Showing posts with label DSM. Show all posts
Showing posts with label DSM. Show all posts

Bad Mental Health Take on Autism - One More from Allen Frances

Before Mental Health Awareness Month draws to its nonconsequential end -- 

Allen Frances

New York Post has published a new interview with Allen Frances about how bad it is to receive a diagnosis, or as he puts it, become a mental patient.

Become a mental patient?

Some background: Allen Frances is a professor emeritus of psychiatry and behavioral sciences at Duke University. His fields of research were wide ranging, including personality disorders, chronic depression, anxiety disorders, schizophrenia, AIDS, and psychotherapy. [Note: not autism]. He served as the chair for the DSM (Diagnostic and Statistical Manual of Mental Disorders) task force, which published the DSM IV in 1994. He later became the chief critic of the DSM 5, which is a modest revision of his work.

In a nutshell--he didn't like any of the revisions.

As part of Frances's critique of the DSM 5, he wrote Saving Normal, subtitled An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. His book was published one week before the DSM-5. Since then he has continued the themes of the subtitle.

In addition to my review of his book linked above, I have commented a few times on Frances's statements. I appreciate his concerns about Big Pharma's influence in the treatment of mental illness and inappropriate use of medication, especially in the case of mild depression. His periodic attempts to save normal, not so much.

A couple quotes from his New York Post interview:

Dr. Allen Frances told The Post that he is “very sorry for helping to lower the diagnosis bar.”

Now, Frances said, he fears his work “contributed to the creation of diagnostic fads that resulted in the massive over-diagnosis of autistic disorders in children and adults.”

Stigma Against Mental Illness

One of the themes of Saving Normal is that diagnosis exposes people to stigma. So it would be worrisome to him that so many people are now mental patients, newly exposed to stigma.

I'll grant Francis this point. Prejudice against mental illness is alive and well - and particularly dangerous when it is expressed in the medical field.

There is scant evidence that Stamp Out Stigma campaigns have moved the needle, except on the issue of depression. Judging by news reports, prejudice against people with mental illness has been growing. 

  • Recently, an ex-Marine is lauded as a hero after putting Jordan Neely, a disturbed man on a New York subway, into a choke hold for fifteen minutes. In two days Daniel Penny raised over $1.5 million for his defense against a charge of second degree manslaughter.
  • As politicians regularly blame mass shootings on mental illness, they also routinely reduce funding to address it.


The thing is, prejudice against difference does not stem from diagnosis. It stems simply from difference itself.

A Diagnosis of Autism

In the case of autism, let me suggest an alternative to Francis's view.

From the anecdotal evidence of many people finally diagnosed in adulthood, the diagnosis brings not stigma but relief. They had already been stigmatized throughout childhood. Not by a psychiatric diagnosis, but by the schoolyard diagnosis weird and the classroom diagnosis behavior problem. They grew up being bullied and punished because they were not normal - to use Dr. Francis's favorite word.

People diagnosed with autism in adulthood often already have other diagnoses, most commonly depression and anxiety. They sometimes have experienced suicidal thoughts or attempts. These are the consequences not of their undisclosed diagnosis of autism, but of the way they have been treated by others - on the basis of their difference which it does not take a psychiatrist to notice. It only takes a psychiatrist to explain.

Hence their relief - finally to have an explanation.

The NYP quotes the statistic that rates of autism in the US have soared 500% over the last sixteen years. This is a bait and switch statistic. The DSM 5 changed the definition of autism, combining profound autism, childhood disintegrative disorder, pervasive developmental disorder, and what was once called Asperger syndrome under one umbrella diagnosis, autism spectrum.

Whether or not combining these conditions with different treatment needs under one label was a good idea is a separate discussion. But the change in rates was not as drastic as the statistic suggests. The numbers for three separate diagnoses have been added to the first.

But it is not the first time Dr. Francis has played fast and loose with statistics to claim over-diagnosis. The statistic does not support his thesis of over-diagnosis because the sample population has changed.

Underserved Children with Autism


The article misses the most significant part of the story, reported in the journal Pediatrics. There are significant disparities in rates of diagnosis between white and black children and between affluent and poor children:

Black children were 30% less likely to be identified with ASD-N compared with white children. Children residing in affluent areas were 80% more likely to be identified with ASD-N compared with children in underserved areas.

The consequence of under-diagnosis is that, while rich white kids get services, poor black kids get placed in the school to prison pipeline.

There are real life consequences to under-diagnosis. Poor black kids should not have to pay the cost for Allen Frances's hobby horse.

More Next Week


So clearly, I have thoughts. Lots of thoughts. It's time to sign off for this week and promise more to come. But you are welcome to join the conversation by commenting below!

How Do You Get Going? Working with ADHD

Screens for ADHD measure five clusters of symptoms: 

  • organizing and activation for work
  • sustaining attention and concentration
  • sustaining energy and effort
  • managing affective interference (emotions that get in the way)
  • utilizing working memory and accessing recall.
The DSM checklist assumes that ADHD is a diagnosis for children. If you didn't have it as a child, you don't have it now.

Well, okay. I am not qualified to quibble with the American Psychiatric Association about how many angels dance on the head of a pin and when they showed up for the dance. But the problem of diagnosis is this: I can't remember which of their criteria I demonstrated in my childhood. And my mother certainly never noticed any struggles that her brilliant and perfect daughter may have experienced in the early 1960s. I mean, she didn't even notice suicidal depression...

So what do I make of that DSM assumption?

CHADD - Children and Adults with Attention-Deficit/Hyperactivity Disorder has this to say about diagnosing adults:

Beyond the DSM: Three Ways to Manage Other Issues of Bipolar Disorder

Medication is approved for a mental illness if it reduces symptoms, the symptoms listed in the Diagnostic and Statistical Manual (DSM).

Did you know that there is more to bipolar disorder than: 

an episode of depression 

elevated or irritated mood, inflated self-esteem, decreased need for sleep, pressure to keep talking, flight of ideas, distractibility, increase in goal-directed activity, psychomotor agitation, and excessive involvement in pleasurable or risky activities?

These are merely the outward and visible signs of what is happening inside the brain. These are how the doctor can tell that you have bipolar disorder.

But even after you suppress these symptoms, you still have a variety of neurological dysfunctions that affect your thinking, your energy metabolism, and your health.

Psych meds do not address all these other issues. They are a piece of treatment, an important piece. But suppressing symptoms, while it relieves the anxieties of those around you, does not fix your life.

Bipolar, Not So Much - A Review

Recurrent depression, treatment-resistant depression, depression with mixed features, cyclothymic disorder -- if your file at the doctor's office is coded for any of these, my heart goes out to you. Chances are you have taken a number of turns around the antidepressant not-so-merry-go-round. I call it "The Chemistry Experiment," and you are the test tube.


Chris Aiken and James Phelps have written the book for you. Bipolar, Not So Much: Understanding Your Mood Swings and Depression introduces the reader to the Bipolar Spectrum. No, they are not talking about the movie version of bipolar, throwing furniture out the window, driving the car into the river... They mean the vast ground between that and your basic depression. They mean depression - with something more.

The authors use a conversational style, speaking directly to the reader and skipping the jargon. They begin by explaining the spectrum. They don't ask the question the way the DSM frames it, Does this person have bipolar? Rather, their question is, How much bipolar does this person have?

Like this:



You won't find the spectrum in the DSM, the manual of diagnoses. The DSM’s symptom silos are designed to put you in one slot or another. The silos came into existence in the 1960s. The spectrum approach is much preferred by the acknowledged experts in bipolar, starting with Goodwin and Jamison who also prefer the name manic depression. But in the recent revision,there was huge resistance to making the change back to the earlier understanding of the disorder. Symptom lists with their precise cut off points seem so tidy and are easier to code. So they remain in the DSM-5, and people like Aiken and Phelps write books to try to inform people who don't know anything more about bipolar than the damn lists. But I digress...

Aiken and Phelps take the approach that you will get the best recovery if you know what is actually going on. So first they thoroughly ground the reader in the spectrum concept, and include the diagnostic and predictive instruments that all the docs can access, but usually don't take the time to use. Damn, I am digressing again...

Next they spend a lot of time on lifestyle changes and other nonpharmocological treatment measures. The thing is, the meds were all developed and work best for the folk on the far ends of that spectrum. Which you already know if you are somewhere in the middle, because they don’t work so well for you, which is how you became a Chemistry Experiment. 

Actually, even if you are clearly unipolar or clearly bipolar 1, Aiken and Phelps have good advice for you regarding sleep, diet, exercise, supplements, and the rest. You’re just going to do better if you don’t ask the meds to do all the work. Mood disorders are more complicated than that mythological chemical imbalance. 

The book's third section is a thorough listing and discussion of all the meds. They have their favorites which may be different from your doctor’s, because they don’t talk to drug reps nor read the ads. They read (and do) the research. Are you getting the sense that I have an agenda here?

Bipolar, Not So Much is the essential resource for for anybody who has depression and maybe something more. It is backed up by Phelp's excellent website PsychEducation.org. It is a humane book by humane doctors who listen and learn from their patients. What a concept, huh? Their dedication page tells the tale:


To our patients. You showed us what life is like in the mood spectrum, and we hope we got it right, or at least close, in this book.

flair from Facebook.com
book cover from Amazon.com
bipolar spectrum graphic from PsychEducation.com.

Not Just Up and Down -- A New Map for Bipolar


Last week a friend told me she had just been diagnosed with bipolar.  I remember eight years ago when she told me she was finally getting treatment for depression.  I didn't say it at the time, but for the next several days my brain was screaming it: Really?  In 2016 people are still being misdiagnosed, and mis-treated, mistreated with meds that make them worse.  I mean, 


F*cking Really?!!

Lives are at stake here, people.  Careers, families, credit, and yes, lives. That is what people lose when their doctors get this call wrong.

Doctors' Prejudice Against Mental Illness

One in four people in the United States meet the criteria for a diagnosable mental illness in any given year.  About half will develop a mental illness sometime in their life.  Allen Frances, editor in chief of DSM-IV wants fewer people, only those with the most serious illness, to be diagnosed to spare them the stigma of the diagnosis.  The chief mechanism to achieve his goal would be to change the DSM criteria, so that fewer people qualify.

This series began by introducing Dr. Frances, whose work has inspired it.  It continues to address the topic of stigma, what it means, where it comes from, how to respond.  Last week I defined terms, adding one that expands our frame.  Briefly, Merriam-Webster says that stigma is a mark of shame or discredit; while prejudice is injury or damage resulting from some judgment or action of another in disregard of one's rights.

I think it is important to distinguish between the two.  To do so, one has to clarify the context.  Stigma, when used by somebody who is the object of stigma, is the internalization of somebody else's prejudice. When it is used by somebody else, stigma is a mechanism of diversion that calls on the object of one's own prejudice to bear the responsibility of that prejudice.

So is Allen Frances trying to protect those whom he calls the worried well from being marked with shame or discredit?  Or is he creating a diversion that calls on people who are suffering to bear the responsibility for somebody else's prejudice?

DSM-5 - Passé Before Published

Most of Allen Frances' ranting against DSM-5 bounces back to hit his own DSM-IV just as well.  He acknowledges this in the preface of Saving Normal, which he says is part mea culpa.  You could sum his argument against DSM-5 as It's DSM-IV, only more so!  We could all find some consensus around that line.

So while I am not pleased with this man's rants [did you pick up on that last week?], I do not come to praise DSM.  To keep us all on the same page, I am reposting my piece from November, 2011.  What I wrote below referred to DSM-IV.  Most of it applies to DSM-5, as well.  The differences between the two do not a difference make in my own critique.  The fatal flaw in DSM-5 is that it is DSM-IV's little brother.  That's what Thomas Insel is talking about...

Introducing Allen Frances

Allen Frances was the editor of the DSM-IV, first published in 1990.  He is now the fiercest critic of its next major revision, the DSM-5.  For over three years, he has been blogging weekly to this end at Psychology Today.  This week I will summarize his steady drumbeat.  I hope soon to publish an open letter to him.

Frances' complaint in a nutshell is that the DSM-5 creates fad diagnoses and changes criteria of older diagnoses to medicalize a whole range of normal behavior and miseries.  The link lists these problem diagnoses and a number of the following points, in an article published all over town last December.

These issues have been discussed widely, in public and private circles.  I am not qualified to address each point, though I did give a series over to one of them, the bereavement exclusion.  The best of the batch, if I do say so myself, is Grief/Depression III - Telling the Difference, which got quoted in correspondence among the big boys.

Looking Under the Hood - A Better Depression Diagnosis?

Corrected July 7, 2013

Maybe my writer's block is an Ecclesiastes issue.  There is nothing new under the sun.

But finally, there is.  No, not the DSM.  Keep reading.

The DSM. Sigh.

But regarding the DSM, and it makes no difference at all which edition, you have to wonder when somebody who is suicidal, losing weight, irritated at the drop of a hat and can't sleep gets the same diagnosis as somebody else who is immobile, gaining weight, couldn't be bothered about anything anymore and sleeps the night and day away.  It's all depression -- the DSM's junk drawer.

Finally, somebody thought to sort the junk drawer, by looking inside the brains of these two sorrowful souls, both taking the same meds for God's sake.

PET Scans - Looking Under the Hood

Helen Mayberg and her team at Emory University School of Medicine used PET scans to look under the hood (to use John McManamy's favorite metaphor).  PET scans use a radioactive tracer to determine where glucose is being used in the brain, i.e., what part of the brain is busy.

Thomas Insel - Toward a New Understanding of Mental Illness




Cutting this guy's budget is like telling Orville and Wilbur Wright to take the month off.

Defending DSM-5 -- Sort Of

Good mental health reporting takes research, careful analysis, nuance and a whole lot of work.  And in the end, it doesn't sell newspapers.  Which is why you see so much bad mental health reporting, even where you thought you'd find better.


[I like to think that opening sentence explains why I post no more often than once a week.  I work to provide a quality product.  But that is for you to judge.]

The long awaited publication of the Diagnostic and Statistical Manual, Edition V has generated a blizzard of easy-to-whip-off articles with sensationalist headlines, just the thing for you to share on Facebook on a boring weekday afternoon, and get a nice Ain't it awful rant going among your friends when, really, you should be doing your life.

The Spectre of the Butterfly Net

Most of these articles follow the same tired theme, Psychiatrists are out to diagnose half the population, turning normal human conditions into mental illnesses, because they are in cahoots with the pharmaceutical industry to put the nation on medication.

These articles write themselves.  Pick any diagnosis that the DSM-V has dared to update from a work last revised nineteen years ago, add a quote from the disgruntled old man who was editor-in-chief of said nineteen-year-old document, which only barely tinkered with the 1980 edition anyway, plug in a statistic on drug sales, and there you have it.

Next, pick another diagnosis, substitute a humanistic psychologist for the disgruntled old man, and you are good to go with next week's article.

I, who love links, am not going to link to any of this trash.

Now I have my problems with the DSM.  But I do have some sympathy for its revisers, caught in the middle of a sea change, trying to update a system that will be tossed into the deep within the decade, and would have been already, if we spent any halfway reasonable amount of money on research.

For now I will do my own op ed piece and offer for your consideration the following assertion, based on my own experience in the system and reports of friends who have been at this a whole lot longer:

There are no psychiatrists running around on the streets, chasing toddlers with temper tantrums, trolling funeral parlors for grieving widows, whipping up business.  People!  There are not enough psychiatrists to deal with the loonies already identified.  They do not need you!

You don't get to see a psychiatrist and submit to trial by DSM until

  • denial
  • snapping out of it
  • hiding
  • behavioral modification
  • herbal remedies
  • and prayer

have not worked, and there is no choice but to go where you do not want to go, in the face of your drinking buddies who all tell you, You'd have to be crazy to see a psychiatrist.

Well, maybe you are.  Maybe you are on the knife's edge.  Be prepared to stay there a while longer.  It will take three months to get an appointment.  Longer, if you don't have insurance.

Seriously, they don't need you.

Diagnosis is Your Best Friend

Do you know anybody who has suffered for years with some unidentified illness, bouncing from doctor to doctor, treatment plan to treatment plan, feeling crazy and out of control, because there is no reasonable explanation for these vague, though debilitating symptoms that come and go, and your friend begins to think that you all think he/she is crazy and not really sick at all?  Lyme Disease, Fibromyalgia, TBI, MS, ALS, Lewy Bodys...

The day that person receives a diagnosis, even a difficult one, is a day of rejoicing.  Now he/she knows, can make plans, can learn about the illness, follow a course of treatment, maybe even find one that helps.

Diagnosis, if it is the right diagnosis, even if it is more serious than the previous diagnosis, even if you really, really don't like the diagnosis, is the first step toward recovery.

I mean, think about it.  If you get out of breath climbing a flight of stairs, do you listen to your friends tell you to rest mid-flight?  Or do you go to a doctor who might tell you that you have a blocked artery?  Is the doctor drumming up business?  Or is he/she saving your life?

Mental Illnesses are Made of Normal Experiences

Let's break out some dialectical thinking.  I know, it's hard.  That is why mental health reporters for USAToday and even the New York Times don't ask you to do it.  Prozac Monologues does ask you to do it.  But we can take it slow.

First, what is dialectical thinking?  It is when you hold two truths that seem to contradict each other in your mind at the same time.  Truth is not about either/or.  It is mostly both/and.

So our first statement is this:

Mental illnesses are made of normal experiences.  Everybody gets sad.  Everybody gets angry.  Everybody gets up in the morning sometimes and just can't get started on the day.  Everybody who walks by a group of scary people thinks they are saying bad things.  Everybody catches something out of the corner of the eye that isn't really there.  Everybody throws something against the wall.  Everybody persists in believing something that is false.  Everybody has an occasional impulse to jump off the bridge.

The symptom lists of the DSM are filled with behaviors that everybody does.

News Flash:  Us loonies inhabit the same planet as everybody else.

That is the first truth in our venture into dialectical thinking.  And it is the source of all those headlines about how the DSM is turning normal behavior into mental illness.  How is this for a thought -- mental illness really is not that weird after all.

The Suffering of Mental Illnesses is not Normal Suffering

But.  Here is the other statement to hold in your mind while remembering the first one:

There is a difference.  You get a diagnosis of some sort of mental illness when a whole lot of normal experiences and a whole lot of normal suffering pile up beyond your ability to function in a normal world.

That's it.  If you are not at the end of your rope, you do not have a mental illness.  Rather you are having a bad day, or week, or year.  If you are functioning well in the world, you do not make an appointment with a psychiatrist, and do not receive a diagnosis.  And the psychiatrist is just fine with that, because he/she doesn't have time to see you anyway.  The DSM is not about you, and does not try to be about you.  So leave it alone and let it help those of us who need its help.

When your loved one dies, you will not be diagnosed with depression just because you are going through a normal grieving process.  A normal grieving process looks like depression, but only on the surface.

If what you have is Major Depressive Disorder, then you don't go through a normal grieving process.  You don't think about your loved one; you don't remember the good times; you don't share those scandalously funny pokes in the ribs during the funeral; you don't cling to your sister; you don't even get mad at the person who deserted you by dying.  You just sit under a black cloud and think about how miserable you are.  So you do not get better, and -- get this -- you do not do normal grieving, until you get treated for your depression.

Grieving widows are in no danger from the DSM, if their grieving really is normal.

When your child throws a temper tantrum, you don't run out for a diagnosis of Disruptive Mood Dysregulation Disorder.  A badly behaved child has good days and bad days.  If the parents are consulting with school and other resources and genuinely working on the issue, things get better.  When they have tried every recommendation in the book, when they fear for their lives, when the child is out of control and scared and miserable about his/her own behavior, and this has gone on for years...

then it is insulting, it is cruel and it is simply not helpful to tell these parents that there is nothing wrong with their child and that the doctor's attempts to figure it out are part of some grand conspiracy that threatens to medicalize normal behavior.  If you don't know, if you have not walked in their shoes, then shut the hell up.

Naughty children are not diagnosed in the DSM, if they can get better without it.

Diagnosis of Mental Illness is Not Easy

The DSM V does not make diagnosis easier.   Yeah, well -- diagnosis of any sort got more complicated when they threw over the four humours theory.

There is more to say in the DSM's defense.  I will get to it.  It will make me work and make you think.  And I don't imagine you will share it on Facebook.

Oh well.  My ad revenue never did pay the mortgage.

flair from Facebook.com

Recovery - From What?

Recovery is the individual lived experience of moving through and then beyond the limitations imposed by the disorder, by the world around us, and even by the treatment itself.

Huh?

Okay, the deal is, unless you know where you are going, it's tough to get there.

Recovery Defined as Escape from the Symptom Silo

The docs know where they want to go.  They want to get rid of your symptoms.  Your illness is defined by a list of symptoms, found in the DSM and measured by survey instruments, and when you score in the normal range, then you have recovered.

Which is sort of like saying that if you don't have chest pain or shortness of breath, then you have recovered from heart disease.  Cardiologists don't think that way.  They want to know the condition of your heart, not just your symptoms.

The Positive Power of Being Strange


It's just too easy [in Iowa] to avoid the weirdos in our life.

First, the TED talk from one of those people who, whenever they have something to say, you want to pay attention to it. I am pleased to call Mike Wagner a friend, so I get regular doses. Here he doesn't use the language, but he's talking about the power of my favorite brain part, the anterior cingulate cortex.

Mike's shingle hangs at White Rabbit Group. The name itself tells you something. He calls it a brand altering experience.



Next, the Prozac Monologues take on the matter, a rerun from September 23, 2011

Differently Abled - More, Please

It's like he is in a world of his own. The first grade teacher, old school, same worksheets for the last thirty years, did not mean it as a complement.

Robert Spitzer Apologizes

Robert Spitzer -- some people call him the Father of Modern Psychiatry.  In 1980 he took the DSM II, widely criticized for unreliability and lack of validity, and as editor of the DSM III, turned this obscure publication of the American Psychiatric Association into the standard reference work that defined every psychiatric disorder we've got.  It was research-based.  It listed objective criteria.  It was honkin' big, but it could be understood, not only by researchers, but also by practitioners.

Spitzer's acolyte, Allen Frances edited the DSM IV, which added a lot of information, but did not change Spitzer's basic framework for how these diseases are characterized.  Frances was a consultant for the DSM V, until he quit, basically because the new editors started to rethink things.  Frances now leads the charge against the DSM V, which has delayed its publication.  I won't develop that theme right now...

Robert Spitzer is the Man.

With Great Power Comes Great Responsibility

Grief/Depression IV - Not the Same/Maybe Both

So a woman goes into the doctor's office, three weeks after her husband died. I got through the funeral just fine. But now I feel awful. There is this ten ton weight on my chest. I'm exhausted; I don't have the energy to wash the dishes. I'm trying to pack up my husband's things, and I am too weak to pick up his shoes. I can't eat. Sometimes I get hit so hard with this wave of anxiety, I think I'm going to throw up.

What are the chances the doctor will say, Of course you feel awful. These are all very natural symptoms of grief. You just need time. But if you still feel like this a month from now, call my nurse and set up an appointment. What are the chances the doctor will not pull out the stethoscope and listen to her chest?

Answer: It depends on whether the doctor is stupid.

Or a psychiatrist.

These are classic symptoms of heart disease. There is significant overlap between the symptoms of heart disease and the experience of grief. But there is no Bereavement Exclusion for a diagnosis of heart disease. Instead, family physicians and cardiologists take the time to examine whether the person presenting these symptoms may have both.

Grief/Depression II - Rise in Rates of Mental Illness

Are we really getting sicker?

A New York Times article, When does a broken heart become a diagnosis? sells papers with its usual technique - latch onto a fringe element and substitute good writing skills for substantive analysis.

I am all for good writing skills, and perhaps stumble in the same direction at times. But depression is my beat. So God willing and the brain permitting, I am going to beat this bit to the ground. Two weeks ago I discussed three contexts for the discussion, the cost of health care, the scientific value of the DSM and the hobby horse of the author featured in the Times article. I promised more contexts to come.

Are We Getting Sicker? - Context IV

James Wakefield's thesis is that we are turning natural human emotions, (the ones we want to get rid of, because they are unpleasant), into a diagnoses. His beat is depression, as well, but the Times is on this bandwagon with autism and no doubt other diagnoses to come.

Well, I grant some validity to the concern in general. Is it shyness or Social Anxiety Disorder? Is it artistic nonconformity or Attention Deficit Hyperactivity Disorder? Is it the sleep disruptions of normal aging or Overactive Bladder Disorder? Was it all those wings, doritos and beer you guzzled Superbowl Sunday (and most Sundays), or Gastroesophageal Reflux Disease?

Grief? Depression? Both?

The New York Times reports this week on a proposed change to the definition of depression for the Diagnostic and Statistical Manual (DSM) V. Asking, When does a broken heart become a diagnosis? it raises the specter that normal grief at the death of a loved one could be classified as a psychiatric disorder.

An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward, said Dr. Jerome Wakefield, author of The Loss of Sadness. This would pathologize them for behavior previously thought to be normal.

Okay, before we get our knickers in a twist -- oops, too late. Knickers in a twist is the current US national pastime. Nevertheless, there is a larger context here. Several, in fact.

DSM Context I - Follow The Money

Narrative and the DSM

My therapist once picked up the DSM and said, This could be called The Book of Behaviors That Make Therapists Nervous.

An apt description.  It is filled with descriptors: adjectives, behaviors, impulses, thoughts, feelings that are all human adjectives, behaviors, impulses, thoughts and feelings.  Almost none of them are strange in and of themselves.  Almost all of them are familiar to all of us.

It's just that at some point, when these descriptors add up, somebody starts to get nervous.

Diagnosis -- Recognizing Deviation From The Norm

I Told Them I Was Sick - DSM Revisited

Have you heard about the man whose tombstone read, "I told them I was sick"?

A New Diagnosis Or Two

So, the docs earned their big fee and the Pension Fund got its money's worth out of this three-day psychiatric evaluation.  I have a couple new diagnoses.

That is really not so remarkable.  If you attend a Peer to Peer course, NAMI's signature ten-week self-help program for loonies, you know this.  One week, the participants go round the circle and tell their diagnoses, or rather, their history of diagnoses.  Most trace a whole tour through the DSM, the Diagnostic and Statistical Manual.

Where Diagnoses Come From

Differently Abled - More, Please

It's like he is in a world of his own. The first grade teacher, old school, same worksheets for the last thirty years, did not mean it as a complement.

The mom was confused. She asked her son's Montessori preschool teachers for their take on it. They, too were confused. Then the light dawned. The way they put it was, He has immense powers of concentration. They thought he was marvelous.

The problem was, he was still absorbed by the story he was writing, when the first grade teacher had moved on from writing to math. The world he was in was not her world.

His second grade teacher recommended him for the Talented and Gifted program.

His fifth grade teacher thought he had ADHD.

People who are different get diagnosed. The Diagnostic and Statistical Manual (DSM) is all about describing the various ways we don't fit. But if you can pass for normal, you don't have a disability. If they can pick you out in that One of These Things is Not Like the Others game, then you do.

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