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Psyched out: what will the new DSM say about you?


As the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is being prepared by the American Psychiatric Association for its release in 2013, warning bells are being sounded from feminist psychiatric quarters.

Critics of the so-called "psychiatrists' bible" and of the process by which it is developed have detailed a wide range of concerns. They include the methodology with which new diagnoses will be determined, allegations of sexism on the parts of those writing the DSM-5, undue drug company influence upon the definition and treatment of disorders, and a lack of transparency in the entire process of developing the DSM-5.

Feminist psychologist Paula J. Caplan, a fellow in the Women and Public Policy Program at Harvard's Kennedy School, once served as an advisor to two DSM committees. But she resigned because of serious concerns about "how fast and loose they play with the scientific research related to diagnosis." Formerly head of the University of Toronto's Centre for Women's Studies in Education, Caplan has become a leading voice in alerting both therapists and the public to the manual's "unscientific nature and the dangers that believing in its objectivity poses."

As Caplan points out, "psychiatric diagnosis is highly subjective." Joined by a chorus of other critics, she charges that the authors of the new Diagnostic and Statistical Manual of Mental Disorders make "expansive claims about their knowledge and authority, wielding enormous power to decide who will and will not be called mentally ill and what the varieties of alleged mental illness will be."

One diagnosis of concern is borderline personality disorder. According to Dana Becker, a professor at the Bryn Mawr Graduate School of Social Wok and Social Research, borderline personality disorder became a diagnosis in the 1980 edition of the Diagnostic and Statistical Manual of Mental Disorders. It is now the most frequently diagnosed personality disorder and roughly 75 percent of patients given that label are women.

The DSM-IV authors defined borderline personality disorder as a persistent pattern of instability and impulsivity. The symptoms currently listed range from self-damaging behaviour to intense mood reactivity, feelings of emptiness and problems controlling anger. In its proposed revision for DSM-5, the working group's recommendation is that the disorder be reformulated as "borderline type." The group posits that "individuals who resemble this personality disorder type have an impoverished and/or unstable self-structure and difficulty maintaining enduring and fulfilling intimate relationships."

The new borderline category would state that "self-concept is easily disrupted under stress" or when there are "chronic feelings of emptiness." It cites "loathing, despondency, and sensitivity to loss or disappointments, linked with reactive, rapidly changing, intense, and unpredictable emotions" and says anxiety and depression are common among those with this personality type. It also cites anger as "a typical reaction to feeling misunderstood, mistreated, or victimized."

The problem, according to Becker, is that "there are over 100 ways to combine borderline personality disorder symptoms so that a patient would qualify as suffering from the disorder. Further, criteria for borderline personality have been altered over the past 50 years to include more and more symptoms related to emotion, accounting at least in part for the sex bias inherent in the diagnosis."

Observing the increased number of women given the borderline label, Becker worries that borderline personality disorder has become a catch-all label given especially to women when they experience acute sadness, emptiness and emotional reactivity (anger).

The consequences of such a diagnosis can be dire, Becker says. Some women have been institutionalized or medicated involuntarily, some have lost custody of their children, while others have been discredited as witnesses in court cases that involve rape or sexual abuse (theirs). This is poignantly ironic, notes Caplan, given that histories of violence often lead to women's feelings of sadness, emptiness and anger.

Another significant area of concern is the area labeled "sexual dysfunctions." Among the dysfunctions being considered in the DSM-5 is one called female orgasmic disorder. In the current edition of the manual, this disorder is said to exist if there is a "persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase." Acknowledging that women have a "wide variability in the type or intensity of stimulation that triggers orgasm," a diagnosis of sexual dysfunction, the draft DSM-5 notes, should be "based on the clinician's judgment that the woman's orgasmic capacity is less than would be reasonable given her age, sexual experience, and the adequacy of sexual stimulation she receives." The DSM-5 modification specifies that either "marked delay in, marked infrequency, or absence of orgasm" or "marked reduced intensity of orgasmic sensation," should be experienced by the patient.

Dealing with women's sexual response in this manner is a mistake, according to Dr. Leonore Tiefer, clinical associate professor of psychology at New York University's School of Medicine. She compares classifying sexual dysfunction to "rearranging deck chairs on the Titanic." Classifying sexual dysfunction as a disorder, she says, is "fundamentally flawed" because scientists still "have a narrow idea of what constitutes human sexuality."

Tiefer is particularly concerned about the lack of understanding regarding the diversity of women's experience of sex. In a paper written for the Association of Women in Psychology, she cites a number of assumptions and errors of omission and commission. For example, she points out that "people complain of many problems with sex other than desire, arousal and orgasm, but these problems have been under-researched and even dismissed because they don't comply with DSM classification.

What about lack of pleasure or intimacy? "What about past abuses? What about sexual incompatibility ... because of fixed preferences or aversions?" She also underscores that "DSM classification includes lack of desire as a disorder, although lack of desire might be completely healthy or expected under many conditions such as grief, relationship strife, fatigue, and financial or family worries."

Because of concerns about inherent sexism in the Diagnostic and Statistical Manual of Mental Disorders approach to women's sexual response, The New View Campaign on Women's Sexual Problems was convened in 1999 to challenge the medicalization of sex. One of its first activities was to write a manifesto directly challenging the DSM and offering instead a classification of factors that contribute to women's sexual problems. The manifesto cites such issues as "an emphasis on genital and physiological similarities between men and women [that] ignores the implications of inequalities related to gender, social class, ethnicity, sexual orientation, etc.," as well as "the leveling of differences among women." (To view the manifesto, see http://newviewcampaign. org/manifesto5.asp)

The American Psychiatric Association (APA) website says its purpose in writing the DSM is to establish criteria for diagnosis and "not to create medical conditions out of the full range of human behaviour and emotions." The APA is dedicated, it says, to "ensuring that the development of DSM-5 is the most open and inclusive in the history of the manual." It cites the fact that "more than 500 of the world's most renowned clinicians and researchers have been involved in working together to provide a solid scientific basis for the proposed changes to DSM-5."

DSM-5 working group members include Kim Yonkers, professor of psychiatry at Yale University's School of Medicine, and Lori Brotto, associate professor in the department of Obstetrics and Gynecology at the University of British Columbia. Both doctors say concerns from professionals have been taken very seriously. Yonkers cites numerous workshops, presentations, published reports and international meetings at which concerns have been raised. Brotto says her working group communicates with the public and takes their concerns into account. She adds that she is personally concerned about the medicalization of sex and the "tendency toward pharmaceutical treatment for women."

Still, Caplan and other feminist critics remain concerned about a continuing shroud of secrecy enveloping the process. Caplan cites as an example a recent conference call, intended for public comment, in which she participated. "Three manual editors' remarks took up over half the time, while six of the 20 consumer representatives invited to call were each allowed to speak for less than two minutes," she says. "In all, six questions were asked, so 14 of the non-DSM callers never got to speak."

Other concerns about the Diagnostic and Statistical Manual of Mental Disorders process include the fact that working group members are required to sign non-disclosure agreements (which means they can't discuss the process of how the disorders are developed, even after the fact). They are also permitted to earn up to $10,000 annually from pharmaceutical companies while they are on DSM-5 committees (and can resume making vastly more once the book goes to press). Another issue that has been flagged is the fact that a public relations firm was hired to advise the DSM team.

"There is a lot of pain and suffering in the world, and it is tempting to believe that the mental health community knows how to help," Caplan acknowledges. "It is widely believed, both by mental health professionals and the general population, that if only a person gets the right psychiatric diagnosis, the therapist will know what kind of measures will be most helpful. Unfortunately, that is not usually the case, and getting a psychiatric diagnosis can often create more problems than it solves."

Reflecting on the DSM-5, Caplan says, "Each time a new edition appears, it is packed with dozens of new categories that are said to be kinds of mental disorder, and the authors herald each new edition with pronouncements that this edition was necessary because the previous one was so unscientific. It would read like a repeated, silly joke were the consequences not so often tragic."

Elayne Clift writes about women, health, politics and social issues from Saxtons River, Vermont.
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Title Annotation:Diagnostic and Statistical Manual of Mental Disorders
Author:Clift, Elayne
Geographic Code:1USA
Date:Sep 22, 2011
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