Thursday, February 11, 2010

More Proposed DSM Revisions

Besides the unification of all the autism-spectrum conditions under a single, simplified definition (which I generally consider a Good Thing, despite the reservations I mentioned in my earlier post; this post of Amanda Forest Vivian's captures what I think is good about it quite well) and the elimination of Rett's Disorder from the DSM entirely, the DSM-V revisions include lots of other interesting ideas.

These include:

- Adding Binge Eating Disorder to the Eating Disorders category

- Eliminating amenorrhea (loss of one's mentrual period) from the criteria for Anorexia Nervosa, which would finally allow men who meet all of the remaining criteria to be diagnosed with full-blown anorexia rather than with the vague, often-minimizing label Eating Disorder Not Otherwise Specified

- Adding a childhood mood disorder called Temper Dysregulation with Dysphoria, which would be characterized by irritability and frequent temper tantrums; this disorder is meant as an alternative diagnosis for many of the children who are (or would be) now diagnosed with bipolar disorder

- Consolidating the personality disorders into five broad, yet-to-be-determined categories

- Adding "Hypersexual Disorder" and Paraphilic Coercive Disorder (in which the person is turned on by the idea of raping another person) to the Sexual and Gender Identity Disorders category

- Expansion of the DSM-IV's Substance-Related Disorders category (which included substance dependence and abuse) to a broader Addiction and Related Disorders category, which will include non-chemical, "behavioral" addictions like gambling; Internet addiction was considered for inclusion in this category, too, but ultimately discarded

Some of these proposed changes --- the two eating-disorder changes I mentioned, as well as the decision to remove some problematic wording from the criteria for anorexia, for instance --- are unadulterated Good Things, and were very much needed. (I'd actually argue, along with Rachel and her commenters, that the reforms to the anorexia criteria didn't go far enough; that BMI should not be the gauge of severity of anorexia because it misses those people who might be restricting their eating and obsessing about food, weight and body image just as severely as someone with diagnosable Severe Anorexia, but who, due to individual metabolic variation, never become underweight.) Others, like the addition of Temper Dysregulation with Dysphoria as a new childhood disorder, the concept of "risk syndromes" for psychosis and dementia, are a mixed bag. They might be helpful, or they might result in more people being marginalized, losing autonomy and/or being pressured to take powerful antipsychotic medications for illnesses that, in the case of the risk syndromes, aren't even present and may never be.

Also in the mixed-bag category is the DSM-V's formulation of Gender Identity Disorder (renamed Gender Incongruence, in an attempt to be less stigmatizing), which it splits into two main categories, one for children and one for adolescents and adults. Good things about the new criteria include the aforementioned move toward value-neutral language, its acknowledgement that sex and gender, even for transgendered people, aren't always binary (there's a long history of doctors "gatekeeping" sexual reassignment surgery, hormone therapy and other medical procedures associated with transition, restricting these things to those trans people who conformed most rigidly to the conventional role of their chosen gender) and its stress on whatever the individual trans person wants as the desired outcome. What's not as good is the retention of the notion of autogynephilia --- sexual fetish as motivation for transition --- in the category of Transvestic Fetishism, and the presence of stricter, gender-binary-enforcing language in the criteria for pediatric Gender Incongruence.

Finally, the creation of Hypersexuality as a new sexual disorder strikes me as colossally wrongheaded. Like sexual addiction --- which is not recognized in the DSM-IV, but which has gained popular acceptance in the addiction-recovery community --- this category would be inherently biased against people with unconventional sexualities: kinky people, swingers, polyamorists, even, depending on how conservative a community the person being evaluated comes from, gay and bisexual people. I also disapprove of the existence of this category for the same reason I disapprove of Hypoactive Sexual Desire Disorder: merely wanting/having sex to a greater or lesser degree than most people do isn't pathology, it's variation.


Sadderbutwisergirl said...

Psychiatry has always been there for the sole purpose of enforcing social norms. I was having an argument with a friend of mine about this as we were discussing Fahrenheit 451. One of the characters is considered "anti-social" because her non-technological interests are considered abnormal. Because of this, she is forced to see a psychiatrist. Another practice within the novel is that whenever someone is caught with books in their possession, their house and books are burned and they are taken to the asylum. My friend said, "This is how screwed up the society is in the book. People are actually assumed to be crazy just for owning books or shunning technology!" I rebutted that argument as so: "The psychiatry business has always been this oppressive towards those considered abnormal. The only reason it is meant to seem disturbing to Bradbury's audience is that it's a different set of social norms than what his audiences are used to."

Stephanie said...

Psychiatry and psychology is generally a way to explain observed behaviors. The science itself has the inherent flaw that it is subject to the priveleges and biases of the observers, with few ways to scientifically verify or control the influence these biases have on the resulting explanations. I don't know if there is any way to resolve the study of psychology to focus more on the individual's perceptions than society's perceptions of the individual, but advocacy seems like the best way to push that available. At best, psychology is incomplete without taking into account the individual's perspective; at worst, it is, as Sadderbutwiser suggests, merely a vehicle to enforce social norms. But I would contend that the latter is a result of how it is applied; not an inherent flaw of the discipline itself.

Maria said...

Another proposed change I haven't heard many people talk about - creation of official diagnostic label "Non-Suicidal Self Injury".

Currently, many people who self-harm being mislabelled "borderline personality disorder", even if they meet few of the other criteria (at least, not to a greater extent than a typical teen/young adult!). "Borderline" label one with very negative associations, stigma, can mean prejudicial (non)treatment etc.

Having an alternative diagnosis to stop *that* from happening should be a good thing?