis. </p>
<p>It also means that decisions about the criteria for each diagnosis – the structure and content of DSM and ICD - are essentially made by committee. In the case of DSM, a taskforce.</p>
<h2>New approaches</h2>
<p>Different clinicians – and particularly psychiatrists and psychologists – differ as to what particular problems should be included or what the criteria should be. Some also question <a href="http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health">the reliability of psychiatric diagnoses</a>, whether we should think of problems as illnesses to be treated or that a broadening of psychiatric diagnoses means a wider variety of personal problems could attract a diagnosis. One widely discussed example is that it might now be possible to receive a diagnosis of “major depressive episode” when one is grieving for the death of a loved-one. </p>
<p>Others fear the opposite: that diagnoses, and therefore psychiatric support, will be taken away. This has <a href="http://www.medpagetoday.com/MeetingCoverage/APA/32578">particularly been the case with changes to the definition of autism</a> and the exclusion of Asperger’s from DSM-5.</p>
<p>While the publication of DSM-5 has catalysed criticism, it is also pushing new approaches into the spotlight.</p>
<p>The director of the US National Institute of Mental Health, the largest funder of mental health research in the world, <a href="http://nyti.ms/12Cfr2k">said this month that it was moving away</a> from a DSM-style approach to focus on biology, genetics and neuroscience, allowing disorders to be defined by causes, not symptoms.</p>
<p>New research will continue to develop our understanding of the causes and treatment of mental illness. But public debate and controversy over the way we should approach it won’t be very far away. </p><img src="https://counter.theconversation.com/content/14127/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Kinderman 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>Traditional psychiatry uses the approaches of medicine to try to understand mental health problems and guide treatment. This means relying on diagnosis – identifying what are believed to be mental illnesses…Peter Kinderman, Professor of Clinical Psychology, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/141322013-05-19T23:11:15Z2013-05-19T23:11:15ZUnder new psychiatric guidebook we might all be labelled mad<figure><img src="https://images.theconversation.com/files/23518/original/vchff3n5-1368199512.jpg?ixlib=rb-1.1.0&rect=1%2C3%2C1022%2C682&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medication misuse is out of control in the US and more psychiatric labelling in DSM-5 will not help.</span> <span class="attribution"><span class="source">Whale05/Flikr</span></span></figcaption></figure><p>“We are all mad here” explains the Cat to Alice when she wonders about the strangeness of Wonderland. Well, life is starting to follow art. If people make the mistake of following DSM-5, the new diagnostic manual in psychiatry that was published on Saturday, pretty soon all of us may be labelled mad.</p>
<p>When I worked on the taskforce for DSM-4, we were very concerned about taming diagnostic inflation - but we only partly succeeded. Then four years ago, I became aware of the excessive enthusiasm around all the new diagnoses being proposed for DSM-5, including many that were untested. I hate to rain on anyone’s parade, but I knew this would be disastrous for the millions of people who were likely to be mislabelled, stigmatised and given excessive treatment.</p>
<p>In the US, the “sick” are distinguished from the “well” by the diagnostic and statistical manuals developed by the American Psychiatric Association.</p>
<p>The problem is that definitions of mental disorders are already written too loosely and are applied much too carelessly by clinicians, especially by the GPs who do most of the prescribing of psychiatric drugs.</p>
<p>And things are about to get much worse. Under DSM-5 diagnostic inflation looks set to become hyperinflation and will lead to an even greater glut of unnecessary medication. I would qualify for a bunch of the new labels myself – and you might too.</p>
<p>The grief I felt when my wife died would now be called “major depressive disorder”; forgetfulness in older age “mild neurocognitive disorder”; my gluttony now “binge eating disorder”; and my hyperactivity “attention deficit disorder”. As for my twin grandsons’ temper tantrums, this could be misunderstood as “disruptive mood dysregulation disorder”. And if you have cancer and your doctor thinks you are too worried about it, there’s “somatic symptom disorder.” It goes on, but you get the idea.</p>
<p>About <a href="http://www.ncbi.nlm.nih.gov/pubmed/15939837">half of Americans already qualify for a mental disorder</a> at some point in their lives and the rates keep skyrocketing, especially among kids. In the past 20 years, the prevalence of autism has increased, childhood bipolar <a href="http://www.nimh.nih.gov/news/science-news/2007/rates-of-bipolar-diagnosis-in-youth-rapidly-climbing-treatment-patterns-similar-to-adults.shtml">has multiplied 40-fold</a> and <a href="http://www.nice.org.uk/nicemedia/pdf/CG72FullGuideline.pdf">attention deficit disorder has tripled</a>.</p>
<p>One consolation: the kids are not suddenly getting much sicker – human nature is pretty stable. But the way we label symptoms follows fickle fashions, changing quickly and arbitrarily. And freely giving out inaccurate diagnoses can lead to grave harms – medication that isn’t needed, stigma, lower self confidence and reduced self expectation.</p>
<p>There are also downstream effects. Many parents were panicked about the alarming rise in rates of autism and fell for <a href="http://www.guardian.co.uk/society/2013/apr/25/measles-mmr-the-essential-guide">the disproven belief that it was caused by vaccination</a>. Trying to avoid a false epidemic of autism caused by nothing more than changed labelling meant they stopped vaccinating their kids and exposed them to the very real measles outbreak that recently occurred.</p>
<p>And medication use is out of control – 20% of Americans regularly use a <a href="http://www.medscape.com/viewarticle/753789">psychotropic drug</a>; <a href="http://www.nytimes.com/2013/04/01/health/more-diagnoses-of-hyperactivity-causing-concern.html?pagewanted=all">10% of teenage boys are taking a stimulant for ADHD</a>; 25% of our active duty troops <a href="http://usatoday30.usatoday.com/printedition/news/20091217/milhealth17_st.art.htm">report abuse of a prescribed med</a>; and the US has more deaths <a href="http://www.cdc.gov/injury/about/focus-rx.html">from prescription drug overdoses</a> than from street drugs.</p>
<p>In the UK you are protected against the worst effects of diagnostic and drug exuberance. Doctors use ICD-10, the classifications compiled by the World Health Organisation, not DSM-5; they follow prudent guidelines from Nice, which sets the standards for health treatment in the UK; the British-based Cochrane group <a href="http://en.wikipedia.org/wiki/Cochrane_Collaboration">emphasises evidence-based medicine</a>; GPs do less prescribing; and drug companies exert much less power and cannot advertise directly to consumers as they do in the US.</p>
<p>But the measles outbreak and ADHD rates prove the UK is not out of the woods. Bad ideas from America sometimes have much more influence than they deserve.</p>
<p>My advice is to be an informed consumer. Never accept a diagnosis or a medication after a cursory evaluation. A psychiatric diagnosis can be a turning point in your life – as important as choosing a spouse or a house. Done well, it can lead to life-improving treatment; done poorly it can lead to an inaccurate label and a harmful treatment.</p>
<p>People who have mild and transient symptoms don’t need a diagnosis or treatment. The likelihood is they are visiting the doctor on one of their worst days and will get better on their own. Medication is essential for severe psychiatric problems but does more harm than good for the worries and disappointments of everyday life. Better to trust time, resilience, support and stress reduction.</p><img src="https://counter.theconversation.com/content/14132/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Allen Frances has two published books critical of DSM-5: Saving Normal and Essentials of Psychiatric Diagnosis</span></em></p>“We are all mad here” explains the Cat to Alice when she wonders about the strangeness of Wonderland. Well, life is starting to follow art. If people make the mistake of following DSM-5, the new diagnostic…Allen Frances, Professor Emeritus of Psychiatry, Duke UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/142212013-05-19T20:17:37Z2013-05-19T20:17:37ZDespite the critics, psychiatrists need guidelines like the DSM-5<figure><img src="https://images.theconversation.com/files/24087/original/3tw74r2d-1368936947.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Clinicians must use their judgement and look beyond the narrow debate about whether mental illnesses have a biological or psychosocial basis.</span> <span class="attribution"><span class="source">crises_crs/Flickr</span></span></figcaption></figure><p>This weekend saw the release of the fifth edition of the American Psychiatric Association’s <a href="http://www.psych.org/practice/dsm/dsm5">Diagnostic and Statistical Manual</a> (DSM-5). The manual has been attracting controversy throughout its revision process, but critical voices reached fever pitch in the weeks leading up to its release. </p>
<p>Indeed, in the fortnight before its release, DSM-5 was panned by the director of the US National Institute of Mental Health (NIMH) as well as the British Psychological Society’s (BPS) division of clinical psychology. Interestingly, the criticisms were at odds with each other. </p>
<p>The NIMH wants psychiatry to focus on the biological bases of mental illness while the BPS opts for psychosocial therapy. It seems that the DSM would have been damned whichever way it opted to go.</p>
<p>NIHM director Dr Thomas R Insel <a href="http://www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html?nl=todaysheadlines&emc=edit_th_20130507&_r=0">accused the manual</a> of lacking scientific rigour, announcing that he intended to:</p>
<blockquote>
<p>reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.</p>
</blockquote>
<p>Criticism from the BPS was not directed straight at DSM-5 but was “provocatively timed”, <a href="http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health?INTCMP=SRCH">according to the Guardian</a>, and questioned the benefits of the manual. Here the BPS’ spokesperson said:</p>
<blockquote>
<p>it was unhelpful to see mental health issues as illnesses with biological causes.</p>
</blockquote>
<p>But what are clinicians like me to think when confronted by criticism from such respectable sources? We need a set of labels, updated routinely, as a shorthand for talking with colleagues. Patients and families expect a diagnosis. We need to justify funding for medication and hospital care. Even funders of talking therapies and social supports expect a label.</p>
<p>The truth is that making a diagnosis in health care is complex, and it is even more complex in psychiatry. Say someone reports a painful arm after a fall. This may indicate a broken bone. The clinical examination that follows is usually helpful in finding tenderness and sometimes deformity. And technology, in the form of X-ray, is commonly used to make a definitive diagnosis. </p>
<p>Now, imagine the difficulty of diagnosis where the bulk of the information is from a patient’s own report of symptoms that are not necessarily observable by the clinician. There’s no definitive X-ray or blood test to point you in the right direction. </p>
<p>Welcome to the world of clinical psychiatry where: </p>
<blockquote>
<p><a href="http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1558423">the boundaries</a> between many disorder “categories” are more fluid over the life course than was previously understood, and many symptoms assigned to a single disorder may occur, at varying levels of severity, in many other disorders. </p>
</blockquote>
<p>Psychiatrists regularly treat people who experience marked distress and loss of function caused by diseases or syndromes that have continued to evade definitive biological definition. </p>
<p>The early DSM editions were American modifications of the World Health Organization’s <a href="http://www.who.int/classifications/icd/en/">International Classification of Diseases</a> (ICD) to give a “pure” mental disorders chapter. <a href="http://www.psychiatry.org/practice/dsm/dsm-history-of-the-manual">DSM-I and DSM-II</a> were clumsy by today’s standards and labelled the world as it was without much help from research.</p>
<p>But the American Psychiatric Association (APA) followed ground-breaking work into the <a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=491943">categorisation of psychiatric conditions</a> of the 1970s with the third edition of the DSM in 1980. DSM-III made a “best guess” at an archipelago of diagnosis, where each island or illness was confirmed as discrete with borders separated by clear water. A revision to iron out inconsistencies followed in the form of DSM-III-R and DSM-IV was published in 1994.</p>
<p>By 2002, the <a href="http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=2292">APA was convinced</a> that two decades of “modern” DSM categories had not generated valid, clearly separated diagnoses. Research, it seemed, had “<a href="http://www.ncbi.nlm.nih.gov/pubmed/19487400">not confirmed the wisdom</a> of the current structure.” The islands tended to stick together and overlapped repeatedly. The map was a mess for researchers and clinicians alike.</p>
<p>In the latest edition of the manual, conditions will be clustered in chapters with dimensional measures encouraged over discrete diagnostic categories. If you can’t separate each island, drag them together and describe different bits as mountains or lagoons. This represents the triumph for supporters of a “spectrum of illness”.</p>
<p>The leaders of the process that changed the diagnostic concepts (driven by more than two decades of peer-reviewed scientific research) might have expected some public applause. Instead, even before the launch of the DSM-5, negative public comments criticised their work.</p>
<p>But the narrow debate that has ensued presumes mental illness has either a biological or psychosocial basis, which does no justice to our current scientific knowledge. Surely, in 2013, we can accept that all human memory, behaviour and emotion is connected to the chemistry of our brain.</p>
<p>But then many clinical psychologists spend all their time working with people who clearly have a biological basis to their problem, such as head injury or brain disease. Should we presume that the social circumstances or psychological make-up of these people never mix with their altered brain anatomy?</p>
<p>All of us are clearly a complex mixture of nature and nurture. Clinicians of all types, including psychologists, need to stay focused on the person in their office and use their judgement when making a diagnosis. </p>
<p>The previous edition of the DSM included a reminder to use diagnostic criteria as guidelines rather than a cookbook. Regardless of other changes, we can hope that this reminder is retained in the latest version lest any of us stray into using multiple unnecessary labels that distract from the distress of the person sitting in front of us.</p><img src="https://counter.theconversation.com/content/14221/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Darryl P. Watson has provided paid consultancy and received speaker's fees from a number of Pharmaceutical comapanies criticised for supporting the development and extension of illness categories. He has received research and educational funding from several pharmaceutical companies.He is affiliated with the Royal Australian and New Zealand College of Psychiatrists but is not the official spokesperson for this organisation.</span></em></p>This weekend saw the release of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5). The manual has been attracting controversy throughout its revision…Darryl P. Watson, Clinical Senior Lecturer in Psychiatry, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/120472013-04-18T19:57:37Z2013-04-18T19:57:37ZMental disorders: debunking some myths of the DSM-5<figure><img src="https://images.theconversation.com/files/21436/original/4xp8fdnb-1363670497.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The DSM-5 doesn't attempt to define what is "normal"; and having a DSM diagnosis is not the same as being “insane”.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>The fifth edition of the <a href="https://theconversation.com/topics/dsm-v">Diagnostic and Statistical Manual of Mental of Mental Disorders</a> (DSM-5) is due to hit psychiatrists’ and psychologists’ shelves next month. Produced by the American Psychiatric Association (APA), the DSM provides a standardised system of diagnosing mental disorders. </p>
<p>From its first edition in 1952, and with each new edition about every 15 to 20 years, the DSM has always had its critics. But as the arrival of DSM-5 approaches, their clamour is becoming louder. </p>
<p>As a member of the <a href="http://www.dsm5.org/MeetUs/Pages/NeurocognitiveDisorders.aspx">DSM-5’s Neurocognitive Disorders Work Group</a>, I’m familiar with some of the procedures involved in bringing the manual into shape. So let’s look at four key criticisms about the DSM-5 – and whether they’re warranted. </p>
<h2>1. It’s impossible to classify mental disorders</h2>
<p>The primary purpose of the DSM-5 is to enable physicians or other clinicians to reliably diagnose patients who present with a mental disorder. The manual also outlines treatment pathways for the diagnosis, and the likely outcome over time.</p>
<p>Unlike other disciplines of medicine, a mental disorder cannot be confirmed by a pathologist peering down a microscope or a biochemist measuring molecules in the blood. Aside from a few exceptions, there is no other way of truly knowing whether a disease really exists.</p>
<p>Inevitably, there will be differences of opinion about what constitutes a disorder, and some of these will be major ones. But using the DSM, two clinicians working remotely from each other should reach the same diagnosis for a particular patient.</p>
<h2>2. The DSM is just a money maker</h2>
<p>Critics have argued the DSM “enterprise” has been very lucrative for the APA, and that book royalties are the primary motivator for producing yet another edition. </p>
<p>Considering that about <a href="http://www.huffingtonpost.com/allen-frances/dsm-5-costs-25-million-apa_b_1554405.html">US$25 million</a> has already been spent on the fifth revision process, as estimated by the chair of the task force, it does not appear to be a great investment if book royalties were the primary objective.</p>
<p>Neuroscientific knowledge is exploding exponentially, so revisiting the classification of mental disorders after two decades is certainly not premature.</p>
<h2>3. Under the DSM-5, more people will be diagnosed with a mental disorder</h2>
<p>The process of revising the DSM is extremely rigorous, and any proposal for a new disorder or a major revision of existing criteria needs to come on the back of strong scientific evidence. </p>
<p>There are 13 DSM-5 working groups, broken down into categories such as mood disorders, eating disorders, and substance-related disorder. Any new proposal must be accepted by other members of the advisory group, all of whom are experts in their field. </p>
<p>The total number of disorders in DSM-5 is yet to be announced, but its chair David Kupfer <a href="http://www.slate.com/articles/health_and_science/medical_examiner/2013/04/diagnostic_and_statistical_manual_fifth_edition_why_will_half_the_u_s_population.html">has said</a> the total number of disorders will not be more than in the DSM-IV: 297. </p>
<p>It’s important to note that the illnesses clinicians encounter in the psychiatric clinic is often a more severe form of a phenomenon that pervades society. Psychiatrists must therefore identify if it is severe or deviant enough to warrant attention. </p>
<p>The DSM-5 is intended to help them make that decision. They often end up applying a threshold at which a particular set of symptoms become a disorder or a diagnosis. The threshold is guided by the level of distress or dysfunction that the individual is suffering. </p>
<p>It is therefore not a culturally influenced whim, but culture does influence the decision. Differences in such thresholds lead to the controversies in the diagnosis of <a href="https://theconversation.com/moving-the-diagnostic-goalposts-medicalising-adhd-8675">attention-deficit hyperactivity disorder</a> (ADHD), for example, or when <a href="https://theconversation.com/why-prolonged-grief-should-be-listed-as-a-mental-disorder-4262">bereavement becomes depression</a>.</p>
<h2>4. The DSM is trying to redefine what’s normal</h2>
<p>The DSM-5, and any other classification of mental disorders, is not an attempt to define what is normal. Being normal is not the same as “not having a DSM-5 diagnosis”, and having such a diagnosis is not the same as being “insane”, as some have wrongly argued about the DSM. </p>
<p>Insanity is in fact a legal term, and “mad” or “crazy” are stigmatising lay terms that do not apply to the vast majority of people with a DSM-5 diagnosis, and should not in fact be used for anybody. </p>
<p>Many individuals, including physicians, find it difficult to accept that mental illness, not unlike physical illness, is common and most of it is not madness or insanity. The <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/4326.0">2007 National Mental Health Survey</a> showed that one in five Australians experienced a mental disorder in the previous 12 months. </p>
<p>When dealing with the imperfections of psychiatric neuroscience, it is clear that the debate on the appropriateness or otherwise of the classification system will continue as the mental health profession ponders what is worth treating and society delineates what is worth helping. </p>
<p>The DSM-5 must simply be regarded as psychiatry’s next faltering step. It’s not above criticism, but is probably the best manual of mental disorders that we are likely to have for some time. </p>
<p>A truly uncontroversial DSM-6 will have to await major breakthroughs in our understanding of psychiatric disorders. Let’s hope we don’t have to wait for more than a generation.</p><img src="https://counter.theconversation.com/content/12047/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Perminder Sachdev receives funding from National. Health & Medical Research Council, the Australian Researhc Council, the National Institute of Health (USA) and Alzheimer's Australia.
He is affiliated with the Centre for Healthy Brain Ageing (CHeBA), University of New South Wales, and the Neuropsychiatric Institute, the Prince of Wales Hospital, Sydney.</span></em></p>The fifth edition of the Diagnostic and Statistical Manual of Mental of Mental Disorders (DSM-5) is due to hit psychiatrists’ and psychologists’ shelves next month. Produced by the American Psychiatric…Perminder Sachdev, Scientia Professor of Neuropsychiatry, Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag: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.