Who dat decidin’ who’s abnormal?
The American Psychiatric Association, dat who. That’s the organization that puts together the Diagnostic and Statistical Manual of Mental Disorders (known as the DSM). Benedict Carey offers an elegant summary of the DSM’s importance in a piece in today’s Times.
…the guidebook that largely determines where society draws the line between normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction — and, by extension, when and how patients should be treated.
The APA is revising the DSM for a new (fifth) edition in 2013, but yesterday they let us have a peek at some of the proposed changes.
The DSM-v will will have new diagnoses and will lump formerly separate diagnoses together. This is serious business, especially with a new diagnosis. Because a diagnosis is a label, one that can be used for good or ill. It can make you eligible for treatment or disability, or it can be a stigma you’ll carry the rest of your life.
On the lighter side, it can be a source of PC speech – we can point out to Rahm Emanuel that it’s not “retarded” but “intellectually disabled” – and it can resonate with the tabloids – diagnostic criteria for the Tiger Woods syndrome: Satyriasis and nymphomania weren’t listed in the DSM-iv but the new edition will include “hypersexual disorder” for men and women with “recurrent ‘out of control’ sexual behaviors that are not inherently socially deviant.” These folks were formerly lumped under Sexual Disorder Not Otherwise Specified.
But it’s serious business where the diagnosis of bipolar disorder in children is concerned. In discussions with other primary care physicians over the past few years, I’ve realized I’m not alone in my concern that it has become a sort of diagnosis du jour for difficult children. And if you think, “What’s in a name?” think again.
Bipolar disorder is widely recognized as having a genetic basis that causes derangements in neurotransmitters – whether serotonin, norepinephrine, GABA, a combination, no one is sure – but that is what the treatment targets: the neurotransmitters. Children with bipolar disorder are treated with anti-psychotics which, to be frank, I, as a primary care doc with just enough knowledge in this field to be dangerous, find scary as hell.
Even scarier is what they might do to a child who fits the diagnostic criteria of bipolar but has something else – a behavioral disorder rather than a neurochemical disorder.
That’s why I’m glad to see a new diagnosis proposed: Temper Dysregulation Disorder with Dysphoria.
A new DSM is always controversial, as it should be. In essence it defines who’s normal and who’s not. Take this one, for example:
DSM-5 Proposed Diagnostic Criteria for Binge Eating Disorder
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- 1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
- 2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
B. The binge-eating episodes are associated with three (or more) of the following:
- 1. eating much more rapidly than normal
- 2. eating until feeling uncomfortably full
- 3. eating large amounts of food when not feeling physically hungry
- 4. eating alone because of being embarrassed by how much one is eating
- 5. feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for three months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (i.e., purging) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
I’m sure many of us met some of those criteria on Superbowl Sunday. The interesting thing here is part C – the distress. You can have A-1 and A-2, B-1, B-2, B-3, D, and E, but without guilt or distress over this sort of behavior, you’re normal!!!