DSM-IV-TR


How do you make your hamster depressed? Leave the TV on at night.

I didn’t even know that hamsters got depressed, but apparently they do, according to an article by PsychCentral. One of the ways you can tell is that they start drinking less sugar water. “Scientists assume this occurs because they’re not getting as much pleasure from normally enjoyable activities.” If that is true, then the hamsters are experiencing anhedonia, which is one of the diagnostic criteria for depression.

The article was about an experiment in which scientists tested the effects of leaving a light on that was about as bright as a TV (5 lux) at night for some hamsters and turning the lights off for other hamsters. Not only did the TV-hamsters get depressed, but when the scientists cut up their brains, they found they had atrophied.

Does this apply to humans? Let’s check it out with sample size one: I prefer total darkness at night, too. The lights from neighbors’ houses shining into my room irritate me. Unfortunately, irritable mood is not one of the diagnostic criteria for depression unless you are a child or adolescent. Adults have to feel moods like “sad” or “empty” to qualify for a depressed mood in the DSM. Plus, my desire for sugar water increases when I’m depressed.

It looks like we’ll have to wait for some human trials of this experiment. Without the cutting-up-their-brains part.

One of the heads of my Couples & Family Therapy program, Jeff Todahl, is launching an exciting and inspiring campaign this coming Saturday. It’s called “90 by 30,” referring to his intention to reduce domestic violence and child maltreatment by 90% by the year 2030 in Eugene and Springfield.  He announced the launch at a domestic violence awareness event I helped put on with the University of Oregon Men’s Center last fall. [Here’s the video of his talk. It’s good.] As an expert on domestic violence and part of the Trauma Healing Project in Eugene, he has decided:

1) We know how to do it–all of the programs necessary have been invented and proven effective in various parts of the US.

2) It is feasible to bring all of those programs into one area and virtually eliminate domestic violence and child maltreatment here.

3) Doing so will be a huge step toward the elimination of domestic violence and child maltreatment nationally and globally.

4) The elimination of domestic violence and child maltreatment would shrink the 943-page Diagnostic and Statistical Manual of Mental Disorders to the size of a pamphlet. That is, it would mean a virtual elimination of mental health problems for humans.

If you are in Lane County and this sounds like an interesting project, join us for a panel presentation by Jeff and his collaborators February 5th, 2011, from 11am – 2pm at the University of Oregon. The event will be held in Room 220, HEDCO building, at 17th and Alder, Eugene, Oregon.

We don’t really know but the DSM estimates between 1 and 6% of children and many fewer adults have this experience. You are more likely to have this happen if you are related to someone who has had this happen, but we have no idea why. It usually just goes away in adolescence. If my parents had been the type to take their kids to mental health professionals, I almost certainly would have gotten this diagnosis as a kid. If so, and if my parents had been the drug-giving kind, I might have been prescribed a benzodiazepine (like Valium) for it. Generally, though, it can be treated by comforting your child when they wake up like this, until it goes away. If you think there might have been a triggering event for the condition, therapy might be helpful.

Here are the criteria, quoted word-for-word from the Diagnostic and Statistical Manual of Mental Disorders IV-TR, page 639:

Diagnostic criteria for 307.46 Sleep Terror Disorder

A. Recurrent episodes of abrupt awakening from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream.

B. Intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing, and sweating, during each episode.

C. Relative unresponsiveness to efforts of others to comfort the person during the episode.

D. No detailed dream is recalled and there is amnesia for the episode.

E. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not due to  the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

 

I attended a lecture today about addiction where the lecturer claimed that the American Medical Association requires that a phenomenon meet the following criteria to be considered a disease:

1) It must be progressive

2) It must manifest identifiable symptoms

3) It must occur chronically in affected individuals

4) It must be fatal if left untreated

That makes some things obvious diseases. Cancers, for example. There are many things that we consider diseases that do not fit these criteria, though. I believe that obesity, for example, is not officially considered a disease because it is not fatal. It’s correlated with many fatal conditions but isn’t fatal on its own. Most mental disorders fail to meet this criteria too. Anorexia is fatal if untreated, but anxiety disorders, dissociative disorders, ADHD, learning disorders, conduct disorders, psychotic disorders, and dissociative disorders and many others are not. There is a pretty good case to make for  alcoholism and some other addictions meeting these criteria. Disorders that are associated with suicidality, too, might qualify, like severe depression, and possibly “gender identity disorder,” though GID may not be progressive and so fail the first criteria.

The existence of Gender Identity Disorder as an official mental disorder is troubling to the trans folks I know. They think of their condition they way most people now think about homosexuality: It’s just another normal way to be a human being that makes people who don’t understand it so afraid that they’ve called it a disorder. Some people are just born into bodies that don’t match their psychological gender.

There are other problems. There is the DSM’s requirement to specify whether the diagnosed individual is attracted to males, females, both, or neither. If homosexuality is not a mental disorder, why should it matter clinically what genders a transsexual is attracted to? Then there’s the fact that GID is in the DSM right next to the sexual disorders like sexual sadism, masochism, and pedophilia. What is the connection?

So in a way, it would be great to get GID removed from the DSM, like homosexuality was in the 1970s. Unfortunately, if GID were not an official mental disorder, insurance companies wouldn’t pay for the expensive surgeries and hormone treatments involved in transitioning. According to my friends, living in a body of the wrong sex is so painful and humiliating that many pre-operation trans folks kill themselves, while suicide is rare for those who do who get the operations. So if you are poor and trans, your life may depend on GID being an official mental disorder.

There may be some changes coming to the diagnosis (see here) in the upcoming DSM-V, and my friends are saying they sound somewhat better. Here’s how they stand right now, in the Diagnostic and Statistical Manual of Mental Disorders IV-TR:

Diagnostic criteria for Gender Identity Disorder

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

In children, the disturbance is manifested by four (or more) of the following:

(1) repeatedly stated desire to be, or insistence that he or she is, the other sex

(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex

(4) intense desire to participate in the stereotypical games and pastimes of the other sex

(5) strong preference for playmates of the other sex

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male  stereotypical toys, haves, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Code based on current age:

302.6     Gender Identity Disorder in Children

302.85   Gender Identity Disorder in Adolescents or Adults

Specify if (for sexually mature individuals):

Sexually Attracted to Males

Sexually Attracted to Females

Sexually Attracted to Both

Sexually Attracted to Neither

Schizophrenia is a fascinating set of phenomena, the study of which has launched a thousand ships including, arguably, my field, family therapy; many of the original family therapists left psychiatry to study schizophrenia (or, as the DSM would have me write it, Schizophrenia–capitalizing words gives them more authority, don’t you think?) as an interactive process. That is, if all behaviors make sense in their context, what context might make schizophrenic behavior necessary?

There was an almost violent backlash against this line of thinking, as it seemed to (and did, in many cases) blame mothers for their schizophrenic children–as in the unfortunate phrase “schizophrenogenic mother.” The conventional wisdom about schizophrenia these days reads like a pharmaceutical company press release, something like, “Schizophrenia is a biological disease of the brain which is at present incurable, but there are drugs which can help manage the symptoms, and if taken regularly can provide a decent quality of life.”

So schizophrenia is assumed to be a biological disease of the brain though it, like every other Mental Disorder, has no laboratory test that can detect its presence. The best we can do is a set of behavioral diagnostic criteria which, frankly, are a bit of a mess. You may notice as you read that different flavors of schizophrenia may have nothing or little in common with each other. Are they really the same “disease”? We don’t know.

We do have good evidence that you can inherit, in some fashion, a tendency for one of these constellations of behaviors. There is good evidence that environmental factors are also important, though they are not a big part of the mainstream discussion. We also have evidence that therapy helps in a lot of cases. There is some (hotly contested, I’m sure) evidence from the World Health Organization that unmedicated schizophrenics can eventually recover while those on medication do not. Here is a trailer for a moving documentary about two recovered women and the public perception of schizophrenia, called Take These Broken Wings. Also, consider checking out the documentary A Brilliant Madness, about John Nash, in which puts the lie to A Brilliant Mind, which showed Nash recovering with the help of psychopharmaceuticals.

The DSM says that schizophrenia may be overdiagnosed (or at least is diagnosed more often) in African- and Asian-American men, that it affects men differently than women (men tend towards the negative symptoms were women tend towards delusions and hallucinations), and that incidence rates are something like .5-1.5% of adults.

Here are a few terms that you’ll need to know to get through the criteria:

affective flattening: does not show emotion. Also, “affect” means “emotion” to scientists and people who like to talk like scientists.

alogia: lack of speech.

avolition: lack of motivation.

prodromal: symptoms coming early on in the course of a disease.

echolalia: repetition of others’ speech sounds.

echopraxia: repetition of others’ movements

And here are the diagnostic criteria, word-for-word, from the DSM-IV-TR, pp. 312-319:

Diagnostic criteria for Schizophrenia

A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

(1) delusions

(2) hallucinations

(3) disorganized speech (e.g. frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction: For a significatn portion of the time since th onset of the distrubance, one or more major areas of functioning such as work, interpersonal relations, or self-care are mardekly below the level achieved prior to the onset (or when the onset is in childhood or adolewscence, faliure to achieve expected level of interpersonal, academic, or occupational achievement).

C. Duration: Continuou signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. Doring these prodromal or residual periods, the signs of the ditrubance may be manifested by only negative symptoms or two or more symptoms listen in Criterion A pressent in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.

F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):

Episodic With Interepisode Residual Symptoms (episodes are difined by the reemergence of prominent psychotic symptoms); also specify if: With Prominent Negative Symptoms

Episodic With No Interepisode Residual Symptoms

Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With Prominent Negative Symptoms

Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms

Single Episode In Full Remission

Other or Unspecified Pattern

Diagnostic criteria for 295.30 Paranoid Type

A type of Schizophrenia in which the following criteria are met:

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Diagnostic criteria for 295.10 Disorganized Type

A type of Schizophrenia in which the following criteria are met:

A. All of the following are prominent:

(1) disorganized speech

(2) disorganized behavior

(3) flat or inappropriate affect

B. The criteria are not met for Catatonic Type.

Diagnostic criteria for 295.20 Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumptions of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Diagnostic criteria for 295.90 Undifferentiated Type

A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.

Diagnostic criteria for 295.60 Residual Type

A type of Schizophrenia in which the following criteria are met:

A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

I was surprised that these criteria did not specifically mention pain. I had thought that sadism and masochism were about wanting to hurt and be hurt. Reading these makes me think that it’s more about issues around control and humiliation than enjoying the sensation of pain.

This is word-for-word from the DSM-IV-TR, pages 573 and 574:

Diagnostic criteria for 302.84 Sexual Sadism

A. Over a period of at least 6 months, recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

B. The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

Diagnostic criteria for 302.83 Sexual Masochism

A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.

B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or important areas of functioning.

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), there is a mental disorder that is usually diagnosed in childhood or adolescence called Oppositional Defiant Disorder. It afflicts somewhere between 2-16% of people, more boys than girls before puberty, but equal numbers of boys and girls after puberty. Family therapists are not into giving medical-model diagnoses in general, but in many cases, a DSM diagnosis is the only way for a family to get their insurance companies to pay for them to get help. In one of my internship sites, for example, I will need to provide a DSM diagnosis after the first session with a family in order to get the clinic paid for our work. As I understand it, this is a common diagnosis for kids who are giving their parents and teachers a hard time.

Note that the word “often” is used to mean something like “more than usual,” so whichever kids who are most like this will qualify for this Disorder, as long as someone important believes that their behavior is significantly impairing their social or academic functioning. Note also that these symptoms could be occurring in just one setting (say, just at school) and the kid will still qualify for ODD, unlike the symptoms for ADHD, which have to occur in at least two settings to qualify for the diagnosis.

Outside of family therapy, ODD is very commonly treated with Ritalin for “comorbid” ADHD. Kids diagnosed with ODD are also fairly commonly given antidepressant and/or antipsychotic medication, on the guess that they have an underlying Mood Disorder or Bipolar Disorder, though there is little to no research on these medications for children, especially in combination.

The following is word-for-word from the DSM-IV-TR, page 102:

Diagnosis criteria for 313.81 Oppositional Defiant Disorder

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

(1) often loses temper

(2) often argues with adults

(3) often actively defies or refuses to comply with adults’ requests or rules

(4) often deliberately annoys people

(5) often blames others for his or her mistakes or misbehavior

(6) is often touchy or easily annoyed by others

(7) is often angry or resentful

(8) is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 or older, criteria are not met for Antisocial Personality Disorder.

This is another DSM-IV-TR Mental Disorder diagnosis that is commonly given to children. The DSM says that its prevelence has been increasing for a few decades now and that up to 10% of kids, mostly boys in “urban settings”, have it. It’s a pretty serious label to give a kid. It’s linked with suicide, homicide, various criminal acts, and is thought of as a precursor to Antisocial Personality Disorder. Here are the criteria, quoted word-for-word from the DSM-IV-TR (pp. 98-99):

Diagnostic criteria for Conduct Disorder

A. A repetitive and persistent pattern of behavior in which the basioc rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months.

Aggression to people and animals

(1) often bullies, threatens, or intimidates others

(2) often initiates physical fights

(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)

(4) has been physically cruel to people

(5) has been physically cruel to animals

(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)

(7) has forced someone into sexual activity

Destruction of property

(8) has deliberately engaged in fire setting with the intention of causing serious damage

(9) has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or theft

(10) has broken into someone else’s house, building, or car

(11) often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)

(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

Serious violations of rules

(13) often stays out at night despite parental prohibitions, beginning before age 13 years

(14) has run away from home overnight at least twice while living in parental or parental surrogate (or once without returning for a lengthy period)

(15) is often truant from school, beginning before age 13 years

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Code based on age at onset:

312.81 Conduct Disorder, Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years

312.82 Conduct Disorder, Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10 years

312.89 Donduct Disorder, Unspecified Onset: age at onset is not known

Specify severity:

Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others

Moderate: number of conduct problems and effect on other intermediate between “mild” and “severe”

Severe: many conduct problems in excess of those required in excess of those required to make the diagnosis or conduct problems cause considerable harm to others

The DSM-IV-TR reports a prevalence of 3-7% for the famous AD/HD, depending, somewhat cryptically, on “the population sampled and the method of ascertainment” (p. 90). AD/HD is a shoe-in for medication in the minds of most mental health professionals. Children have been treated for this Disorder with stimulants since 1937. We still do not know for certain, however, what the effects are on adults who took stimulants as children. We do know that AD/HD tends to go away during adolescence.

Here are the diagnostic criteria, straight from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Note that criterion C is an attempt to make sure that the troublesome behavior is not just a reaction to one situation, like school–you shouldn’t be diagnosed AD/HD based on behavior that only happens at school, or just at home. That would be something else going on. Note also that, according to the “coding note” at the bottom that once you have this diagnosis, unless you have none of these symptoms, you will always be considered AD/HD “in partial remission.” One last note: I notice in reading literature referring to this Disorder that it is usually referred to as ADD/ADHD. I don’t know why this is, as there is no “Attention Deficit Disorder” in the DSM-IV-TR. Perhaps there was in earlier editions.

Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder

A. Either (1) or (2):

(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Inattention

(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities

(b) often has difficulty sustaining attention in tasks or play activities

(c) often does not seem to listen when spoken to directly

(d) often does not follow through on instructions and fails to finish school-work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

(e) often has difficulty organizing tasks and activities

(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)

(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)

(h) is often easily distracted by extraneous stimuli

(i) is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with development level:

Hyperactivity

(a) often fidgets with hands or feet or squirms in seat

(b) often leaves seat in classroom or in other situations in which remaining seated is expected

(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

(d) often has difficulty playing or engaging in leisure activities quietly

(e) is often “on the go” or often acts as if “driven by a motor”

(f) often talks excessively

Impulsivity

(g) often blurts out answers before questions have been completed

(h) often has difficulty awaiting turn

(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g., at shool [or work] and at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “In Partial Remission” should be specified.

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