The DSM-V: Coming Soon, Criticisms, Flaws and All

DSM-5_3DThe long awaited and controversial Diagnostic and Statistical Manual of Mental Disorders, version five (DSM-V) is slated to come out toward the end of this month.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered the bible of psychiatry. It is the guide we use in the mental health field to help us diagnose clients and this May, the newest version of the DSM, version five, is slated to be released, but not without much controversy.

The DSM is considered a research standard worldwide, yet, outside of the United States it is rarely used. Still, what is in the DSM is of international concern because trends in diagnosing in the United States (i.e., attention deficit disorder, autism) tend to spread worldwide especially in many European countries, China, Japan and Brazil.

Much of the criticism about the DSM comes from both the way illnesses are categorized and the ever expanding criteria for mental illness that basically makes everyday life issues a diagnosis.

Other  criticisms include weak scientific support and poor reliability in some of the DSM-V field trials, which leave some to believe that it will lose its role as the international standard for research journals.

One of the real dangers if the DSM-V is really that severely flawed is that all of the mental health field will also become tainted, with people not trusting those who are trusted to test, diagnose and help people in need.

With the DSM-V, we also put ourselves at more risk of mis-diagnosing, over-diagnosing and over-medicating individuals.

Some say that the changes to disorders such as Generalized Anxiety Disorder can include almost everyone, as well as a proposed new diagnoses called Somatic Symptom Disorder which will be diagnosed to any patient who has “excessive and disproportionate thoughts, feelings and behaviors” in relationship to an illness, which includes chronic pain and cancer. How much worry constitutes “excessive” worrying. Who wouldn’t be worried when they are dealing with a painful, chronic, potentially debilitating or life threatening illness?

Some believe that much of the flaws in the DSM period are because disorders are placed in discrete categories such as Bipolar Disorder and Schizophrenia, instead of “dimensionality” in which mental illnesses may overlap and people may be placed on one of several spectra such as the proposed Autistic Spectrum Disorders.

Most clients I see have a combination of symptoms, some which do not meet complete criteria for one specific diagnosis, but can meet several others and present differently at different periods, which is why I may see a client who has received three different diagnosis over the same number of years.

However, most in the mental health field prefer for mental disorders to continue to be categories as they already are which is one reason dimensionality won’t likely be introduced into the DSM anytime soon even in the face of growing evidence that disorders are more fluid and less rigid than previously thought.

It would take more research and funding into dimensionality for it to truly be accepted, but much of that research and funding is already put into confirming the categorization of mental disorders the way they already are.

Basically, people don’t really want change. Much of the mental health field, drug and insurance companies, like the rigidity of the DSM even though it is clear that it is failing many people.

Even patient groups and charities prefer the rigidity of the DSM because it highlights their disorder and keeps it visible. They do not want to see schizophrenia or bipolar disorder re-labeled into a spectrum just as Aspergers Disorder is slated to be dissolved into the autistic spectrum disorders.

On top of that health-insurance in the United States pay for treatment based on current DSM diagnosis. As a matter of fact, that is one of the most frustrating things about dealing with insurances.

In order to get paid for my services, they want a diagnosis almost immediately, usually after the first session or two of me meeting a client. Sometimes a DSM diagnosis is obvious, other times it is not and more time with the client is needed, but insurance companies won’t pay for that unless you diagnose them with something first. Insurance companies are probably the last ones who want to see the DSM categories dissolved.

According to Dr. Allen Francis, former chair of the DSM IV task force, the ten worse changes to the DSM-V are:

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment. This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Even with much of it’s flaws and criticisms, the DSM-V is likely to be the best guide for diagnosing mental disorders that we have had thus far. We can only hope that with further research and funding, the next revision of the DSM will be better and more forward thinking.

My Journey To Becoming A Therapist

couch_wide-eb7410d70ac8d556c8331f723e49c918ec26f2dd-s6-c10“What made you want to become a therapist?” That’s one of the most frequent questions I get asked by adults, many who marvel at me as if the ability to sit with, empathize, listen to and accept someone just as they are is some mystical superpower bestowed upon a select few.

Many follow that question by saying that they wouldn’t be able to deal with talking with “crazy people” or emotionally disturbed children all day without going crazy themselves, even saying that they can’t  deal with their own children, friends or family members when they are angry, sad or being irrational.

There was a time when I thought that counseling was something any and everyone could do, but now I know that not everyone can or should be a therapist. I’ve met some very bad therapists, people who may have had the education and credentials to counsel people, but definitely didn’t have the heart, patience or personality that is just as important if not more so.

Thankfully, most of these counselors learned pretty quickly that sitting down and helping someone unravel the complexities of their lives weren’t for them and ended up either getting out of the helping profession all together or moved to a part of the field that was less people oriented, such as working for insurance companies or becoming program directors.

I’ve witnessed teachers, administrators and other professional adults with good intentions do some very bad counseling. Some even made me cringe at either their bad advice, judgmental attitudes or total lack of empathy and I honestly was very thankful and relieved that these individuals weren’t officially counselors.

Being a therapist pretty much comes natural to me. Growing up I was always a very intuitive, carrying and empathetic person. I was always in touch with my feelings and would spend ours alone just trying to figure out why I felt a certain way. That curiosity soon lead to wandering why other people felt certain ways and why they did or didn’t do certain things. People watching became one of my favorite past-times.

In high school I was the person that girls would call and talk to about their problems with their parents, friends or boyfriends. I enjoyed helping them figure out and solve their problems  just as I enjoyed sitting in deep reflection about my own. I was probably one of the only boys in my high school that keep a journal and read self-help books.

Still, at that time I wasn’t even thinking about becoming a counselor. At that time I was interested in becoming a writer, an artist, a dentist or a meteorologist.

In college I decided I wanted to lean towards becoming a writer or an English teacher. I enjoyed writing just as I do today and it was writing that lead me to psychology. I was always interested in making my characters real and multi-dimensional which lead me to reading books on character development and eventually personalities and personality disorders.

There I found my love for psychology.

Soon I started taking every psychology course I could because I found it interested, but even more so because it helped with my writing. This is where I came in contact with Dr. Skinner who was not only my favorite psychology professor, but also became one of my first and most important mentor. He was always encouraging me to further my education in psychology which is one of the main reasons I decided to go on to graduate school.

In graduate school I initially was going to become a guidance counselor because I wanted to work with teenagers, but after taking all the courses required for guidance counseling, I still felt a hunger to learn more about psychology and counseling in general and so I transferred to the counseling and psychology track which was a lot of hard work when it came to reading, writing papers and giving presentations almost constantly.

It was learning the stuff I loved which is why I maintained a 4.0 throughout graduate school while working as a substitute teacher.

It was in graduate school that I started doing official counseling, and I was terrified!  To graduate from the program you had to do a 1,000 hour internship, not with friends or people I already knew, but complete strangers. To make it worst, I knew that I never wanted to be a substance abuse counselor and yet, my internship was at an inpatient substance abuse facility. I was determined to hate it.

I grew up in an inner-city neighborhood. I grew up around drug addicts. I already had my prejudices about people who used drugs and didn’t want to have to deal with them more than I already had growing up.

My dad also had struggled with substance addiction pretty much my whole life. He had been in and out of numerous treatment facilities and I had decided that substance abuse counseling just didn’t work. I tried my hardest to get my internship site changed, but couldn’t.

By the end of my 1,000 hour internship filled with individual, group and family counseling, I had a new respect for those who struggle with addictions and their families. I met people who had been trying to get sober since the 1970s! I met a popular high school football coach who gave up everything, his wife, kids and his prized job for alcohol.

I met women, mothers and daughters, so addicted to drugs and alcohol that their families had them committed to treatment and they were some of the sweetest women you could ever meet, who struggled everyday to control their cravings and stay clean.

Sure it was hard work, sometimes frustrating, disappointing and hard breaking (relapse is a b*tch), but it helped me deal with one of my own demons… it helped me understand my father and his battle with addiction so much better. It allowed me to forgive him.

After graduating I moved on from addiction counseling, perhaps it was still too close to home, and went to work in a psychiatric hospital. I always wanted to work with the severely mentally ill. dsmiv-c317a8bc457aaab1c0fb6b1a1de2b813d655dd09-s6-c10

In the Diagnostic and Statistic Manual of Mental Disorders (DSM) taught to us in school, I had learned so much about schizophrenia, bipolar disorder and other conditions that are rarely seen, yet I wanted to experience them face to face.

I spent three years working overnight in the psychiatric hospital giving psychological evaluations and crisis counseling to some of the most fascinating people ever.

I’ll never forget talking to a rather lucid schizophrenic woman who was having visual hallucinations. She gave me the best explanation of visual hallucinations ever, better than any professor or textbook I had ever read.

I remember trying to calm down a paranoid schizophrenic woman who was shaking like a leaf because she believed a killer was locked in the hospital with us and was specifically trying to kill her.

And I remember giving an evaluation to a tomato red faced woman (all the blood vessels in her face had broken) who had just been released from the hospital after trying to hang herself after finding out her husband was cheating on her.

So many experiences came from my time there, but I knew I was missing out on truly developing my counseling skills. One of my goals was to become a licensed mental health counselor, which is a whole lot of extra work after graduate school and I believed to be a great therapist, I had to know how to not only assess, diagnose and do crisis counseling, but also how to do more traditional counseling with clients who had more everyday type problem.

I still longed to work with children as well so I left the hospital and started working at an inner city high school, focusing mainly on anger management and substance abuse, but soon my job description expanded to include pretty much any and everything that stood in a child’s way of being able to concentrate and focus on their school work.

This is where I learned to work with defiant teens, broken families, damaged teens and teens who just needed someone to guide, care for and encourage them. This is where I saw our future, both promising and disheartening.

While here I also attained my goal of becoming a licensed mental health counselor and continue to learn every single day.

One of the most important things I learned is self-care and to take breaks for myself. Carrying the weight of so many other peoples problems can sneak up on you and break you down before you know it. Sometimes when people know you are a counselor, they will purposely or inadvertently dump their problems on you and that includes family and friends. It becomes important to take the counseling hat off sometimes and if that means going and sitting some place alone, then that’s what I will do.

Being a counselor/therapist is a very rewarding career, but it is probably one of the most mentally and emotionally draining careers I can think of. I enjoy the skills I have developed to analyze people, to read body languages and to be able to already have some ideal what’s going on with a person before he or she even says a word, but sometimes it’s hard to turn that off which sometimes impact my personal life.

One minute a friend will be asking me for advice or wanting to talk to me about a problem, but they don’t want me to “counsel” them. Then the next minute when I make a statement, they will stay “get out of my head” or “stop analyzing me”.

Sometimes I am more comfortable when I am in the counseling role and I will find myself retreating to that mode whenever I am uncomfortable or meeting someone new… not always a good thing. I realize it’s a defense mechanism I use where I limit the amount of information a person knows about me while I gain tons of information about them. That isn’t really fair, but I do it all the time and most people are so happy to talk about themselves that they never call me out on or even notice it.

Lastly, another thing I’ve learned is that being authentic with someone… being present with them and actively listening does miracles. There’s been times when I listened to someone and was present with them, but had no real ideal what to do or say, and after our session they were so grateful to me for listening to and helping them. It’s amazing. Sometimes I didn’t even say a word and yet they would be so grateful. That’s why I stress so much on listening, rather than talking in this blog. I believe that listening sometimes solves more problems than talking, lecturing or berating someone.

Combating Depression: 10 Tips

depressionistockDepression affects about 17. 5 million Americans and out of those, an estimated 9.2 million will have what is considered major or clinical depression.

What’s the difference between depression and major depression?

Major depression is categorized as:

  1. a depressed mood, most of the day, nearly everyday for at least two weeks. In children, adolescence and some adults, depression may present as irritation or anger.
  2. Marked diminished interest in or pleasure in all, or nearly all activities most of the day, nearly everyday.
  3. Significant weight loss (when not dieting), decrease in appetite, or significant weight gain or appetite nearly everyday.
  4. Insomnia or hypersomnia nearly everyday.
  5. Psychomotor agitation or retardation (i.e. moving extremely slow or faster than normal) nearly everyday.
  6. Fatigue or loss of energy nearly everyday.
  7. Feelings or worthlessness or excessive or inappropriate guilt nearly everyday.
  8. Decreased ability to think or concentrate, or indecisiveness nearly everyday.
  9. Recurrent thoughts  of death, suicidal thoughts with or without a plan or a suicide attempt.

A person doesn’t have to have all of these symptoms to be diagnosed as having major depression, but they have to have the majority of these symptoms for at least two weeks and they can’t be accounted for something else, such as bereavement (i.e., losing someone close to them recently).

Depression has been given a bad name and so many people who feel depressed don’t like to admit to it and may not seek help or even the comfort of a friend when they are feeling depressed. The thing about depression in general is that it is not always a bad thing.As a matter of fact, very often, depression is your minds way of telling you that something in your life is not going the way you want it to go.

Instead of ignoring that feeling or trying to make it go away immediately, it may be a good time to sit with it and evaluate your life and see what is it that is not going the way you want it to go, and if you can change it, then change it, if you can’t, then try to change the way you think about it.

More often then not, this is what depression is and it is possible for a person who is in tune with themselves, to take this self-evaluation, correct the problem(s) and eliminate their symptoms. Other times, a depressed person may need the help of a professional to help them analyze what’s going wrong in their lives and help them learn how to deal with it. And yet, still there are times when medication is needed due to chemical imbalances or if a person gets to the point where they are so depressed that they don’t have the capacity to be introspective.

While most of us have or will experience depression at least once in our lifetimes, major depression can be a very dark and dangerous place. The Center for Disease Control has intentional suicide as the number ten cause of death in the United States last year, killing an estimated 38, 364 people.

10 Tips To Fighting Depression

**First off… if you or someone you know is suicidal, don’t be afraid to call 911 or 1-800-suicide for immediate help**

  • Opposite Actions is a technique from Dialectical Behavior Therapy that basically says, do the opposite of what the depression is telling you to do. If you feel like staying in bed all day, get up and do something. If you feel like blowing off your friends, don’t, call them and force yourself to be out with them.  One of the things about depression is that it is a self-feeding disease. It zaps a persons motivation, makes them want to isolate themselves and stop doing things like going to the gym, all of which end up making the person feel more depressed.
  • Set an alarm that will help you wake up, that will remind you to eat, or to do whatever it is you need to do.
  • Take care of yourself by getting out of your bed, making it, and taking a shower. Letting yourself go is one of the hallmarks of being depressed and will make it easier for you to start avoiding other people.
  • Go outside for at least ten minutes a day. It doesn’t matter where you go, or if you don’t go anywhere. Going outside, getting some fresh air, some sun even, can do natural miracles when battling depression.
  • Exercise. You won’t feel like it, but it will be good for you and will get your blood flowing and your endorphin and dopamine (natural feel good hormones) going.
  • Make a list of activities to do, hopefully some will involve other people.
  • Keep a schedule, that way you can stay on track during the days you don’t feel like doing anything.
  • Make a daily necessity schedule if needed that reminds you when to eat, take  a bath, brush your teeth, etc. Yes, in the middle of severe depression, it’s easy to neglect all these things.
  • Visit people like healthy family and friends. Once again, you will feel like isolating yourself, but having good family and friends around will help pull you out of the fog.
  • Last, but not least, if all self-help fails, do not be afraid to see your doctor or a psychotherapist.  80% of people with major depression who received treatment had significant improvements.

Depression will affect us or someone we know to some degree, and it’s always good to have some idea of what you’re dealing with and how to begin fighting it.