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#1 TheLeviathan

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Posted 01 February 2013 - 09:57 PM

Anyone else really getting concerned about some of the changes in the DSM?

Summary of Concerns Regarding the DSM-5 as Currently Proposed

Disruptive Mood Dysregulation Disorder in DSM-5: Criticism of a new diagnosis. - Slate Magazine

The first link has an obvious slant, but I've been getting more and more concerned about how broad the labels for mental illness are becoming. Was just throwing it out there because it's been on my radar for awhile and we're getting closer to an update.

#2 PseudoSABR

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Posted 02 February 2013 - 12:29 AM

I'm going to look into this, but to be fair, I've got all kinds of problems with the DSM IV, disordered diagnosis in general. I'm so out of the loop these days, I didn't even know they were updating their central text.

#3 TheLeviathan

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Posted 02 February 2013 - 08:00 AM

I didn't either until about two weeks ago and I'm in the same boat as you. I didn't bring it up after the Newtown incident with all the mental health talk, but to me the DSM is a central part of our problem in the mental health world today. People like to blame insurance companies, but I point my finger here first. I'd be curious to know what you think after you look into it a bit, I'm holding back on my full opinion obviously. Was interested in ben's take too.

#4 biggentleben

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Posted 02 February 2013 - 10:42 AM

It's been in the works for 2 years as we were asked to give input at quite a wide spectrum of things in early 2011. What's interesting is that neither articles discuss the personality disorders being removed from the DSM-V reportedly (because even the authors haven't seen the true final version yet). For instance, in the new DSM, there is not such a thing as multiple personality disorder, and disassociative personality disorder (where multiple personalty was brushed into when it was removed in the DSM-IV) will be drastically rewritten or completely removed to combat overdiagnosis of a personality disorder.

One thing that intrigues me, having worked with adults primarily, but also spending some times with our children's unit, is the tantrum disorder. I had not heard of this, but it actually makes a ton of sense for the reasoning explained. A personality disorder is not addressed with medications as a primary method of treatment. Diagnosing that same child as having bipolar disorder of any type means medication is the initial method of treatment, meaning children as young as 6 years old will now be getting behavior modification treatment rather than throwing drugs down their throat and never approaching the real issue.

The major issue here is the broadening of diagnostical allowances. In order to be eligible for certain programs and insurance, one must show they have a severe and persistent mental illness (SMI). Where this most often gets abused is not to acquire Social Security disability payments or Medicaid, but in the court of law. Social Security and Medicaid/Medicare require psychiatrists with very good reputations (as determined by those organizations) to make/confirm the diagnosis of SMI. In South Dakota, for instance, there are less than a dozen such psychiatrists that can make that determination in the whole state. In the court of law, any psychiatrist holding active certification and degree will be allowed to render whether a person is sane or not at the time of criminal activity in any state at this time. Some states even allow for those with state certifications and an MSW or related master's level degree to be used in determination for court of law. Broadening the definitions to qualify for SMI won't really change how many people get benefits, but it could have a drastic change on our legal system, and honestly, that's not an area I can really address with a lot of knowledge as far as the effects on increased SMI diagnosis in our prison system.

Overall, a lot of the things leaked to our psychiatrist in our agency have been clarifications on broad statements about SMI that made diagnosing too subjective in his eyes. Perhaps that's because he had direct input on those areas that he's been leaked them, but he has reported being pleased with changes made for the ability of mental health professionals to more accurately treat consumers. As far as the overall manual, I'll have to withhold judgement on the totality until I've had a chance to see it.

Edited by biggentleben, 02 February 2013 - 10:46 AM.

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#5 TheLeviathan

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Posted 02 February 2013 - 12:06 PM

One thing that intrigues me, having worked with adults primarily, but also spending some times with our children's unit, is the tantrum disorder. I had not heard of this, but it actually makes a ton of sense for the reasoning explained. A personality disorder is not addressed with medications as a primary method of treatment. Diagnosing that same child as having bipolar disorder of any type means medication is the initial method of treatment, meaning children as young as 6 years old will now be getting behavior modification treatment rather than throwing drugs down their throat and never approaching the real issue.


I'm sorry, but these days those are the same thing. If anything, this opens the door for MORE medicating of children. Which is precisely my worry and my growing concern that while the panel determining the DSM swears it has no self-interest and no ties to drug companies, the changes in the last two have both forced me to be less confident in that.

We are having a real shift in this country to believe that everything can be explained by "mental illness". For one, as you talk about slightly later in the post, people have trouble seeking out mental help. But here's the thing, there are always going to be limited resources - insurance companies are not. How we meet the need beyond those resources is with drug companies. So health insurance to me, is a lame excuse. If we continue to expand the realm of what qualifies as a "need" we'll be unable to meet it regardless of how health insurance is constructed.

Personally, I'd much rather reserve mental health diagnoses and services for those that truly need it. I think we're getting away from that with this constant expansion of the definitions. What happens then is the truly needy get lost in a sea of people who aren't nearly as needy.

#6 biggentleben

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Posted 02 February 2013 - 06:30 PM

I'm sorry, but these days those are the same thing. If anything, this opens the door for MORE medicating of children. Which is precisely my worry and my growing concern that while the panel determining the DSM swears it has no self-interest and no ties to drug companies, the changes in the last two have both forced me to be less confident in that.

We are having a real shift in this country to believe that everything can be explained by "mental illness". For one, as you talk about slightly later in the post, people have trouble seeking out mental help. But here's the thing, there are always going to be limited resources - insurance companies are not. How we meet the need beyond those resources is with drug companies. So health insurance to me, is a lame excuse. If we continue to expand the realm of what qualifies as a "need" we'll be unable to meet it regardless of how health insurance is constructed.

Personally, I'd much rather reserve mental health diagnoses and services for those that truly need it. I think we're getting away from that with this constant expansion of the definitions. What happens then is the truly needy get lost in a sea of people who aren't nearly as needy.


I get the concern, but I don't see any way this leads to more medication of children just with that added diagnosis. You cannot treat a personality disorder with medication, and it'd frankly be a legal nightmare to defend any person without a diagnosis beyond personality disorder causing any self (or public) harm with an anti-psychotic. The treatment for any personality disorder is behavior modification, such as CBT, DBT, or ACT therapy strategies.

A big part of the issue with lack of available service also has to do with the lack of ability for anyone but a psychiatrist to make decent money working in mental health, and even a psychiatrist goes to school as long as any other doctor and, depending on which study you read, sits on the bottom of the average salary of a position requiring an MD degree. I could not work in social work in Minnesota because my undergraduate happens to be in Marketing. The near-decade that I've worked in social services has no bearing whatsoever. Minnesota requires licensing, and to obtain that licensing, I need a bachelor's in the field of social work (including psychology, counseling, etc.) plus experience or a master's degree. I wouldn't even be able to be hired for my current job if I came in with the experience I had when I was originally hired because South Dakota now requires a bachelors in a social work field or a minimal amount of experience (and the latter requires a petition to the state just to make an offer to a candidate). Making it harder and harder for those who have a heart to do the job to get into the field simply means the folks in the job, who are quite underpaid, have no issue being for sale. Who's going to stop them?

I will tell you that my boss recently went through our office and removed anything (pens, sticky notes, clocks, etc.) that had a drug company's logo on it. It cost significant dollars to replace medication trays and a number of other items that had been given by drug companies in the past. There are people out there doing what is best for consumers and what is right, but all too often, much like the iPhone toting welfare recipient, people are skewed in their thoughts by the bad apples.
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#7 TheLeviathan

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Posted 02 February 2013 - 07:25 PM

The treatment for any personality disorder is behavior modification, such as CBT, DBT, or ACT therapy strategies.


I can assure you, as someone that has worked primarily with children, that it is almost never limited to behavior modification.

Also I would suggest you read the article and think about it, we treat personality disorders with medication all the time. We've become a society that feels you can rebalance any chemical imbalance and "fix" mental illness. Behavior modification is time-consuming, lengthy, expensive, and requires a lot of manpower. It's why we've shifted so heavily to medication. The link from Slate lays a lot of this out.

Edited by TheLeviathan, 02 February 2013 - 08:29 PM.


#8 biggentleben

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Posted 02 February 2013 - 08:35 PM

I can assure you, as someone that has worked primarily with children, that it is almost never limited to behavior modification.

Also I would suggest you read the article and think about it, we treat personality disorders with medication all the time. We've become a society that feels you can rebalance any chemical imbalance and "fix" mental illness. Behavior modification is time-consuming, lengthy, expensive, and requires a lot of manpower. It's why we've shifted so heavily to medication. The link from Slate lays a lot of this out.


Nah, how they do that is they tab another diagnosis with it. I've yet to treat someone who's a pure personality disorder in my work, mainly because I work with a very intense unit of those just one step away from the step hospital. Even if the major issue is a personality disorder, there is often a diagnosis like bipolar along with it in order to validify using anti-psychotics. However, lesser intensive personality disorders would have great difficulty being diagnosed with anything else because they wouldn't exhibit any of the physical symptoms.
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#9 TheLeviathan

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Posted 02 February 2013 - 08:44 PM

Nah, how they do that is they tab another diagnosis with it. I've yet to treat someone who's a pure personality disorder in my work, mainly because I work with a very intense unit of those just one step away from the step hospital. Even if the major issue is a personality disorder, there is often a diagnosis like bipolar along with it in order to validify using anti-psychotics. However, lesser intensive personality disorders would have great difficulty being diagnosed with anything else because they wouldn't exhibit any of the physical symptoms.


Just what are you counting as a personality disorder? Are you splitting hairs over whether medications are prescribed for the diagnosis vs. symptoms of it? Because to me that's a bit silly, even if no medication specifically is being given for that diagnosis it will, inevitably, open the door for the same kinds of medications other personality disorders have for symptoms.

One diagnosis is often the open door needed for more to follow.

#10 biggentleben

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Posted 02 February 2013 - 10:18 PM

Just what are you counting as a personality disorder? Are you splitting hairs over whether medications are prescribed for the diagnosis vs. symptoms of it? Because to me that's a bit silly, even if no medication specifically is being given for that diagnosis it will, inevitably, open the door for the same kinds of medications other personality disorders have for symptoms.

One diagnosis is often the open door needed for more to follow.


Personality = borderline, antisocial, disassociative (though that's going away), OCD, PTSD.

You can rail on treating symptoms vs. treating disease, but it is a major distinction. You don't give a borderline Clozapine without a primary diagnosis requiring it. All personality disorders are classified as Axis II disorders, meaning they are not to be a primary diagnosis in medication.

I can tell you from the families who have struggled with a child out of control (far beyond the description in your first post, mind you), having a diagnosis and knowing treatment options is often akin to the cancer patient hearing the word "remission". It's huge, monumental. Yes, it's a "label", but in more cases than not, that label then allows for progress to be made in order to allow the person to live the life they were created to live.
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#11 TheLeviathan

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Posted 02 February 2013 - 10:55 PM

You can rail on treating symptoms vs. treating disease, but it is a major distinction. You don't give a borderline Clozapine without a primary diagnosis requiring it. All personality disorders are classified as Axis II disorders, meaning they are not to be a primary diagnosis in medication.


The distinction in terms of how you used it is irrelevant. Fact is, most diagnoses for any personality disorder come with medications for symptoms. Without that diagnosis, these kids will not be able to be medicated. It's very much the gateway to drugging them. If more kids are being labeled - there will be more medicated. Your distinction about what is being treated with drugs is irrelevant to this discussion.

I can tell you from the families who have struggled with a child out of control (far beyond the description in your first post, mind you), having a diagnosis and knowing treatment options is often akin to the cancer patient hearing the word "remission". It's huge, monumental. Yes, it's a "label", but in more cases than not, that label then allows for progress to be made in order to allow the person to live the life they were created to live.


Are we not discussing the problems detailed in the first post? Please don't twist the point. I'm not dismissing the value of a diagnosis for kids who truly need it. In fact, I'm trying to preserve the difference between "need" and "convenient". We have been moving in this direction for the last decade and this DMDD is many of those worst fears come to life. That's exactly the point.

I haven't even touched on a number of the other points in the Slate article, but the truth is we are moving more and more to a world in which we are all "mentally ill". In such a world, I doubt those who truly are mentally ill will get nearly the degree of help they need because we have minimized and trivialized that term so greatly that it, in fact, becomes normal.

Edited by TheLeviathan, 02 February 2013 - 10:58 PM.