I have to confess at the outset that I am not a fan of DSM anything. I have no wish to criticize the hundreds of hard-working individuals who have devoted many hours of their lives to rewriting the Diagnostic and Statistical Manual of Mental Disorders—a thankless task if there ever was one—but I wish they had directed their talents and energies elsewhere. Perhaps they do, too, sometimes.
Although there is value to precise psychological and psychiatric definitions of distress, the DSM seems to me to vary those definitions according to what it considers politically and economically expedient at the time it is written, and then parse those definitions into discrete numerical classifications, which regulate who gets state aid, who gets medication, who merits insurance reimbursement, and who does not. It defines who is considered “ill”—often designating people as such because they don’t conform to what some feel are social norms. We can applaud the DSM’s ability to change with the times and help people, but I wonder who defines what those changing times and their social norms require.
Some of the main changes to the DSM-V apply to Asperger’s, disruptive mood dysregulation, obsessive compulsive and excoriation disorder, bereavement and depression, shyness, and gender identity. Some behaviors that I consider “normal” have been made into diagnostic categories, and a few diagnoses are being changed to fit in somewhere else. These differences may result in some people losing the help they need, and others getting help that they not only may not need, but that might be unnecessary or even harmful.
Let’s look at these proposed changes one by one, and see what they mean and what effects they may have, if any:
- The DSM-V has erased Asperger’s disorder and includes it instead in autism spectrum disorder. This will affect those previously diagnosed with Asperger’s, who are emotionally but not cognitively challenged, and may disqualify them from disability payments, special schooling and tutoring, or supported housing, all of which they may need in order to live independently.
- Hoarding was previously included under obsessive compulsive disorder, but now is its own category. I am not sure what effects this will have.
- Disruptive mood dysregulation disorder, or DMDD, refers to children who have recurrent temper tantrums. I am very reluctant to consider this a diagnostic category at all. Children exhibit a vast spectrum of behaviors, which is a normal part of growing up. Temper tantrums are not a diagnostic category, in my opinion, and making them such can lead to medicating children for normal, if extreme, behavior, which can have negative consequences on their physical, neurological, social, and emotional development. The change was made to lower the high rate of children who are now mistakenly classified as having bipolar disorder, and given too many drugs, but I am afraid that too many drugs will still be prescribed, this time for DMDD. Other treatments, such as play therapy and family therapy, have good results and are far safer. Perhaps schools will find DMDD a helpful step on the path toward getting more school aid.
- Another new category is excoriation, which refers to skin picking and is associated with trichotillomania, or hair pulling. As with hoarding, I am not sure what effects making this a new category will have, or if it’s needed.
- Bereavement is not the same as depression. People whose loved ones die feel the loss and experience sadness and depression. That’s a normal part of our lives, and needs to be lived through. It’s called mourning, and takes far longer than the two months given as “normal” by the DSM. To be fair, this change was to make sure depression is not a missed diagnosis in someone who is mourning. You can be in mourning and also have a significant depression, but some depression is normal after a loved one dies.
- Shyness is now included in the “social phobia” label. I always thought being shy was in the normal range of human behavior, like being an extrovert, for example. Confession: I am not an extrovert.
- Gender dysphoria, previously called gender identity disorder, removes the stigma associated with the word “disorder.” Changing the name from “disorder” to “dysphoria” does not help people who securely live between the male-female binary; rather, it pathologizes people who are comfortably transgender. On the other hand, this diagnostic category could be used to justify insurance coverage of gender reassignment, to decide who wins child custody in a suit, or in employment discrimination cases.
So there you have it—the good, the bad, the neutral, and the ridiculous. My problem with the DSM is twofold: philosophical and pragmatic. First, it reduces human behavior to numerical equivalents based on “social norms” which are often vague, biased, and simply too narrow to describe our beautiful human variability, the vast all of who we all are, and it pathologizes normal behaviors. Next, the DSM should help the people it describes; even though it may want to, it often does not.
Do I use the DSM in my work? Not so much.
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