It is often assumed by the general public that psychological diagnosis is a normal part of therapy that always occurs. Some people who have been in therapy may be unaware they have received a diagnosis. For their part, therapists have a wide range of views and practices pertaining to diagnosis, ranging from seeing it as essential to seeing it as unnecessary. Consumers have a right to know the advantages and risks of diagnosis.

Advantages of Diagnosis

Some people find relief and validation in receiving a diagnosis, as it symbolizes they are not alone. This can decrease the guilt, shame, and feelings of isolation that often are experienced. Diagnosis can also open up resources. This may be true, in particular, for children who are struggling with challenges in their social, emotional, and behavioral functioning.

For professionals, diagnosis can be a good way to quickly and easily communicate information, helping them to be more informed when working with a person in treatment. Also, diagnosis is often required for insurance to pay for therapy, which is a significant financial benefit.

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Risks of Diagnosis

The risks of diagnosis are less frequently acknowledged. Most people I work with in therapy are surprised when I discuss the advantages and disadvantages of diagnosis with them; almost all who previously have been in therapy note that no therapist has done this with them before. But there are indeed risks, and consumers have a right to be aware of them.

Diagnoses often stick with people. I have had people who came to me for therapy with a previous diagnosis that followed them from childhood well into adulthood. In some cases, it was quite clear they were misdiagnosed early on, yet the label stuck with them. Diagnoses can also change over time and may no longer be accurate.

Further, diagnoses can be misunderstood by those outside the mental health profession. I have spoken with many previously diagnosed people who, upon sharing this with people they trusted, found it changed their relationship and, in some cases, ended it.

What Is Diagnosis?

What constitutes a diagnosis is debated by therapists (Kinderman, 2017). In essence, a psychological diagnosis is a label placed on a group of behaviors or experiences that are often called symptoms. The determination of what amounts to a diagnosis is determined largely by what is considered “normal” or average. There are some who maintain that diagnosis almost always has a biological origin, while others believe it tends to emerge largely from personal or social experience. Many believe it may be a combination of these two.

At times, a diagnosis can lead to focusing solely on the symptoms of that diagnosis, without considering the challenges or thought processes that may be contributing factors. This can limit the understanding of you, your concerns, and what you want from therapy.

A cluster of symptoms that fit a diagnosis may emerge from different causes. For example, depression may result from having endured difficult experiences in life or may, at times, have a biological cause. Yet, some assume that, regardless of whether there is a social/personal cause or a biological cause, the treatment of a condition should be through medication. This is a concern of many therapists who have witnessed therapy, without medications, successfully treat many conditions.

At times, a diagnosis can lead to focusing solely on the symptoms of that diagnosis, without considering the challenges or thought processes that may be contributing factors. This can limit the understanding of you, your concerns, and what you want from therapy.

After the release of the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013, many therapists were upset with the changes (Kinderman, 2017; Robins, Kamens, & Elkins, 2017). These changes included a general lowering of the threshold of the criteria to give people certain diagnoses. Some therapists voiced concern that this could lead to medicating people who do not need medication.

In the end, psychological diagnosis is based in part on science, in part on theory, and in part on the politics of the field of psychology. There is much that remains unknown and much that is hotly debated. I generally urge caution when any mental health professional is married to any one perspective on diagnosis and does not acknowledge other views.

Consumer Rights with Diagnosis

I believe that, in most instances, consumers should be part of the decision about whether to be given a diagnosis. It is not something that should be imposed upon the consumer without their input or perspective. Here are my recommendations for consumers regarding diagnosis:

• If your therapist does not bring up diagnosis in the first session, ask if they are going to give you a diagnosis and what the diagnosis is.
• Ask what the diagnosis means and your therapist’s reason for giving you the diagnosis.
• If you do not want to be diagnosed, tell the therapist. They may be required to give a diagnosis if you are using insurance; however, you have a right to be a part of that discussion.
• You have a right to ask how the therapist will use the diagnosis.
• If you believe your therapist is treating you like a diagnosis and not like a person, discuss this with them.
• Ask your therapist how your diagnosis may impact you.
• If you are not comfortable with your therapist’s approach to diagnosis or the diagnosis they give, get a second opinion or consider finding a different therapist who may be a better fit for you.

Diagnosis can be a difficult issue for therapists and consumers alike. It is best approached as a collaborative process within the therapeutic relationship. Regardless, you have a right to know what is going on with your diagnosis.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th). Washington, DC: Author.
2. Kinderman, P., Allsopp, K., & Cooke, A. (2017). Responses to the publication of the American Psychiatric Association’s DSM-5. Journal of Humanistic Psychology, 57, 625-649.
3. Robbins, B. D., Kamens, S. R., & Elkins, D. N. (2017). DSM-5 reform efforts by the Society for Humanistic Psychology. Journal of Humanistic Psychology, 57, 602-624.

Definitions convey meaning, but in the mental health field they have also historically wrought serious consequences, often while reflecting progress, procrastination, and prejudice.

As words, concepts, and public perceptions evolve along with modern psychology, clarifying certain words can help reduce suffering, encourage treatment, and eliminate the stigma often associated with mental health conditions. However, terms that are outdated, inaccurate, or just ill-conceived can be spread by institutions, media, and fear while halting needed progress.

In recent decades, greater attention has been paid to accurately shaping definitions of conditions, symptoms, and diagnoses. The afflicted—as they were once widely called and viewed—are now more appropriately seen as individuals exhibiting symptoms of a condition.

Words such as “affliction” and “sufferers” can each connote a literal meaning that projects negativity or suggests a threat. Such unsound terms have, in part, been responsible for much of the stigma that still affects the conversation surrounding mental health.

Language, when used by health care professionals, can carry even more weight in shaping public perception and policy. When outdated terminology is implemented professionally or at the public policy level, false meanings may become institutionalized, potentially extending their lifespan by decades.

What’s in a Word?

A 2010 study from the Centers for Disease Control and Prevention (CDC) examined the historical use of the term “wellness” over “illness” in the mental health field, noting each carries a clear but opposing distinction—even when used interchangeably.

One suggests positive energy, enthusiasm, and life itself, while the other reflects the presence of a disease. The CDC report posits, “the major focus of (mental) health reform should be to promote wellness and well-being.”

While more general words like “wellness” are broad and used with considerable flexibility, the greater issue definition-wise is with more specific terms that directly depict false or misleading information. Through ambiguity and assumptions, a thick glossary of malleable terms persists.

[fat_widget_right]A study last year in the journal Frontiers in Psychology examined the issue and aimed to “promote clear thinking and clear writing among students and teachers of psychological science by curbing terminological misinformation and confusion.” The study’s authors offered a provisional list of 50 commonly used terms that they recommended should only be used sparingly or completely avoided.

The spotlighted terms were a mixture of inaccurate, misleading, and often misused definitions. These included:

Closure

Described by the authors as “hopelessly vague,” closure is challenged in its popular meaning as a “purported experience of emotional resolution” following a trauma. The authors point to a lack of specificity and research to support the idea that it will be clear when trauma victims reach a desired end to their emotional state.

Personality Type

Categorizing personalities into neat little boxes—such as introvert or extrovert—is still common, even among many medical professionals. This continues despite little significant evidence for the accuracy or completeness of such labels, which often overlook the nuanced degree of various personality traits.

Scientific Proof

It is often premature to suggest certainty while forgetting that science is provisional and always evolving. The concept of scientific confirmation can convey a clarity that clashes with the self-correcting nature of the field. As the authors suggest, no theory should be viewed as strictly proven, as all theories may end up being overturned by additional evidence.

Chemical Imbalance

Despite slim scientific credentials, the notion that mental health conditions such as depression are sparked by a chemical imbalance of neurotransmitters in the brain has become an assumed truth. This is largely unsupported, and some treatment methods contradict any available evidence suggesting there even is an optimal level of neurotransmitters in the brain.

Brainwashing

The idea that long-term perceptions and behavior can be altered through conditioning is not science fiction. Real and positive benefits from changing perceptions and attitudes are possible, but the idea of scrubbing the mind—either voluntarily or involuntarily—suggests erasing emotion rather than treating symptoms. According to the report, the techniques generally used in “brainwashing” are similar to those used in typical persuasion.

Autism Epidemic

The media likely bears much responsibility for the idea that a sudden rash of autism has been seen in recent years despite little corroborating evidence. What did increase were the actual diagnoses as both parents and professionals became more aware and informed about the condition. The most recent version of the Diagnostic and Statistical Manual (DSM) also lowered the diagnostic threshold for the condition, which likely resulted in increased diagnoses.

When outdated terminology is implemented professionally or at the public policy level, false meanings may become institutionalized, potentially extending their lifespan by decades.Genetically Determined

While genes can certainly influence psychology, the idea that they flatly determine psychological capacities is inaccurate. The concept may even deter treatment in individuals who might see a condition as irreversible. Believing something is genetically determined usually does not leave enough room for undetermined environmental influences.

Hard-wired

Similar to “genetically determined,” the idea that an individual might be innately predisposed to a given psychological framework (based on gender, for instance) is challenged by research. Studies have shown growth in data on neural plasticity, meaning only few things are completely inflexible in behavior expression. Most capacities, such as language and emotions, can be modified by the environment.

Underlying Biological Dysfunction

Another innate concept is the suggestion that certain psychological conditions or variables are biologically prepackaged. This approach often ignores other factors or even additional conditions at play beyond simple biology.

Multiple Personality Disorder

Though it was relabeled as dissociative identity disorder (DID) in the DSM in 1994, the perception that multiple personalities develop within a single individual is still widely held in many academic sources. Continued use of the misnomer perpetuates a view that falsely depicts people experiencing DID, while promoting stigma associated with DID and other mental health conditions as well.

The Evolution of the DSM

The industry’s touchstone for many years has been the DSM, from the American Psychiatric Association. The fifth edition was released in 2013, and like previous updates, it caused controversy and confusion upon its arrival. Dropped from the manual that year was the classification of dyslexia as a learning disorder, while Asperger’s syndrome was folded into the autism spectrum diagnosis.

The beauty of psychology as a science is its ability to change to more accurately define itself. The challenge is conveying such concepts in an open and honest exchange—ever aware of the consequential power mere words can wield.

References:

1. Lilienfeld, S. (2015, August 3). Fifty psychological and psychiatric terms to avoid. Retrieved from http://journal.frontiersin.org/article/10.3389/fpsyg.2015.01100/full
2. Manderscheid, R. W. (2010, January 9). Evolving definitions of mental illness and wellness. Retrieved from http://www.cdc.gov/pcd/issues/2010/jan/09_0124.htm
3. (2012, January 20). Word of drastic changes to DSM-V autism definitions reaching the mainstream press. Retrieved from http://www.pediastaff.com/blog/word-of-drastic-changes-to-dsm-v-autism-definitions-reaching-the-mainstream-press-6671

is inextricably linked to cultural norms, and the latest version of the Diagnostic and Statistical Manual of Mental Disorders—psychiatry’s diagnostic bible—makes this readily apparent. Although sexual kinks are still a source of cultural controversy, their taboo status is steadily lifting, and the DSM-V treats unusual sexual behavior differently than previous versions of the manual.

Changing Sexual Norms

A little over a century ago, Sigmund Freud, modern psychiatry’s godfather, argued that clitoral orgasms were a sign of immature sexuality. For Freud, healthy adult sexuality meant nothing less than a vaginal orgasm. Contemporary sex researchers now emphasize the fact few women can reach orgasm with vaginal stimulation alone, and sex therapists frequently advise people having trouble with orgasm to focus on the clitoris. There have been other advances in thinking, of course, when it comes to sexuality. Until 1973, homosexuality was listed as a disorder in the DSM. Contemporary psychologists and psychiatrists now condemn conversion therapy, a treatment designed to “cure” homosexuality.

Contemporary sexual fetishes run the gamut. Many people have engaged in or acted on some form of sexual fetish at one time or another, and groups dedicated to advocating for the rights of those with unusual sexual interests have sprung up all over the Internet. More and more sex researchers recognize these behaviors as part of a sexual continuum and not necessarily indicative of a mental health issue.

The DSM-V’s Stance

Like their predecessors, contemporary mental health professionals frequently wrestle with the intersection of cultural norms and mental health, and the new DSM reflects this ongoing dialogue. Previous editions of the manual listed atypical sexual behaviors as diagnoses. For example, the DSM-IV listed the behavior of sexual masochism as a disorder. The new version, however, is largely silent on behavior, and defines fetishes as problematic only when they cause significant distress. Thus, masochistic behavior is now termed sexual masochism disorder only when the behavior causes problems for the individual.

When Is a Kink a Problem?

So when does a sexual kink cross the line into a disorder diagnosis? Some sexual behavior is inherently disordered, according to the new manual. For example, pedophilia remains a diagnosis because it’s impossible to act on a sexual attraction to children without breaking the law or causing harm to others. But for those who are blissfully dedicated to feet, bondage, or garter belts, the manual no longer defines the behavior itself as a problem. Instead, the so-called disorder is partially in the eye of the beholder. If your sexual fetish causes serious problems in your romantic relationships or significant personal distress, it may be time to consult a professional. Otherwise, the creators of the DSM-V are content to allow people to engage in whatever sexual behavior they want to without finding issue.

Ongoing Controversy

Not everyone is happy with the changes to the manual. Sex-positive writers and researchers point to the fact the new book still provides a list of sexual fetishes, which serves to label some sexual behaviors as inherently deviant even when they don’t cause problems. And the fact the DSM has changed its approach to diagnosis doesn’t mean every mental health professional has followed suit. The American Association of Sexuality Educators, Counselors, and Therapists publishes a list of therapists who adopt a nonjudgmental stance toward kinks. People who engage in non-normative sexual practices such as swinging, polyamory, and sexual fetishism report that they often struggle to find professionals who don’t view their behavior as deviant.

References:

1. Paraphilic disorders [PDF]. (n.d.). Arlington: American Psychiatric Publishing.

2. Parry, W. (2013, May 30). Normal or not? A sexual attraction to objects. LiveScience.com. Retrieved from http://www.livescience.com/36982-is-fetish-normal-dsm5.html

3. Savage, D. (n.d.). Finding a sex-positive therapist isn’t always easy. Creative Loafing Charlotte. Retrieved from http://clclt.com/charlotte/finding-a-sex-positive-therapist-isnt-always-easy/Content?oid=3043389

The new revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the long-standing resource of mental health diagnoses, has been met with criticism from virtually every corner of mental health advocacy. Despite the often-aggressive criticism of the DSM, however, many mental health experts were surprised when the National Institute of Mental Health, which is the largest organization of mental health research, and a significant source of funding for mental health researchers, issued a statement that was harshly critical of the updated manual, the DSM-V.

Headlines in the popular press have treated this development as a shock to the mental health world and a complete torpedoing of the DSM. The reality, however, turns out to be a lot more nuanced. The NIMH is not withdrawing support for the DSM-V. Instead, it is developing its own mental health diagnostic system that it believes will be more useful than the DSM. The NIMH’s statements about the DSM in recent months have been very critical, and a statement on the NIMH website reads, in part, “Patients with mental disorders deserve better.”

The NIMH’s Concerns
The NIMH has raised several concerns about the new DSM-V in particular, as well as general traditions in diagnosing mental health issues. Particularly troubling to the NIMH is the fact that mental health diagnoses are based primarily upon symptoms, and that experts diagnose diseases based upon agreed-to symptoms rather than tests, such as blood work. This, argues the NIMH, makes the diagnostic standards in the NIMH less valid than diagnostic standards in other areas of medicine.

Noah Rubinstein, GoodTherapy.org founder and CEO, said, “It makes sense that NIMH, in its support of the disease model of mental health, would focus on biological markers rather than symptomology, and thus reject the DSM-V. However, the purpose of the DSM‘s historical focus on symptoms is to remain atheoretical and preclude any explanation about the etiology of the various diagnoses.”

Biological Psychiatry
The NIMH’s new mental health diagnostic guidelines might not please many critics of the DSM. The new model will focus on biological psychiatry, a field that understands mental health disorders as diseases caused by problems with brain chemistry or the nervous system. “For many of the syndromes listed in the DSM, underlying causes have always been up for interpretation, and the APA has not wanted to take a theoretical stance,” Rubinstein said. The NIMH intends to work on uncovering genetic markers for mental illness as well as brain pathways and nervous system functions that can contribute to the development of mental illness. Diagnostic criteria will then be based around biological functions rather than similar symptoms.

But there are reasons to hesitate about this approach. “Indeed, there are some mental health disorders that could be argued as purely biologically based,” Rubinstein said. “However, many of the issues that bring people to therapy do not necessarily have biochemical origins. These issues include adjusting to life changes, grief, self-esteem issues, anger, relationship problems, certain forms of dysthymia, anxiety, and many others.” Rubinstein predicts that, “unfortunately, as problematic as the APA’s DSM-V is, NIMH’s version will do no better.”

What It All Means
For generations, psychiatry has diagnosed patients based upon symptoms, and disorders have been treated as similar when they have similar symptoms. Under the NIMH model, however, two disorders that seem quite similar might fit into completely different diagnostic categories. The change also could mean that the NIMH will be less likely to fund research that does not focus on biological psychiatry.

This change could be a problem for some philosophies of mental health. Treatment that focuses on altering a person’s environment while also treating his or her brain—for example, by encouraging meditation and the development of relationship skills in conjunction with antidepressants—might begin to fall by the wayside.

“There is so much interplay between the environment and biochemistry—between what happens to us, around us, and inside of us,” Rubinstein said. “It is illogical to claim, for example, that the cause of a person’s depression is biochemical, when the biochemical imbalance could just as well be a result of spouse abandonment. In other words, biochemical imbalance can just as easily be viewed as a symptom.”

What Happens Next?
There’s no way to predict how the NIMH’s diagnostic criteria will end up looking. It may be that some illnesses don’t neatly fit into a single category or that researchers can’t yet determine the physical causes of some disorders. It could be that some disorders are a product of environment, and it’s likely that many disorders are likely the result of a complex interaction between the environment and the genes.

Rubinstein seems optimistic that this interaction may be considered soon. “I imagine that future research will try to tease out what comes first, the biochemical change or the environmental event, in an effort to identify true mental health issues,” he said. But he acknowledges that this work is “complicated, and perhaps impossible,” and ultimately, until this research is accomplished, he says “the NIMH diagnostic guidelines will remain biased, limited, and inaccurate.”

Rubinstein is not alone. Mental health advocates who argue in favor of holistic approaches to treatment are unlikely to be satisfied by the NIMH’s position. Some advocates have objected that the DSM pathologizes normal behavior or that the addition of new diagnoses is an attempt to label everyone as mentally ill. The NIMH’s approach doesn’t answer this critique, but it is likely a welcome answer to advocates who have long argued that the DSM‘s diagnostic criteria are unscientific.

References:

1. Grohol, J. M., Psy.D. (n.d.). Did the NIMH withdraw support for the DSM-5? No. Psych Central.com. Retrieved from http://psychcentral.com/blog/archives/2013/05/07/did-the-nimh-withdraw-support-for-the-dsm-5-no/
2. Transforming diagnosis. (2013, April 29). NIMH RSS. Retrieved from http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

Exorcisms occupy a hallowed place in horror movies, with some claiming to be “based on a true story”—attracting mass audiences, rampant skepticism, and much discussion. But the ancient practice of expelling demons or other entities from a person isn’t merely fodder for fright flicks or some relic of a less enlightened time. Exorcisms are very much a part of cultural mythology, and occupy an important place in some religions. The Catholic Church has 10 exorcists in the United States. Even Mother Teresa underwent an exorcism at the direction of the archbishop of Calcutta.

No one can say with absolute certainty whether demons walk among us and occasionally take control of living beings, but science can offer a helpful window into exorcisms and what might cause a person to appear “demonically possessed.” The Diagnostic and Statistical Manual of Mental Disorders does not recognize demonic possession as a psychiatric issue. There is little doubt, however, about the influence of issues that are recognized by the DSM, and no one questions the power of suggestion.

What Causes the Appearance of Possession?
Historically, exorcisms have been used to treat a wide variety of symptoms that are now associated with mental issues. People with schizophrenia, personality issues, delusions, hallucinations, or severe depression might all have been considered candidates for exorcisms in generations past. Each of these issues can, in some cases, cause unusual or frightening behavior.

In a culture where many believe certain behaviors may be caused by demonic possession, the manifestations of mental health issues may conform to popular mythology. A person with schizophrenia might, for example, believe he or she hears the voice of Satan, or that he or she is in fact Satan, because he or she grew up amid culturally ingrained messages that this is possible.

Even in contemporary times, people with mental issues may be subject to exorcisms, particularly in devoutly religious communities and developing countries. Epilepsy, which can cause severe seizures, may lead to exorcism being performed. Substance abuse, head injuries, and brain tumors can also dramatically alter behavior, leading someone to appear possessed.

What Happens During an Exorcism?
Exorcisms tend to follow a predictable path. The apparent victim of possession’s behavior becomes increasingly erratic, perhaps even violent, until the exorcist casts the demonic spirit out. “Possessed” people may speak in tongues, vomit, become violently ill, or harm themselves. And while these behaviors might seem shocking, they can be easily explained.

Mental issues can cause strange behavior, and people tend to conform to expectations. This means a person experiencing an exorcism is more likely to act in ways he or she has heard of others behaving during exorcisms. Exorcisms sometimes also involve the use of potions, drugs, or fasting, each of which can induce violent illness and strange behavior. Starvation can affect brain function, and the stress of an exorcism may radically alter behavior.

Some exorcism advocates insist that exorcism works. And it very well may. People undergoing exorcisms may enter hypnotic trances, during which time they may be much more suggestible, which means their behavior may later change. The dramatic ritual of an exorcism can also be cathartic for some deeply religious people, and may inspire a change in behavior or personality.

Exorcisms As Abuse
Although every person has the right to practice his or her own religious beliefs, exorcisms sometimes become a form of abuse, and some mental health experts are concerned that they may replace competent psychiatric treatment for people with mental health issues.

Over the past decade, several people have died during exorcisms. A woman in Fort Wayne, Indiana, attempted to exorcise her son by forcing him to drink vinegar and olive oil, then held him down during an exorcism. The boy suffocated, and his mother was convicted of murder in 2011. A 3-year-old in Arizona was nearly choked to death by her grandfather, who was attempting to exorcise her; the grandfather was shot and killed by police.

References:

1. Attempted exorcism ends in man’s death. (2007, July 29). MSNBC.com. Retrieved from http://www.nbcnews.com/id/20027027/
2. Batty, D. (2001, May 02). Exorcism: Abuse or cure? The Guardian. Retrieved from http://www.guardian.co.uk/society/2001/may/02/socialcare.mentalhealth1
3. Interview with the exorcist. (2000, September 21). The Daily Beast. Retrieved from http://www.thedailybeast.com/newsweek/2000/09/21/interview-with-the-exorcist.html
4. Libaw, O. (2012, September 11). Exorcism thriving in the U.S., say experts. ABC News. Retrieved from http://abcnews.go.com/US/story?id=92541
5. Mom convicted in son’s exorcism death. (2011, May 29). WISH TV. Retrieved from http://www.wishtv.com/dpp/news/local/north_central/boy-dead-after-attempted-exorcism
6. Peter, B. (2005). Gassner’s Exorcism—not Mesmer’s Magnetism—is the Real Predecessor of Modern Hypnosis. International Journal of Clinical and Experimental Hypnosis, 53(1), 1-12. doi: 10.1080/00207140490914207

Imagine losing someone very close to you; perhaps your partner dies. How might you feel and behave in the weeks following this death? You might feel a sense of sadness and emptiness so intense that it is difficult to hold back tears. Perhaps you would have little interest in activities that you usually enjoy. Maybe you would find it difficult to sleep after sharing a bed with your partner for so many years. You might begin eating more or less and either gain or lose a significant amount of weight. It might be difficult to concentrate on your work. You might be preoccupied with a sense of guilt, wondering whether you could have done something to prevent your partner’s death. You might even wish for the day that you and your partner are reunited in death.

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These kinds of feelings and behaviors, while certainly difficult, probably seem like pretty normal and appropriate responses to a significant loss. They certainly don’t seem indicative of a diagnosable mental illness, right? Well, until the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is released in May, your hunch is correct. Currently, these feelings and behaviors aren’t considered evidence of mental illness.

In order to meet the diagnostic criteria for major depressive disorder (MDD), five out of nine specific symptoms must be exhibited, more often than not, for two weeks or longer, and they must impair your ability to function. The example above actually includes seven of the nine symptoms of MDD. These symptoms would probably be present much of the day for several weeks and would certainly impair normal functioning.

Currently, however, there is an exemption for bereavement in the diagnostic criteria that allows for such symptoms to persist for up to two months after the death of a loved one. Only after two months of persistent and pervasive depressive symptoms can a diagnosis of MDD be made in the context of bereavement. This exemption acknowledges that while grieving can look and feel virtually identical to depression, it is, quite simply, not depression. Unfortunately, the new version of the DSM will remove the bereavement exemption from the diagnostic criteria, and come May, the very appropriate reaction to the death of a loved one described above will be pathologized and diagnosed as MDD.

The world looks to the field of psychology to understand normal versus abnormal behavior, and the field of psychology uses the DSM as its guide for drawing the often fine line between what is normal and abnormal. This is a responsibility that should not be taken lightly. Labeling someone as mentally ill has significant implications. In the best case, a person who receives a diagnosis is given a lens through which to better understand himself or herself. It can be deeply empowering for someone to understand that the thoughts, feelings, and behaviors that have plagued him or her have a name, and that there are not only treatment options, but hope­ as well—hope for healing, hope for growth, and hope to become the person he or she has always wanted to be.

However, in cases where a perfectly healthy person is labeled as mentally ill, the implications can be devastating—just ask the gay man who was considered mentally ill in the early 1970s before homosexuality was removed from the DSM. To be labeled as sick, to be pathologized, for being who you are, or for being appropriately devastated by the loss of a loved one, serves no purpose and may be quite harmful.

Imagine being told that the anguish you are feeling over the loss of your partner means that you are mentally ill. Is there any way that this could be helpful, or would it just serve to make you feel much more lost and hopeless? What would it be like if a doctor suggested you take medication? Imagine being told to take a pill to get over the death of a loved one. Should you find yourself in a therapist’s office grieving the loss of a loved one and your therapist suggests a diagnosis of MDD, don’t be so quick to accept the label—it is entirely possible that you are simply, and appropriately, grieving.

The American Psychiatric Association has approved changes to the Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM. The fifth edition of the flagship guide to psychiatric diagnosis, due for release in May 2013 and known as the DSM-5, features several controversial revisions.

The DSM establishes criteria for the diagnosis of mental health conditions. Because changes to the manual can affect insurance coverage for certain issues and help define “normal” behavior, advocacy groups are often concerned about the effect additions and alterations will have. The latest revision is no exception.

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Children and Mental Health
Diagnosing children with mental health conditions is often dicey because of concerns about stigma and the use, or overuse, of psychiatric drugs. At a time when some groups argue that fewer children should be diagnosed with mental health issues, the DSM-5 adds new diagnostic criteria for children. Those over the age of 6 who display irritability or frequent angry outbursts now qualify for a diagnosis of disruptive mood dysregulation disorder. While some mental health professionals emphasize that this new diagnosis could make it easier to plan early intervention for children who have extreme difficulties controlling their emotions, some advocacy groups have expressed concern that such a diagnosis could stigmatize normal childhood behavior or lead to the prescribing of unnecessary drugs to young children.

Autism Spectrum Disorder
The DSM-5 eliminates Asperger’s syndrome, folding it into a broader category called autism spectrum disorder. Diagnoses of Asperger’s and autism have been steadily increasing over the past several years, and many children with less severe symptoms of autism have been diagnosed with Asperger’s. The DSM-5, however, incorporates several autism-like issues, including Asperger’s, into the diagnosis of autism spectrum disorder. Not everyone is happy with this change. Many people with Asperger’s view the issue as part of their identity and do not want it to be lumped in with other issues. The APA, however, argues that this change will make diagnosis of autism more consistent and access to treatment easier.

Grief and Depression
Previous versions of the DSM incorporated a bereavement exception into depression diagnoses. This exclusion prevented mental health professionals from diagnosing a person who was grieving the death of a loved one with depression. The DSM-5, however, permits depression diagnoses in the bereaved. Members of the APA argued that the old bereavement exception excluded grieving people who had been diagnosed with chronic depression from being diagnosed with, and receiving treatment for, depression. But some people worry that the new changes pathologize grief and turn normal grieving—which often looks a lot like depression—into a mental health diagnosis.

Other Changes
The DSM-5 adds hoarding and excoriation disorder—a diagnosis for people who compulsively pick their skin. The APA also rejected several proposed disorders, including parental alienation syndrome, hypersexual disorder, and anxious depression. While the APA emphasized that the revisions—like all changes to the DSM—are intended to clarify diagnostic criteria and improve consistency in diagnosing, mental health advocacy groups argue that many diagnostic criteria have been loosened and that the DSM-5 will increase the number of people diagnosed with mental health conditions.

Which changes to the DSM did you find most controversial? Please share your comments below.

References:

1. Asperger’s syndrome dropped from American Psychiatric Association manual. (n.d.). MedPage Today. Retrieved from http://www.medpagetoday.com/Psychiatry/DSM-5/36206
2. Gever, J. (n.d.). DSM-5 wins APA board approval. MedPage Today. Retrieved from http://www.medpagetoday.com/Psychiatry/DSM-5/36206
3. Gupta, P. (n.d.). Controversial changes to stay in DSM-5. Salon. Retrieved from http://www.salon.com/2012/12/02/controversial_changes_to_stay_in_dsm_5/
4. Spiegel, A. (2012, November 30). Weekend vote will bring controversial changes to psychiatrists’ bible. NPR. Retrieved from http://www.npr.org/blogs/health/2012/11/30/166252201/weekend-vote-will-bring-controversial-changes-to-psychiatrists-bible