tag:theconversation.com,2011:/us/topics/dsm-1843/articlesDSM – The Conversation2023-11-21T19:06:39Ztag:theconversation.com,2011:article/2179212023-11-21T19:06:39Z2023-11-21T19:06:39ZAustralia’s rates of autism should be celebrated – but real-life impact, not diagnosis, should determine NDIS support<p>Ahead of the release of the government’s <a href="https://www.ndisreview.gov.au/about">review into the National Disability Insurance Scheme (NDIS)</a>, the topic taking centre stage is the diagnosis of autism. Over one third of people accessing the scheme list it as a primary disability. </p>
<p>NDIS Minister Bill Shorten has <a href="https://www.smh.com.au/politics/federal/shorten-flags-autism-changes-says-ndis-can-t-be-surrogate-school-system-20231120-p5elci.html">flagged changes</a> to NDIS access, shifting the emphasis from diagnosis to the real-world impact of autism on learning or participation in society. He’s called for education and health systems to step up and be part of a broader ecosystem of supports. </p>
<p>“We just want to move away from diagnosis writing you into the scheme,” the minister <a href="https://www.smh.com.au/politics/federal/shorten-flags-autism-changes-says-ndis-can-t-be-surrogate-school-system-20231120-p5elci.html">said</a> this week. “Because what [then] happens is everyone gets the diagnosis.”</p>
<p>Is autism “over diagnosed” in Australia due to the NDIS, or is it being better identified? </p>
<h2>What the data really shows</h2>
<p>Recently <a href="https://www.theage.com.au/politics/federal/the-unique-factor-that-could-explain-why-autism-rates-in-australia-are-growing-faster-than-the-global-average-20231108-p5eig4.html">reported</a> non-peer reviewed research suggests the NDIS has fuelled Australia’s diagnosis rates to be among the highest in the world at one in 25 children. But the same research reported Japan – with early identification and supports in place since the early 1990s – has similar rates.</p>
<p>It’s useful to look at the <a href="http://otarc.blogs.latrobe.edu.au/autism-prevalence-in-australia-what-we-know-so-far/">peer-reviewed</a> data available. A <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789926">recent</a> screening study we conducted with 13,511 Victorian children aged one to 3.5 years found one in 31 (3.3%) were autistic. This finding was based on data collected between 2013–18 (before and during the rollout of the NDIS). </p>
<p>The <a href="https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(23)00045-5/fulltext">United Kingdom</a> reports a prevalence rate of one in 34, based on 2000–2018 data for 10- to 14-year-olds. </p>
<p>The United States <a href="https://www.cdc.gov/mmwr/volumes/72/ss/ss7202a1.htm?s_cid=ss7202a1_w">Centers for Disease Control and Prevention</a> report a 2020 prevalence rate of one in 36 children aged eight.</p>
<p>Before the full nationwide rollout of the NDIS, 2020 research based on the <a href="https://pubmed.ncbi.nlm.nih.gov/32124539/">Longitudinal Study of Australian Children</a> showed a prevalence rate of one in 23 (4.4%) in 12- to 13-year-olds – even higher than the recently reported paper claiming NDIS was driving up autism diagnosis rates. </p>
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Read more:
<a href="https://theconversation.com/the-ndis-has-a-parent-problem-changes-could-involve-parents-more-in-disability-support-and-reduce-stress-212099">The NDIS has a parent problem. Changes could involve parents more in disability support and reduce stress</a>
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<h2>We’re getting better at identification</h2>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/32124539/">Longitudinal Study of Australian Children</a> also shows younger children (born 2003–04) have a higher autism prevalence (4.4%) than older children (2.6%; born between 1999–2000). Yet, younger children had fewer social, emotional and behaviour challenges than older children. These findings tell us we are getting better at identifying children with more subtle traits at earlier ages. This is leading <a href="https://link.springer.com/article/10.1007/s10803-017-3279-x">to better outcomes</a>.</p>
<p>There is growing awareness of the presentation of autistic people (<a href="https://www.yellowladybugs.com.au/">particularly girls, woman and gender-diverse people</a>) who have historically missed out on diagnosis in childhood due to a lack of understanding of their “<a href="https://autisticgirlsnetwork.org/wp-content/uploads/2022/11/Keeping-it-all-inside.pdf">internalised</a>” presentation, leading to “masking” and “<a href="https://link.springer.com/article/10.1007/s40489-020-00197-9">camouflaging</a>” their differences. They may do this until the demands of life exceed their capacity to cope, leading them to seek a diagnosis. </p>
<p>This has contributed to the overall percentage of autistic participants <a href="https://www.ndis.gov.au/about-us/publications/quarterly-reports/archived-quarterly-reports-2022-23">accessing the NDIS</a>.</p>
<h2>Diagnostic overshadowing</h2>
<p>Another reason for the rise of autism diagnosis is a phenomenon known as “<a href="http://www.intellectualdisability.info/changing-values/diagnostic-overshadowing-see-beyond-the-diagnosis">diagnostic overshadowing</a>”. This is a tendency to explain all differences in a person based on their primary diagnosis. </p>
<p>In the past, many autistic people were diagnosed only with intellectual disability, or misdiagnosed with intellectual disability. As knowledge of autism has improved, more people were correctly diagnosed as autistic, or as both autistic and having an intellectual disability. The result? A clear change in prevalence rates of these two disabilities. </p>
<p>A US <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683759/">study</a> conducted between 2000 and 2014 found the trend of autism diagnosis was on the rise, while the diagnosis of intellectual disability had <a href="https://auc-word-edit.officeapps.live.com/we/Figure%201">declined</a>. If prevalence of autism was truly on the rise, rates of intellectual disability would remain static as rates of autism rose.</p>
<p>We see a similar trend of people accessing the NDIS between 2017 and 2023 based on NDIS <a href="https://www.ndis.gov.au/about-us/publications/quarterly-reports">data</a>. Autistic participants rose by 6% (29% to 35%) from 2017 to 2023, while participants with intellectual disability dropped by 20% (36% to 16%). </p>
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<a href="https://images.theconversation.com/files/560648/original/file-20231121-4482-d1cauc.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="graph shows intellectual disability percentage falling over time and autism percentage growing" src="https://images.theconversation.com/files/560648/original/file-20231121-4482-d1cauc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/560648/original/file-20231121-4482-d1cauc.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=284&fit=crop&dpr=1 600w, https://images.theconversation.com/files/560648/original/file-20231121-4482-d1cauc.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=284&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/560648/original/file-20231121-4482-d1cauc.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=284&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/560648/original/file-20231121-4482-d1cauc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=357&fit=crop&dpr=1 754w, https://images.theconversation.com/files/560648/original/file-20231121-4482-d1cauc.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=357&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/560648/original/file-20231121-4482-d1cauc.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=357&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="attribution"><span class="source">Compiled by authors from NDIS data</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>This suggests we are not only correctly diagnosing autism as the primary disability, but we may also be reducing co-occuring disability that can significantly impact day-to-day life. This functional focus was the original intention of the NDIS and the purpose Shorten and <a href="https://youtu.be/IOAomqtXGGY?si=hz457CgBx82BWy-2">NDIS review co-chairs</a> have said they want to return to.</p>
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<figcaption><span class="caption">Bruce Bonyhady says we need to get away from a system that has focused up to now on primary medical diagnosis rather than functional needs.</span></figcaption>
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Read more:
<a href="https://theconversation.com/the-ndis-is-set-for-a-reboot-but-we-also-need-to-reform-disability-services-outside-the-scheme-204041">The NDIS is set for a reboot but we also need to reform disability services outside the scheme</a>
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<h2>A diagnostic ticket to the NDIS</h2>
<p>Current eligibility to access the NDIS is based on permanent disability, which substantially impacts the individual’s everyday activity. (Children from birth to nine years old with any developmental concerns or differences can access the <a href="https://www.ndis.gov.au/understanding/families-and-carers/early-childhood-approach-children-younger-9#:%7E:text=It%20is%20about%20giving%20children,%2Dcentred%20and%20strengths%2Dbased.">Early Childhood Approach</a>, an arm of the NDIS based on needs not diagnosis.) </p>
<p>The National Disability Insurance Agency (the NDIA, which administers the scheme) currently interprets “severity” levels for autism from the <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">diagnostic manual</a> to determine funding. Severity levels range from “requires support” (level one), to “requires very substantial support” (level three). But the diagnostic manual used by clinicians says: </p>
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<p>[…] descriptive severity categories should not be used to determine eligibility for and provision of services; these can only be developed at an individual level and through discussion of personal priorities and targets.</p>
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<p>This means NDIA <a href="https://ourguidelines.ndis.gov.au/home/becoming-participant/applying-ndis/list-conditions-are-likely-meet-disability-requirements">eligibility criteria</a> for the scheme excludes needed, meaningful, support for children receiving “level one” diagnoses. </p>
<p>As a result, some clinicians have been accused of “<a href="https://www.afr.com/policy/health-and-education/over-diagnosing-autism-in-children-does-them-a-great-disservice-20230418-p5d1ek#:%7E:text=Those%20with%20levels%20two%20and,risk%2C%E2%80%9D%20says%20Professor%20Jureidini.">manufacturing</a>” level two diagnosis and “<a href="https://www.smh.com.au/politics/federal/sharp-rise-more-than-8-per-cent-of-young-school-children-now-on-ndis-20230519-p5d9rc.html">rorting of the system”</a> to ensure NDIS eligibility. </p>
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Read more:
<a href="https://theconversation.com/a-decade-on-the-ndis-has-had-triumphs-challenges-and-controversies-where-to-from-here-208463">A decade on, the NDIS has had triumphs, challenges and controversies. Where to from here?</a>
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<h2>Challenges change over time</h2>
<p>NDIS access and funding should not be based on diagnostic levels; it must be based on individual needs. To make the fundamental shift Shorten and the NDIS review co-chairs are foreshadowing, access to the NDIS should not be <a href="https://theconversation.com/on-my-worst-day-how-the-ndis-fosters-a-deficit-mindset-and-why-that-should-change-208846">deficits based</a>. The NDIA will need to educate and train its staff in a holistic approach, focusing on what autistic people can achieve with appropriate supports in place.</p>
<p>If we invest in early supports, autistic children are less likely to require <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2784066">as many supports as they age</a>. This is a good thing for the financial sustainability of the NDIS, which was designed as an insurance scheme and not a welfare system. </p>
<p>Australia is at the forefront of <a href="http://otarc.blogs.latrobe.edu.au/tag/prevalence/">identifying</a> autism early, consequently improving children’s and <a href="https://link.springer.com/article/10.1007/s10803-023-05992-x">families’</a> quality of life. Our rates of early diagnosis should be celebrated, not demonised.</p>
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Read more:
<a href="https://theconversation.com/on-my-worst-day-how-the-ndis-fosters-a-deficit-mindset-and-why-that-should-change-208846">'On my worst day ...' How the NDIS fosters a deficit mindset and why that should change</a>
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<img src="https://counter.theconversation.com/content/217921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nancy Sadka receives funding from La Trobe University </span></em></p><p class="fine-print"><em><span>Josephine Barbaro receives funding from La Trobe University, the National Health and Medical Research Council (NHMRC), the UK National Institute for Health Research Global Health Research Units, and the Victorian Government Department of Families, Fairness and Housing and Department of Health and Human Services.</span></em></p>We’re getting better at early identification and adult diagnosis has contributed to NDIS numbers. But functional impairment is likely to be given greater emphasis in the NDIS reboot.Nancy Sadka, Research Fellow, Olga Tennison Autism Research Centre, La Trobe UniversityJosephine Barbaro, Associate Professor, Principal Research Fellow, Psychologist, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2120972023-08-28T01:53:41Z2023-08-28T01:53:41Z20% of children have developmental delay. What does this mean for them, their families and the NDIS?<p>Professor Bruce Bonyhady is often described as the architect of the National Disability Insurance Scheme (NDIS) and is co-chair of the panel reviewing it. He <a href="https://www.ndisreview.gov.au/sites/default/files/2023-08/a-question-of-balance-speech.pdf">spoke last week</a> about the sustainability challenges faced by the scheme. </p>
<p>Among the key issues identified was that <a href="https://www.abc.net.au/news/2023-08-22/concerns-about-ndis-raised-by-co-chair-of-review/102758296">20% of Australian children</a> experience learning difficulties, developmental concerns, developmental delay or are found to have disability. Bonyhady <a href="https://www.ndisreview.gov.au/news/future-ndis-and-where-we-are-heading">said</a> this made it a “mainstream issue”. He added the NDIS was never designed to be the main support system for the majority of these children. </p>
<p>With the <a href="https://www.ndisreview.gov.au/resources/reports/what-we-have-heard-report">NDIS review</a> due to report to state and federal ministers in October, the comments signal a re-calibration of the scheme. </p>
<p>This presents another challenge: which government systems outside the NDIS will embrace the large number of children who need developmental support?</p>
<h2>What is a developmental delay?</h2>
<p><a href="https://raisingchildren.net.au/guides/a-z-health-reference/developmental-delay#:%7E:text=Developmental%20delay%20can%20show%20up,short%20term%20or%20long%20term.">Developmental delay</a> is a general term that refers to young children who are slower to develop communication, physical, social, emotional and cognitive skills than typically expected. The pace of a child’s development can be measured in many ways, one of which is comparing their development to established <a href="https://www.healthdirect.gov.au/developmental-milestones">milestones</a>, such as when they learn their first word or when they learn to walk.</p>
<p>Many things can cause developmental delay. These include biological differences (such as genetic conditions), environmental challenges (including deprivation) or a combination of both. In many cases, the causes of a child’s developmental delay remain unknown.</p>
<p>Developmental delay is a term commonly used in clinical practice, but not included in official diagnostic manuals like the <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">Diagnostic and Statistical Manual</a>. This is because developmental delay is viewed as a temporary state in child development. It is most often used for children under five. </p>
<p>As children grow older, some developmentally catch up with their peers. Others continue to lag behind. At a certain point in development – typically around five - children in the latter group will start to be referred to as having a developmental disability. </p>
<p>Developmental disabilities are included in official diagnostic manuals and include autism, attention deficit hyperactivity disorder (ADHD), intellectual disability, specific learning disorders, communication disorders and developmental coordination disorder.</p>
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<h2>Developmental delay and the NDIS</h2>
<p>The NDIS has a <a href="https://www.ndis.gov.au/understanding/families-and-carers/early-childhood-approach-children-younger-9/developmental-delay-and-early-childhood-approach#how-an-early-childhood-partner-will-evidence-developmental-delay-for-children-younger-than-6">specific definition of developmental delay</a> which encompasses three areas. Children are considered to have a developmental delay if their delay is: </p>
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<li>due to mental or physical impairments</li>
<li>substantially reduces functional capacity</li>
<li>requires specialist services. </li>
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<p>Around <a href="https://www.ndis.gov.au/about-us/publications/quarterly-reports">11% of all NDIS participants</a> are classified as having a developmental delay. There are also a significant number of children with developmental delay who are not within the NDIS. Taken together, these groups make up about 20% of Australian children under five. </p>
<p>While there is a general community view that developmental delay is an increasing issue in Australia, there is a lack of data tracking over time to understand if this view is accurate.</p>
<p>Our clearest indication comes from <a href="https://www.aedc.gov.au/early-childhood/findings-from-the-aedc">Australian Early Development Census</a>, which surveys more than 300,0000 children entering primary school. </p>
<p>The latest available data indicate there are now slightly fewer children who are “developmentally on track” (down from 55.4% in 2018 to 54.8% in 2021) and an increase in the number of children who are “developmentally vulnerable” in any one area of development (up from 21.7% in 2018 to 22% in 2021). </p>
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Read more:
<a href="https://theconversation.com/a-decade-on-the-ndis-has-had-triumphs-challenges-and-controversies-where-to-from-here-208463">A decade on, the NDIS has had triumphs, challenges and controversies. Where to from here?</a>
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<h2>Supporting children with developmental delay</h2>
<p>There has always been a large number of children experiencing developmental delay. But the fragmentation across state/territory and Commonwealth health and disability systems has meant the true scale of children struggling with development has not been clear. The unified system of the NDIS has made the percentage of children with delays clearer.</p>
<p>But, as Bonyhady notes, the NDIS was not designed to support all these children. The NDIS was meant to complement existing systems such as health and education, and to provide additional support to children with the most significant disability impacts. This figure is estimated to be a small proportion of the 20% of children who meet criteria for developmental delay.</p>
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Read more:
<a href="https://theconversation.com/what-is-early-intervention-for-infants-with-signs-of-autism-and-how-valuable-could-it-be-205839">What is 'early intervention' for infants with signs of autism? And how valuable could it be?</a>
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<h2>Meeting children and families where they are</h2>
<p>The NDIS is rightly <a href="https://www.ndisreview.gov.au/news/future-ndis-and-where-we-are-heading">described</a> as a policy miracle, and has benefited hundreds of thousands of Australians – with millions more to come. Its future thriving is highly dependent on how our community supports children with developmental delay. </p>
<p>The NDIS has accelerated a trend for the <a href="https://www.afr.com/policy/economy/children-undermining-the-sustainability-of-the-ndis-20230630-p5dkp7">medicalisation</a> of development supports. Children with developmental delays receive supports within clinics, rather than in the natural settings in which they live and function every day. </p>
<p>This has <a href="https://theconversation.com/more-children-than-ever-are-struggling-with-developmental-concerns-we-need-to-help-families-connect-and-thrive-209866">weakened major protective factors</a> known to support child development, such as community connection and parental empowerment.</p>
<p>Building capacity to support children with developmental delay in their everyday contexts – at home, in childcare, kindergartens or preschools, in the local community – will be crucial to ensuring children with developmental delay and their families thrive into later childhood. </p>
<p>And it will help the NDIS remain the life-changing system it is.</p>
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<img src="https://counter.theconversation.com/content/212097/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Whitehouse is the Director of CliniKids, which is the community health arm of the Telethon Kids Institute. Children accessing CliniKids may be supported through the NDIS. Andrew receives research funding from NHMRC, ARC, the Autism CRC, and the Angela Wright Bennett Foundation</span></em></p>Developmental delay is viewed clinically as a temporary state where children are slower to develop than expected. It is most often used for children under five.Andrew Whitehouse, Bennett Chair of Autism, Telethon Kids Institute, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2065802023-08-24T20:20:46Z2023-08-24T20:20:46ZFriday essay: ‘black bile’, malaria therapy and insulin comas – a brief history of mental illness<p>Possibly the earliest account of a disturbed mind is recorded in a 3,500-year-old <a href="https://en.wikipedia.org/wiki/Vedas">Hindu text</a> that describes a man who is “gluttonous, filthy, walks naked, has lost his memory and moves about in an uneasy manner”.</p>
<p>In the Bible’s Old Testament, in the first <a href="https://www.britannica.com/topic/Books-of-Samuel">Book of Samuel</a>, we read that King David simulated madness to gain safety: </p>
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<p>And he changed his behaviour … and feigned himself mad in their hands, and scrabbled on the doors of the gate, and let his spittle fall down upon his beard.</p>
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<p>In the <a href="https://www.britannica.com/topic/The-Book-of-Daniel-Old-Testament">Book of Daniel</a>, we find a vivid description of King Nebuchadnezzar’s mental state: </p>
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<p>And he was driven from men, and did eat grass as oxen, and his body was wet with the dew of heaven, till his hairs were grown like eagles’ feathers, and his nails like birds’ claws.</p>
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<p>The ancient Greeks made early attempts to explain madness. In the 5th century BC, <a href="https://fherehab.com/learning/humors-ancient-mental-health">Hippocrates</a> viewed it as seated in the brain and influenced by four bodily fluids: blood, phlegm, black bile and yellow bile. </p>
<p>The Greek physician Galen, who practised in Rome 600 years later, argued that depression was caused by an excess of black bile (hence the term “melancholia”, from <em>melan</em>, black, and <em>khole</em>, bile). </p>
<p>His contemporary, <a href="https://www.britannica.com/biography/Aretaeus-of-Cappadocia">Aretaeus of Cappadocia</a>, colourfully described how, if black bile moves upwards in the body, “it forms melancholy; for it produces flatulence and eructations [or, belches] of a fetid and fishy nature, and it sends rumbling wind downwards, and disturbs the understanding”. </p>
<h2>A troubled mind, possessed</h2>
<p>During the Middle Ages, monasteries preserved the view of madness as an illness, and of those afflicted as sick rather than sinful. At the same time, the more sinister belief that the <a href="https://pubmed.ncbi.nlm.nih.gov/25208453/">principal cause</a> of the troubled mind was possession by spirits or the devil prevailed.</p>
<p>Sufferers were taken to sanctioned healers for <a href="https://theconversation.com/exorcisms-have-been-part-of-christianity-for-centuries-107932">exorcisms</a>, a practice still carried out today in some cultures. People who failed to respond to such treatment might then seek out a celebrated expert. </p>
<p>Consider Hwaetred, a young man living in what is now England in the 7th century, who became tormented by an “evil spirit”. So terrible was his madness that he attacked others with his teeth and killed three men with an axe when they tried to restrain him. Taken to several sacred shrines, he obtained no relief. His despairing parents then heard of Guthlac, a monk who lived a hermit life north of Cambridge. After three days of prayer and fasting, Hwaetred was purportedly cured.</p>
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<a href="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543694/original/file-20230821-29-c0gqfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">St Francis Borgia Helping a Dying Impenitent – Goya (1788)</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Over time, the role of religious authorities in mental illness dwindled, and the medical profession claimed the exclusive practice of the healing arts. Insanity once more came to be seen more as a physical malady than a spiritual taint. Even so, life for the mentally ill could be appalling. </p>
<p>During the 17th century, religiously inspired persecution of the mentally ill was justified by the clerical hierarchy, and treatment was often some combination of neglect and bestial restraint. </p>
<p>Psychiatrists Martin Roth and Jerome Kroll <a href="https://books.google.com.au/books/about/The_Reality_of_Mental_Illness.html?id=pCQ4AAAAIAAJ&redir_esc=y">describe</a> the insane in this period as “miserable individuals, wandering around in village and in forest, taken from shrine to shrine, sometimes tied up when they became too violent”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-invention-of-satanic-witchcraft-by-medieval-authorities-was-initially-met-with-skepticism-140809">The invention of satanic witchcraft by medieval authorities was initially met with skepticism</a>
</strong>
</em>
</p>
<hr>
<h2>A watershed: asylums</h2>
<p>The late 18th century was a watershed in the history of psychiatry. The insanity of England’s <a href="https://www.bbc.com/news/magazine-22122407">King George III</a> revealed society’s ambivalence to the mentally ill (vividly captured in the 1994 film <a href="https://www.imdb.com/title/tt0110428/">The Madness of King George</a>). </p>
<p>In France, <a href="https://www.britannica.com/biography/Philippe-Pinel">Philippe Pinel</a> released the chains that had fettered the “lunatic” for centuries, ushering in an unprecedented phase of benevolent institutional care. </p>
<p><a href="https://dictionary.apa.org/moral-therapy">Moral therapy</a>, a form of individualised care in small hospital settings, was promoted by English Quakers at the <a href="https://en.wikipedia.org/wiki/The_Retreat">York Retreat</a> and gradually supplanted inhumane physical treatments such as purging, bleeding and dunking in cold water.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BHNSAK8d3qc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">English society’s ambivalence to the mentally ill in the 18th century is depicted in the 1994 film, The Madness of King George.</span></figcaption>
</figure>
<p>As populations grew and urbanised, the sheer numbers of mentally ill people in burgeoning city slums demanded action. An institutional solution emerged. </p>
<p>Asylums (from the Greek word meaning “refuge”) were built in rural settings with the best of intentions, planned to be havens in which patients would receive humane care. In the serenity of the countryside, and through carrying out undemanding tasks, they could be distracted from their internal torment and find dignity far from the bustling crowd. </p>
<p><a href="https://www.britannica.com/biography/Daniel-Defoe">Daniel Defoe</a>, the English writer, remained unconvinced: “This is the height of barbarity and injustice in a Christian country; it is a clandestine Inquisition, nay worse.”</p>
<p>Although conceived in a spirit of optimism, asylums tended to deteriorate into centres of hopelessness and demoralisation. They soon became overcrowded dumps. Institutions built for a few hundred people were soon holding thousands. Very few residents were discharged; many stayed for decades. Brutal oppression replaced anything that might have resembled treatment; malnutrition and infectious disease became rife.</p>
<p>In the grim environment, people were shut away and forgotten. With them out of sight and out of mind, a loss of public interest and political neglect became the norm.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=483&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=483&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=483&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=607&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=607&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543690/original/file-20230821-15-v420lw.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=607&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Asylums were conceived optimistically, but more often housed oppression than treatment. Picture: The Hospital of Bethlehem.</span>
<span class="attribution"><span class="source">Wellcome Collection</span></span>
</figcaption>
</figure>
<p>The brooding building on the hill came to symbolise the stigma and fear attached to mental illness. By the mid-19th century, critics were voicing concerns that asylums had become human warehouses that entrenched mental illness rather than curing it. </p>
<p>The combination of powerless patients, hospitals run more for the convenience of staff than for the benefit of the sick, inadequate inspection by state bodies, and lack of resources led at times to quite disgraceful conditions. Unwittingly, the spread of asylums also triggered the movement of psychiatry away from the mainstream of medicine.</p>
<p>The conditions of the asylums are evocatively described in Henry Handel Richardson’s Australian novel <a href="https://www.textpublishing.com.au/books/the-fortunes-of-richard-mahony">The Fortunes of Richard Mahony</a>. We read of Richard’s decline, probably from syphilis affecting the brain, which at that time afflicted a large proportion of mental patients.</p>
<p>Towards the end of the novel, his wife comes to visit him in the asylum:</p>
<blockquote>
<p>She hung her head … while the warder told the tale of Richard’s misdeeds. 97B was, he declared, not only disobedient and disorderly, he was extremely abusive, dirty in his habits … he refused to wash himself, or to eat his food … she had to keep a grip on her mind to hinder it from following the picture up: Richard, forced by this burly brute to grope on the floor for his spilt food, to scrape it together, and either eat it or have it thrust down his throat … There was not only feeding by force, the straitjacket, the padded cell. There were drugs and injections, given to keep a patient quiet and ensure his warders their freedom.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-case-for-the-fortunes-of-richard-mahony-by-henry-handel-richardson-24474">The case for The Fortunes of Richard Mahony by Henry Handel Richardson</a>
</strong>
</em>
</p>
<hr>
<h2>Great and desperate cures</h2>
<p>In the asylum, psychiatry turned into a modern medical discipline. The
accumulation of thousands of patients provided the first opportunity
to study mental illness systematically and to develop theories about its
causes. </p>
<p>The idea that these conditions were due to brain alterations, and especially degenerative processes, became dominant, encouraged by the discovery of the cerebral pathology associated with <a href="https://www.healthline.com/health/neurosyphilis">neurosyphilis</a> and <a href="https://theconversation.com/what-causes-alzheimers-disease-what-we-know-dont-know-and-suspect-75847">Alzheimer’s disease</a>. A similar degenerative process was proposed by the great German psychiatrist <a href="https://www.britannica.com/biography/Emil-Kraepelin">Emil Kraepelin</a> to cause <a href="https://www.sciencedirect.com/topics/computer-science/dementia-praecox">dementia praecox</a> – later renamed “schizophrenia” – leading to pessimism about the possibility of recovery.</p>
<p>But the priority for asylums was to relieve the suffering of overwhelming numbers of disturbed patients. Psychiatrists grasped for “great and desperate cures”. <a href="https://en.wikipedia.org/wiki/Henry_R._Rollin">Henry Rollin</a>, an English psychiatrist and medical historian, captures the intense zeal:</p>
<blockquote>
<p>The physical treatment of the frankly psychotic during these centuries makes spine-chilling reading. Evacuation by vomiting, purgatives, sweating, blisters, and bleeding were considered essential […] There was indeed no insult to the human body, no trauma, no indignity which was not at one time or other piously prescribed for the unfortunate victim.</p>
</blockquote>
<p>Treatments were sometimes based on rational grounds. Malaria therapy, for instance, was launched as a treatment for neurosyphilis by the Viennese psychiatrist <a href="https://www.britannica.com/biography/Julius-Wagner-Jauregg">Julius Wagner-Jauregg</a> in 1917, earning him a Nobel Prize ten years later. </p>
<p>The high fever caused by the malarial parasite disabled the <a href="https://www.britannica.com/science/spirochete">spirochete</a> that caused neurosyphilis, but the hope that it would be equally effective for other forms of psychosis was soon dashed. The wished-for panacea was not to be.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543703/original/file-20230821-10846-x44evz.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">Malaria therapy, a treatment for neurosyphilis, earned its inventor a Nobel Prize.</span>
<span class="attribution"><span class="source">Jimmy Chan/Pexels</span></span>
</figcaption>
</figure>
<p><a href="https://www.britannica.com/science/insulin-shock-therapy">Insulin-coma therapy</a> was introduced by Manfred Sakel in the 1930s in Vienna and was soon being used in many countries to treat schizophrenia. An insulin injection was administered six days a week for several weeks, producing a state of light coma lasting about an hour, because of reduced glucose reaching the brain. </p>
<p>Many years later, an investigation carried out in the Institute of Psychiatry in London, a leading research centre at the time, showed conclusively that the coma itself was of no therapeutic value. Any positive change was probably due to the staff’s painstaking care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/girl-interrupted-interrogates-how-women-are-mad-when-they-refuse-to-conform-30-years-on-this-memoir-is-still-important-199211">Girl, Interrupted interrogates how women are 'mad' when they refuse to conform – 30 years on, this memoir is still important</a>
</strong>
</em>
</p>
<hr>
<h2>ECT and lithium</h2>
<p>The first widely available and effective biological treatments for mental illness were developed in the asylum. The discovery in 1938 of <a href="https://theconversation.com/electroconvulsive-therapy-a-history-of-controversy-but-also-of-help-70938">electroconvulsive therapy</a> (ECT) by <a href="https://www.psychiatrictimes.com/view/ugo-cerletti">Ugo Cerletti</a> and Lucio Bini, two Italian psychiatrists, led to a dramatically effective treatment for people with severe depression. </p>
<p>ECT was eagerly adopted in practice, but its history illustrates a typical pattern of treatment in psychiatry: unbridled early enthusiasm is later tempered by a protracted process of scientific evaluation. </p>
<p>The same can be said of the use of brain surgery to modify psychiatric symptoms. This was pioneered in 1936 by Portuguese neurologist <a href="https://www.britannica.com/biography/Antonio-Egas-Moniz">António Egas Moniz</a> (another Nobel Prize winner in the field of psychiatry) and surgeon Almeida Lima, and remains controversial in psychiatry to this day.</p>
<p>A momentous breakthrough was the discovery in 1949 by <a href="https://www.nature.com/articles/d41586-019-02480-0">John Cade</a>, an Australian psychiatrist, of lithium as a treatment for manic excitement. The lithium story reveals how the incorporation of a new medication into psychiatric practice is not always smooth. </p>
<p>Several US and Danish psychiatrists had experimented with lithium in the 1870s and 1890s, only to have their work ignored until Cade’s rediscovery. It was another 18 years before lithium was shown to prevent the recurrence of severe changes of mood, its primary clinical use now.</p>
<p>Major tranquillisers were added to the growing range of psychiatric medications after being discovered fortuitously in 1953. An antihistamine used to calm patients undergoing surgery was shown to reduce the torment of psychotic patients, but without making them sleepy. </p>
<p>Shortly after this, the US psychiatrist <a href="https://www.nytimes.com/1983/02/14/obituaries/nathan-kline-developer-of-antidepressants-dies.html">Nathan Kline</a> discovered that a drug being tested for its effect in patients with tuberculosis had antidepressant properties — the forerunner of medications for depression. All these drugs radically transformed the practice of psychiatry. </p>
<h2>Freud, ‘talking cures’ and shell shock</h2>
<p>A very different aspect of mental health care arose in the 1890s, outside
the asylum. Concerned with neurotic conditions, the new treatment grew chiefly out of neurology but was also influenced by a scientific interest in hypnosis and the unconscious. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=816&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=816&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=816&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1025&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1025&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543695/original/file-20230821-25-qtirft.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1025&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sigmund Freud.</span>
<span class="attribution"><span class="source">Max Halberstadt/Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Sigmund Freud conceived a dynamic model of the mind in which, through the mechanism of repression, painful or threatening emotions, memories and impulses are prevented from escaping into conscious awareness. </p>
<p><a href="https://theconversation.com/a-dangerous-method-in-defence-of-freuds-psychoanalysis-5989">Psychoanalysis</a> grew to become an integrated set of concepts about normal and abnormal mental functioning and personality development, and spawned a new method of psychologically based treatment. Psychoanalysis emerged as a major theoretical underpinning of contemporary “talking cures” (psychotherapies), and its influence spread far beyond treating mental ill-health.</p>
<p>Both world wars profoundly influenced the field. The high incidence of “<a href="https://theconversation.com/shell-shock-treatments-reveal-the-conflict-in-psychiatrys-heart-29822">shell shock</a>” in World War I drove home the lesson that mental illness could affect not only those genetically predisposed, but even the supposedly robust. It soon emerged that anyone exposed to traumatic experiences was vulnerable. </p>
<p>A positive outcome from World War II was the development of techniques for screening large numbers of recruits, which revealed the substantial prevalence of emotional problems among young adults. </p>
<p>The need to treat numerous psychiatric casualties led to the development of group therapies. These paved the way for the so-called <a href="https://en.wikipedia.org/wiki/Therapeutic_community">therapeutic community</a>, based on the idea that an entire ward of patients could be an integral part of treatment.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ehPcYibzUKc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Group therapy, as depicted in One Flew Over the Cuckoo’s Nest.</span></figcaption>
</figure>
<p>The idea of deinstitutionalisation began to gather pace in the 1960s, driven by a burgeoning civil-rights movement. <a href="https://www.penguin.com.au/books/asylums-9780241548004">Asylums</a>, an influential book at the time by sociologist Erving Goffman, containing his minute observations of the sense of oppression experienced by patients in these “total institutions”, was one catalyst for their closure. </p>
<p>Hundreds of thousands of long-stay patients began to be transferred to alternative accommodation and specialist care in the community, a process that is still in progress.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-body-keeps-the-score-how-a-bestselling-book-helps-us-understand-trauma-but-inflates-the-definition-of-it-184735">The Body Keeps the Score: how a bestselling book helps us understand trauma – but inflates the definition of it</a>
</strong>
</em>
</p>
<hr>
<h2>What is mental illness?</h2>
<p>It is challenging to define what makes a pattern of behaviour and experience a mental disorder. Generally, such a pattern – or “syndrome” – is considered to be a disorder if it is associated with psychological distress, such as intense and prolonged anxiety or sadness, or significant dysfunction, such as a serious impairment in functioning in one or more key areas of daily life. </p>
<p>If the pattern is short-lived, relatively mild, or entirely understandable in light of the trials and tribulations of the person’s life, it should be seen as a problem in living rather than a mental disorder. Such problems may still benefit from consultation with a mental health professional despite not being diagnosable disorders.</p>
<p>This definition of what counts as a mental disorder also clarifies what is not a mental disorder. Merely being unusual or violating social norms does not mean a person has a disorder. </p>
<p>It is difficult sometimes to decide whether a new kind of behaviour is a mental disorder. For instance, should <a href="https://theconversation.com/no-youre-probably-not-addicted-to-your-smartphone-but-you-might-use-it-too-much-89853">excessive smartphone use</a> or <a href="https://theconversation.com/gambling-on-pokies-is-like-tobacco-no-amount-of-it-is-safe-51037">compulsive gambling</a> be counted as diagnosable addictions?</p>
<h2>Troubling cases</h2>
<p>These decisions about what to include under the umbrella of mental illness are fraught, and there have been some troubling historical cases when disturbing decisions were made or proposed. </p>
<p>In the 1850s, for example, Samuel Cartwright, a physician from Alabama, proposed a new diagnosis called “<a href="https://www.nytimes.com/2000/01/15/arts/bigotry-as-mental-illness-or-just-another-norm.html">drapetomania</a>” to explain why African-American slaves would wish to escape their servitude. </p>
<p>He recommended slaves should be treated kindly and humanely to prevent the disorder, but whipped if this treatment failed. A more patent abuse of the concept of mental illness would be hard to imagine, and it should be noted that other physicians ridiculed Cartwright’s proposal at the time.</p>
<p>Two other controversial cases date to the last century. In the early 1970s, one of us (Sidney) stumbled across disturbing media reports that many political and religious dissenters and human-rights activists in the Soviet Union were being labelled as mentally ill and detained in mental hospitals indefinitely or until they renounced their “disturbed ideas”. </p>
<p>For instance, <a href="https://en.wikipedia.org/wiki/Petro_Grigorenko">General Pyotr Grigorenko</a> criticised the privileges of the Soviet elite and publicly espoused the rights of the <a href="https://en.wikipedia.org/wiki/Crimean_Tatars">Crimean Tatar</a> ethnic minority group. He was diagnosed with paranoid tendencies, one symptom being his “reformist ideas”, and forcibly committed to a psychiatric facility. </p>
<p>In effect, Soviet psychiatry’s definition of mental illness, and psychosis in particular, was so broad that political beliefs about the desirability of social change were recast as delusions.</p>
<p>The second case comes from the US. <a href="https://daily.jstor.org/how-lgbtq-activists-got-homosexuality-out-of-the-dsm/">Until 1973</a>, homosexuality was defined as a sexual deviation and included in the set of recognised mental disorders. Under pressure from civil, women’s and gay rights activists, it was removed from the diagnostic manual.</p>
<p>Noting such cases, whenever the boundary of a mental illness is expanded to include new diagnoses or loosen old ones, some critics will worry we are treating normal behaviour as a pathology and that we will harm people by labelling them. And whenever the boundary contracts, others will worry that people with psychological troubles are being excluded from clinical care. </p>
<p>Deciding what is and isn’t a mental illness is difficult, but has marked consequences.</p>
<hr>
<p><em>This is an edited extract from <a href="https://scribepublications.com.au/books-authors/books/troubled-mindSees-9781922585875">Troubled Minds: Understanding and treating mental illness</a> by Sidney Bloch and Nick Haslam (Scribe Publications), published 29 August 2023.</em></p><img src="https://counter.theconversation.com/content/206580/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Haslam receives funding from the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Sidney Bloch 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>Humans have attempted to understand and treat mental illness for centuries – from ancient Greek medicine, Middle Ages exorcisms and the rise of asylums, to modern medical breakthroughs.Sidney Bloch, Emeritus Professor in Psychiatry, The University of MelbourneNick Haslam, Professor of Psychology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1992112023-03-20T19:23:28Z2023-03-20T19:23:28ZGirl, Interrupted interrogates how women are ‘mad’ when they refuse to conform – 30 years on, this memoir is still important<figure><img src="https://images.theconversation.com/files/511307/original/file-20230221-28-pq60te.jpeg?ixlib=rb-1.1.0&rect=0%2C1%2C1024%2C573&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Winona Ryder played Susannah Kaysen in the film of Kaysen's memoir, Girl, Interrupted</span> <span class="attribution"><span class="source">Columbia Pictures/IMDB</span></span></figcaption></figure><p>Thirty years ago, American writer Susanna Kaysen published her memoir <a href="https://www.hachette.com.au/susanna-kaysen/girl-interrupted">Girl, Interrupted</a>. It tells the story of her two years inside McLean Hospital in Boston as a psychiatric patient. </p>
<p>She was admitted, aged 18, in 1967. A few months earlier, she had taken 50 aspirin in a state of despair. Late in the book, she reveals she had a sexual relationship with her male English teacher at school. </p>
<p>Kaysen was interviewed briefly by a doctor before she was admitted as a “voluntary” patient: a legal category used to indicate a person’s status in the institution. Despite what the term implies, “voluntary” doesn’t mean a patient can leave without the consent of their medical team, as Kaysen explains. People admitted as voluntary patients acknowledge their own need for treatment. </p>
<p>During Kaysen’s stay, she was treated with an <a href="https://theconversation.com/story-of-antipsychotics-is-one-of-myth-and-misrepresentation-18306">antipsychotic</a> medication, chlorpromazine, and received psychotherapy. In her memoir, the stories of other young women confined with her at McLean convey sympathetic and recognisable experiences of the institutional world and its regime.</p>
<p>Girl, Interrupted is one of the most famous memoirs of hospitalisation and mental illness. More <a href="https://www.euppublishing.com/doi/abs/10.3366/ircl.2019.0310?journalCode=ircl">recent interpretations</a> describe it as a narrative of “trauma”. </p>
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<span class="caption">Susanna Kaysen was admitted as a ‘voluntary’ psychiatric patient aged 18, in 1967. She wrote about her experience in Girl, Interrupted.</span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-can-publishers-support-the-authors-of-trauma-memoirs-as-they-unpack-their-pain-for-the-public-new-research-investigates-189251">How can publishers support the authors of trauma memoirs, as they unpack their pain for the public? New research investigates</a>
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</em>
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<h2>‘Mad’ or refusing to conform?</h2>
<p>Kaysen did not anticipate the book’s reception at the time of its publication in 1993. It seemed to open readers up to tell their own stories, and they wrote to her from many places around the world to tell her about their hospitalisation. Looking back in a new edition published this year by Virago Books, she writes “it was surprising to me how many people had been in a mental hospital or had what used to be called a nervous breakdown”. </p>
<p>When it appeared, her book was widely reviewed as “funny”, “wry”, “piercing” and “frightening”. Set out as a series of short vignettes, the book allowed readers the space to “insert themselves” into this story of human suffering. </p>
<p>Investigating whether she had ever really been “crazy” – or just caught up in an oppressive approach to girls whose lives strayed from expectations – likely meant possible personal exposure, admission of frailty, and fear of judgement for Kaysen. </p>
<p>Thirty years later, we have better understandings of trauma and of care for people with mental illness. So what can this book tell us now?</p>
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<a href="https://images.theconversation.com/files/516241/original/file-20230320-28-em9w25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/516241/original/file-20230320-28-em9w25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/516241/original/file-20230320-28-em9w25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=943&fit=crop&dpr=1 600w, https://images.theconversation.com/files/516241/original/file-20230320-28-em9w25.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=943&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/516241/original/file-20230320-28-em9w25.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=943&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/516241/original/file-20230320-28-em9w25.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1185&fit=crop&dpr=1 754w, https://images.theconversation.com/files/516241/original/file-20230320-28-em9w25.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1185&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/516241/original/file-20230320-28-em9w25.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1185&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Kaysen had waited almost three decades after these experiences before sharing her story in the early 1990s. This may be one reason it resonated with readers. The book was published at a time when most large institutions had closed as part of a worldwide trend towards deinstitutionalisation. Many people were starting to talk more openly about their own episodes of mental illness and recalling periods of hospitalisation that were sometimes grim and harrowing. </p>
<p>By the 1990s, there was also much greater awareness of the uneven power relationships in psychiatric treatment. Women and girls, subject to gendered social expectations, have historically received different forms of medical and psychiatric treatment. Women have been described as “mad” for centuries when they refused to conform to gender norms.</p>
<p>The book – an account of adolescent turmoil, with girlhood at the centre – can tell us about the lived experiences of teenage girls who face interior struggles over their mental health and wellbeing. Published in 1993 about the events of the late 60s, its insights are enduringly relevant.</p>
<h2>A controversial diagnosis</h2>
<p>In 1993, The New York Times ran an article titled “<a href="https://www.nytimes.com/1993/06/20/books/a-designated-crazy.html">A Designated Crazy</a>” that explained Kaysen had hired a lawyer to access her patient clinical records, 25 years after being at McLean. These appear in the book.</p>
<p>Placed at intervals in the narrative, these notes show the objectifying medical practices of admission, collecting information and establishing a diagnosis. The information in these clinical pages is deeply personal. Sharing them is an act of resistance and defiance.</p>
<blockquote>
<p>“Needed McLean for [the past] 3 years”<br>
“Profoundly depressed – suicidal”<br>
“Promiscuous … might get herself pregnant”<br>
“Ran away from home”<br>
“Living in a boarding house”<br></p>
</blockquote>
<p>Kaysen’s father, an academic at Princeton, wrote these notes in April 1967.</p>
<p>In June 1967, the formal medical notes from her admitting doctor stated she had “a chaotic and unplanned life”, was sleeping badly, was immersed in “fantasy” and was isolated.</p>
<p>Kaysen was admitted as “depressed”, “suicidal” and “schizophrenic”, with “borderline personality disorder”. </p>
<p>While the psychiatric diagnoses used in the 1960s still exist, the borderline diagnosis is <a href="https://theconversation.com/borderline-personality-disorder-is-a-hurtful-label-for-real-suffering-time-we-changed-it-41760">now controversial</a>. Progressive psychologists and feminist psychologists are more likely to use the term “complex trauma”. Some of the other young women in the memoir had traumatic life experiences of sexual abuse and violence, which manifested as <a href="https://theconversation.com/how-many-people-have-eating-disorders-we-dont-really-know-and-thats-a-worry-121938">eating disorders</a> and <a href="https://theconversation.com/explainer-what-is-self-harm-and-why-do-people-do-it-11367">self harm</a>.</p>
<p>Diagnostic labels have evolved over time. The first edition of the <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Diagnostic and Statistical Manual</a> (DSM) was published in 1952. In 1967, the year of Kaysen’s committal, the DSM did not include “borderline personality disorder”, though the borderline concept had been <a href="https://www.press.jhu.edu/newsroom/dsm-history-psychiatrys-bible">theorised from the 1940s.</a> </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/borderline-personality-disorder-is-a-hurtful-label-for-real-suffering-time-we-changed-it-41760">Borderline personality disorder is a hurtful label for real suffering – time we changed it</a>
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<hr>
<h2>McLean’s famous patients</h2>
<p>We can also read the book as an exposé of the controlling world of psychiatric institutions for people in the 1960s. The vast majority of people with psychiatric conditions were confined in public institutions, in often overcrowded conditions. Abuses happened, and violence was common.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/511316/original/file-20230221-24-gyaveb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/511316/original/file-20230221-24-gyaveb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/511316/original/file-20230221-24-gyaveb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=905&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511316/original/file-20230221-24-gyaveb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=905&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511316/original/file-20230221-24-gyaveb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=905&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511316/original/file-20230221-24-gyaveb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1137&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511316/original/file-20230221-24-gyaveb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1137&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511316/original/file-20230221-24-gyaveb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1137&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">John Forbes Nash, whose life inspired the film A Beautiful Mind, was also a McLean patient.</span>
<span class="attribution"><span class="source">Peter Badge</span></span>
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</figure>
<p>One distinction for those hospitalised at McLean in Boston, a private institution, was that it housed people whose families could afford the steep fees. Kaysen’s father had to declare his salary when he signed the paperwork. Famous patients included the mathematician <a href="https://theconversation.com/the-legacy-of-john-nash-and-his-equilibrium-theory-42343">John Forbes Nash</a> (whose story was told in the film, <a href="https://www.imdb.com/title/tt0268978/">A Beautiful Mind</a>), and New England poets Robert Lowell and <a href="https://theconversation.com/60-years-since-sylvia-plaths-death-why-modern-poets-cant-help-but-write-after-sylvia-199477">Sylvia Plath</a> in the late 1950s.</p>
<p>McLean’s own “biography” is the subject of another book. <a href="https://www.theatlantic.com/magazine/archive/2002/01/the-asylum-on-the-hill/303058/">Gracefully Insane</a> shows its reputation as housing sometimes idiosyncratic and wealthy people whose families wanted them to be hidden, fearful of the stigma of mental illness in the family.</p>
<p>Plath’s <a href="https://www.allenandunwin.com/browse/book/Sylvia-Plath-Bell-Jar-9780571268863">The Bell Jar</a> fictionalises her hospitalisation at McLean in the 1950s, following a suicide attempt. </p>
<blockquote>
<p>Doctor Gordon’s private hospital crowned a grassy rise at the end of a long, secluded drive that had been whitened with broken quahog shells. The yellow clapboard walls of the large house, with its encircling verandah, gleamed in the sun, but no people strolled on the green dome of the lawn.</p>
</blockquote>
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<a href="https://images.theconversation.com/files/511310/original/file-20230221-14-ildw55.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/511310/original/file-20230221-14-ildw55.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/511310/original/file-20230221-14-ildw55.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=915&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511310/original/file-20230221-14-ildw55.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=915&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511310/original/file-20230221-14-ildw55.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=915&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511310/original/file-20230221-14-ildw55.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1150&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511310/original/file-20230221-14-ildw55.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1150&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511310/original/file-20230221-14-ildw55.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1150&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"></span>
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<p>Like Kaysen, Plath’s character Esther Greenwood has been involved in sexual relationships with men that made her uneasy, affecting her confidence and sense of self. Skiing with Buddy Willard, she falls and breaks her leg: “you were doing fine”, someone says, “until that man stepped into your path”. </p>
<p>Later, floundering at college, she too is admitted by a male doctor acting on the advice of her mother: she has not slept, she is exhausted, she is not herself. He advises she needs shock therapy.</p>
<p>In her new biography of Plath, <a href="https://www.penguin.com.au/books/red-comet-9781529113143">Red Comet</a>, Heather Clark describes McLean in the 1950s as reliant on shock therapy and activities, rather than psychoanalysis and careful therapeutic interventions. It was reputedly only a “notch above” a public institution, though it had the veneer of being for elite residents.</p>
<p>Just a few years before Kaysen’s admission to McLean, Plath died by suicide in 1963, aged 30. The Bell Jar had been published one month earlier, under a pseudonym. By the late 1960s, teenage admissions were a focus for McLean’s doctors. </p>
<p>Did adolesence present a new challenge for families and authorities, making young women vulnerable to institutionalisation?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/511317/original/file-20230221-16-j9qc6b.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/511317/original/file-20230221-16-j9qc6b.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511317/original/file-20230221-16-j9qc6b.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511317/original/file-20230221-16-j9qc6b.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511317/original/file-20230221-16-j9qc6b.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511317/original/file-20230221-16-j9qc6b.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511317/original/file-20230221-16-j9qc6b.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511317/original/file-20230221-16-j9qc6b.jpeg?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"></a>
<figcaption>
<span class="caption">McLean Hospital’s famous patients included Sylvia Plath and Robert Lowell, as well as John Forbes Nash and Susanna Kaysen.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/by-naming-pennhurst-stranger-things-uses-disability-trauma-for-entertainment-dark-tourism-and-asylum-tours-do-too-185581">By naming 'Pennhurst', Stranger Things uses disability trauma for entertainment. Dark tourism and asylum tours do too</a>
</strong>
</em>
</p>
<hr>
<h2>Psychiatry and romantic love</h2>
<p>Revisiting Girl, Interrupted, I am struck by its raw and honest recognition of the way women have sometimes experienced relationships with men as inherently oppressive. The structures of psychiatry and romantic love intersect throughout this book. </p>
<p>Kaysen, like Plath, sees the family as a toxic institution. Male psychiatrists loom over both women, imposing in their authority to diagnose. “He looked triumphant”, wrote Kaysen of her doctor. “Doctor Gordon cradled his pencil like a slim, silver bullet”, wrote Plath.</p>
<p>Women writing about their own madness has a long history. American writer Charlotte Perkins Gilman (1860–1935) penned the story <a href="https://www.goodreads.com/book/show/286957.The_Yellow_Wall_Paper">The Yellow Wallpaper</a> in The New England Magazine in 1892. It <a href="https://www.theguardian.com/artanddesign/2020/feb/07/charlotte-perkins-gilman-yellow-wallpaper-strangeness-classic-short-story-exhibition">tells the tale</a> of a woman’s mental and physical exhaustion following childbirth.</p>
<p>Historians such as Elizabeth Lunbeck <a href="https://press.princeton.edu/books/paperback/9780691025841/the-psychiatric-persuasion">write about</a> the way a “psychiatric persuasion” came to dominate thinking about gender in the early 20th century. Psychiatrists began to see everyday life difficulties – such as the changes experienced during adolescence – as signalling illness (we might say, pathologising “normal” responses to stressful events). The rise of psychiatric expertise paralleled their professional reactions to women (and men) who struggled with life.</p>
<p>In Australia, the history of “good and mad women” up to the 1970s by <a href="https://books.google.com.au/books/about/Good_and_Mad_Women.html?id=NIZ9QgAACAAJ&redir_esc=y">Jill Julius Matthews</a> showed that women who experienced hospitalisation as a result of mental breakdown were perceived as having “failed” to meet the gendered expectations of them. Femininity and its constraints left some women unable to function or live authentic lives.</p>
<h2>Institutions on film</h2>
<p>Girl, Interrupted was released <a href="https://www.imdb.com/title/tt0172493/">as a film</a> by Columbia Pictures in 1999, with a cast of rising and established young actors, including Winona Ryder, Angelina Jolie and Brittany Murphy. It dramatised the interpersonal relationships inside the hospital described by Kaysen.</p>
<p>The film script was not only the perfect vehicle for an ensemble cast of these women. It was also another opportunity to make mental illness visible on the screen. Another page-to-screen adaptation in 1975, Milos Forman’s film of Ken Kesey’s <a href="https://www.imdb.com/title/tt0073486/">One Flew Over the Cuckoo’s Nest</a>, brought to life the dramatic environment of institutional control and violence personified by the character of Nurse Ratched. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/vL7c0Aqn_Pw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Girl, Interrupted, like One Flew Over the Cuckoo’s Nest, emphasised resistance to institutional control.</span></figcaption>
</figure>
<p>Girl, Interrupted’s screenplay surfaced different women’s experiences of abuse, neglect, trauma and violence to explain their behaviours and responses to institutional constraints. </p>
<p>Like One Flew Over the Cuckoo’s Nest, the film also emphasised the theme of resistance to institutional control. Patients hid pill medications under the tongue, broke into the hospital administration office to look at their case files, and found ways to circumvent the routines of institutional life. The film depicted the drama of group therapy, and the power dynamic between staff and patients.</p>
<p>Not everyone who was institutionalised reacted the same way to being in hospital.</p>
<p>Kaysen wrote:</p>
<blockquote>
<p>For many of us, the hospital was as much a refuge as it was a prison. Though we were cut off from the world and all the trouble we enjoyed stirring up out there, we were also cut off from the demands and expectations that had driven us crazy.</p>
</blockquote>
<p>A recent collaborative history of institutional care by Australian poet <a href="https://theconversation.com/secrecy-psychosis-and-difficult-change-these-lived-experiences-of-mental-illness-will-inspire-a-kaleidoscope-of-emotions-191011">Sandy Jeffs</a> and social worker Margaret Leggatt, <a href="https://podcasts.apple.com/am/podcast/out-of-the-madhouse-with-sandy-jeffs/id992762253?i=1000501765764">Out of the Madhouse</a>, challenges the idea of the institution as a place of alienation. Jeffs found community and solace at Larundel Hospital in Melbourne in the late 1970s and 1980s. However, the book also acknowledges this is not a universal response for institutionalised people.</p>
<p>Like Kaysen, people with lived experiences of mental illness and hospitalisation have found it therapeutic to write about their personal challenges. For some, it provides an opportunity to embrace the “mad” identity, to find empathy for others. And to create a new self out of the chaos of mental breakdown.</p><img src="https://counter.theconversation.com/content/199211/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catharine Coleborne received funding from the Australian Research Council as a CI on a relevant Discovery Grant, 'The development of Australian community psychiatry’ (2019-2022).</span></em></p>Why was Susanna Kaysen really hospitalised? Her memoir Girl, Interrupted turns 30 this year. It investigates whether she was ‘mad’, or medicalised for a ‘chaotic’ life that defied gender norms.Catharine Coleborne, Professor of History, School Humanities, Creative Industries and Social Sciences, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2011682023-03-07T06:11:21Z2023-03-07T06:11:21ZBlack Inc. has stumbled with its anthology of neurodivergent writing. The term is not a diagnosis – it is part of a political movement<figure><img src="https://images.theconversation.com/files/513885/original/file-20230307-18-atzhip.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C2771%2C1842&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Autistic actor Chloe Hayden has worked to transcend the limits of a world not designed for neurodivergent people.</span> <span class="attribution"><span class="source">Feros Care</span></span></figcaption></figure><p>I am blind and autistic. Like many people who grew up experiencing the world differently to mainstream Australians, I was thrilled last Thursday to read Black Inc.’s <a href="https://www.blackincbooks.com.au/news/growing-neurodivergent-australia-call-submissions">announcement</a> of a new anthology, to be edited by <a href="https://en.wikipedia.org/wiki/Osher_G%C3%BCnsberg">Osher Gunsberg</a>: “Growing up Neurodivergent in Australia: Call for submissions.” </p>
<p>Finally, I thought, after 25 years of the neurodiversity movement, founded by Australian sociologist Judy Singer, its birth country would have an anthology representing the range of our experiences.</p>
<p>But I was dismayed to read, in the first paragraph of the callout, that contributors were required to “have been diagnosed as neurodivergent”. This might sound like a reasonable request, but it fails to account for what the neurodivergent community is, what diagnosis is, and what has been expected of previous contributors to the <a href="https://www.blackincbooks.com.au/series/growing-series">Growing Up</a> series.</p>
<h2>Why diagnosis is a problem</h2>
<p>Neurodivergent people, many of them autistic, questioned the framing and language of Black Inc.’s callout, and asked it to reconsider the requirement for a diagnosis. The publisher <a href="https://twitter.com/BlackIncBooks/status/1631118113189273601">replied</a>: </p>
<blockquote>
<p>In the interests of protecting those who are yet to seek intervention, and to be ethically responsible in how we present this issue – we are only inviting submissions from people with a medical diagnosis.</p>
</blockquote>
<p>There was an outcry in response. Radio personality <a href="https://theconversation.com/real-life-autism-disclosures-are-complex-and-reactions-can-range-from-dismissal-to-celebration-199869">Em Rusciano</a>, diagnosed with ADHD and autism, wrote on Twitter:</p>
<blockquote>
<p>Getting diagnosed is nearly impossible atm. Most of us grew up ND [neurodivergent] in Australia without even realising we were until we figure it out as adults. Self diagnosis is totally valid… Do better.</p>
</blockquote>
<p>Two days later, Black Inc. <a href="https://www.blackincbooks.com.au/news/statement-regarding-growing-neurodivergent-australia">published a statement</a> apologising for the pain it had caused, but continuing to use the same framing and language regarding neurodiversity, and not changing its position on diagnosis.</p>
<p>The project is now on hold, while the publisher is “considering all the issues”.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1631944497394483201"}"></div></p>
<p>Black Inc.’s shift to requiring proof of identity should be of concern to all writers. We write to tell our stories of various identities, and when we submit them under nonfiction, we are labelling them as our truth. A submission process that requires proof of identity demands evidence that often does not or cannot exist. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/real-life-autism-disclosures-are-complex-and-reactions-can-range-from-dismissal-to-celebration-199869">Real-life autism disclosures are complex – and reactions can range from dismissal to celebration</a>
</strong>
</em>
</p>
<hr>
<h2>‘A tool of inclusion’</h2>
<p>Of course, there is no specific “neurodivergent” diagnosis, although neurodivergence covers a range of conditions that can be diagnosed, including <a href="https://theconversation.com/its-25-years-since-we-redefined-autism-heres-what-weve-learnt-125053">autism</a>, <a href="https://theconversation.com/i-think-i-have-adhd-how-do-i-get-a-diagnosis-what-might-it-mean-for-me-190239">ADHD</a>, <a href="https://theconversation.com/what-is-bipolar-disorder-the-condition-kanye-west-lives-with-143198">bipolar</a>, <a href="https://theconversation.com/epilepsy-sorting-the-myths-from-the-facts-of-a-common-disorder-47276">epilepsy</a>, <a href="https://theconversation.com/you-cant-be-a-little-bit-ocd-but-your-everyday-obsessions-can-help-end-the-conditions-stigma-49265">obsessive-compulsive disorder</a> (OCD), <a href="https://theconversation.com/what-causes-schizophrenia-what-we-know-dont-know-and-suspect-102651">schizophrenia</a> and <a href="https://theconversation.com/what-is-tourette-syndrome-the-condition-lewis-capaldi-lives-with-200630">Tourette syndrome</a>.</p>
<p>But the neurodiversity movement, which embraces a social model of disability over the medical model, is specifically against requiring a neurodivergent person to have a diagnosis of any kind. </p>
<p>Kassiane Asasumasu, who <a href="https://www.psychologytoday.com/au/blog/neurodiverse-age/202108/negotiating-the-neurodiversity-concept">coined the term</a> “neurodivergent”, <a href="https://sherlocksflataffect.tumblr.com/post/121295972384/psa-from-the-actual-coiner-of-neurodivergent">has written</a>: </p>
<blockquote>
<p>It is not another damn tool of exclusion. It is specifically a tool of inclusion. </p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/513898/original/file-20230307-24-asvvv5.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman with glasses in a black tank-top and a necklace, with a fringe and shoulder-length hair" src="https://images.theconversation.com/files/513898/original/file-20230307-24-asvvv5.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/513898/original/file-20230307-24-asvvv5.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513898/original/file-20230307-24-asvvv5.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513898/original/file-20230307-24-asvvv5.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513898/original/file-20230307-24-asvvv5.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513898/original/file-20230307-24-asvvv5.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513898/original/file-20230307-24-asvvv5.jpeg?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"></a>
<figcaption>
<span class="caption">Kassiane Asasumasu, who coined ‘neurodivergence’, says: ‘It is not another damn tool of exclusion. It is specifically a tool of inclusion.’</span>
<span class="attribution"><span class="source">Commission for People with disAbilities 2017 Inclusion Jubilee</span></span>
</figcaption>
</figure>
<p>A diagnosis requirement would make many neurodivergent people ineligible to submit their story. Diagnoses are prohibitively expensive for many: current estimates for the cost of an <a href="https://theconversation.com/wondering-about-adhd-autism-and-your-childs-development-what-to-know-about-getting-a-neurodevelopmental-assessment-197528">autism diagnosis</a> in Australia, for instance, range from $1,000 to $8,000. </p>
<p>And while things are changing, the diagnostic tools for conditions like autism and ADHD have often failed to recognise those who fall outside the long-typical presentation of an otherwise non-disabled white male child.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/les-murray-said-his-autism-shaped-his-poetry-his-late-poems-offer-insights-into-his-creative-process-188212">Les Murray said his autism shaped his poetry – his late poems offer insights into his creative process</a>
</strong>
</em>
</p>
<hr>
<h2>What is neurodiversity?</h2>
<p>The word “<a href="https://www.webmd.com/add-adhd/features/what-is-neurodiversity">neurodiversity</a>” was born in the 1998 <a href="https://www.amazon.com.au/NeuroDiversity-Birth-Idea-Judy-Singer-ebook/dp/B01HY0QTEE">sociology Honours thesis</a> of Judy Singer, a student at University of Technology Sydney. </p>
<p>She was drawn to sociology after learning about the history of classifying human differences according to how compatible or otherwise they might be with industrial production, and how the medical profession gained its power through being the arbiter of who was or was not productive. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/513896/original/file-20230307-14-20m6qx.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A white woman with a silver-blonde bob and a black T-shirt" src="https://images.theconversation.com/files/513896/original/file-20230307-14-20m6qx.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/513896/original/file-20230307-14-20m6qx.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513896/original/file-20230307-14-20m6qx.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513896/original/file-20230307-14-20m6qx.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513896/original/file-20230307-14-20m6qx.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513896/original/file-20230307-14-20m6qx.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513896/original/file-20230307-14-20m6qx.jpeg?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">Autistic Australian sociologist Judy Singer coined the concept of ‘neurodiversity’ in 1998.</span>
<span class="attribution"><span class="source">Autism Awareness Australia</span></span>
</figcaption>
</figure>
<p>She learned of a group of physically impaired UK activists who challenged this medical model with a social model of disability. The social model argues that the way an environment is constructed privileges those who are classified as “normal”, while disabling those classified as “abnormal”. </p>
<p>For example, stairs are more common than ramps or elevators because more people walk than use wheelchairs – so wheelchair users are disabled in terms of accessing buildings with stairs because they are not built to accommodate them, but to accommodate people who walk. Singer discovered the social model was foundational to the academic discipline of disability studies, and enrolled in this degree to learn more.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/513900/original/file-20230307-30-ocsgvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A short-haired wheelchair user impressively navigates a flight of stairs." src="https://images.theconversation.com/files/513900/original/file-20230307-30-ocsgvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/513900/original/file-20230307-30-ocsgvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513900/original/file-20230307-30-ocsgvb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513900/original/file-20230307-30-ocsgvb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513900/original/file-20230307-30-ocsgvb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513900/original/file-20230307-30-ocsgvb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513900/original/file-20230307-30-ocsgvb.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">Wheelchair users are disabled in terms of accessing buildings with stairs because they’re not built to accomodate them.</span>
<span class="attribution"><span class="source">Nadia Doloh/Pexels</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>At the same time, Singer’s baby daughter was developing differently to other children her age. Singer was searching for an explanation when she read about autistic scientist and author <a href="https://theconversation.com/temple-grandin-the-effect-mr-spock-had-on-me-38472">Temple Grandin</a>, and recognised her daughter’s characteristics. This led Singer to realise she and her mother were also autistic. There were few people in Australia she could discuss her situation with. </p>
<p>On the internet, which was just then beginning to expand beyond university walls, she discovered a world of people like her. All of them had stumbled through a maze of misdiagnosis and social isolation to finally find each other. So often, they’d been told they and their experiences of the world were “weird” and wrong. Accepting each other’s self-descriptions was key to this community.</p>
<p>Together they designed a future that did not exclude them from society. They created the term “neurotypical” to refer to those whose brains function in typical ways, leading them to instinctively communicate in ways society classified as normal. They referred to themselves as “autistics and cousins”.</p>
<p>Recognising the importance of this moment in history, Singer wanted to document the movement and its implications. To her, the most important of these implications was that humanity was constituted by a range of neurotypes, all of them vital for its survival. </p>
<p>Understanding humans as one element of Earth’s biodiversity, she coined the term “neurodiversity” to refer to this variety of minds. Neurodiversity is not simply a characteristic of humankind, she argued, but essential to its survival.</p>
<h2>‘Truly revolutionary’</h2>
<p>As the term “neurodiversity” became known beyond their online community, it was clear a similarly compact way to refer to “autistics and cousins” was needed. So Hapa and Asian American autistic activist Kassiane Asasumasu invented the term “neurodivergent”, to refer to people whose brains diverge from the typical.</p>
<p>Singer’s thesis has been truly revolutionary for the neurodivergent community. It has positively transformed the way many neurodivergent people understand themselves: allowing them to find their kin, to understand their worth, and to live the kind of lives the medical model - which framed their characteristics in terms of deficits - told them was impossible.</p>
<p>As a result of neurodivergent people who have concentrated on their strengths while working to transcend the limits of a world not designed for them, Australia is known for <a href="https://theconversation.com/hannah-gadsby-navigates-the-mirror-maze-of-trauma-as-an-autistic-gender-queer-comedian-176010">Hannah Gadsby</a>’s groundbreaking comedy, <a href="https://theconversation.com/there-is-great-strength-in-vulnerability-grace-tames-surprising-irreverent-memoir-has-a-message-of-hope-191074">Grace Tame</a>’s work to support survivors of sexual abuse, and <a href="https://theconversation.com/teenage-misfits-messy-emotions-and-joyous-discussions-on-consent-heartbreak-high-is-a-bright-new-piece-of-television-188733">Chloe Hayden</a>’s acting.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/513901/original/file-20230307-14-b4peij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/513901/original/file-20230307-14-b4peij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/513901/original/file-20230307-14-b4peij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/513901/original/file-20230307-14-b4peij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/513901/original/file-20230307-14-b4peij.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/513901/original/file-20230307-14-b4peij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/513901/original/file-20230307-14-b4peij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/513901/original/file-20230307-14-b4peij.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Neurodivergent people like autistic comedian Hannah Gadsby have worked to transcend the limits of a world not designed for them.</span>
<span class="attribution"><span class="source">Allen & Unwin</span></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hannah-gadsby-navigates-the-mirror-maze-of-trauma-as-an-autistic-gender-queer-comedian-176010">Hannah Gadsby navigates the mirror maze of trauma as an autistic, gender queer comedian</a>
</strong>
</em>
</p>
<hr>
<h2>Why diagnosis isn’t simple – or available to all</h2>
<p>“Neurodivergent” is a proudly nonscientific identifier. The neurodivergent community welcomes people who experience the world atypically – and does not base membership on the medical labels people do or do not have. </p>
<p>Therefore, to require a neurodivergent person to have a diagnosis directly contradicts the community’s foundations. It also ignores the many difficulties and complications involved in seeking a diagnosis.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1631288219944865795"}"></div></p>
<p>Diagnosis is of course necessary to be prescribed medication, or when applying for <a href="https://theconversation.com/understanding-the-ndis-how-does-the-scheme-work-and-am-i-eligible-for-funding-58726">NDIS assistance</a>. However, if you need medication or NDIS assistance, you will not be given a diagnosis of “neurodivergent”. You will be given one or more medical labels, such as autism, dyslexia, epilepsy or Tourette syndrome. </p>
<p>These medical labels are not as conclusive as they may seem. There is not a blood test for autism. People can be diagnosed with epilepsy even with a normal EEG and MRI. Many neurological medical conditions are diagnosed entirely on the basis of questionnaires and self-reported medical history.</p>
<p>And what each medical label encompasses changes over time. This is why the <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Diagnostic and Statistical Manual</a> (DSM) is continually debated and regularly updated. </p>
<p>For example, autism was originally described as a form of childhood schizophrenia, and only became its own diagnosis in 1980. In 1994, autism was divided into so-called low-functioning “autism” and so-called high-functioning “Asperger’s Syndrome”. In 2013, <a href="https://theconversation.com/redefining-autism-in-the-dsm-5-6385">Asperger’s Syndrome was retired</a> as a term, and folded back into “autism”. </p>
<p>An increasing number of conditions, including autism and ADHD, have been revealed to be based on disablist, racist and sexist stereotypes, leading to misdiagnosis and underdiagnosis.</p>
<p>Seeking a diagnosis engulfs your life. This is not hyperbole. It is time-consuming, traumatising, exhausting and expensive. It involves waiting lists, multiple assessments, multiple specialists, and a lot of travel. And, particularly if you are from one or more of the groups that are frequently misdiagnosed and underdiagnosed, such as women or First Nations people, you may have to endure it several times over. The only shortcut through this process in Australia is wealth.</p>
<h2>Proof of identity</h2>
<p>When neurodivergent people began to explain to Black Inc. why their requirement for diagnosis was unacceptable, disabled activist Carly Findlay was quick to support us. When she was editor of <a href="https://www.blackincbooks.com.au/books/growing-disabled-australia">Growing up Disabled in Australia</a>, and when she contributed to <a href="https://www.blackincbooks.com.au/books/growing-african-australia">Growing up African in Australia</a>, proof of identity was not required.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1631281930435190786"}"></div></p>
<p>Where it does exist, proof of identity will always be vulnerable to accusations of inadequacy. And when it puts vulnerable people at risk when their private medical information is stored by organisations and companies who might not be equipped to manage it safely.</p>
<p>Many neurodivergent people avoid diagnostic labels so as to avoid discrimination. This happens to diagnosed people in many aspects of their lives, including getting an education, getting a job, accessing healthcare and health insurance, signing contracts, and moving to or from Australia.</p>
<p>An absence of proof of course makes it possible for situations such as the 1995 Miles Franklin award, where <a href="https://www.smh.com.au/culture/books/from-the-archives-1995-writer-demidenko-revealed-to-be-helen-darville-20200813-p55ldc.html">Helen Demidenko faked a Ukrainian identity</a>, to occur. But this is rare. I do not want to minimise the pain one fake causes a whole community. I want to argue that a whole community should not be punished because of the rare fake.</p>
<p>Nevertheless, Black Inc.’s bad example has been a reminder both of the strengths of the neurodivergent community, and the allies who respect our history and culture. This has resulted in a burst of creativity, including three neurodivergent anthologies in the works that I know of – all committed to the principles of neurodiversity.</p><img src="https://counter.theconversation.com/content/201168/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amanda Tink 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>After an outcry on social media over its requirement that writers provide a medical diagnosis, Black Inc. has put on hold a planned anthology: Growing up Neurodivergent in Australia.Amanda Tink, PhD Candidate, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1847352022-08-08T20:03:30Z2022-08-08T20:03:30ZThe Body Keeps the Score: how a bestselling book helps us understand trauma – but inflates the definition of it<figure><img src="https://images.theconversation.com/files/477044/original/file-20220802-11-9u5e1u.jpg?ixlib=rb-1.1.0&rect=245%2C16%2C2532%2C1632&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Artem Maltsev/unsplash</span></span></figcaption></figure><p><em>In a new series, we look at books that have become cultural touchstones.</em></p>
<p>If new books are lucky they enjoy a brief honeymoon of attention before ebbing away into oblivion. Not so <a href="https://www.goodreads.com/book/show/18693771-the-body-keeps-the-score?ac=1&from_search=true&qid=nLFdw1vdbT&rank=2">The Body Keeps the Score</a>, a publishing phenomenon that has kept selling long after it first hit the shelves in 2014. The book has spent more than 150 weeks on the New York Times best seller list for paperback nonfiction, including over half a year in the coveted #1 spot during 2021. It has reportedly sold almost 2 million copies.</p>
<p>Why a long, dense, and demanding book on the psychology and neurobiology of trauma should occupy so bright a spotlight for so long is not immediately obvious. Post-traumatic stress disorder is old news, a staple of psychological chatter for over four decades, and the book doesn’t offer any quick fix solutions for self-helpers.</p>
<p>Clues to what has driven The Body Keeps the Score’s success can be found in its sales trajectory. On <a href="https://bookriot.com/the-body-keeps-the-score-popularity/">bookriot.com</a>, writer Gina Nicoll notes that sales began to liven up around 2018 and then grew in spurts, reaching a peak in 2021. The pandemic may have contributed to this surge by bringing collective trauma to our doorsteps, she speculates, but the pre-pandemic upswing suggests other factors are also at play. </p>
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<a href="https://images.theconversation.com/files/477041/original/file-20220802-23-z39j1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/477041/original/file-20220802-23-z39j1.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/477041/original/file-20220802-23-z39j1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=881&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477041/original/file-20220802-23-z39j1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=881&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477041/original/file-20220802-23-z39j1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=881&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477041/original/file-20220802-23-z39j1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1107&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477041/original/file-20220802-23-z39j1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1107&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477041/original/file-20220802-23-z39j1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1107&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Reckonings with sexual and racial trauma in the wake of #MeToo and Black Lives Matter have combined to raise the cultural profile of trauma, Nicoll suggests. </p>
<p>But alongside this increase in cultural attention, there has been a broadening of what we take trauma to be.</p>
<p>People are seeing trauma everywhere and re-conceptualising their own experiences of misery and misadventure in its terms. They are doing so, at least in part, because the concept’s meaning has been stretched. More on that later.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/six-psychiatric-concepts-that-have-mutated-for-better-or-worse-72912">Six psychiatric concepts that have mutated: for better or worse</a>
</strong>
</em>
</p>
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<h2>The book explained</h2>
<p>So what is all the fuss about? <a href="https://en.wikipedia.org/wiki/Bessel_van_der_Kolk">Bessel van der Kolk</a>, a Dutch-born psychiatrist who has been a successful researcher and clinician in the Boston area since the late 1970s, wrote The Body Keeps the Score as a guide to the understanding and treatment of trauma. </p>
<p>The book adopts several standard features of the popular psychology genre: case studies from the author’s clinical practice, autobiographical reflections, and sharp critiques of mainstream views to assure readers the author is not merely doing good but slaying dragons in the process. </p>
<p>However, its presentation of the science of trauma is unusually compelling, setting it above most works of popularisation. Van der Kolk has substantial legitimacy as a researcher, and his interleaving of the personal and the scientific makes for an engaging read.</p>
<p>Van der Kolk begins his blockbuster with a discussion of the neuroscience of trauma, complete with explorations of brain anatomy and function and how they underpin reactions to extreme threat. </p>
<p>He presents traumatic reactions not simply as disturbances of fear and anxiety – how <a href="https://www.britannica.com/science/amygdala">the amygdala</a> becomes an over-sensitive “smoke detector” that triggers traumatised people into fight or flight reactions – but also as disruptors of interpersonal relationships and a stable sense of self.</p>
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<p>Trauma’s somatic signature extends beyond the brain. Van der Kolk explains at length how hormonal influences and the vagus nerve, which runs from brain to abdomen and regulates several internal organ functions, reverberate its effects throughout the body. </p>
<p>In trauma, he argues, people may lose a sense of body ownership to accompany their loss of self, felt connection to others, and even their sense of being fully alive. Recovering a sense of personal agency and of bodily ownership – what he refers to as befriending the body – is a key to recovery. </p>
<h2>Childhood trauma</h2>
<p>Trauma in childhood becomes the second major focus of the book. Whereas early investigations of post-traumatic reactions focused on adult combatants in war, van de Kolk directs much of his attention to impacts of trauma and hardship earlier in life. Once again, his focus is expansive, extending beyond traumatised individuals in isolation to the disruptions trauma creates in their intimate attachments. </p>
<p>Abusive family environments produce children who lack a secure sense of connection to others and suffer elevated risks of illness and re-traumatisation. They are more likely than their peers to experience and perpetrate violence as adults, to engage in self-damaging behaviour, and to experience cancer, heart disease, obesity and a range of psychiatric conditions.</p>
<p>Van der Kolk presents childhood trauma as a “hidden epidemic”, swept under the carpet by society at large and by psychiatry in particular. He advocates for policy responses that combat the economic and societal drivers of childhood adversity, and for better recognition by organised psychiatry of the mental health impacts of trauma. </p>
<p>In this second quest he has had limited success. His proposal of new diagnoses that recognise the outcomes of repeated childhood trauma – “complex PTSD” and “developmental trauma disorder” – were rebuffed by the developers of American psychiatry’s classification of mental disorders, the DSM. </p>
<p>The DSM’s third edition, published in 1980, recognised PTSD for the first time. But the fourth and fifth editions, DSM-IV (1994) and DSM-5 (2013), would have none of these new proposals. </p>
<p>Van der Kolk’s outrage at this rejection, and his jaundiced, if sometimes straw-mannish view of the psychiatry profession, seasons his book with anti-establishment saltiness. The alternative view – that the DSM’s guardians were wary of adding new disorders that overlapped substantially with existing conditions, privileging trauma as the single, dominant cause of a diffuse and multi-determined set of symptoms – does not get a hearing. </p>
<p>The Body Keeps the Score closes with an extended exploration of alternative forms of treatment. Despite his neuro-biological leanings, van der Kolk does not see medication as the best line of intervention. He contends that effective therapies must target meaning rather than chemistry and allow traumatic memories to be processed rather than blunted. </p>
<p>Among his diverse collection of preferred treatments are neurofeedback, in which people learn to alter brain waves via real-time <a href="https://www.dictionary.com/browse/encephalography">encephalographic</a> feedback, somatic psychotherapies, yoga, theatre, and eye movement desensitisation and reprocessing (<a href="https://en.wikipedia.org/wiki/Eye_movement_desensitization_and_reprocessing">EMDR</a>, in which people recall traumatic experiences while performing rhythmic, therapist-guided eye movements). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477049/original/file-20220802-16-lyh256.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/477049/original/file-20220802-16-lyh256.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477049/original/file-20220802-16-lyh256.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477049/original/file-20220802-16-lyh256.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477049/original/file-20220802-16-lyh256.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477049/original/file-20220802-16-lyh256.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477049/original/file-20220802-16-lyh256.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477049/original/file-20220802-16-lyh256.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&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">Van der Kolk is enthusiastic about therapies including eye movement desensitisation and reprocessing.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>His enthusiasm for these interventions, some of which veer towards the fringe and the faddish, sometimes outstrips the evidence for their efficacy, but has contributed to their growing popularity.</p>
<h2>Understanding the book’s appeal</h2>
<p>The Body Keeps the Score has been remarkably popular for reasons beyond its alignment with our current cultural preoccupations. For one, it is a hopeful book. Although it underscores the sweeping extent of traumatic experiences and the severity and range of their impacts, it also argues that therapy works and post-traumatic distress need not be a life sentence. </p>
<p>The same optimism shines through in the book’s dialectical account of the history of the mental health disciplines. A period of “brain-less” psychoanalytic interest in the meaning of psychological distress – carried out with no eye for biological processes – gave way to an era of “mind-less” psychopharmacology. We have now arrived at a stage in which neurobiology and a deep appreciation of human psychology can go hand in hand.</p>
<p>The book also contributes to an ongoing de-masculinising of trauma studies. Psychiatric thinking about trauma was long dominated by investigations of combat reactions in soldiers, described variously as <a href="https://en.wikipedia.org/wiki/Shell_shock">shell shock</a> or battle fatigue. The flood of psychological casualties among Vietnam veterans spurred the official recognition of PTSD in 1980. </p>
<p>Van der Kolk pays much more attention to sexual abuse and violence as sources of trauma. These disproportionately affect women and girls and account at least partially for women’s higher rates of PTSD diagnoses.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/477045/original/file-20220802-24-l30rib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477045/original/file-20220802-24-l30rib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477045/original/file-20220802-24-l30rib.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477045/original/file-20220802-24-l30rib.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477045/original/file-20220802-24-l30rib.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477045/original/file-20220802-24-l30rib.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477045/original/file-20220802-24-l30rib.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">Sexual violence disproportionately affects women.</span>
<span class="attribution"><span class="source">Ehimetalor Akhere Unuabona/Unsplash</span></span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-complex-ptsd-and-how-does-it-relate-to-past-abuse-and-trauma-172497">What is complex PTSD and how does it relate to past abuse and trauma?</a>
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<p>The same feminising of trauma can be seen more symbolically in van der Kolk’s emphasis on the bodily and relational dimensions of trauma. Historically, the gender binary has been overlaid on the mind/body distinction, and on the distinction between stereotypically masculine independence and stereotypically feminine relatedness.</p>
<p>By paying heed to somatic impacts and treatments of trauma, and the ways in which it disrupts attachments and relationships, van der Kolk is making the psychology of trauma more inclusive of the experiences of female trauma survivors.</p>
<h2>Inflating trauma</h2>
<p>The Body Keeps the Score offers a vision of trauma that is inclusive in some respects. But is it over-inclusive in others? Van der Kolk’s understanding of trauma is expansionary, offering a broad view of its impacts and implications.</p>
<p>He recognises a wide range of manifestations of trauma, promotes new trauma-related diagnoses, affirms a broad definition of what counts as a traumatic event, and recommends diverse modes of treatment.</p>
<p>For example, conventional descriptions of PTSD point to a restricted set of symptoms, such as flashbacks, nightmares, and hyper-vigilance. Van der Kolk connects trauma to a much wider web of phenomena. It is examined as a primary source of relationship problems, emotional disturbances, and forms of acting out such as rebellious, defiant, impulsive, and inattentive behaviour. </p>
<p>Most significantly of all, Van der Kolk sees trauma lurking beneath an array of somatic complaints. Trauma is embodied and manifested in such concerns as irritable bowel, auto-immune conditions, fibromyalgia, headaches, and a range of diffuse physical symptoms.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/477046/original/file-20220802-22-bqpm3p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/477046/original/file-20220802-22-bqpm3p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477046/original/file-20220802-22-bqpm3p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477046/original/file-20220802-22-bqpm3p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477046/original/file-20220802-22-bqpm3p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477046/original/file-20220802-22-bqpm3p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477046/original/file-20220802-22-bqpm3p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477046/original/file-20220802-22-bqpm3p.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">Van der Kolk sees trauma lurking beneath an array of somatic complaints.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>Similarly, Van der Kolk’s work expands the range of events that are considered traumas. When PTSD was first defined in DSM-III, the condition could only be diagnosed if the event that precipitated it was life-threatening and outside the range of normal human experience. </p>
<p>Later editions of the diagnostic manual loosened the definition to include unpleasant events witnessed indirectly, which are not physically endangering. </p>
<p>Van der Kolk uses the term “trauma” more freely still, often employing it to refer to almost any form of life adversity, including enduring circumstances rather than only discrete incidents. Trauma can easily be stretched to encompass minor illnesses, normal romantic breakups and disappointing exam results.</p>
<p>On this broadened definition, all but the most cosseted among us have been traumatised and can view our struggles and sufferings through the potentially magnifying lens of trauma.</p>
<p>This expansion of the meaning of trauma has taken place in parallel with a steep rise in the cultural prominence of the concept. <a href="https://muse.jhu.edu/article/773952/summary">Research</a> shows that the word “trauma” appears in everyday discourse much more frequently now than it did even two decades ago. </p>
<p>That rise has been even more dizzying within the mental health professions, a <a href="https://psycnet.apa.org/doiLanding?doi=10.1037%2Famp0000847">recent study</a> finding that “trauma” appeared at an almost 20 times higher rate in psychology journal articles in the 2010s as it did in the 1970s. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-than-half-of-australians-will-experience-trauma-most-before-they-turn-17-we-need-to-talk-about-it-159801">More than half of Australians will experience trauma, most before they turn 17. We need to talk about it</a>
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</em>
</p>
<hr>
<h2>Backlash</h2>
<p>It should not be surprising to learn that this sharply spiking interest in trauma has generated some push-back. In 2021, <a href="https://www.theatlantic.com/health/archive/2021/10/trauma-books-wont-save-you/620421/">Eleanor Cummins</a> observed in The Atlantic that the concept of trauma has become “uselessly vague – a swirl of psychiatric diagnoses, folk wisdom, and popular misconceptions”. In the same year, writer <a href="https://harpers.org/archive/2021/12/a-posthumous-shock-trauma-studies-modernity-how-everything-became-trauma/">Will Self</a> criticised “how everything became trauma” and <a href="https://www.newyorker.com/magazine/2022/01/03/the-case-against-the-trauma-plot">Parul Sehgal</a> decried how trauma-driven plots flatten fictional narratives and hollow out characters in The New Yorker.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/477048/original/file-20220802-25-9u5e1u.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/477048/original/file-20220802-25-9u5e1u.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/477048/original/file-20220802-25-9u5e1u.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=845&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477048/original/file-20220802-25-9u5e1u.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=845&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477048/original/file-20220802-25-9u5e1u.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=845&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477048/original/file-20220802-25-9u5e1u.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1062&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477048/original/file-20220802-25-9u5e1u.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1062&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477048/original/file-20220802-25-9u5e1u.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1062&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">Will Self: argues ‘everything has become trauma’.</span>
<span class="attribution"><span class="source">Goodreads</span></span>
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<p>In 2022, in the New York Times, <a href="https://www.nytimes.com/2022/02/04/opinion/caleb-love-bombing-gaslighting-trauma.html">Jessica Bennett</a> asked “if everything is trauma, is anything?” and denounced “post-traumatic hyperbole”. <a href="https://www.vox.com/the-highlight/22876522/trauma-covid-word-origin-mental-health">Lexi Pandell</a>, writing for Vox, argued this “word of the decade” has become close to meaningless.</p>
<p>Like Bennett and Pandell, several writers have queried whether trauma is now being used too promiscuously. Some have distinguished big “T” trauma from less severe little “t” trauma to resist this <a href="https://www.tandfonline.com/doi/abs/10.1080/1047840X.2016.1082418?journalCode=hpli20">concept creep</a>.</p>
<p>Others worry that the growing popularity of trauma narratives represents an encroachment of medical language into the realm of ordinary adversity, reducing unjust social arrangements to individual pathologies, or promoting personal fragility. Still others have voiced concerns that the concept of trauma has become <a href="https://www.commentary.org/articles/christine-rosen/trauma-political-tool/">politicised</a>.</p>
<p>The argument that broad concepts of trauma produce fragility rests on the belief that defining moderate life challenges as mind-shattering traumas might undermine our resilience.</p>
<p>Understanding an adversity as a trauma implies that it overwhelms our capacity to cope and is likely to have lasting effects. In the popular mind, trauma still carries a connotation of indelibility. </p>
<p>Of course, many adversities do take people beyond their breaking points and have enduring consequences. The question is whether perceiving less severe experiences as traumas makes them loom larger and longer than they need to. <a href="https://psycnet.apa.org/record/2021-61041-001">Emerging research</a> evidence suggests that it might.</p>
<p>Van der Kolk can’t be held entirely responsible for the runaway success of his book or for the runaway semantic inflation and popularity of its central concept. The Body Keeps the Score has been successful because it resonates with its cultural moment, and it has helped to mould that moment for millions of readers.</p>
<p>The recent elevation of trauma attests to a time in which people are keenly attuned to their individual and collective suffering, increasingly attribute it to causes beyond their control, and look to a therapeutic mindset to resolve it. Van der Kolk’s book is a lucid guide to this new reality.</p><img src="https://counter.theconversation.com/content/184735/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Haslam receives funding from the Australian Research Council. </span></em></p>A lucid, demanding book on the psychology and neurobiology of trauma has become a publishing phenomenon. It resonates, writes Nick Haslam, with an age in which people are seeing trauma everywhere.Nick Haslam, Professor of Psychology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1250532019-11-12T19:03:39Z2019-11-12T19:03:39ZIt’s 25 years since we redefined autism – here’s what we’ve learnt<figure><img src="https://images.theconversation.com/files/300582/original/file-20191107-12521-1pg5b01.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The frequency and intensity of repetitive behaviours vary between mild and severe, which is why it's called a spectrum.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/boy-headphones-looking-out-window-airport-219436822?src=4360f59d-f1ce-4544-ab94-e99b723f70cc-2-6">Dubova/Shutterstock</a></span></figcaption></figure><p>It’s 25 years since the fourth edition of the <a href="https://theconversation.com/explainer-what-is-the-dsm-14127">Diagnostic and Statistical Manual</a> (DSM-IV) was published. The manual is the clinical “bible” that defines the criteria for the diagnosis of psychiatric and neurodevelopmental conditions, and was a landmark document for autism spectrum disorder.</p>
<p>The first mention of autism came in the third edition of the DSM in 1980, with the introduction of the diagnostic category of “<a href="https://www.ncbi.nlm.nih.gov/pubmed/3716967">infantile autism</a>”. This label was generally only applied to children with substantial language impairment and intellectual disabilities.</p>
<p>In 1994, the DSM-IV recognised people could also show the core behaviours of autism without having significant language impairment or any intellectual disability. This change in how we described autism contributed to a <a href="https://theconversation.com/do-more-children-have-autism-now-than-before-4497">surge in diagnoses</a>. </p>
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<a href="https://theconversation.com/do-more-children-have-autism-now-than-before-4497">Do more children have autism now than before? </a>
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<p>There was also a surge in autism research, from around <a href="https://www.ncbi.nlm.nih.gov/pubmed?term=(Autism%5BTitle%5D)%20AND%20(%221994%2F01%2F01%22%5BDate%20-%20Publication%5D%20%3A%20%221994%2F12%2F31%22%5BDate%20-%20Publication%5D)">96 studies</a> in 1994, to <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=(Autism%5BTitle%5D)+AND+(%222000%2F01%2F01%22%5BDate+-+Publication%5D+%3A+%222000%2F12%2F31%22%5BDate+-+Publication%5D)">207</a> in 2000, and then <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=(Autism%5BTitle%5D)+AND+(%222018%2F01%2F01%22%5BDate+-+Publication%5D+%3A+%222018%2F12%2F31%22%5BDate+-+Publication%5D)">2,789</a> in 2018.</p>
<p>So, 25 years on, what have we learnt about autism?</p>
<h2>The autism concept</h2>
<p>In the 1990s, we viewed autism as one condition, with all children showing similar, severe difficulties with social and communication skills. </p>
<p>We now know the reality is very different.</p>
<p>In its most literal sense, autism is diagnosed when a person displays a set of behaviours typified by difficulties in social interaction and communication, as well as having more restricted interests and repetitive behaviours than we typically expect.</p>
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<a href="https://theconversation.com/why-do-some-people-with-autism-have-restricted-interests-and-repetitive-movements-94401">Why do some people with autism have restricted interests and repetitive movements?</a>
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<p>The severity of the behaviours that characterise autism <a href="https://journals.sagepub.com/doi/abs/10.1177/1362361319852831">vary considerably</a> between people. Social interaction and communication difficulties, for example, can range from having no verbal language to highly fluent language. </p>
<p>The frequency and intensity of autism behaviours – such as repetitive play with objects and repeated body movements like rocking and hand flapping – vary between mild and severe. </p>
<p>And intellectual abilities can range from significant disability to a very high IQ.</p>
<p>This variation is the so-called “autism spectrum”, which has also led to the worldwide movement of “<a href="https://journals.sagepub.com/doi/full/10.1177/1362361318820762">neurodiversity</a>”. This views neurological conditions such as autism as part of the natural spectrum of human diversity, and posits that this diversity should be respected rather than pathologised. </p>
<p>Neurodiversity challenges the medical model of autism as a disorder, instead viewing autism as an inseparable aspect of identity.</p>
<p>Autism is diagnosed by a team of clinicians, through a <a href="https://theconversation.com/new-autism-guidelines-aim-to-improve-diagnostics-and-access-to-services-104929">consistent and rigorous diagnostic process</a>. While the dividing line between “typical” and “atypical” can be blurry, a diagnosis is made when the core behaviours of autism have a functional impact on an individual’s daily life. </p>
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<img alt="" src="https://images.theconversation.com/files/301055/original/file-20191111-194665-o65yvq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301055/original/file-20191111-194665-o65yvq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301055/original/file-20191111-194665-o65yvq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301055/original/file-20191111-194665-o65yvq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301055/original/file-20191111-194665-o65yvq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301055/original/file-20191111-194665-o65yvq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301055/original/file-20191111-194665-o65yvq.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">Some people with autism have very high IQs.</span>
<span class="attribution"><span class="source">LDprod/Shutterstock</span></span>
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<p>It’s now clear that autism is not one condition in the sense that there is a <a href="https://www.mja.com.au/system/files/issues/whit11667.pdf">common cause</a> shared by all people on the autism spectrum. </p>
<p>Instead, autism is best thought of as an <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Autism_spectrum_disorder/">umbrella term</a> which describes a range of different people, all with relatively similar behaviours, which may or may not be caused by the same biological factors.</p>
<p>Critically, autism is not just a childhood condition. While the behavioural characteristics of autism first emerge during childhood, they almost always persist into adolescence and adulthood, but often present in a different form. </p>
<p>Social difficulties in childhood might be shown through a preference to play alone, for example, while in adulthood this may be reflected by difficulty in maintaining social relationships.</p>
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Read more:
<a href="https://theconversation.com/we-need-to-stop-perpetuating-the-myth-that-children-grow-out-of-autism-119540">We need to stop perpetuating the myth that children grow out of autism</a>
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<p>The dramatic refinement of our understanding of autism from a severe childhood condition, to a cluster of complex and variable conditions that endure into adulthood, is a great achievement of scientific research and has driven all other research and policy advances. </p>
<h2>Causes</h2>
<p>In 1994, there was already a good understanding that autism originated from <a href="https://www.ncbi.nlm.nih.gov/pubmed/562353">genetic differences</a>.</p>
<p>Advances in genetic research in the late 1990s and 2000s – first by sequencing the human genome, then the dramatic reduction in the cost of this sequencing – led scientists to believe they would soon find the single gene that causes the brain to develop differently.</p>
<p>But after several decades of intensive research, the picture turned out to be far <a href="https://theconversation.com/what-causes-autism-what-we-know-dont-know-and-suspect-53977">more complex</a>. </p>
<p>There is now <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650984/">consensus</a> that there is no one genetic difference shared by all individuals with autism. And rarely does one person possess a single genetic factor that leads the brain to develop differently. </p>
<p>There is also evidence to suggest other biological factors may play a role in the development of autism, including <a href="https://theconversation.com/bugs-and-allergies-in-pregnancy-linked-to-child-developmental-disorders-like-autism-and-adhd-87358">inflammation</a> and <a href="https://theconversation.com/extreme-male-brain-theory-of-autism-confirmed-in-large-new-study-and-no-it-doesnt-mean-autistic-people-lack-empathy-or-are-more-male-106800">hormonal factors</a>. But the evidence for these factors remains preliminary.</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>We now know a range of conditions, including Fragile X syndrome and tuberous sclerosis, have very clear genetic or chromosomal differences that can lead to autistic behaviours. In total, these conditions account for around <a href="https://www.ncbi.nlm.nih.gov/pubmed/22089167">10%</a> of all people on the autism spectrum.</p>
<p>Genetic factors are still very likely to underpin autism in the remaining majority of people. But the genetic differences are likely more complex, and require advances in statistical techniques to better understand why the brain develops differently for some children.</p>
<h2>Therapies and treatments</h2>
<p>In the 1990s, behavioural interventions for autism were dominated by applied behaviour analysis (<a href="https://theconversation.com/behavioural-method-is-not-an-attempt-to-cure-autism-19782">ABA</a>), an approach to therapy that helps children learn new skills.</p>
<p>While ABA remains prominent throughout the world, other therapeutic models have emerged, such as those based on <a href="https://raisingchildren.net.au/autism/therapies-guide/teacch">developmental principles</a>, those that target <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755315/">communication</a> and those that use a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5121131/">combination of approaches</a>.</p>
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<img alt="" src="https://images.theconversation.com/files/301054/original/file-20191111-194650-xqkdi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301054/original/file-20191111-194650-xqkdi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301054/original/file-20191111-194650-xqkdi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301054/original/file-20191111-194650-xqkdi3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301054/original/file-20191111-194650-xqkdi3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301054/original/file-20191111-194650-xqkdi3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301054/original/file-20191111-194650-xqkdi3.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">Therapies have come a long way.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/happy-little-child-during-therapy-school-755297134">Photographee.eu/Shutterstock</a></span>
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<p>While these therapies help the development of some children with autism, no one therapy model will be effective for all. The great advance of the last 25 years has been to provide families with <a href="https://theconversation.com/a-guide-for-how-to-choose-therapy-for-a-child-with-autism-64729">alternate options</a> if their original choice of therapy isn’t as beneficial as they hoped.</p>
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Read more:
<a href="https://theconversation.com/a-guide-for-how-to-choose-therapy-for-a-child-with-autism-64729">A guide for how to choose therapy for a child with autism</a>
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<p>But pharmacological (drug) treatments have not seen as much progress. Despite substantial research investment, there remains <a href="https://journals.sagepub.com/doi/full/10.1177/0269881117741766">no medication with good evidence</a> for reducing the disability associated with the core social and communication difficulties of autism. </p>
<p>Pharmacological intervention in autism is primarily used to assist with other challenges that can be associated with autism such as anxiety, attention problems, epilepsy and sleeping difficulties.</p>
<h2>Where to next?</h2>
<p>Despite progress over the past 25 years, health and disability challenges remain pervasive for people on the autism spectrum, and our policy responses continue to be fragmented across health, disability and education systems.</p>
<p>Given the ever-marching advance of science, it’s impossible to predict the next 25 years of research. A key challenge for scientists is how we use the knowledge we create to lead to clear and tangible benefits for humanity.</p>
<p>This will likely require meaningful partnerships with autistic people and their families to better understand their priorities for their lives. We need to learn how the knowledge we’ve obtained, and that still to come, can best support each person to discover their own strengths and what they want for their lives.</p><img src="https://counter.theconversation.com/content/125053/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Whitehouse receives funding from the National Health and Medical Research Council and the Australian Research Council.</span></em></p>It’s been 25 years since autism was redefined and the surge in diagnoses and research began. But while we’ve come along way in our understanding of the spectrum, advances in drug therapies has lagged.Andrew Whitehouse, Bennett Chair of Autism, Telethon Kids Institute, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1206222019-07-24T13:37:24Z2019-07-24T13:37:24ZWhat exactly is a disease?<figure><img src="https://images.theconversation.com/files/285188/original/file-20190722-11314-1vrn0qn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Not all disease is easy to spot.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1407569297?src=_V1oZAF_73mzq0rXE74X4w-1-6&studio=1&size=medium_jpg">Yok_onepiece/Shutterstock</a></span></figcaption></figure><p>There is an ongoing <a href="https://www.bmj.com/content/366/bmj.l4258">lively debate</a> among healthcare professionals about whether or not obesity is a disease. Differences between those who argue that it’s a disease and those who argue that it’s just a risk factor for conditions such as type 2 diabetes and heart disease are unlikely to be resolved any time soon. The debate, however, raises other questions, such as, what exactly is a disease and who gets to decide?</p>
<p>A <a href="https://www.medicinenet.com/script/main/art.asp?articlekey=3011">simple definition</a> of disease is an “illness or sickness characterised by specific signs or symptoms”. But it is interesting that some <a href="https://www.collinsdictionary.com/dictionary/english/disease">dictionaries</a> suggest that diseases are caused by “bacteria or infections”, seemingly dismissing psychological and noncommunicable conditions as diseases, which is odd given that <a href="https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death">noncommunicable diseases</a>, such as cardiovascular disease and cancer, make up most ill health in the world today.</p>
<h2>Official catalogue of disease</h2>
<p>On a global level, diseases are catalogued by international groups of experts for the World Health Organisation (WHO). This catalogue, the International Classification of Disease, is now in its tenth revision (<a href="https://icd.who.int/browse10/2016/en">ICD-10</a>). Despite its name, the classification doesn’t stop at diseases but includes related health problems, which may be linked to a particular disease, or may be a symptom as part of a syndrome or even a consequence of a medical procedure. For example, even dehydration appears in ICD-10, where it is also called “volume depletion”. So perhaps there is not even agreement on what is meant by disease. And what <em>is</em> classified as disease is essentially down to expert consensus.</p>
<p>While the WHO doesn’t seem to have a clear definition of disease, it does at least have a definition of health. It is <a href="https://www.who.int/about/who-we-are/constitution">defined as</a> “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. </p>
<p>The definition of health appears to be broad and inclusive, but defining disease appears to be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1299105/">more challenging</a> than defining its opposite. Few people would disagree that measles, say, is a disease. But what happens when society decides to classify a certain human behaviour or characteristic, which some groups happen to find disturbing, as a disease. </p>
<h2>Sin as a source of disease</h2>
<p>Examples of classifying characteristics as diseases can be seen throughout human history. Many of these might be grounded in traditional beliefs and views of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695779/">health, disease and their links to sin</a>. </p>
<p>The development of psychology as a science potentially led some perceived “sins” to be translated into mental health disorders. Perhaps the best example of this is homosexuality. Homosexuality was classified as a mental disorder by the American Psychiatric Association (APA) in 1968. This was later challenged by a vote among APA members in 1973, where <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695779/">a majority of 58%</a> chose to remove it from the diagnostic manual. Homosexuality was not fully removed from the diagnostic manual for another decade and is now considered to be a normal characteristic within the diversity of human nature.</p>
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<img alt="" src="https://images.theconversation.com/files/285379/original/file-20190723-110154-19r5hjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/285379/original/file-20190723-110154-19r5hjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/285379/original/file-20190723-110154-19r5hjq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/285379/original/file-20190723-110154-19r5hjq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/285379/original/file-20190723-110154-19r5hjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/285379/original/file-20190723-110154-19r5hjq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/285379/original/file-20190723-110154-19r5hjq.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">
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<span class="caption">Being gay was once considered to be an endocrine disorder.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1099936808?src=l_4eaFhdo4Aa_-EWEnGYlQ-1-0&studio=1&size=medium_jpg">lazyllama/Shutterstock</a></span>
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<p>This disturbing episode raises further questions: on what basis and in whose interests are diseases classified? </p>
<p>In 2013, researchers at Bond University in Australia looked at <a href="https://theconversation.com/how-diseases-get-defined-and-what-that-means-for-you-16965">who gets to classify diseases</a>. They found that common diseases often had their definitions widened by expert groups, without considering the <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">potential risks</a> or challenges of increasing the number of people living with disease. They also noted that experts who widened definitions of diseases often have conflicts of interests in the form of funding from pharmaceutical companies.</p>
<h2>On the spectrum</h2>
<p>Sometimes, risk factors for a disease – such as high blood pressure – eventually get defined as a disease in their own right. And once these risk factors are reclassified as a disease, their <a href="https://www.health.harvard.edu/heart-health/reading-the-new-blood-pressure-guidelines">targets or ranges</a> tend to shift over time, increasing the number of people who have the disease. For example, high blood pressure used to be anything over 140/90. But in 2017, the US <a href="https://www.health.harvard.edu/blog/new-high-blood-pressure-guidelines-2017111712756">changed the threshold</a> to 120/80.</p>
<p>Distinguishing a disease from a risk factor is not easy, especially when it comes to chronic diseases, which tend to be a spectrum from health to illness. Blood glucose (sugar) is a clear example as levels move from healthy through pre-diabetes into type 2 diabetes. So spotting where health finishes and disease begins is difficult, to the point that the WHO and International Diabetes Federation suggest there is no such thing as a <a href="https://www.who.int/diabetes/publications/Definition%20and%20diagnosis%20of%20diabetes_new.pdf">normal level of blood glucose</a>. </p>
<p>Nevertheless, the definition of gestational diabetes (diabetes in pregnancy) changed in 2014, when the blood glucose threshold was lowered. The change increased the incidence of gestational diabetes by <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326329/">74% with no improvement in short-term outcomes</a>, such as the mother needing a caesarean section, according to one Australian study.</p>
<p>Many <a href="https://www.bmj.com/content/350/bmj.h2308">clinicians</a> are critical of this trend, calling it <a href="https://www.theguardian.com/commentisfree/2014/jul/19/patients-hospital-care-over-intervention">over-medicalisation</a>.</p>
<h2>Normal ageing or disease?</h2>
<p>Sometimes, conditions previously thought of as being a natural part of getting older have become diseases. For example, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32112-3/fulltext">osteoporosis</a> was considered a normal part of ageing until 1994 when the WHO <a href="https://www.ncbi.nlm.nih.gov/pubmed/7941614">officially recognised it as a disease</a>. Given osteoporosis’s link with an increased risk of fractures and the devastating impact broken bones can have on the elderly, this seems like a change in definition that is justified.</p>
<p>Other physiological changes that occur in older age, such as a fall in testosterone levels in men, may not benefit from disease status. But that hasn’t stopped some healthcare experts trying to create a new condition called “<a href="https://www.nhs.uk/conditions/male-menopause/">the andropause</a>”. So far, though, resistance to recognising this change as a disease has been strong.</p>
<p>All of the above goes to show that deciding what is or isn’t a disease is not easy, but hopefully you’ll be better equipped to ask some critical questions such as, who benefits from this new definition? And do they have my best interests at heart? The answer to the latter question is usually yes – but not always.</p><img src="https://counter.theconversation.com/content/120622/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 organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It seems like an easy question, until you take a closer look. Then things get messy.Duane Mellor, Senior Teaching Fellow, Aston Medical School, Aston UniversityShahid Merali, Clinical Senior Lecturer: Lead for Primary Care Education, Aston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1172832019-06-03T13:33:57Z2019-06-03T13:33:57ZMillions use cannabis, but figures for how many become dependent aren’t reliable<figure><img src="https://images.theconversation.com/files/277361/original/file-20190531-69071-1oanvji.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/625586630?src=i-bvuMEefR9YIggY2BFXsw-1-4&size=medium_jpg">Mitch M/Shutterstock</a></span></figcaption></figure><p>Cannabis has an image of being a relatively harmless drug. But all drugs carry a degree of risk, and cannabis is no exception. One of those risks is dependence, which many people assume is only something that happens to those who use “hard drugs”, such as crack or heroin. In fact, the <a href="https://accp1.onlinelibrary.wiley.com/doi/abs/10.1002/j.1552-4604.2002.tb06000.x">estimated</a> risk of dependence on cannabis is about one in ten. </p>
<p>This risk may seem relatively low, but given that there are an <a href="https://apps.who.int/iris/bitstream/handle/10665/251056/9789241510240-eng.pdf">estimated</a> 200m cannabis users across the globe, the potential number of people who are dependent on the drug is around 20m – roughly, the population of <a href="https://www.worldometers.info/world-population/romania-population/">Romania</a>. </p>
<p>It’s worth exploring how this figure of one in ten is constructed. Several studies of cannabis dependence used the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767415/#R66">criteria</a> (see below) laid out in the American Psychiatric Association’s diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM) to determine cannabis dependence. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/276644/original/file-20190527-193501-85jejp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/276644/original/file-20190527-193501-85jejp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276644/original/file-20190527-193501-85jejp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276644/original/file-20190527-193501-85jejp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276644/original/file-20190527-193501-85jejp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276644/original/file-20190527-193501-85jejp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276644/original/file-20190527-193501-85jejp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276644/original/file-20190527-193501-85jejp.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"></a>
<figcaption>
<span class="caption">DSM IV Substance Dependence Criteria.</span>
<span class="attribution"><span class="source">American Psychiatric Association</span></span>
</figcaption>
</figure>
<p>Examining these criteria highlights just how challenging making this diagnosis is. A reliable way to assess dependence on any drug, including cannabis, is to see what happens when a person stops using it. If they experience physical or psychological withdrawal symptoms, then it is likely they are dependent. </p>
<p>The DSM makes it clear that to qualify for a diagnosis of cannabis dependence, these withdrawal symptoms should not be due to another substance – which is logical but fiendishly difficult to determine in practice. For example, many people <a href="https://theconversation.com/how-we-could-make-cannabis-safer-for-users-73638">mix</a> tobacco with cannabis. Compared with cannabis, the chances of becoming dependent on tobacco are <a href="https://www.bmj.com/content/365/bmj.l2204?utm_source=twitter&utm_medium=hootsuite&utm_term=&utm_content=&utm_campaign=editors">five times greater</a>. So the discomfort people experience when they stop smoking joints could be due to tobacco rather than cannabis. There is considerable overlap in the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345250/">withdrawal</a> symptoms of both drugs.</p>
<p>Previous versions of the DSM criteria for substance dependence had a gender bias. One of the <a href="https://link.springer.com/article/10.1007/s00406-019-01008-x">questions</a> assessing dependence asked if the person was ever intoxicated while driving a truck. Given that more men drive trucks than women, this raised the dependency criteria threshold for women. Consequently, we have underestimated the number of women who are dependent. Also, cannabis-related offences are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767415/">greater</a> for men than women. DSM criteria include this issue, again contributing to an underestimate of women.</p>
<p>Psychiatrists decide whether a person qualifies for a diagnosis of cannabis dependence, so, although cannabis is used across the world, most of the data we have about population-level use of cannabis and dependence is <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395919301318">drawn</a> from America, Europe and Australia. This significantly limits estimates of cannabis dependence in non-Western countries where there are few psychiatrists. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/276585/original/file-20190527-40059-1217jox.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/276585/original/file-20190527-40059-1217jox.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/276585/original/file-20190527-40059-1217jox.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/276585/original/file-20190527-40059-1217jox.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/276585/original/file-20190527-40059-1217jox.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/276585/original/file-20190527-40059-1217jox.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=453&fit=crop&dpr=1 754w, https://images.theconversation.com/files/276585/original/file-20190527-40059-1217jox.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=453&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/276585/original/file-20190527-40059-1217jox.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=453&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Cannabis use versus treatment.</span>
<span class="attribution"><span class="source">Public Health England & ONS</span></span>
</figcaption>
</figure>
<h2>Credible stats</h2>
<p>Several countries and US states have legalised or decriminalised cannabis. This policy change has contributed to the <a href="https://www.newyorker.com/magazine/2019/01/14/is-marijuana-as-safe-as-we-think">perception</a> that cannabis use is risk free. To challenge this perception, we need credible estimates for cannabis dependence. As we’ve seen, the methods used to date aren’t up to scratch and the assessment criteria are biased towards Western men. No one is helped by estimates of cannabis dependence that overlook key groups in a population, namely women and those from non-Western countries. </p>
<p>Most people who use cannabis won’t become dependent, but there needs to be raised awareness of the risk. The danger is that people don’t realise they have a problem or if they become aware of their dependency; they believe they are unique. Added to which is the <a href="https://link.springer.com/chapter/10.1007/978-3-319-90365-1_10">misconception</a> that anyone can just abstain from cannabis without experiencing withdrawal symptoms.</p>
<p>However, improving the way we count those dependent on cannabis is not ambitious enough, we should be able to predict who is at <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/add.14174">risk</a> in the first place. This offers the potential to reduce rates of dependence, not merely calculate the numbers after the problem has developed.</p><img src="https://counter.theconversation.com/content/117283/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton is affiliated with Alcohol research UK.</span></em></p>One in ten cannabis users are dependent on the drug, according to some estimates.Ian Hamilton, Associate Professor, University of YorkLicensed 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/738292017-03-17T00:07:48Z2017-03-17T00:07:48ZWhat’s behind phantom cellphone buzzes?<figure><img src="https://images.theconversation.com/files/160993/original/image-20170315-5340-1n74g8s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This is your brain on plugs.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/478917871?src=-ktPYA6l1Gi6QOxI8XWMDg-2-39&size=huge_jpg">'Brain' via www.shutterstock.com</a></span></figcaption></figure><p>Have you ever experienced a phantom phone call or text? You’re convinced that you felt your phone vibrate in your pocket, or that you heard your ring tone. But when you check your phone, no one actually tried to get in touch with you. </p>
<p>You then might plausibly wonder: “Is my phone acting up, or is it me?”</p>
<p>Well, it’s probably you, and it could be a sign of just how attached you’ve become to your phone. </p>
<p>At least you’re not alone. Over 80 percent of college students we surveyed <a href="http://www.sciencedirect.com/science/article/pii/S0747563217300171">have experienced it</a>. However, if it’s happening a lot – more than once a day – it could be a sign that you’re psychologically dependent on your cellphone.</p>
<p>There’s no question that cellphones are part of the social fabric in many parts of the world, and some people spend hours each day on their phones. Our research team recently found that most people will <a href="https://link.springer.com/article/10.1007/s41347-017-0012-8">fill their downtime</a> by fiddling with their phones. Others even do so in the middle of a conversation. And most people will check their phones <a href="https://link.springer.com/article/10.1007/s41347-017-0012-8">within 10 seconds</a> of getting in line for coffee or arriving at a destination. </p>
<p>Clinicians and researchers still debate whether excessive use of cellphones or other technology can constitute an addiction. <a href="http://onlinelibrary.wiley.com/doi/10.1111/appy.12164/abstract">It wasn’t included</a> in the latest update to the <a href="http://www.psychiatry.org/psychiatrists/practice/dsm">DSM-5</a>, the American Psychiatric Association’s definitive guide for classifying and diagnosing mental disorders.</p>
<p>But given <a href="https://www.nytimes.com/2017/03/13/health/teenagers-drugs-smartphones.html?_r=0">the ongoing debate</a>, we decided to see if phantom buzzes and rings could shed some light on the issue.</p>
<h2>A virtual drug?</h2>
<p>Addictions are pathological conditions in which people compulsively seek rewarding stimuli, despite the negative consequences. We often hear reports about how cellphone use can be problematic <a href="https://theconversation.com/she-phubbs-me-she-phubbs-me-not-smartphones-could-be-ruining-your-love-life-68463">for relationships</a> and <a href="https://sites.psu.edu/siowfa15/2015/09/16/are-cell-phones-ruining-our-social-skills/">for developing effective social skills</a>.</p>
<p>One of the features of addictions is that people become hypersensitive to cues related to the rewards they are craving. Whatever it is, they start to see it everywhere. (I had a college roommate who once thought that he saw a bee’s nest made out of cigarette butts hanging from the ceiling.)</p>
<p>So might people who crave the messages and notifications from their virtual social worlds do the same? Would they mistakenly interpret something they hear as a ring tone, their phone rubbing in their pocket as a vibrating alert or even think they see a notification on their phone screen – when, in reality, nothing is there?</p>
<h2>A human malfunction</h2>
<p>We decided to find out. <a href="http%3A%2F%2Fwww.amta.org.au%2Famta%2Fsite%2Famta%2Fdownloads%2Fpdfs.2005.web%2Fdr.phillips.monash.cyber.psychology.mar.05.pdf">From a tested survey measure of problematic cellphone use</a>, we pulled out items assessing psychological cellphone dependency. We also created questions about the frequency of experiencing phantom ringing, vibrations and notifications. We then administered an online survey to over 750 undergraduate students.</p>
<p>Those who scored higher on cellphone dependency – they more often used their phones to make themselves feel better, became irritable when they couldn’t use their phones and thought about using their phone when they weren’t on it – <a href="http://www.sciencedirect.com/science/article/pii/S0747563217300171">had more frequent phantom phone experiences</a>.</p>
<p>Cellphone manufacturers and phone service providers <a href="http://online.liebertpub.com/doi/10.1089/cyber.2015.0406">have assured us</a> that phantom phone experiences are not a problem with the technology. As <a href="https://en.wikipedia.org/wiki/HAL_9000">HAL 9000</a> might say, they are a product of “human error.”</p>
<p>So where, exactly, have we erred? We are in a brave new world of virtual socialization, and the psychological and social sciences can barely keep up with advances in the technology. </p>
<p>Phantom phone experiences may seem like a relatively small concern in our electronically connected age. But they raise the specter of how reliant we are on our phones – and how much influence phones have in our social lives. </p>
<p>How can we navigate the use of cellphones to maximize the benefits and minimize the hazards, whether it’s improving our own mental health or honing our live social skills? What other new technologies will change how we interact with others? </p>
<p>Our minds will continue to buzz with anticipation.</p><img src="https://counter.theconversation.com/content/73829/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel J. Kruger 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>Have you ever checked your phone thinking you had felt it vibrate or heard it ring, only to see that no one tried to reach you? One researcher decided to study this phenomenon.Daniel J. Kruger, Research Assistant Professor, University of MichiganLicensed 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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<iframe width="440" height="260" src="https://www.youtube.com/embed/wwwxJhmTZuE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<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/380252015-09-06T20:08:31Z2015-09-06T20:08:31ZBack to black: why melancholia must be understood as distinct from depression<figure><img src="https://images.theconversation.com/files/93483/original/image-20150901-25748-1pqq056.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Melancholia may be a distinct type of depression, with its own clinical signs and symptoms</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/helga/4723657763/">Helga Weber/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>First described by Hippocrates, “melancholia” or melancholic depression was considered a specific condition that commonly struck people out of the blue – and put them into the black. In modern times, it came to be described as “<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1979411/">endogenous depression</a>” (coming from within) in contrast to depression stemming in response to external stressors. </p>
<p>In 1980, the third edition of the Diagnostic and Statistical Manual (<a href="http://www.terapiacognitiva.eu/dwl/dsm5/DSM-III.pdf">DSM-III</a>), the official classificatory system of the <a href="http://www.psychiatry.org/">American Psychiatric Association</a>, re-modelled depressive disorders. The new classification operated largely on degrees of severity, comprising “major” depression and several minor depressions. </p>
<p>This is how depression came to be modelled as a single entity, varying only by severity (this is known as the dimensional model). And over the last decade, this model has been extended to include “sub-clinical depressions”, which is basically when someone is sad or down but not diagnosable by formal mental illness criteria. </p>
<h2>Problematic model</h2>
<p><a href="http://www.oup.com.au/titles/academic/psychology/9780199921577">The changes generated concern</a> about the extension of “clinical depression” to include and “pathologise” sadness. While everyone feels down or sad sometimes, normally these moods pass, with little if any long-term consequences. </p>
<p>The boundary between this everyday kind of feeling down and clinical depression is imprecise. But the latter is associated with a greater severity of symptoms, such as losing sleep or thinking life isn’t worth living, lasts for longer and is much more likely to require treatment.</p>
<p>The dimensional model is intrinsically limited; “major depression” is no more informative a diagnosis than “major breathlessness”. It ignores the differing – biological, psychological and social – causes that may bring about a particular depressive condition and which inform the most appropriate therapeutic approach (be it an antidepressant drug, psychotherapy or social intervention). </p>
<p>Ignoring the cause of depression leads to both under-treatment, such as failure to prescribe an effective medication, and over-treatment, such as prescription of medication that’s unnecessary and may have side effects.</p>
<p>The model also essentially marginalised melancholia as a categorically different type of depression, with progressive DSM manuals according it insignificant status as a major depression “specifier” (an addendum to a diagnosis intended to provide more detail). </p>
<p>As a specifier, and not a disorder in its own right, melancholia is not considered categorically separate to other types of depression. And this matters – much less research and training is devoted to it as a result, and doctors are often unaware of its clinical implications. </p>
<h2>A distinct pattern</h2>
<p><a href="http://www.blackdoginstitute.org.au/public/research/meetourresearchers/gordonparker.cfm">My research team</a> is trying to establish melancholia’s categorical status and detection, and so improve its management. Here’s what we know – or think we know - about the distinctness of melancholia.</p>
<p>First, it shows a relatively clear pattern of <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733615/">symptoms and signs</a>. The individual experiences profound bleakness and has no desire to socialise, for instance, finding it hard to obtain any pleasure in life or to be cheered up. </p>
<p>Sufferers also experience a lack of energy and have difficulty concentrating, although they generally show “diurnal variation”, reporting improvement in mood and energy as the day goes on. Reflecting changes to their sleep/wake cycle, people with melancholia tend to wake early in the morning. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=554&fit=crop&dpr=1 754w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=554&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/93498/original/image-20150901-25759-1obstd7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=554&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People with melancholic depression may feel no pleasure in socialising or regular activities.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-161548835/stock-photo-lone-man-is-sitting-at-the-table-in-conference-hall-rear-view.html?src=TSYwkSoBp1HczwYLv80nxA-3-3">Maxin Blinkov/shutterstock</a></span>
</figcaption>
</figure>
<p>Episodes commonly emerge “out of the blue”. Even if it follows a stressor, it’s disproportionately more severe than might be expected and lasts longer than the stressor. </p>
<p>We’ve <a href="http://www.ncbi.nlm.nih.gov/pubmed/22868058">progressively developed</a> a clinician-rated measure (the SMPI or Sydney Melancholia Prototype Index) that has about 80% accuracy in differentiating melancholic and non-melancholic depression. When we add course of illness, causal and other clinical factors, we’ve been able to statistically <a href="http://www.ncbi.nlm.nih.gov/pubmed/25565428">differentiate melancholic and non-melancholic depression</a> at a high level.</p>
<h2>Physical underpinnings</h2>
<p>Melancholia has a strong genetic contribution, with sufferers likely to report a family history of “depression”, bipolar disorder or suicide. It’s largely biologically underpinned rather than caused by social factors (stressors) or psychological factors, such as personality style.</p>
<p>The illness is also unlikely to respond to placebo, whereas major depression has a <a href="http://www.ncbi.nlm.nih.gov/pubmed/1388334">placebo response rate</a> in excess of 40%. But melancholia shows greater response to physical treatments, such as antidepressant drugs (especially those that work on a broader number of neurotransmitters), and to ECT (electroconvulsive therapy). ECT is rarely required, however, if appropriate medications are prescribed. </p>
<p>Melancholia shows a lower response to psychotherapy, counselling and psychosocial interventions - these treatments are more salient and effective for non-melancholic depression. </p>
<p>It’s useful to draw an analogy here with diabetes: while Type 1 is more a biological disease state and generally requires drug treatment (insulin), Type II is more likely to reflect other factors, such as obesity. The latter generally benefits most from non-drug strategies, such as exercise and dietary changes. </p>
<p>Melancholia shows similar “treatment specificity”, with medication being the treatment of choice.</p>
<h2>Tracing biological origins</h2>
<p>Melancholia has long been thought to have <a href="http://www.ncbi.nlm.nih.gov/pubmed/7458567">primary biological origins</a>, including perturbations in the hypothalamic-pituitary-adrenal (HPA) axis, in sleep architecture and in neural circuits.</p>
<p>Early this year, our research team <a href="http://www.ncbi.nlm.nih.gov/pubmed/1388334">published a neuroimaging study</a> that suggested a differential key “signature” marker found only in people with melancholic depression (when compared to people with non-melancholic depression and non-depressed controls). </p>
<p>We showed incoming connections to the brain system that control attention (the insula) were halved, while connections from the insula to the brain’s executive control centre were also decreased. </p>
<p>The implications of these findings will require further investigation, but they could mean that a disruption to brain connectivity may explain some of melancholia’s symptoms. </p>
<p>Clearly, melancholia needs to be recognised as a distinct psychiatric condition – not simply as a more severe expression of depression. This recognition could lead to improved clinical and community awareness, which is important because managing melancholia requires a specific treatment approach.</p><img src="https://counter.theconversation.com/content/38025/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gordon Parker receives funding from the National Health and Medical Research Council and has been a paid speaker for several drug companies. He is affiliated with the University of New South Wales and was the founding director of the Black Dog Institute <a href="http://www.blackdoginstitute.org.au/">http://www.blackdoginstitute.org.au/</a>.</span></em></p>Melancholia has a strong genetic contribution, so it’s largely biologically underpinned rather than caused by social factors (stressors) or psychological factors, such as personality style.Gordon Parker, Scientia Professor , UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/402382015-05-03T19:37:52Z2015-05-03T19:37:52ZSchool refusal is not the same as wagging<figure><img src="https://images.theconversation.com/files/80024/original/image-20150501-30721-1k1xs3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">School refusal needs to be recognised as a psychological problem, rather than being glossed over in school attendance policies. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Attempting to understand school refusal is no mean feat. Many people still consider it in a similar vein to “wagging” or parent-condoned absenteeism. However, school refusal is an often misunderstood and serious difficulty for many students.</p>
<h2>School refusal is a psychological problem, not truancy</h2>
<p>School refusal can be classified under the category of Separation Anxiety, which is listed in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (<a href="http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596">DSM-V</a>). However, school refusal is not specifically mentioned in this book. School refusal was previously known as School Phobia, which demonstrates its consideration as more a psychological issue rather than one of simple truancy. It is still poorly researched and not properly understood within education.</p>
<p>The consideration of school refusal as a psychological issue is highlighted in <a href="http://jsn.sagepub.com/content/21/3/147.abstract">an article</a> in The Journal of School Nursing. This explains some of the commonly described symptoms of school refusal, including physical complaints such as stomachache and headache. </p>
<p>These usually mask the psychological issue of an anxiety which may or may not be related to school. For example, if there has been domestic abuse, then a child may not want to leave his or her parent out of fear that the parent could be hurt if the child is not with them. This anxiety may or may not be related to a specific event nor is it to do with recency. </p>
<p><a href="http://www.med.monash.edu.au/scs/psychiatry/developmental/clinical-research/school-refusal-program/">Monash University in Melbourne</a> is conducting research into the effectiveness of various treatments, such as <a href="https://theconversation.com/explainer-what-is-cognitive-behaviour-therapy-37351">cognitive behavioural therapy</a> for school refusal. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/80026/original/image-20150501-30698-1xchfsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/80026/original/image-20150501-30698-1xchfsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/80026/original/image-20150501-30698-1xchfsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/80026/original/image-20150501-30698-1xchfsw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/80026/original/image-20150501-30698-1xchfsw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/80026/original/image-20150501-30698-1xchfsw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/80026/original/image-20150501-30698-1xchfsw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/80026/original/image-20150501-30698-1xchfsw.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">Some children refuse to go to school in situations of domestic abuse of a parent. For other children it can’t be explained.</span>
<span class="attribution"><span class="source">from www.shutterstock.com.au</span></span>
</figcaption>
</figure>
<p>The Monash team put prevalence of school refusal at about 1-2% of the school population; however, it is not clear if this is an Australian figure or not. <a href="http://qldalliance.org.au/wp-content/uploads/2014/10/Microsoft-Word-FinalCopy_Public_Abridged_Version_24-02-09.pdf">Another source</a> suggests that the figures could be as high as 28% but highlights the lack of a clear understanding of what school refusal constitutes. </p>
<p>What is clear is that there have not been proper studies as to the actual figures for students affected by school refusal. The attendance figures in all states and territories are widely available but these do not break down numbers due to school refusal. Therefore it is impossible to estimate.</p>
<h2>What parents need to do</h2>
<p>School leaders and teachers are acutely aware of the importance of students attending school regularly, and of the impact of non-attendance on students’ academic and social progress. In fact, most Australian states and territories have policies to promote increased and consistent school attendance. </p>
<p><a href="http://www.education.vic.gov.au/school/principals/participation/Pages/everyday.aspx">Victoria</a> and <a href="http://education.qld.gov.au/everydaycounts/">Queensland</a> have both developed initiatives centred on the “Every Day Counts” slogan, with information available for schools and families about the need for students to attend school every day.</p>
<p>Families must begin conversations with the school as soon as they notice a pattern of school refusal behaviour. The longer the problem persists, the more difficult it can be to re-engage the student in school. </p>
<p>It is important the school has this information for two reasons. Firstly, schools are required to keep rigorous data records on student attendance, and this information will assist in an accurate representation of what is occurring.</p>
<p>Secondly, <a href="http://www.mheducation.com.au/9780335244683-aus-what-works-in-inclusion">research shows</a> that for any students who experience additional support needs, the best approach for both schools and families is to work together. It is no different in the case of supporting students who are refusing to attend school. </p>
<p>The school and family need to work together to identify the problem of the school refusal, seek advice and/or support from other professionals (such as psychologists, school counsellors), and collaboratively develop and implement a plan. </p>
<p>The plan may include actions such as home visits, gradual re-entry into school, and flexible learning programs. It should be negotiated between the student, the school and the family. </p>
<p>This also means schools can put plans in place to ensure that students who have experienced issues with school refusal in the past will be well supported during times of high risk, such as transitioning between primary and secondary school, and moving between schools.</p>
<p>The most important aspect that the parent can do is to remember that the child could be experiencing severe anxiety. Parents know their child the best, more than anyone in school or other professional. It is key that the parent is able to spot school refusal as early as possible. </p>
<p>Recognising it as psychological difficulty and not just “wagging” will help bring a quicker and hopefully successful conclusion. Seeking help from an educational and developmental psychologist with expertise in the area is a very important step.</p>
<h2>School refusal often ignored in attempt to increase attendance rates</h2>
<p>Two aspects have to be dealt with when a child is refusing to go to school: school attendance policies and the wellbeing of the student. Stand-alone policies addressing school refusal are rare. As a result it is the policies governing student attendance that are most likely to influence the way schools approach these situations. </p>
<p>These policies are usually <a href="http://det.wa.edu.au/policies/detcms/cms-service/download/asset/?asset_id=15795074">long</a>, <a href="https://www.det.nsw.edu.au/policies/student_admin/attendance/sch_polproc/PD20050259.shtml">complex</a> and <a href="http://www.decd.sa.gov.au/docs/documents/1/AttendanceRequirements.pdf">difficult</a> to interpret. </p>
<p>The message, delivered through a range of <a href="http://education.qld.gov.au/everydaycounts/">government advertising campaigns</a> in different states, is that <em>Every Day Counts</em>. The flip side of this message is that for schools every day is counted. This is where the policy environment and school refusal behaviours are most likely to come into conflict and cause problems for the family and the administration of the school. </p>
<p>Schools, particularly government schools, are required to report student attendance rates and often use this data as a performance measure for individual schools and districts or regions. </p>
<p>In December 2014, federal Education Minister Christopher Pyne <a href="https://ministers.education.gov.au/pyne/my-school-updated-improved-school-attendance-data">announced</a> that from 2015 the MySchool website would include average school attendance rates for Indigenous and non-Indigenous students. </p>
<p>This increased accountability brings additional pressure for schools to quickly address student absence issues. These measures range from controversially <a href="https://www.dss.gov.au/our-responsibilities/families-and-children/programs-services/welfare-payments-reform/improving-school-enrolment-and-attendance-through-welfare-reform-measure-seam">punitive</a> tactics through to more <a href="http://education.qld.gov.au/everydaycounts/docs/get-teenager-to-school.pdf">supportive</a>, <a href="http://www.education.vic.gov.au/school/principals/health/Pages/referral.aspx">wrap-around</a> services. </p>
<p>School refusal is a serious issue in the education sector. However, it is often forgotten in the striving for higher attendance rates. The people who are most affected by the lack of knowledge are students who have difficulty attending school due to psychological issues rather than choosing not to attend.</p><img src="https://counter.theconversation.com/content/40238/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 organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>School refusal is a serious difficulty for many students, but it is often ignored in policies for increasing school attendance.Christopher Boyle, Senior Lecturer in Educational Psychology , University of New EnglandDr Joanna Anderson, Lecturer in Inclusive Education , University of New EnglandNatalie Swayn, Lecturer, Inclusive Education and Psychology, University of New EnglandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/271242014-06-22T20:25:45Z2014-06-22T20:25:45ZListen up hypochondriacs, how do you want to be remembered?<figure><img src="https://images.theconversation.com/files/51600/original/zxrpw75h-1403146157.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People who worry excessively about catastrophic consequences of seemingly benign symptoms are known as hypochondriacs.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/karrienodalo/5484585874">Karrie Nodalo/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>We all worry about our health from time to time, at least to some degree, but some people worry excessively about catastrophic consequences of seemingly benign symptoms. They’re known as hypochondriacs.</p>
<p>This is the sort of process hypochondriacs go through: what’s that? A benign lump or malignant bump on your face, breast or rump? Adrenaline rush, heart pumping, sweating, and light-headedness follow, confirming the gravity of the terminal self-diagnosis. </p>
<p>Thoughts racing and images of a foreshortened future, orphaned children, and opportunities missed. Overwhelming distress. Must plan the epitaph – see, I told you I was sick!</p>
<p>Our future and physical health are inherently uncertain. But people with hypochondriasis (or, since the latest edition of the <a href="https://theconversation.com/explainer-what-is-the-dsm-14127">Diagnostic and Statistical Manual of Mental Disorders</a>, somatic symptom disorder) immediately resolve any uncertainty about novel physical sensations and symptoms on the side of catastrophe.</p>
<h2>Seeking symptoms</h2>
<p>The body is constantly in a state of flux. The heart pumps, blood flows, muscles twitch, lungs inflate, and bowels contract. Strange symptoms come and go. And most pass without conscious awareness as we focus on daily tasks.</p>
<p>But try this. Hold your hand upwards, so that your palm and fingertips face the sky. Focus all your attention on the tips of your fingers and wait …and wait …until you notice some sensations. Tingling, temperature changes, or just an awareness of the sensations on your skin. </p>
<p>Here’s an even simpler task. As you read this, shift your attention on to the sensations of the ground or chair pushing up against your body. Chances are you were unaware of all these sensations just moments ago.</p>
<p>Attention, you see, is the microscope of the mind. It can filter in or out any of your internal or external experiences. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/51602/original/n48tjdh4-1403146416.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/51602/original/n48tjdh4-1403146416.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=447&fit=crop&dpr=1 600w, https://images.theconversation.com/files/51602/original/n48tjdh4-1403146416.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=447&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/51602/original/n48tjdh4-1403146416.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=447&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/51602/original/n48tjdh4-1403146416.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=562&fit=crop&dpr=1 754w, https://images.theconversation.com/files/51602/original/n48tjdh4-1403146416.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=562&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/51602/original/n48tjdh4-1403146416.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=562&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Focus all your attention on the tips of your fingers and you will start to notice sensations.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/jessandcolin/2247446957">Jess Liotta and Collin Liotta/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>Now imagine becoming hypervigilant to all the physical changes naturally occurring in your body. Try it. Just focus on all the sensations in your body for a minute. Amazing, isn’t it? Itchy toes, tense jaw, mild headache, numbness, and so on. All the normal workings of a healthy body.</p>
<p>People with somatic symptom disorder are experts at searching for and noticing normal bodily changes. They’re also experts at interpreting these in potentially catastrophic ways – fatigue is leukemia; a lump on the arm is cancer.</p>
<p>The number one enemy of someone with the disorder is Dr Google (“cyberchondria”). Indeed, the only thing more catastrophically creative than a hypochondriac’s mind is Google’s 2.42 million webpages on the causes of cancer. Every possible symptom can be linked to every possible diagnosis, by at least one disreputable source or another. </p>
<p>The hypochondriac is searching not for information, but for confirmation of their imminent demise. If they’re unlucky, they might come across contradictory information or additional ailments they hadn’t yet considered.</p>
<p>Their intense worry and anxiety feel intolerable and must be neutralised. Seeking out a sympathetic doctor or other source of reassurance, or avoiding the health section of the newspaper all provide temporary relief until the next physical symptom is perceived.</p>
<h2>Moving forward from health anxiety</h2>
<p>So what are some things that keep hypochondriacs worrying?</p>
<p>Belief: worrying will help me catch something early.</p>
<p>No, it won’t. Worrying will just keep you miserable until you’re old enough to find out how you will shuffle off this mortal coil (unless, of course, your demise is a blissfully brief surprise). Worry itself will not get you any closer to predicting, preventing, or planning for your death.</p>
<p>Belief: I can get certainty about my health.</p>
<p>Nope, can’t get that either. No amount of checking, doctor visits, Googling, reassurance-seeking will guarantee with 100% certainty that you’re well. I can, however, guarantee that the unrelenting pursuit of certainty will make you miserable.</p>
<p>So, how can you manage health anxiety?</p>
<p>First, develop some healthy guidelines for monitoring your health and stick to them.</p>
<p>Based on your past experience, how long do benign symptoms typically last? One day, two days, one week? Decide how long you will wait before seeking any form of certainty or reassurance (from the internet, friends, family, or medical practitioners) the next time you notice a symptom, especially ones you’ve worried about in the past. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/51604/original/37nrn69j-1403146539.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/51604/original/37nrn69j-1403146539.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/51604/original/37nrn69j-1403146539.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/51604/original/37nrn69j-1403146539.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/51604/original/37nrn69j-1403146539.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/51604/original/37nrn69j-1403146539.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/51604/original/37nrn69j-1403146539.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hypochondriacs need to learn to sit with uncertainty about their health.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/seandreilinger/2194655714">Sean Dreilinger/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>Once this time expires (no pun intended), make a decision about whether you need to get the symptom checked or whether you can wait another little while before doing so. Follow guidelines from reputable sources about the recommended frequency of body checking.</p>
<p>And, be willing to sit with uncertainty about your health. None of us ever have certainty about our health. I could have a brain tumour as I write these words. I am willing to accept this possibility and shift my attention onto the next paragraph.</p>
<p>Think about it this way: if I offered you a $2 million insurance policy for your house, even if I promised to build you a gold-plated replacement if it were destroyed, you would likely consider it far too expensive.</p>
<p>So, how much are you willing to pay to prevent any possibility of illness? Are you willing to give up your capacity to work, time you would otherwise spend with friends and family, and ultimately your happiness? This is a very high price to pay.</p>
<p>Spend energy on things you truly value, rather than wasting it on a false insurance policy. Learn to accept uncertainty about your health. Revel in not knowing when or how the end will come. Focus instead on the time between now and then.</p>
<p>Ultimately, what you have to decide is which epitaph you would prefer when your inevitable end arrives: “lived decades in misery and fear of death”, or “didn’t see that coming but my life was far richer for it.”</p>
<p><br>
For more information about how to manage health anxiety, see the <a href="http://www.cci.health.wa.gov.au/">Helping Health Anxiety modules here</a>.</p><img src="https://counter.theconversation.com/content/27124/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter McEvoy 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>We all worry about our health from time to time, at least to some degree, but some people worry excessively about catastrophic consequences of seemingly benign symptoms. They’re known as hypochondriacs…Peter McEvoy, Associate Professor of Clinical Psychology, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/275912014-06-10T20:28:53Z2014-06-10T20:28:53ZLooking for psychopaths in all the wrong places: fMRI in court<figure><img src="https://images.theconversation.com/files/50677/original/sw9jzpdw-1402381846.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People are becoming more likely to believe that high-tech visualising techniques might allow us to see psychopathy in the actual physiology of the brain.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/jetheriot/6186786217/in/photolist-aqGTZT-niwG-sUk8Y-5kpAF6-6SCgyS-2ZKyJ-88vUCB-7A2f5q-96kggg-5DFXnV-4J6pL9-5uFETL-7qPG4L-kjAshW-5vuQhg-3MYT-5U2AQc-e4CcRp-3MZj-8v8DYZ-7zQwgc-aXr9yn-7iG2pk-4PTLMq-5Rjfht-5TMrYz-5Mchw8-5G4EHt-5MxeE7-5GsB5B-36fL9x-5yxm2W-5Nz4pi-4rdZ9E-7si8jt-ShC9j-7N5Pot-61DQLB-4wVAX1-kWfuq-4KH9B2-dLSKTQ-7x6RJG-fzT9Xx-9Xsr6X-6oi5aB-bPbME2-4wjQDd-tmJ6c-5yiug4">JE Theriot/Flickr (resized)</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><em>In the latest instalment of our series <strong><a href="https://theconversation.com/topics/biology-and-blame">Biology and Blame</a></strong> Micol Seigel poses some important questions about the assumptions behind the legal use of fMRI.</em></p>
<hr>
<p>Of the current uses of psychiatry in legal settings, the claim that psychopaths can be identified through <a href="https://theconversation.com/the-science-of-medical-imaging-magnetic-resonance-imaging-mri-15030">functional magnetic resonance imaging</a> (fMRI) is among the most worrisome. </p>
<p>Psychiatrists who make this claim present their polychrome powerpoints, which, to the rest of us, look like Jackson Pollock in a sunshiney mood, and point to this or <a href="https://theconversation.com/adventures-in-blobology-20-years-of-fmri-brain-scanning-4095">that stripe or blip as proof</a> of a physiological predisposition to carry out dastardly deeds.</p>
<p>No matter that psychopathy is only glancingly referred to in the American Psychiatric Association’s <a href="https://theconversation.com/explainer-what-is-the-dsm-14127">Diagnostic and Statistical Manual of Mental Disorders</a>. (Rumours that the fifth edition, which came out earlier this year, would embrace the terminology explicitly, turn out to have been exaggerated.) </p>
<p>And no matter that the interpretation of such images are in a stage we might generously term “developmental.”</p>
<h2>Two broken tools equal?</h2>
<p>The scientists offering fMRI images admit their data is unconvincing on its own. Their solution is to cross the scans with results from a diagnostic tool based on personal interviews using the <a href="http://en.wikipedia.org/wiki/Hare_Psychopathy_Checklist">Psychopathy Check List-Revised</a>.</p>
<p>As an analytic instrument, the <a href="http://www.jonronson.com/psycho.html">Check List is not much better</a> than the brain scan. It suffers from a lack of specificity, tabulating a series of rather common characteristics – egocentricity, lack of realistic long-term goals, manipulation, dishonesty, impulsivity, grandiose self-righteousness, narcissism, dependence, irresponsibility, bullying, boredom, and promiscuity. </p>
<p>The blurriness of these profiling points can reveal them everywhere or nowhere.</p>
<p>So, take one inconclusive diagnostic test, cross it with another inconclusive diagnostic test, and … honest science would agree you have nothing at all. </p>
<p>As <a href="http://www.jstor.org/discover/10.2307/25619824?uid=3737536&uid=2&uid=4&sid=21104133560837">one group of researchers puts it</a>:</p>
<blockquote>
<p>the medical and psychological understanding of psychopathy itself is an empty vessel, a characterization of behaviors without stable symptoms, a disease without a cause.</p>
</blockquote>
<p>Yet the champions of fMRI diagnosis continue to forge ahead, and in an era in which neuroscientific explanations are offered <a href="http://www.nytimes.com/2012/11/25/opinion/sunday/neuroscience-under-attack.html">for every arena of human experience</a> (success in business, for instance, political leanings, and sexuality), their arguments are gaining ground. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/50673/original/xyxm5q8y-1402380937.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">Psychopathy researchers assume people in prison did heinous things and that most heinous things land their agents in prison.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/thomashawk/10490113913">Thomas Hawk/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>People are more and more likely to believe that psychopathy is a disorder inscribed upon the body. And that high-tech visualising techniques might allow us to see psychopathy in the actual physiology of the brain.</p>
<h2>An alarming similarity</h2>
<p>To a historian such as myself, this claim sends off little alarm bells, recalling 19th-century criminal anthropologists such as Italian legal scholar <a href="http://en.wikipedia.org/wiki/Cesare_Lombroso">Cesare Lombroso</a>, who conducted research in prisons and mental asylums to determine the physical characteristics of criminal types. Mapping cranial shapes and sizes, he claimed to find congenital, hereditary, and unavoidable evidence of criminality.</p>
<p>Lombroso has long been in ill-repute thanks to the overly-biological focus of his assumptions and the circularity of his research design: he studied prisoners to draw conclusions about crime. </p>
<p>So even if there had been clear patterns of bumps and bones of the skull, his science could not determine whether they were evidence of criminal types, or traits of the poor and working people in the district of the jail — or even qualities acquired inside, as adaptations to imprisonment itself.</p>
<p>Interestingly, the problem of research location is something modern psychopathy research shares with its 19th-century precedents: proponents of psychopathy as a coherent diagnosis have all researched in prisons or focus on incarcerated subjects. </p>
<p>This is a methodological misstep, to put it mildly. Researchers assume psychopaths are concentrated in prisons, run experiments in prisons, and then conclude that psychopaths are concentrated in prisons. </p>
<h2>A tautological definition</h2>
<p>Indeed, <a href="http://www.newyorker.com/reporting/2008/11/10/081110fa_fact_seabrook?currentPage=all">one of the most-cited definitions</a> of psychopathy is actually:</p>
<blockquote>
<p>the condition of moral emptiness that affects between fifteen to twenty-five per cent of the North American prison population… </p>
</blockquote>
<p>This is what logicians call a tautology – a circular proof, a statement that substitutes premise for conclusion.</p>
<p>Again, some scientists recognise this problem. <a href="http://www.hare.org/scales/pclr.html">Robert Hare</a>, the author of the famous checklist, for example, wrote a book called <a href="http://www.snakesinsuits.com/">Snakes in Suits</a> about psychopaths in corporate boardrooms. But many researchers continue merrily to scan those ever-available brains behind bars.</p>
<p>Using the prison as site for research, psychopathy researchers embrace and ignore one overwhelmingly distracting, toxic assumption: that the criminal justice system works. </p>
<p>Their research assumes people in prison did heinous things (that they are guilty) and that most heinous things land their agents in prison (that the balance of miscreants are caught). </p>
<p>What if prisons actually mainly house the poor, the mentally ill, the addicted, and over-policed black and brown youth? What if the majority of prisoners is in for crimes of poverty or as casualties of the drug war – or both? </p>
<p>If the truly evil are not in prison, why is neuropsychiatry looking for them there? And can we trust its conclusions in a court of law?</p>
<p><br></p>
<p><em>This is the fourth article in our series <strong><a href="https://theconversation.com/topics/biology-and-blame">Biology and Blame</a></strong>. Click on the links below to read other pieces:</em></p>
<p><strong>Part one – <a href="https://theconversation.com/genes-made-me-do-it-genetics-responsibility-and-criminal-law-27395">Genes made me do it: genetics, responsibility and criminal law</a></strong></p>
<p><strong>Part two – <a href="https://theconversation.com/irresponsible-brains-the-role-of-consciousness-in-guilt-27432">Irresponsible brains? The role of consciousness in guilt</a></strong></p>
<p><strong>Part three - <a href="https://theconversation.com/psychiatrys-fight-for-a-place-in-defining-criminal-responsibility-27514">Psychiatry’s fight for a place in defining criminal responsibility</a></strong></p>
<p><strong>Part five - <a href="https://theconversation.com/why-shouldnt-addiction-be-a-defence-to-low-level-crime-27520">Why shouldn’t addiction be a defence to low-level crime?</a></strong></p>
<p><strong>Part six – <a href="https://theconversation.com/natural-born-killers-brain-shape-behaviour-and-the-history-of-phrenology-27518">Natural born killers: brain shape, behaviour and the history of phrenology</a></strong></p>
<p><strong>Part seven - <a href="https://theconversation.com/put-down-the-smart-drugs-cognitive-enhancement-is-ethically-risky-business-27463">Put down the smart drugs – cognitive enhancement is ethically risky business</a></strong></p><img src="https://counter.theconversation.com/content/27591/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Micol is a member of Decarcerate Monroe County, a local prison activist group, and the national grassroots abolitionist organization Critical Resistance.</span></em></p>In the latest instalment of our series Biology and Blame Micol Seigel poses some important questions about the assumptions behind the legal use of fMRI. Of the current uses of psychiatry in legal settings…Micol Seigel, Associate Professor in American Studies & History, IUPUILicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/256462014-04-29T20:30:57Z2014-04-29T20:30:57ZIs ‘sluggish cognitive tempo’ a valid new childhood disorder?<figure><img src="https://images.theconversation.com/files/47198/original/rwww93jw-1398734457.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sluggish cognitive tempo is used to describe kids whose attentional deficits are due to low levels of mental energy.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/courosa/5240046576">Alec Couros/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>Sociology influences medicine more than we like to admit. One only needs to look at the history of psychiatric disorders – a term used broadly here to incorporate developmental disorders – to see how “normal” in one era is often deemed “abnormal” in another. And how the dividing line between these two ends is often wafer thin.</p>
<p>Research advances are certainly key to what we claim as being a disorder, but political and social influences also play their part.</p>
<p>Autism is an excellent case in point; the cutoff for “abnormal” has shifted from recognising severely affected individuals only (30 years ago) to a more moderate position (20 years ago) and now to a point somewhere in between (today).</p>
<p>Variations aren’t just seen over time, but also between geographical locations. The proportion of children receiving a particular diagnosis can vary dramatically between states, for instance. Without question, the social and political influences of different jurisdictions are major drivers of this variation. </p>
<p>That’s not to say that people receiving these diagnoses don’t warrant assistance from health professions – they clearly do – but rather that our decisions about normal and abnormal are not as objective as we pretend.</p>
<h2>Enter ‘sluggish cognitive tempo’</h2>
<p>Consider the case of a possible new developmental disorder called sluggish cognitive tempo, identified by US researchers and discussed at length in <a href="http://www.nytimes.com/2014/04/12/health/idea-of-new-attention-disorder-spurs-research-and-debate.html?_r=0">a recent New York Times article</a>.</p>
<p>The disorder is characterised by behavioural symptoms such as drowsiness, daydreaming, mental confusion, physical lethargy and apathy, and appears to be an offshoot of attention deficit/hyperactivity disorder (ADHD). </p>
<p>Whereas some children may have attentional deficits because of hyperactivity (the child who is “bouncing off the walls”), sluggish cognitive tempo is used to describe kids whose attentional deficits are due to low levels of mental energy.</p>
<p>The case for sluggish cognitive tempo representing a new disorder has been gathering pace over the past five years, so much so that the <a href="http://link.springer.com/journal/10802/42/1/page/1">Journal of Abnormal Child Psychology</a> dedicated most of its January issue to research related to the subject. </p>
<p>Indeed, in the issue, the journal claimed to have “laid to rest” any questions over the existence of the disorder, and that the cluster of symptoms is well on the way to being recognised as a legitimate disorder.</p>
<h2>Cause for controversy</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/47199/original/dm4hyztf-1398734830.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/47199/original/dm4hyztf-1398734830.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=764&fit=crop&dpr=1 600w, https://images.theconversation.com/files/47199/original/dm4hyztf-1398734830.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=764&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/47199/original/dm4hyztf-1398734830.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=764&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/47199/original/dm4hyztf-1398734830.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=960&fit=crop&dpr=1 754w, https://images.theconversation.com/files/47199/original/dm4hyztf-1398734830.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=960&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/47199/original/dm4hyztf-1398734830.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=960&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sluggish cognitive tempo stands in contrast to attentional deficits because of hyperactivity.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/courosa/4207788360">Alec Couros/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>Still, the proposal for sluggish cognitive tempo to be recognised as a disorder has been met with derision from many within the scientific community. </p>
<p>Allen Frances, a former chair of the task force that delivered a previous revision of the <a href="https://theconversation.com/explainer-what-is-the-dsm-and-how-are-mental-disorders-diagnosed-9568">Diagnostic and Statistical Manual</a> (the so-called psychiatrist’s bible), has been among the most vocal critics.</p>
<p>In a recent article <a href="http://www.huffingtonpost.com/allen-frances/no-child-left-undiagnosed_b_5139060.html">No Child Left Undiagnosed</a>, he wrote:</p>
<blockquote>
<p>‘Sluggish Cognitive Tempo’ is a remarkably silly name for an even sillier proposal…[It] may possibly be the very dumbest and most dangerous diagnostic idea I have ever encountered.</p>
</blockquote>
<p>These are fighting words, and there’s no hint of a backdown.</p>
<p>I am more circumspect than Dr Frances in my evaluation of sluggish cognitive tempo, but there are two aspects that cause me concern.</p>
<p>The first is about clinical need. The point of a diagnosis is to identify people who require assistance from health professionals, and then use that diagnosis to inform treatment. </p>
<p>At this point, research hasn’t demonstrated that children with these behaviours require assistance from health and education professionals. Is sluggish cognitive tempo just pathologising normal variation in childhood behaviour?</p>
<p>My second concern is the unclear influence of pharmaceutical companies on this line of research. Pharmaceutical giant Eli Lilly has a long-standing association with Professor Russell Barkley, one of the key researchers in the sluggish cognitive tempo field, and the company has already funded drug trials in this area.</p>
<p>This may be a completely innocent relationship driven by a mutual desire to help children. But, at the very least, it’s a bad look.</p>
<h2>Higher standard of evidence</h2>
<p>Disorders of the body are typically diagnosed based on clear biological observations. A diagnosis of diabetes, for example, is based on fasting blood sugar levels, and a diagnosis of kidney disease is based on a suite of urine tests.</p>
<p>We don’t have that luxury with disorders of the mind. Diagnoses are based on behaviours, which makes it an inherently subjective task that will always attract vehemently opposing views.</p>
<p>For this reason, the field must demand the highest levels of scientific evidence showing this cluster of symptoms characterises a group of children who require assistance from health professionals.</p>
<p>At this stage, sluggish cognitive tempo is not even close to reaching these standards.</p><img src="https://counter.theconversation.com/content/25646/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Whitehouse receives funding from the National Health and Medical Research Council, the Australian Research Council, and the Autism Cooperative Research Centre. </span></em></p>Sociology influences medicine more than we like to admit. One only needs to look at the history of psychiatric disorders – a term used broadly here to incorporate developmental disorders – to see how “normal…Andrew Whitehouse, Winthrop Professor, Telethon Institute for Child Health Research, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/145662014-01-02T19:44:55Z2014-01-02T19:44:55ZFeeling down: when does a mood become a disorder?<figure><img src="https://images.theconversation.com/files/37746/original/22nf5sb3-1386913892.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Clinical depression is distinguished severity, duration, persistence, and recurrence. </span> <span class="attribution"><span class="source">darcyadelaide/flickr</span></span></figcaption></figure><p>We’ve all felt sad, anxious or down at one time or another, but where does the normal experience of emotion end and the clinical picture of a mood or anxiety disorder begin?</p>
<p>Psychiatry has two widely used classificatory systems that provide definitions of “clinical” states of such emotions as differentiated from “normal” states – the World Health Organisation’s <a href="https://theconversation.com/two-visions-for-understanding-illness-dsm-and-the-international-classification-of-diseases-14167">International Classification of Diseases</a> and the American Psychiatric Association’s <a href="https://theconversation.com/explainer-what-is-the-dsm-14127">Diagnostic and Statistical Manual</a> (DSM). </p>
<p>The boundaries are not absolute and, in recent decades, the DSM in particular has been criticised for expanding the boundary of clinical states into essentially normal domains.</p>
<h2>Degrees of depression</h2>
<p>Clinical depression is distinguished in such diagnostic manuals by a number of parameters including severity, duration, persistence, and recurrence. </p>
<p>More severe depressive disorders are accompanied by the individual experiencing gravid depressive symptoms (such as suicidal preoccupations), by distinct impairment (such that it prevents them from going to work) and lasting more than two weeks.</p>
<p>Although severity is an important thing to consider in depression, we prefer to distinguish by depression type, not just severity. Depressive disorders can be divided into two types – melancholic and non-melancholic conditions. </p>
<p>The latter is a diverse group that could reflect the contribution of severe life events, such as being humiliated by a partner or a personality style that predisposes someone to depression. </p>
<p>Such personality styles include being an anxious worrier, sensitive to judgement by others, being a perfectionist, having intrinsically low self-esteem, being profoundly shy or having a low sense of self-worth since childhood. </p>
<p>In contrast, melancholic depression is better positioned as a disease, having rather specific clinical features, a strong genetic contribution, biological underpinnings and responding only partially to counselling or psychotherapy but well to antidepressant drugs. </p>
<p>During melancholic depressive states, the individual lacks energy, experiences little pleasure in life, is physically slowed down, and tends to feel much worse in the morning. </p>
<p>Extremely severe melancholic depression may even include psychosis, though importantly this is normally very responsive to appropriate medical treatment.</p>
<h2>Bipolar disorders</h2>
<p>The bipolar disorders are also better positioned as “diseases”. We now distinguish bipolar I (previously manic depressive illness) and bipolar II conditions – by the extremity of the highs. </p>
<p>While both bipolar I and bipolar II are characterised by swings from high to low moods, in bipolar I the highs (mania) are more extreme and can include psychosis or hospitalisation. </p>
<p>Highs (hypomania) in bipolar II are less extreme and will never include psychosis or a need for hospitalisation. While it’s normal for everyone to experience periods of happiness in their life, the highs experienced in bipolar are distinctly different. </p>
<p>The individual loses day-to-day anxieties, feels bulletproof or invulnerable, is excessively talkative, grandiose, creative, needs little sleep without feeling tired, is indiscreet, spends money on things that subsequently cause financial difficulty and may become sexually indiscreet or possibly aggressive.</p>
<h2>Anxiety disorders</h2>
<p>It’s normal for everyone to feel anxious in a variety of situations. Some people might feel anxious going to a party where they don’t know many people, for instance, or giving a speech. </p>
<p>The difference between normal anxiety and an anxiety disorder is when the anxiety is so persistent it stops you doing things you want to, or persists even when all logical reasons to be anxious are absent. </p>
<p>Generalised anxiety disorder, for instance, involves chronic worry without a definitive cause and social phobia involves a fear of talking to or being around others. </p>
<p>There are many different anxiety disorders, and it can be difficult to distinguish when normal anxiety starts to become a problem.</p>
<h2>Awareness and increase</h2>
<p>There are two possible reasons why there has been an increase in these conditions.</p>
<p>First, more people are willing to talk about their experiences, as the stigma of these conditions is slowly decreasing. And changes to criteria in diagnostic manuals have effectively classified some “normal” states as clinical conditions.</p>
<p>But being diagnosed with a mood or anxiety disorder can be a stressful experience itself. The reaction generally depends on how well the person relates to the diagnosis, whether or not the diagnosis was something anticipated and whether or not they expect a diagnosis and adequate treatment will improve their life. </p>
<p>The vast majority of conditions can be treated either psychiatrically or psychologically, but finding the right treatment, while ultimately rewarding, can also at times be frustrating.</p>
<p>It’s our opinion that Australia is ahead of many other western countries in having destigmatised mood disorders, and the stigma and negative consequences linked to seeking help has reduced considerably.</p>
<p>Unfortunately, this doesn’t mean that stigma is completely eradicated. Some employers may take advantage of knowing that an individual has a psychiatric condition. And the declaration of any condition can prevent people obtaining income protection, and even travel insurance.</p>
<p>But that shouldn’t stop people from seeking help when they feel their emotional health is at risk.</p><img src="https://counter.theconversation.com/content/14566/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gordon Parker receives funding from the National Health and Medical Research Council and Department of Health and Ageing.</span></em></p><p class="fine-print"><em><span>Amelia Paterson 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>We’ve all felt sad, anxious or down at one time or another, but where does the normal experience of emotion end and the clinical picture of a mood or anxiety disorder begin? Psychiatry has two widely used…Gordon Parker, Scientia Professor , UNSW SydneyAmelia Paterson, Research Assistant, UNSW SydneyLicensed 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/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.