|
|
The ever-shrinking domain of the normal...
As chairman of the task force that created the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which came out in 1994, I learned from painful experience how small changes
in the definition of mental disorders can create huge, unintended consequences.
Our panel tried hard to be conservative and careful but inadvertently contributed to three false "epidemics" -- attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net
was cast too wide and captured many "patients" who might have been far better off never entering the mental health system.
The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically
deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a
mental disorder. The pharmaceutical industry would have a field day -- despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.
The manual, prepared by the American Psychiatric Assn., is psychiatry's only official way of deciding who has a "mental disorder" and who is "normal." The quotes are necessary because this distinction is
very hard to make at the fuzzy boundary between the two. If requirements for diagnosing a mental disorder are too stringent, some who need help will be left out; but if they are too loose, normal people
will receive unnecessary, expensive and sometimes quite harmful treatment.
Where the DSM-versus-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status -- to say nothing of stigma and the individual's sense of personal
control and responsibility.
What are some of the most egregious invasions of normality suggested for DSM-V? "Binge eating disorder" is defined as one eating binge per week for three months. (Full disclosure: I, along with more than 6%
of the population, would qualify.) "Minor neurocognitive disorder" would capture many people with no more than the expected memory problems of aging. Grieving after the loss of a loved one could frequently be
misread as "major depression." "Mixed anxiety depression" is defined by commonplace symptoms difficult to distinguish from the emotional pains of everyday life.
The recklessly expansive suggestions go on and on. "Attention deficit disorder" would become much more prevalent in adults, encouraging the already rampant use of stimulants for performance enhancement.
The "psychosis risk syndrome" would use the presence of strange thinking to predict who would later have a full-blown psychotic episode. But the prediction would be wrong at least three or four times
for every time it is correct -- and many misidentified teenagers would receive medications that can cause enormous weight gain, diabetes and shortened life expectancy.
A new category for temper problems could wind up capturing kids with normal tantrums. "Autistic spectrum disorder" probably would expand to encompass every eccentricity. Binge drinkers would be
labeled addicts and "behavioral addiction" would be recognized. (If we have "pathological gambling," can addiction to the Internet be far behind?)
The sexual disorders section is particularly adventurous. "Hypersexuality disorder" would bring great comfort to philanderers wishing to hide the motivation for their exploits behind a psychiatric excuse. "Paraphilic
coercive disorder" introduces the novel and dangerous idea that rapists merit a diagnosis of mental disorder if they get special sexual excitement from raping.
Defining the elusive line between mental disorder and normality is not simply a scientific question that can be left in the hands of the experts. The scientific literature is usually limited, never easy to
generalize to the real world and always subject to differing interpretations.
Experts have an almost universal tendency to expand their own favorite disorders: Not, as alleged, because of conflicts of interest -- for example, to help drug companies, create new customers or increase
research funding -- but rather from a genuine desire to avoid missing suitable patients who might benefit. Unfortunately, this therapeutic zeal creates an enormous blind spot to the great risks that come
with overdiagnosis and unnecessary treatment.
This is a societal issue that transcends psychiatry. It is not too late to save normality from DSM-V if the greater public interest is factored into the necessary risk/benefit analyses.
| |
|
|
Last Modified: 6 December 2010 |
The Evolution of DSM-5
Personality — Notes and References |
|
The Diagnostic and Statistical Manual of Mental Disorders is a standardized classification of mental/psychiatric disorders intended
to reflect a consensus of current formulations in the field; it is designed to facilitate diagnosis, communication, and further study, and is widely used by clinicians and researchers
in a range of disciplines. DSM-I was published in 1952, followed by DSM-II (1968), DSM-III (1980), DSM-III-R (1987), DSM-IV (1994), and the DSM-IV-R (2000). The American Psychiatric Association
strives to make the DSM a practical and useful guide to diagnostic criteria presented in brief sets, with clear language and explicit diagnostic constructs. There have been many changes, however, over time. The history
of the DSM clearly reflects an evolution of thought with respect to nomenclature, theoretical orientations, information collection, and empirical validation.
DSM-5 is scheduled for publication in May 2013. While previous editions were developed by task force and committees with limited broad-scale input, a preliminary draft of the new edition
was published online, where it remains open to public review at www.dsm5.org.
DSM-5 is a document-in-process, and monitoring the website for changes and additions is most informative, particularly given the profound impact the new edition
may be expected to have on our lives.
On 5 October 2010, APA announced the beginning of DSM-5 field trials to "help assess the practical use of proposed DSM-5
criteria in real-world clinical settings".
After completion of the first phase of field trials and another period of public comment via the DSM5.org
web site, work group members will make any necessary revisions to their draft criteria. This will be followed by a second phase of field trials for further examination of selected criteria, scheduled to take
place in 2011 and 2012.
"The process for developing DSM-5 continues to be deliberative, thoughtful and inclusive," said Darrel Regier, M.D., M.P.H., vice-chair of the DSM-5 Task Force, and APA research director. "Large-scale field
trials are the next critical phase in this important process and will give us the information we need to ensure the diagnostic criteria are both useful and accurate in real-world clinical settings."
The conceptual frameworks for "Mental Disorder",
"Personality Traits",
"Personality and Personality Disorders",
"Dissociative Disorders",
"Asperger's Disorder" (which the work group is proposing be subsumed into
Autistic Disorder (Autism Spectrum Disorder), and
"Cross-Cutting Dimensional Assessment" are of major interest to me.
This page contains selected excerpts on those frameworks, plus related notes and references.
DSM-IV
definition of mental disorder
- Features
- A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual
- Is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly
increased risk of suffering death, pain, disability, or an important loss of freedom
- Must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one
- A manifestation of a behavioral, psychological, or biological dysfunction in the individual
- Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or
conflict is a symptom of a dysfunction in the individual
- Other Considerations
- No definition adequately specifies precise boundaries for the concept of "mental disorder"
- The concept of mental disorder (like many other concepts in medicine and science) lacks a consistent operational definition that covers all situations
|
DSM-5
proposed definition of mental disorder
A proposed revision for the definition of a mental disorder is being addressed by select members of the Anxiety, Obsessive-Compulsive, Posttraumatic,
and Dissociative Disorders Work Group, a member of the Mood Disorders Work Group, and additional individuals [...] [Stein DJ, Phillips KA, Bolton D, Fulford KW, Sadler JZ, Kendler KS. What is a mental/psychiatric disorder? From DSM-IV
to DSM-V. Psychol Med. 2010 Nov;40(11):1759-65.]
- Features
- A behavioral or psychological syndrome or pattern that occurs in an individual
- That reflects an underlying psychobiological dysfunction
- The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)
- Must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)
- That is not primarily a result of social deviance or conflicts with society
- Other considerations
- That has diagnostic validity on the basis of various diagnostic validators (e.g., prognostic significance, psychobiological disruption, response to treatment)
- That has clinical utility (for example, contributes to better conceptualization of diagnoses, or to better assessment and treatment)
- No definition perfectly specifies precise boundaries for the concept of either "medical disorder" or "mental/psychiatric disorder"
- Diagnostic validators and clinical utility should help differentiate a disorder from diagnostic "nearest neighbors"
- When considering whether to add a mental/psychiatric condition to the nomenclature, or delete a mental/psychiatric condition from the nomenclature, potential benefits (for example, provide better patient care,
stimulate new research) should outweigh potential harms (for example, hurt particular individuals, be subject to misuse)
| |
Personality
Personality Traits
Proposed Revision
The Work Group recommends that patients be rated on 6 broad, higher order personality trait domains each comprised of several
lower order, more specific trait facets. The broad trait domains and their definitions are listed below, with the trait facets comprising each domain listed below the domain name. The
proposed trait model is in the process of empirical validation. |
|
Trait levels are assessed on a four-point scale:
0 = Very little or not at all
1 = Mildly Descriptive
2 = Moderately Descriptive
3 = Extremely Descriptive |
Where lies "normal"?
The musings of an Introverted, Schizotypic, Compulsive with Negative Emotionality, Disinhibited and Antagonistic traits...
To apprehend a model such as traits (domain, facet, level) — hereafter called "the model" — I internalize it. This is an introspective
exercise in creative imagination which requires an understanding of the rules of the model, followed by psychoemotional engagement of each descriptor. The introspection takes place
in a 'self' that presents as a malleable (plural) identity integration, characterized by frequent build-ups and break-downs in egoic self-concept, and a strong capacity to dissociate.
The exercise is meaningful within the larger universe of the (Jungian) Self, which informs my experience. Descriptors are analyzed in various ways: Do they present as intrapsychic realities?
are they cathected? drives or complexes? am I in pain? disharmony? does the model adequately address known psychodynamics? reveal new information?
Some descriptors seem much 'stronger' than others, in this case. Introversion is most pronounced, but Schizotypy, Compulsivity, and Negative Emotionality also resonate. Antagonism is
recognizable, a contained shadow element, and Disinhibition is a roving subliminal. I observe, during all of this, that my capacity for introspection and empathy are undiminished (I do not fall victim to individual descriptors), and self-directedness is not
at all in question (see below, "Personality Disorder — General Diagnostic Criteria", for more on these markers in personality). The results of the exercise help me appreciate the limits
of the model, and are of obvious introspective value.
To an outside observer, however, my approach and the stated identifications might appear to deviate from 'normal', particularly in the sense that, with reference to the DSM-5 spectra of "Self" and "interpersonal", both are generalized strategies on my part.
And while my "abnormality" might not indicate psychopathology per se, it is not difficult to correlate it with a "personality disorder" on further cross-dimensional assessment.
But aren't all of these trait domains found to varying degrees in everyone? To the extent that the identified trait domains and facets will be used to specify deviation "in the context of the individual's cultural norms
and expectations", it strikes me that what is 'normal' may become increasingly attenuated in favor of diagnostic inclusivity. By elevating these six as diagnostic gateways to the 'abnormal', we exclude other descriptors
(e.g., "Extraversion") which might prove equally useful with respect to cultural norms and expectations — about which the subjective evaluative scales tell us nothing. In this sense, the idiosyncratically
creative is placed at increasing risk as the concept of 'normality' grows more circumscribed.
It may be best practice that, as with Five Phases Theory in Chinese medicine, clinicians only use the model when it works. I suspect, however, that the contrary will apply as the model is made to fit that which it
neither appreciates nor includes. Unfortunately, the inadequately descriptive has a tendency to become unfortunately prescriptive and proscriptive in generalized application. | |
|
Negative Emotionality:
Experiences a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, etc.), and the behavioral and interpersonal manifestations of those experiences
Trait facets: Emotional lability, anxiousness, submissiveness, separation insecurity, pessimism, low self-esteem, guilt/ shame, self-harm,
depressivity, suspiciousness
Introversion:
Withdrawal from other people, ranging from intimate relationships to the world at large; restricted affective experience and expression; limited hedonic capacity
Trait facets: Social withdrawal, social detachment, restricted affectivity, anhedonia, intimacy avoidance
Antagonism:
Exhibits diverse manifestations of antipathy toward others, and a correspondingly exaggerated sense of self-importance
Trait facets: Callousness, manipulativeness, narcissism, histrionism, hostility, aggression, oppositionality, deceitfulness
Disinhibition:
Diverse manifestations of being present- (vs. future- or past-) oriented, so that behavior is driven by current internal and external stimuli, rather than by past learning and consideration of future consequences
Trait facets: Impulsivity, distractibility, recklessness, irresponsibility
Compulsivity:
The tendency to think and act according to a narrowly defined and unchanging ideal, and the expectation that this ideal should be adhered to by everyone
Trait facets: Perfectionism, perseveration, rigidity, orderliness, risk aversion
Schizotypy:
Exhibits a range of odd or unusual behaviors and cognitions, including both process (e.g., perception) and content (e.g., beliefs)
Trait facets: Unusual perceptions, unusual beliefs, eccentricity,
cognitive dysregulation, dissociation proneness | |
Personality Function — Levels Of
The Work Group recommends the following for severity of impairment in personality functioning.
Personality psychopathology fundamentally emanates from disturbances in thinking about self and others.
Because there are greater and lesser degrees of disturbance of the self and interpersonal domains, the following continuum — comprised
of levels of self and interpersonal functioning — is provided for assessing individual patients.
Each level is characterized by typical functioning in the following areas:
Self: Identity Integration, Integrity of Self-concept, and Self-directedness
Interpersonal: Empathy, Intimacy and Cooperativeness, and Complexity and Integration of Representations of Others
|
Personality Disorder — General Diagnostic Criteria
The Work Group recommends a revised definition of personality disorder and a corresponding revised set of general criteria.
Definition: Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the
individual's cultural norms and expectations.
- Adaptive failure is manifested in one or both of the following areas:
- Impaired sense of self-identity as evidenced by one or more of the following:
- Identity integration. Poorly integrated sense of self or identity (e.g., limited sense of personal unity and continuity; experiences shifting self-states;
believes that the self presented to the world is a façade)
- Integrity of self-concept. Impoverished and poorly differentiated sense of self or identity (e.g., difficulty identifying and describing self attributes; sense of
inner emptiness; poorly delineated interpersonal boundaries; definition of the self changes with social context)
- Self-directedness. Low self-directedness (e.g., unable to set and attain satisfying and rewarding personal goals; lacks direction, meaning, and purpose to life)
- Failure to develop effective interpersonal functioning as manifested by one or more of the following:
- Empathy. Impaired empathic and reflective capacity (e.g., finds it difficult to understand the mental states of others)
- Intimacy. Impaired capacity for close relationships (e.g., unable to establish or maintain closeness and intimacy; inability to function as an effective attachment figure;
inability to establish and maintain friendships)
- Cooperativeness. Failure to develop the capacity for prosocial behavior (e.g., failure to develop the capacity for socially typical moral behavior; absence of altruism)
- Complexity and integration of representations of others. Poorly integrated representations of others (e.g., forms separate and poorly related images of significant others)
- Adaptive failure is associated with extreme levels of one or more personality traits.
- Adaptive failure is relatively stable across time and consistent across situations with an onset that can be traced back at least to adolescence.
- Adaptive failure is not solely explained as a manifestation or consequence of another mental disorder
- Adaptive failure is not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma)
| | |
|
|
  |
Herbal & Homeopathic Remedies
250 Remedies
Safe & Effective
100% Guaranteed
All Natural Remedies |
|
|
