Monday, May 27, 2013

DSM-5 Released: The Big Changes By JOHN M. GROHOL, PSY.D.



DSM-5 Released: The Big ChangesThe DSM-5 was officially released today. We will be covering it in the weeks to come here on the blog and over atPsych Central Professional in a series of upcoming articles detailing the major changes.
In the meantime, here is an overview of the big changes. We sat in on a conference call that the American Psychiatric Association (APA) had in order to introduce the new version of the diagnostic reference manual used primarily by clinicians in the U.S. to diagnose mental disorders. It is called the Diagnostic and Statistical Manual of Mental Disorders and is now in its fifth major revision (DSM-5).
James Scully, Jr., MD, CEO of the APA, kicked off the call by remarking that the DSM-5 will be a “critical guidebook for clinicians” — a theme echoed by the other speakers on the call.

Why has it taken on such a large “role [both] in society as well as medicine?” he asked. Dr. Scully believes it’s because of the prevalence of mental disorders in general, touching most people’s lives (or someone we know).
The APA has published three separate drafts of the manual on their website, and in doing so received over 13,000 comments from 2010 – 2012, as well as thousands of emails and letters. Every single comment was read and evaluated. This was an unprecedented scale of openness and transparency never before seen in the revision of a diagnostic manual.
“The manual is first and foremost a guidebook for clinicians,” reiterated David Kupfer, M.D., DSM-5 task force chair, who walked us through the major changes detailed below.

1. Three major sections of the DSM-5

I. Introduction and clear information on how to use the DSM.
II. Provides information and categorical diagnoses.
III. Section III provides self-assessment tools, as well as categories that require more research.

2. Section II – Disorders

Organization of chapters is designed to demonstrate how disorders are related to one another.
Throughout the entire manual, disorders are framed in age, gender, developmental characteristics.
Multi-axial system has been eliminated. “Removes artificial distinctions” between medical and mental disorders.
DSM-5 has approximately the same number of conditions as DSM-IV.

3. The Big Changes in Specific Disorders

Autism
There is now a single condition called autism spectrum disorder, which incorporates 4 previous separate disorders. As the APA states:
ASD now encompasses the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.
ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs). Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.
Disruptive Mood Dysregulation Disorder
Childhood bipolar disorder has a new name — “intended to address issues of over-diagnosis and over-treatment of bipolar disorder in children.” This can be diagnosed in children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol (e.g., they are out of control).
ADHD
Attention deficit hyperactivity disorder (ADHD) has been modified somewhat, especially to emphasize that this disorder can continue into adulthood. The one “big” change (if you can call it that) is that you can be diagnosed with ADHD as an adult if you meet one less symptom than if you are a child.
While that weakens the criteria marginally for adults, the criteria are also strengthened at the same time. For instance, the cross-situational requirement has been strengthened to “several” symptoms in each setting (you can’t be diagnosed with ADHD if it only happens in one setting, such as at work).
The criteria were also relaxed a bit as the symptoms now have to had appeared before age 12, instead of before age 7.
Bereavement Exclusion Removal
In the DSM-IV, if you were grieving the loss of a loved one, technically you couldn’t be diagnosed with major depression disorder in the first 2 months of your grief. (I’m not sure where this arbitrary 2 month figure came from, because it certainly reflects no reality or research.). This exclusion was removed in the DSM-5. Here are the reasons they gave:
The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III. Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes. Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression. In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive episode.
PTSD
More attention is now paid to behavioral symptoms that accompany PTSD in the DSM-5. It now includes four primary major symptom clusters:
  • Reexperiencing
  • Arousal
  • Avoidance
  • Persistent negative alterations in cognitions and mood
“Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.”
Major and Mild Neurocognitive Disorder
Major Neurocognitive Disorder now subsumes dementia and the amenstic disorder.
But a new disorder, Mild Neurocognitive Disorder, was also added. “There was concern we may have added a disorder that wasn’t ‘important’ enough.”
“The impact of the decline was noticeable, but clinicians lacked a diagnosis to give patients,” noted Dr. Kupfer. There were two reasons for this change: “(1) Opportunity for early detection. The earlier the better for patients with these symptoms. (2) It also encourages an early effective treatment plan, ” before dementia sets in.
Other New & Notable Disorders
Both binge eating disorder and premenstrual dysphoric disorder and now official, “real” diagnoses in the DSM-5 (they were not prior to this, although still commonly diagnosed by clinicians). Hoarding disorder is also now recognized as a real disorder, separate from OCD, “which reflects persistent difficulty dis-carding or parting with possessions due to a perceived need to save the items and distress associated with discarding them. Hoarding disorder may have unique neurobiological correlates, is associated with significant impairment, and may respond to clinical intervention.”

Jeffrey Lieberman, MD, President-Elect of the APA reminded us that the DSM-5 is not a pop-psychology book intended for consumers: “[It is] a guide, an aide to assist clinicians to … help facilitate treatment.”
The APA also noted that a large number of sessions — 21 — will be dedicated to the DSM-5 this weekend at the APA’s annual meeting.
Commenting on the swirling controversy regarding the DSM-5, that perhaps the diagnostic system isn’t good enough, Dr. Lieberman said, “It can’t create the knowledge, it reflects the current state of our knowledge.”
“We can’t keep waiting for such breakthroughs,” (in reference to biomarkers and laboratory tests). “Clinicians and patients need the DSM-5 now.
Critics have accused the DSM-5 of lowering diagnostic thresholds across the board, making it far easier for a person to be diagnosed with a mental disorder. Lieberman disagrees, however: “How [the DSM-5] is applied reflects critical practice… it’s not necessarily because of the criteria [themselves]. It’s because of the way the criteria are applied.”

Thursday, May 16, 2013

Escapism



Escapism is mental diversion by means of entertainment or recreation, as an "escape" from the perceived unpleasant or banal aspects of daily life. It can also be used as a term to define the actionspeople take to help relieve persisting feelings of depression or general sadness.

History 

Entire industries have sprung up to foster a growing tendency of people to remove themselves from the rigors of daily life.[citation needed] Many activities that are normal parts of a healthy existence (e.g., eating, sleeping, exercise, sexual activity) can also become avenues of escapism when taken to extremes or out of proper context. In the context of being taken to an extreme, the word "escapism" carries a negative connotation, suggesting that escapists are unhappy, with an inability or unwillingness to connect meaningfully with the world.

However, there are some who challenge the idea that escapism is fundamentally and exclusively negative. For instance, J. R. R. Tolkien, responding to the Anglo-Saxon academic debate on escapism in the 1930s, wrote in his essay "On Fairy-Stories" that escapism had an element of emancipation in its attempt to figure a different reality. C. S. Lewis was also fond of humorously remarking that the usual enemies of escape were jailers. Some social critics warn of attempts by the powers that control society to provide means of escapism instead of actually bettering the condition of the people. For example, Karl Marx wrote about religion as being the "opium of the people". Escapist societies appear often in literature. The Time Machine depicts the Eloi, a lackadaisical, insouciant race of the future, and the horror their happy lifestyle belies. The novel subtly criticizes capitalism, or at least classism, as a means of escape. Escapist societies are common in dystopian novels; for example, in Fahrenheit 451 society uses television and "seashell radios" to escape a life with strict regulations and the threat of the forthcoming war. In science fiction media escapism is often depicted as an extension of social evolution, as society becomes detached from physical reality and processing into a virtual one, examples include the virtual world of OZ in 2009 Japanese animated science fiction Summer Wars and the game "Society" in the 2009 American science fiction film Gamer. Drugs cause some forms of escapism which can occur when certain performance enhancing drugs are taken which make the participant forget the reality of where they are or what they are meant to be doing. This is highly illegal because it can make users act strangely and do unpredictable things.
German social philosopher Ernst Bloch wrote that utopias and images of fulfilment, however regressive they might be, also included an impetus for a radical social change. According to Bloch, social justice could not be realized without seeing things fundamentally differently. Something that is mere "daydreaming" or "escapism" from the viewpoint of a technological-rational society might be a seed for a new and more humane social order, as it can be seen as an "immature, but honest substitute for revolution".
The Norwegian psychologist Frode Stenseng has presented a dualistic model of escapism in relation to different types of activity engagements. He discusses the paradox that the flow state (Csikszentmihalyi) resembles psychological states obtainable through actions such as drug abuse, sexual masochism, and suicide ideation (Baumeister). Accordingly, he deduces that the state of escape can have both positive and negative meanings and outcomes. Stenseng argues that there exists two forms of escapism with different affective outcomes dependent on the motivational focus that lays behind the immersion in the activity. Escapism in the form of self-suppression stems from motives to run away from unpleasant thoughts, self-perceptions, and emotions, whereas self-expansion stems from motives to gain positive experiences through the activity and to discover new aspects of self. Stenseng has developed the Escape scale to measure self-suppression and self-expansion in people´s favorite activities, such as sports, arts, and gaming. Empirical investigations of the model have shown that (1) the two dimensions are distinctively different with regards to affective outcomes, (2) that some individuals are more prone to engage through one type of escapism, and (3) that situational levels of well-being affects the type of escapism that becomes dominant at a specific time.