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Feb. 10 2010 - 11:08 am | 505 views | 0 recommendations | 6 comments

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!!!



6 Total Comments
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  1. collapse expand

    Wasn’t the mother-of-all switches from “abnormal” to “normal” the decision in the 70’s to stop regarding homosexuality as a pathology?

    I think it was the APA that was attacked for it in a conservative magazine I read in the late ’80s, still railing about how it was a highly-politicized activist group within the APA that pushed it through.

    Via six separate YouTube postings, I recently saw a BBC show, “The Making of Me” with SF (Dr Who and spinoff) actor John Barrowman. He goes through various tests that confirm even on fMRI that his brain simply doesn’t register attraction to pictures of women; that his brain processes information in characteristically female/gay ways – and that current theory is these parts of the brain have their functions laid down before birth.

    I’m not trying to change the topic to gay issues; just pointing out that science does seem, with fMRI and many other approaches, to be gaining the ability to separate out “decided to act this way” from “just naturally act this way and it takes a concerted effort, and possibly neuro-medication, to act differently. If that’s even healthy.”

    Until we get there for these new “diseases”, the APA gets to make some tough calls. When they remove a thing from the pathologies list, like the gays, I’m more inclined to trust. When they ADD something…well, more work for psychiatrists, no? At least a slight conflict-of-interest…

  2. collapse expand

    Diagnosis is one thing, treatment is another.

    My brother was denied long-term care for his schizophrenia. This is discrimination. The health care reform bill leaves people like my brother uninsured for long-term care.

    If we are to be serious about insurance parity. We need to remove the legal barriers people with severe mental illness face to receive the appropriate long-term care they need, determined by the severity of their illness, just like someone with chronic lung disease or Alzheimer’s.

    Someone who has chronic lung disease and who qualifies for Medicaid will be admitted to a nursing home. Someone with schizophrenia who qualifies for Medicaid will not. Nursing homes are afraid to be classified as Institutes for Mental Diseases (if more than 50% of their patients are mentally ill the are classified as an IMD). If so, ALL of their patients will no longer be eligible for Medicaid, regardless of what type of illness they have. That is due to a little known provision in the Medicaid laws called the IMD Exclusion.

    You see, it’s OK to discriminate against people with severe brain disorders. The federal government says so.

    State hospitals will not admit patients on a long-term basis anymore because they ARE classified as IMDs. They don’t care about what the patient needs; it’s all about the money.

    The community mental health systems that were put into place when the state hospitals opened their doors and dumped out their patients, are ill-equipped to deal with people who don’t even recognize the are sick in the first place, as do many people who have the most severest forms of some serious brain disorders, like schizophrenia.

    My brother’s early death was a direct result of his release from the state hospital. He never had a day without a delusion, yet he was expected to manage his own care, everyone on the “outside” is. As a result he cycled in and out of psychotic state after another, in and out of the ER dept and local hospital psych ward. Paul was even was re-admitted to the state hospital for a relatively long stint, but they refused to keep him. Instead, he was released to an adult home that had all the bad qualities of a state hospital with few of the good, where the cycle of psychotic events continued.

    It wasn’t what was best for him; it was what was best for the state.

    The Medicaid IMD Exclusion is discriminatory and should be repealed; what the state did was pure negligence.

  3. collapse expand

    The DSM comes from the American Psychiatric Assoc. and not the American Psychological Association.

    And I agree with you about Temper Dysregulation Disorder.

  4. collapse expand

    Spanks. That’s what these kids need. Really truly.

  5. collapse expand

    Why can’t we just live and be happy? Why do we need to label and dislike everything different than we are?

    And I wonder what would happen to childhood social disorders if 50% of sugar intake and junk foods were replaced with veggies, fruits and proteins. Just a thought….

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