Should Impusle Control Disorders and Conduct Disorders Be Classified Under the Same Category?

The DSM-V workgroup proposes to include impulse control disorders and conduct or disruptive behavior disorders in the same category. This implies, in my opinion, that there is something intrinsically similar among these conditions. Now I am personally strongly opposed to this connotation, as I was originally diagnosed with impulse control disorder NOS in 2008, and one of my major fears was being seen as merely behaviorally disordered. Now in the current DSM-V draft, only intermittent explosive disorder is listed along with conduct disorder, oppositional defiant disorder, dyssocial personality disorder (antisocial personality disorder) and disruptive behavior disorder not elsewhere classified. Trichotillomania, now called hair-pulling disorder, is reclassified under the obsessive-compulsive and related disorders. I have not yet seen what happed to kleptomania, pyromania and impulse control disorder NOS.

Now I can see why intermittent explosive disorder would be seen as a behavior disorder, in the sense that people do have an essential problem with aggression. However, etiologically speaking, there is quite a difference between willfully destroying property or attacking someone and doing so in an impulse. I know that for the victim it makes little difference, but that’s not my point. Treatment is also quite different if someone is malicious rather than impulsive.

Now the DSM should be focused on observable behavior, not on etiology. I am not sure, therefore, what I think yet. Is it merely my personal fear of being diagnosed with something seen as a behavior disorder again, or is it something else? As a side note, my current psychologist removed the diagnosis of impulse control disorder NOS from my file in 2010.

Read Full Post »

Subthreshold Hypomania: A Review and Implications for DSM-V

Should DSM-V include a diagnostic category for people with major depressive disorder with subthreshold hypomania? This isthe question that is at the center of the paper I just read. My initial answer to this question was a resounding “No”,because of some of the challenges the authors discuss. However, having read the paper, I have come to the conclusion that there may be some use for subsyndromal hypomania as a separae diagnosis.

The authors start by evaluating the prevalence and possible misdiagnosis of unipolar depression vs. bipolar disorder. Previous research found that aproximately 40-50% of people with major depressive disorder have a lifetime history ofsubsyndromal hypomania, depending on the precise criteria used. Furthermore, individuals with such a history are much more likely than individuals without subthreshold hypomania to eventually be diagnosed with bipolar disorder, usually even bipolar I.

In addition, those with major depression and a history of sunthreshold hypomania generally have a worse outcome, more mood episodes, and more work impairment than depressed individuals without a history of subsyndromal hypomania. With regards to family history, people with major depression and subthreshold hypomania are more likely to have family members with mania or other bipolar disorders than those with only depressive symptoms. An early onset (before age 21) of depression and a presentation with atypical features are also characteristic of people with subthreshold hypomania.

For the above reasons, the authors recommend that subthreshold hypomania be included in DSM-V. There is some debate as to which criteria should be used, but they advise an emphasis on overactivy rather than just mood elevation and a duration of at least two days with at least three of seven hypomania symptoms met. The authors also recommend that subthreshold hypomania should be seen as in the middle between pure depression and bipolar II. They argue against the diagnosis of individuals with major depression and subthreshold hypomania as bipolar, because of the stigma this can create.

This stigma was one of my initial reasons to oppose the widening of the bipolar spectrum to include subsyndromalhypomania. The other reason, which the authors also address, is the potential overprescription of antipsychotics and moodstabilizers. There is no evidence that antidepressants would be bad for individuals with major depression who might havesubthreshold hypomania, and neither is there evidence that mood stabilizers or antipsychotics prevent a worsening fromsubsyndromal hypomania to full-blown (hypo)mania. Given the fact that antipsychotics and mood stabilizers have significantside effects, it is not recommended that they be used without merit.

However, the authros do argue for better psychosocial treatmetn of individuals with depression and subthresholdhypomania. They state that cognitive-behavioral therapy, psychoeducation and some other psychosocial interventions may betailored more effectively towards those with subthreshold hypomania if this is idenftified in people with major depression.This is also in light of the worse outcome usually seen in individuals wiht subtreshold hypomania. Psychotherapy,apparrently, might help people manage their hypomanic symptoms.

So, contrary to what I expected, the authors of this study are not Big Pharma puppets who advocate the widespread use ofthe newest and most expensive medications. They also, interestingly, do not seem to suggest that mood disorders as a wholeare underdiagnosed, or that in general more people should be seen as mentally ill. They rather try to pinpoint the symptomsof a subgroup of depressed individuals more precisely than could previously be done. This does not directly change myopinion on subthreshold bipolar yet, but it does give me some thought.

Reference

Nusslock R, Frank E (2011), Subthreshold Bipolarity: Diagnostic Issues and Challenges. Bipolar Disorders, 13:587-603. DOI: 10.1111/j.1399-5618.2011.00957.x.

Read Full Post »

Disruptive Mood Dysregulation Disorder Still Proposed for DSM-V

I just found out that termper dysregulation disorder with dysphoria (TDD) is still included in the proposal for DSM-V, but under the category of depressive disorders. It is now named disruptive mood dysregulation disorder. This reflects the fact that the predonimant feature of this disorder is a mood problem rather than a behavior problem. The “disruptive” part does show that there is still consideration that this disorder is a behavior problem in essence, however.

The criteria are very strict, but unfortunately, bipolar disorder has to be ruled out first before a child can be diagnosed with this disorder. This makes it easier for doctors to diagnose pediatric bipolar disorder, while it seems the TDD idea was to correct the misdiagnosis of pediatric bipolar.

I still think that I would’ve been diagnosed with this had this disorder been present in DSM-IV. I used to meet all the criteria before I went on Abilify, except that a pervasive developmental disorder should be ruled out first.

Read Full Post »

Adjustment Disorder and Bereavement in DSM-V

Adjustment disorder has been a category of its own in DSM-IV. IN DSM-V, the workgroup is proposing that it be included in a category of trauma and stressor-related disorders. I agree to this, as there is a lot of resemblance with other trauma and stressor disorders. Further, the criteria are almost the same as those in DSM-IV. However, a few new subtypes are considered:

• With PTSD/ASD-like symptoms: if the person experiences symptoms similar to PTSD or acute stress disorder, but the full critieria for trauma or for the symptoms of PTSD/ASD are not met.


• Related to bereavement: when the stress reaction is related to the death of a close relative or friend, and the person experiences intense longing for the deceased that is in excess to what is normal.

The workgroup also proposes a new disorder for research purposes only: bereavement related disorder. In this condition, after the death of a close relative or friend, the person not only experiences intense longing for the deceased, but also a number of specific symptoms, including social or identity disturbances and reactive distress symptoms. This condition is very controversail, as it is generally believed that grief and distress are normal responses to death, and that even complicated greif is not a psychiatric disorder. I agree to this and feel that bereavement related disorder should not be included in DSM-V.

The disturbance in adjustment disorder must last for no longer than six months after the stressor or its consequences have stopped. An exception is made for the bereavement-related type, where the adjustment problems must last for at least twelve months. I consider that a reasonable timeframe, if bereavement is going to be seen as a disorder at all, but I do not agree to the six months cut-off for the other types, that is also present in DSM-IV. After all, an adjustment problem can last for more than six months, and it is strange that a person must then be diagnosed with another mental illness which they may not have. In my own case, I was diagnosed with impulse control disorder NOS after my six months with adjustment disorder, and this diagnosis was not only incorrect, but failed to reflect the fact that my behavior was in large part a reaction to an unstable situation.

Read Full Post »

Complex PTSD Should Be Included in DSM-V

There are many strange disorders being proposed by outside parties or by the American Psychiatric Association for inclusion in DSM-V. Oddly enough, however, complex PTSD is not among them. C-PTSD is not just gradually different from regulat PTSD, but encompasses other features such as those seen in personality disorders. It is a disorder caused by captivity or other situations of long-term, severe trauma.

Of course, the subtype of chronic PTSD is included in DSM-IV as well as DSM-V, but this is merely regular PTSD that lasts for more than six months, without the additional features of impaired self-concept, trust, and emotion regulation, among others. In my opinion, complex PTSD is more warranted as a specific disorder than such things as parental alienation syndrome and body integrity identity disorder, both of which are proposed by outside parties.

There are many people who would meet the criteria for complex PTSD but not the full criteria for regular PTSD. What do they end up being diagnosed with, if anything at all? Do they fall within a treatment loophole, getting no counseling because they don’t have a legitimate mental condition? Or do they end up with stimgatizing and incorrect diagnoses that don’t reflect the fact that they are trauma victims?

Today, June 27, is PTSD Awareness Day. Let’s stand up for the rights of victims of long-term, severe child abuse, war camps, or other states of captivity, to get the recognition and treatment they deserve.

Read Full Post »

Parental Alienation Disorder Possibly Included in DSM-V

Last week, I heard on an E-mail list that the DSM-V workgroup is considering adding parental alienation disorder to DSM-V. It was only looking for feedback, so my hope is that enough people have campaigned against this diagnosis that it will not be included.

Parental alienation disorder is a specific set of symptoms, where a child chronically denigrates one parent, usually in the context of custody battles. The child may belittle, accuse or otherwise detach themself from one parent. The assumption is that the disorder is caused by unconscious or conscious indoctrination by one parent against the other, as well as the child’s on personality. Included in parental alienation disorder are false accusations of abuse.

In my opinion, if this were a real concept at all rather than a fantasy to cover up actual child abuse, this should be a psychological concept rather than a psychiatric one. Parental alienation disorder, if it exists, is the manifestation of a dynamic between parents and children, rather than a mental disorder on the part of the child. So, for that reason, it does not belong in a psychiatric handbook like the DSM.

I, personally, do not believe in parental alienation enough to consider it an actual condition at all. Sure, it may happen on occasion, but not on the large scale that proponents assume it occurs.

Besides, even if a child denigrates a parent without reason, this does not mean it has to occur in the context of custody battles or that it is the other parent’s ffault. It may be that a child has an attachment issue, which in the DSM can only be caused in the context of pathological care, but which, in my opinion, can be caused by a number of factors. Also, it may be that a child has a problem with irritability, such as oppositional defiant disorder, and is acting it out specifically towards the less assertive parent.

I do not deny that indoctrination in the context of custody battles happens, but if it does, it is not something the child is responsible for, and therefore does again not reflect a disorder of the child. Rather, if indoctrination is present, the parent doing it has a serious psychological problem, though not a mental disorder. So, rather than concluding that parental alienation is a disorder, look at the broader picture of whether the child may have other issues causing them to act out against one parent, whether either parent has a psychological problem, etc. And please don’t pathologize problematic but non-medical behavior.

Read Full Post »

Hear Voices? You’re No Longer Schizophrenic in DSM-V

In DSM-IV, if you hear voices, you can be diagnosed with schizophrenia even if this is the only “psychotic” symptom. This has been controversial for a while, because many people hear voices without being actually psychotic. Not only other conditions – such as dissociative identity disorder – are characterized by voice-hearing, but voice-hearing may be a normal symptom related to stress.

Thankfully, the DSM-V workgroup is recommending that someone must have two or more characteristic symptoms of schizophrenia for a substantial period of time in order to be diagnosed. These two symptoms must include at least one core symptom, which are determined to be delusions, hallucinations and disorganized speech. In addition, people must display a significant deterioration in their social or occupational functioning. This criterion was considered for elimination, but the workgroup thankfully decided against this. Again, this protects functioning voice-hearers from a false diagnosis.

Of course, there is the newly considered diagnosis of attenuated psychosis syndrome, which includes symptoms suggesting a person is at risk of a psychotic disorder. This diagnosis may cause voice-hearers to be pathologized after all, which is a very sad thing.

Read Full Post »

Factitious Disorder

I have been told a few times that I fake being dissociative. Faking is often assumed to be a behavior problem, sometimes even an offense, rather than a mental illness. In fact, factitious disorder, popularly known as Münchhausen Syndrome, is a real mental health condition.

In DSM-IV, factitious disorder is characterized by intentional feigning or creating of symptoms or signs of illness, which is present even without obvious external reward, and which is not due to another mental disorder (eg. delusional disorder). Furthermore, the person must present themself to others as ill or impaired.

In the current proposal for DSM-V, slight modifications have been made to the wording. The part about intent has been replaced with wording about a pattern of falsification of signs or symptoms. It is added that the faking of symptoms or signs must be associated with deception. This change of wording was made in order to clarify that intent or motivation must be objectified, rather than inferred.

The DSM-V workgroup is still uncertain as to how to classify severity. It is proposed that level one is diagnosed when a person only reports faked symptoms, level two when lab tests were modified, level three when a person makes themself sick, and level four when one’s faking leads to life-threatening illness. Of course, here, it seems there is an overemphasis on physical symptoms, because psychological symptoms do not present themselves on lab tests or the like. I do not know how the faking of psychological symptoms would be graded.

Obviously, of course, I do not have factitious disorder. Imagining of symptoms – even assuming my DID symptoms are indeed not real, which I do not believe – is not the same as intentionally falsifying them. There is, however, no category in the DSM for people who unintentionally imagine a (psychological) disease.

Read Full Post »

Binge Eating Disorder to Be Fully Included in DSM-V

After having been in the appendix for research purposes only since 1994, binge eating disorder (BED) will likely move to full inclusion in DSM-V once it is published. Binge eating disorder involves repeated episodes of overeating which are characterized by both the eating of far more than would be normal in a certain time period, and a sense of having lost control over one’s food intake. Associated features are at least three of the following:

1. Eating much more rapidly than normal.


2. Eating until feeling uncomfortably full.


3. Eating large amounts of food when not feeling physically hungry.


4. Eating alone because of feeling embarrassed by how much one is eating.


5. Feeling disgusted with oneself, depressed, or very guilty afterwards.

The binge eating causes significant distress, occurs on average at least once a week for three months, and is not associated with repeated inappropriate compensatory behaviors, such as purging. The binge eating does not occur exclusively during the course of another specific eating disorder. The severity of binge eating disorder is determined by the frequency of episodes per week.

I like the recommendation that BED be fully included in DSM-V. I think its criteria are more strict than those commonly used for compulsive overeating in such organizations as Overeaters Anonymous. This is good, because, in order to be classified as a formal mental disorder, something needs to be defined more strictly than in order to be classified as something to simply warrant some kind of help. I also like the change to the frequency requirement from the DSM-IV appendix – it used to be twice a week for six months -, although this apparently is not a major change.

Read Full Post »

TDD: Mood Disorder or Personality Trait?

There is an interesting article at Psychiatric Times on the temper dysregulation disorder (TDD) controversy. Particularly, it is noted that TDD is classified as a mood disorder rather than a state of disordered personality development:

In English, that asks whether we should put temper outbursts in with depression and other mood disorders (ie, in the clearly-defined cluster of genetically-determined
chemical imbalances of the brain, or should they be lumped with the personality disorders?). Is an impulsively aggressive person with a long record of assault, drug and alcohol abuse, poor work record, and unstable interpersonal relations suffering a formal mental illness (with all the forensic and social complications that would imply), or is he or she simply choosing to act this way, and is therefore responsible for his/her actions? This is not a trivial question, but it flows directly from the question of whether “such diverse symptoms as irritability, anger, agitation, aggression, distractibility, hyperactivity,
and conduct problems” are or are not of the same ontological nature as depression and hallucinations. For example, in Australia, which has universal welfare
and treatment, if these behavioral factors are held to be mental illness per se, then the “sufferer” is entitled to a pension for life, unlimited (world class) treatment, and an endlessly renewable excuse for all manner of antisocial conduct.

I wonder, actually, why it makes a difference. People who are personality disoredered, should in fact get treatment as much as, or even more than, those with a mental illness. In the Netherlands, in fact, people with personality disorders are entitled to the same welfare and treatment as those with an axis I disorder – which welfare and treatment are by no means universal, by the way.

Also, TDD is a proposed childhood disorder rather than a lifelong disorder, so why should one worry? I think that children with TDD warrant as much treatment as those with oppositional defiant disorder, who at least in the Netherlands do get treatment. Indeed, TDD was at one point proposed as a subtype of ODD, but this idea was thrown out for a reason.

Of course, it is important to decide whether children with TDD are presumed to choose their behaviors, not for the sake of excusing or whether they’re allowed treatment, but because of what treatment is chosen. I, in this light, support the classification of TDD as a mood disorder, especially because dysphoria is part of its currently proposed criteria. Children who are dysphoric (or depressed, as many TDD kids seem to be) need to have this mood recognized and treated with psychotherapy and, in severe cases, medication. Behavior modification alone isn’t going to help.

I have an interest in the matter, of course, in that I would’ve been diagnosed with TDD had it existed in DSM-IV. I was treated with harsh forms of informal behavior modification, and they didn’t work. It could be because I am autistic instead of TDD – and autism needs to be ruled out first before diagnosing TDD -, but it is likely many children currently diagnosed with Asperger’s/PDD and/or ADHD will later be diagnosed with TDD based on observations and the fact that TDD will be the new fashion disease. Now I have little against new fashion diseases – I do not think the children diagnosed with them, are just brats -, but at least these warrant proper, caring treatment.

Read Full Post »