mental disorders


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

I posted in February about how the committee that is redesigning the DSM is accepting feedback on their proposed changes. The Diagnostic and Statistical Manual of Mental Disorders is the book used around the world by clinicians to determine what kinds of human suffering count as mental disorders, what symptoms one has to show to qualify as having one of those disorders, and what what can get covered by insurance. The content of this book will shape the lives of those who will interact with the mental health system for the next generation. Being labeled with a mental disorder is a big deal, and which one you get can mean the difference between decent and indecent treatment. Personality Disorder? You’re pretty much screwed. Very few people think they can help you and no insurance will cover you. Adjustment Disorder? PTSD? You’re in luck, most likely. We’re all very hopeful for, and will pay for, your recovery.

If you’re life has in any way been affected by anything labeled a mental disorder, I encourage you to look at the appropriate proposed changes to your future and the future of your loved ones, and write them an email about what you think. You have until April 20, 2010.

Structural, Cross-Cutting, and General Classification Issues for DSM-5
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Delirium, Dementia, Amnestic, and Other Cognitive Disorders
Mental Disorders Due to a General Medical Condition Not Elsewhere Classified
Substance-Related Disorders
Schizophrenia and Other Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual and Gender Identity Disorders
Eating Disorders
Sleep Disorders
Impulse-Control Disorders Not Elsewhere Classified
Adjustment Disorders
Personality Disorders
Other Conditions that May Be the Focus of Clinical Attention

There are two official DSM diagnoses for eating disorders, with two variations each. This gives us four options: Anorexia Nervosa, Restricting Type; Anorexia Nervosa, Binge Eating/Purging Type; Bulimia Nervosa, Purging Type; Bulimia Nervosa, Nonpurging Type.

This is are direct direct quotes from the DSM-IV-TR. “Postmenarcheal” means after the onset of the menstrual cycle. In addition to Anorexia Nervosa and Bulimia Nervosa, there is a category with no diagnostic criteria called Eating Disorder Not Otherwise Specified that clinician can give to someone “for disorders of eating that do not meet the criteria for any specific Eating Disorder.” People diagnosed with EDNOS are even more likely to die from their conditions than those in AN or BN.

Diagnostic criteria for 307.1 Anorexia Nervosa

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during a period of growth, leading to body weight less than 85% of that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Specify type:

Restricting Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Diagnostic criteria for 307.51 Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxative, diuretics, enemas, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behavior both occur, on average, at least twice a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight.

E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Specify type:

Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

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