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NIMH v DSM-5: Mental health professionals continue to disagree

The bigwigs of mental health research have slammed the bigwigs of psychiatry, which will probably mean more confusion for the rest of us.

In 10 days, on May 27, 2013, the American Psychiatric Association’s new Diagnostic and Statistical Manual of Mental  Disorders 5th Edition, or DSM-5, will be published. This is the massive reference book that psychiatrists and therapists use in order to diagnose mental illness.

But a few weeks ago, the head of the National Institute of Mental Health (NIMH), which is the world’s largest funding agency for research into mental health, trashed the DSM-5. More precisely, Thomas R. Insel, M.D., director of NIMH, said the government agency would no longer fund research based on DSM-5 categories. Read:

The NIMH withdraws support for DSM-5, by Christopher Lane, Ph.D., on PsychologyToday.com.

Transforming diagnosis, by Thomas Insel, on NIMH.NIH.gov.

Defining and diagnosing sociopaths was already a mess, with mental health professionals disagreeing on what they should be called and how the disorder should be defined.

Psychiatrists use the term “antisocial personality disorder.” Research psychologists use the term “psychopathy.” Neither psychopathy nor sociopathy are clinical diagnoses in the DSM-5. The new DSM-5 did make  changes to the way antisocial personality disorder was defined and diagnosed, but the research psychologists still say it’s different from psychopathy.

While the experts argue with each other, the public is clueless that these social predators live among us.

So what will happen with this even bigger dispute between segments of mental health professionals? I have no idea, but I imagine the public will still be in the dark.

 UPDATE:

The Wall Street Journal offered a thought-provoking analysis of this situation in its review of two related books:

The Book of Woe, by Gary Greenberg, “takes us on a rollicking journey from the DSM-5’s inception to its publication, regaling us with stories, alternately hilarious and infuriating, of internecine battles, personality clashes and political machinations.”

Saving Normal was written by Dr. Allen Frances, who was task-force chair for the DSM-IV revision. He “attempts the delicate task of debunking the DSM-5 while justifying his own DSM-IV. He was alarmed by the DSM-5’s proposals of ‘new diagnoses that would turn everyday anxiety, eccentricity, forgetting and bad eating habits into mental disorders.'”

Read: How psychiatry went crazy, on WSJ.com.

 

 



17 Comments on "NIMH v DSM-5: Mental health professionals continue to disagree"

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  1. Imara says:

    I am a licensed clinical social worker. The DSM has been a mess since the fourth edition was instituted… have to say I come down in favor of the NIMH in this spat!!!
    More relevant to us here is the fact that in our graduate school programs we were not taught a single separate course on personality disorders…and yet in Sandra Brown’s research she claims that the helping professions themselves are disproportionately represented as targets of cluster B individuals. My belief though is that unless we have experienced the targeting and the consequent hurt we can never truely understand the soul searing hurt and the fallout that happen after demean and discard.
    So for purposes of training new therapists and generating public awareness of the RED FLAGS I think the mental health community need not only to look at its own. I think my fellow professionals have a long way to go….But DSM diagnosed or not, healthy and unhealthy relational dynamics remain the same and we can definitely educate the next generation of therapists.



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    • Imara says:

      Also it is notoriously difficult to diagnose spectrum disorders…that is why the same controversy is occuring due to Aspergers syndrome being eliminated. I think a large part of this is also because as a society we are redefining what we consider “normative”.



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    • KK says:

      This news is very interesting. I’ve had a chance to look at the DSM 5 (April version) and found the criteria much easier to understand than previous versions. It can be difficult to diagnose personality disorders accurately because there can be overlapping and comorbidity of symptoms, but I feel the new DSM provides a better guide for categorizing personality traits.



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  2. Imara – I frequently hear from Lovefraud readers who have gone to counseling, and the the therapists truly do not understand what they experienced during relationships with sociopaths. Can you comment further on this? What are the schools teaching about how counselors should work with people who have been targeted by sociopaths? Or is there no specific information, and they’re taught to treat these clients the same as everyone else?



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    • Imara says:

      Personality disorders are coded on AXIS 2. using the DSM. Most insurance companies do not provide reimbursement for treatment of Axis 2 diagnosis. Therefore even very new therapists learn to bill for symptomatic issues that may result from an Axis 2 diagnosis. For example, depression can be diagnosed as an Axis 1 diagnosis and a therapist will be reimbursed for creating a treatment plan to address that. But no insurance is going to pay to address a diagnosis of a personality disorder especially something like ASPD.
      My belief is that the reason graduate curriculums do not address Axis 2 diagnoses is because in recent years due to the way managed health reimbursement works students have been guided to work with shorter term more solution focused modalities. Long term more psychodynamic therapies which would be more efficatious with personality disorders are just “out of fashion” and harder to get reimbursed for. Most people seeking longer term treatment pay out of pocket, and that can get expensive. Also the very nature of personality disorders especially the cluster Bs make it difficult to deal with those issues. Recently there have been a spate of newer evidence based treatment modalities that have been found effective… DBT being one example. BUT and here’s the crux…these are being taught largely by way of continuing education, and thus on a very individual basis!!! Therefore clients seeking therapists currently need to do due diligence themselves to assure that whoever they see is qualified to do the kind of work that is needing to be addressed. Unfortunately most clients seeking help after being victimised by cluster Bs are in crisis and most unable to best advocate for their own self interest. Most graduate programs have now started teaching work with PTSD… however EMDR and other evidence based treatments are still taught only in seminars and continuing education courses. So there IS a disconnect on several fronts and that is why most victims feel like they are not heard.
      On a personal level I was victimised too and not able to “see” what I was dealing with. Cognitive dissonance is another reason most clients do not feel understood…. If a therapist has not dealt with this on a personal or professional basis then my belief is that they would be wholly unsuited to deal with “our” population. Typically a phenomenon like cognitive dissonance would not be addressed in a classroom but rather in the field training placements that graduate students have to train in. If they train with agencies that do not deal with victim services then most likely they would not be trained in the handling and diagnosis of cognitive dissonance.
      I think that the best we can do right now is to advocate for all therapists who work with victim services to be trained in dealing with the aftermath that inevitably results from involvement with disordered individuals. More CEU giving trainings would help more professionals understand the very difficult path most victims travel.



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      • fight says:

        Imara: Very interesting post and I appreciate the perspective of someone who was victimized and must “fit” clients into the DSM for reimbursement.

        I have an MA in the Counseling field. However, I worked in higher education counseling which is very different. I did not want to work in the “trenches,” but wanted to help people. I am too sensitive to have worked with mentally ill people. I ran into a few, but could refer them to community services.

        In my particular grad program, we did cover a lot of subjects that are not in the DSM. Students who wanted to become licensed had a lot more coursework so they could cover the DSM and be in the system that requires specifics for compensation. I remember one particular instructor discussing Borderline Personality Disorder. He said that it is a catchall mostly for women who have been abused and never truly heard because of a male dominated society. So, I got a lot more depth from former “clinical” PhDs who were now teaching instead.

        I am so glad you brought up Cognitive Dissonance. I KNOW I have Cognitive Dissonance because of all of the terrible things that have happened to me throughout my life and I agree that THAT is probably what most survivors of a Sociopath/Personality Disordered abuser have. It is a terrible thing to live with. Cognitive Dissonance is probably there in the forefront of nearly every DSM allowed diagnosis. Yet, clinicians covered under insurance have to cite Major Depressive Disorder, Severe Complex PTSD, etc. to get paid for treating victims of severe emotional, verbal and physical abuse. After I got my “official” diagnosis, the next step is always medication. I take some, but have had a lot more problems caused by the medication when intensive counseling for Cognitive Dissonance is what is needed.

        I actually tell any therapist I have had for years that I have severe Cognitive Dissonance since being moved at 16 and with each successive trauma including abuse by narcissistic parents, being moved to a population with a higher preponderance of paranoid sociopaths, and being involved as an adult with sociopath partners, bosses, co-workers, etc. Most of them gloss over that, but it is the core of it as you have stated here. Cognitive Dissonance is when normal meets crazy and crazy keeps telling normal they are abnormal. Crazymaking being received on a regular basis creates Cognitive Dissonance. If victims here look it up and study it, recognizing that spath(s) have created Cognitive Dissonance in the victim’s brain is a lot healthier than so many labels put on the victim. Thank you for discussing this core issue.



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  3. Thanks Imara – I had heard that insurance companies won’t reimburse when the diagnosis is antisocial personality disorder – do you think therapists therefore do not make that diagnosis, even when they feel it would be correct?



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  4. Imara says:

    Guilty as charged!!!
    For me, it’s more a function of not labeling someone with a diagnosis that will follow them the rest of their lives than a matter of reimbursement… I’m likely to re evaluate that stance the next time I come up against this issue….
    Diagnosis like ASPD or BPD are hugely weighted and not to be made without absolute conviction and extensive evaluation…
    As an outpatient therapist I would very likely see more kids who I would diagnose with conduct disorder than adults who would allow me to do a thorough enough evaluation to make a ASPD diagnosis.
    So I would likely make an accurate axis 1 diagnosis and address the axis 2 stuff through that. In 30 years of outpatient work I have not to the best of my knowledge ever given a ASPD diagnosis… I have however diagnosed BPD and NPD and ….
    Point is, that THAT is the real problem with the DSM 5. My belief is that in dissolving the real issue and trying an umbrella approch we will further dissuade the clinical community from attaching accurate diagnosis.



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    • behind_blue_eyes says:

      Very interesting. Thus, the nature of our private insurance driven healthcare system may cause an under-reporting of a series of disorders that affects many with disastrous consequences for more.

      Certainly, Narcissists are impossible to treat along with ASPD. What about Borderlines? Very difficult to treat, but Borderlines also suffer a lot.

      But more important, back to my original comment, vital statistics are not being captured simply because of the system.



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  5. fight says:

    I was bothered by the loss of the Autism Spectrum because a lot of people with anything from Tourette Syndrome to OCD to severe Autism will go untreated. This makes me very sad because a lot of people, and parents of people, with the Austism Spectrum actually want to be helped. They are more likely to want to get counseling and assistance for understanding social skills.

    If they wanted to remove something, it is my opinion that they should have removed Alcoholism and Drug Addiction from the latest version of the DSM. I do have a counseling oriented grad degree, but have never worked in an area where I had to deal with the DSM as I prefer working for non profits who help people reach goals rather than dealing with any systematic counseling or psychiatric care. I haven’t seen it, of course, but during my life, the only people I find who get a lot of medical services they don’t deserve are addicts. My spath lived in a VA paid for halfway house system for 6 years for a fraction of what one would pay for a normal apartment/rent. He had a good job and got paid a lot more than I ever made. Once he got in the system and lost his job because of drinking and stealing drugs, he got FREE tax paid housing. He was supposed to have constant monitoring in these places, but loves to brag that he was drinking the whole time. A lot of recent research on addicts finds that when they get old and poor, suddenly they don’t need to be high or sloshed all of the time. They have run out of enablers because they have no money and suddenly, they are cured. These people are getting free meals in these facilities and food stamps because they are considered homeless.

    Don’t get me wrong. I believe our systems for poor people are humane and necessary. I believe many people deserve and need food stamps. I am especially concerned about poor working families who receive minimum wage. I also believe that disabled children and adults must be served by their fellow Americans to keep them from being homeless or starving. But, after what I have witnessed at VA tax paid facilities for addicts and watched them get VA funds, VA housing, Social Security disability WHILE continuing to drink and use in those facilities has caused me to believe removing addiction from the DSM should have been done. Not removing the Autism Spectrum which will impact innocent families who do not make a choice when a child ends up with Autism or any of the peripheral disorders in that branch of brain differences that make life very disabling for them.

    Addicts make a choice every time they do what they do…until they run out of money and get old.

    As far as sociopaths, I doubt many of them are ever properly diagnosed. They are just too charming. How many of us have been to marriage counseling and found ourselves having to explain why we are so sick, tired and upset with living with these seemingly wonderful people as they turn on the charm for the therapist. Mine spath is old and sick and has no car and can barely walk. His substance abuse isn’t supported here although I recently found out he had walked to a local liquor store at least once when he could walk. I think because most sociopaths are not diagnosed until after they have gone so far as to harm or kill someone and they get noticed by the law, they aren’t diagnosed. That is why it is so important for people to have books and sites like this to make their choices regarding a sociopath, or anyone with a personality disorder, being in their lives. I think family members or partners are the ones who really do most of the diagnosing of sociopaths and then have to make a decision regarding if they want to be around them or not.

    It will be interesting to see what the new DSM brings. On January 1st next year, a lot of people just under poverty level will have access to inexpensive or free medical care, so if they are willing to seek treatment, they can easily do that. But, I don’t think many of them will be sociopaths (antipersonality disorder, narcissistic personality disorder, etc) trying to get true medical help. They usually enjoy victimizing as long as they can.



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    • gatitosmommy says:

      @fight:

      Have you noticed connections/similarities between “addicts who don’t Choose recovery” and “sociopaths”?



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      • fight says:

        Hi gatitosmommy:

        I just saw this. I have observed narcissists and addicts on my father’s side and had relationships with three addicts in my life. I would have to say that a sociopath is a sociopath is a sociopath. The first one was a boyfriend for less than a year when I was younger. I caught on to him within a few months and broke up with him.

        My feeling about the first husband who has been sober for 20 years now was still on the sociopath spectrum in choosing to attend recovery meetings just as he was with drinking. He became ensconced in recovery, became “popular,” and loved to tell his bragalogue. When we went to open meetings together, he attracted women (and a lot of those women are very easy to attract) and I found it very uncomfortable. He is still sober. I have only seen him once in 20 years and have talked to him on the phone or through email a handful of times. I would say that I think his addiction played a large role in his lies and manipulation. However, I think he was a problem before he ever picked up his first drink. He actually was addicted to me…more of a stalker time…and it took a lot of finagling to divorce him and give him plenty of opportunity to whomever was next in line. The first one had a different level of sociopath characteristics. He seemed more capable of some love and empathy, but had to be in control, lie, abuse, etc.

        The spath I have as a neighbor/room mate now and have been around off and on for 16 years is different than the first husband. He was someone I knew never to marry. I accepted so much of the unacceptable from him and still accept some for reasons that have nothing to do with love. He is a chronic liar, cheater, porn addict, food addict, alcohol, prescription drugs, cigarettes….anything he could get his hands on from a young age, he will get addicted to it. Not to people ever. He uses all people as if they are not people. I honestly don’t think he knows what truly loving someone feels like. He went to recovery meetings at my behest many years ago. After I broke up with him because I got tired of his unloving, lying, cheating, etc., each time, he would attend meetings again and call me…more for my good credit and a safe place to land than anything else I think. Now, he says he is an atheist, so won’t go to AA. So, I found a great secular recovery program (I still receive their emails as they help me as a codependent), and he went to a few of their meetings, but he is not a real human being so doesn’t do anything to be a better one. He told me he was never going to drink again (lie) so he didn’t need any type of recovery. Anyone who knows about addiction recovery knows there is a lot more to it than not doing it any more. The meetings can help people learn human behaviors they don’t have. I believe they have helped my first husband quite a bit as far as being more human and humble.

        This guy who caused me so much trouble again in recent years (the reason I found this site) only does what he has to do to live in my duplex and he is transparent a lot of the time as I learn more and more about him and about sociopaths. I would say he is definitely in the anti-social personality disorder category. He spends some time with me. He is funny and can be charming and can be anything he wants me to think he is. He is a good actor. But, as he ages and continues to have failing health, he slips a lot more into who he really is. I recently found out he has had alcohol here at least twice. When he moved in, he was not smoking for a couple of months and “would never smoke again” to live with me. But, found an excuse to abuse and get cigarettes within two weeks of getting here. He will lie about tiny things. He does the baiting where he will tell part of a story about a woman he knew and there is more to the story. He used to do this all of the time when he was young and healthier. Bait me into a conversation about some poor thing he was playing with so I would feel bad and suspect what was going on. Then, if I let him know I found it unacceptable, he would get to feel “wanted” by everyone and have rages and accuse me of being a nag…nothing was going on….I’m a jealous %*%^…the usual stuff the ones who are so deep in it since childhood He has the whole thing down on how to create doubt and chaos and a competition. In recent years, he had VA counseling weekly for years and enjoyed fooling them. I forced him into anger management at the VA before I knew he was a socioopath and it wasn’t worth the trouble. He didn’t finish it.

        Sorry for the long answer. I guess my short answer is I don’t think most severe sociopaths will get anything but a new hunting ground for easy sexual partners and attention from going to recovery meetings. I have known some people who have found if their addict is a sociopath, it is better for them to have him drinking in a chair at home every night until he passes out than being out in the world where he can create more problems for them.

        A true sociopath can’t be changed by anything unless he/she chooses change themselves. The only way I’ve gotten any change out of mine is by having leverage over whether or not he lives in a nice place or in lesser VA housing. A few months ago, when I began to focus more on myself and start thinking of what I want, I gave him printed out definitions of the traits of a sociopaths and someone with anti-social personality disorder. I told him, “This is what you are and I am relieved to have finally found out what you are. Now I can focus on me and do the least I have to do for you to get my basic needs met.” Now, I say directly to him, “You are transparent in your manipulation right now because of the type of personality you are. Try asking for what you want next time.” I then leave him and go garden or watch a movie. He has nowhere to go, though. He has no car. I help him get his groceries. He is on a walker right now awaiting a second surgery. He is old and broken now. I am older and he is grocery money. If you are young, get out. The addictions don’t get any better. Recovery in a sociopath’s mind is relative and subjective to their never ending compulsions and lack of conscience.

        MY recovery is much more important than his. I am very glad to have found a secular program on line that helps ME take care of me and deal with my addiction to him. As a Humanist, I believe humans are responsible for their behavior. This gives no excuse for addiction or mental illness to abuse me as a human being.



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  6. graceous says:

    Yes, it sounds like the DSM5 is a mess, but so much of this is just a tool for diagnoses for managed care and is sometimes influenced by the popular diagnosis of the year. I certainly agree that the field of psychotherapy has its fill of predators and also many licensed clinicians who are clueless about the dynamics of Axis 2 disorders and predators. I wrote previously about the therapist I saw decades ago after getting a predator out of my life and how she never believed my stories of what he did, and ended up asking me if I was on drugs. A recent predator in the work world was actually a multi-degree licensed managerial person in the helping professions. My coworkers and I instinctively knew to keep their distance, fly under the radar, not ask questions if possible, but I doubt if they really understood the extent of the pathology there. They just identified managerial person as “wacky.” Sad thing, this person is in a big organization doing damage and making a lot of people very uncomfortable. The things most valuable to me: my education in predators, largely self-taught, looking at and working through recovery material on the topic of love addiction, and EMDR and related tapping techniques, are the things that really helped me get my life back on track, and yet all all things are not taught in traditional programs and can be dismissed as nonsense by some segments of the psyc hierarchy.



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  7. The Wall Street Journal offered a thought-provoking analysis of this situation in its review of two related books:

    The Book of Woe, by Gary Greenberg, “takes us on a rollicking journey from the DSM-5′s inception to its publication, regaling us with stories, alternately hilarious and infuriating, of internecine battles, personality clashes and political machinations.”

    Saving Normal was written by Dr. Allen Frances, who was task-force chair for the DSM-IV revision. He “attempts the delicate task of debunking the DSM-5 while justifying his own DSM-IV. He was alarmed by the DSM-5′s proposals of ‘new diagnoses that would turn everyday anxiety, eccentricity, forgetting and bad eating habits into mental disorders.’”

    Read: How psychiatry went crazy, on WSJ.com.

    http://stream.wsj.com/story/latest-headlines/SS-2-63399/SS-2-234911/



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  8. jm_short says:

    I think the most unfortunate issue pertaining to why psychopathy and sociopathy are not diagnosed, is that an adult with the diagnosis would not remain in therapy. It’s simply contra to their view of the universe that there’s actually something wrong with them.

    While the Marriage Counselor, a Psychiatrist, that my ex and I engaged, imparted that my ex was a psychopath, he did so privately and very likely, never told my ex. Had he done so, I’m sure it would have been their last appointment.

    It was the ah-hah moment that caused me to give up on the relationship.

    In spite of all the wrangling, it seems the DSM explanation could be a rather simple one: Anti-Social Personality Disorder seems to be an umbrella catch-all phrase for disparate profiles, all of which emanate from lack of empathy. Whether the person got that way through a genetic pre-disposition, through social interaction when they were young, whether they pursue power struggles through narcissism, BPD, psychopathy or sociopathy, what real difference does it make? The predators, themselves, are not the people who will seek therapy.

    The damage they do is profound and it’s the impacts on their victims, not their unreachable, self-satisfying selves, that needs addressing. At the moment, therapists who are knowledgeable in PTSD, Betrayal Bonding or Rape Syndrome are likely to be the best bets.

    Once a person reaches maturity with the disorder, it would be totally unexpected that they would change. Why would they, who feel there is nothing wrong with them, spend money on therapy they don’t think they need?

    Instead of focusing on bringing about change in folks who have no interest in changing, I believe we need to address the importance of building empathy in children while they are young, so that the volume of people who mature with this disorder is curtailed. I loved Dr. Vidig’s comment in her explanation about whether children are psychopaths. She responded something like, “No one gets psychopathy as a birthday present when they turn 18.”

    I struggled to raise a child who I strongly suspect is a psychopath. His behavior was classic of this pattern, yet, although I don’t consider myself a stupid woman, and I brought my son to several therapists, absolutely none gave the slightest concern to the lack of empathy he displayed to everyone and I could only hope that maturity would make him a caring person.

    John Quinones has a wonderful show called “What Would You Do?” It stages various vignettes of bad behavior and videos as passersby involve or fail to involve themselves. It seems to me that the folks who step in are the ones who behave with empathy toward the victims. The ones who ignore the problem simply have less empathy and can disregard the problems they witness.

    We all have abilities that fall somewhere on a Bell Curve. It would seem that empathy is a character that could be measured just as learning disabilities and ADHD are measured. And with this measurement, parents could be more in tune with the evolution of their child’s character.

    Of course, this measurement could only benefit if there were a methodology established to impart empathy to a child who has a weakness in this area.

    Early intervention would seem to be the best approach for staving off ASPD behaviors, but that would take a considerable education of the public concerning the proliferation of the disorder in society. It would be nice if the psychiatric community could create consensus so that a uniform voice could break through the silence and make an impact that would bring about change.

    Joyce



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  9. behind_blue_eyes says:

    My problem with the removal of Aspergers as a diagnosis is that not only is it definable, those with such really need counseling to help their daily life.

    For example, I have a friend with Aspergers. Interestingly, while he is seeing a counselor, I wonder if she has diagnosed him as such. The reason I say this is he is very open about his depression and various other problems, almost too much so, but he has never mentioned Aspergers.

    Yet, this morning I got a text from him — he locked himself out of his apartment. I had my phone off and my the time I responded, he had already gotten in from the landlord. But now he is obsessed with him having a copy of my keys.

    The chances of me locking myself out are about the same as winning Powerball…

    Several times he has locked keys in the car. Or, locked the house keys in the car and lost the car keys…

    There are many other aspects of his disorder that have affected his life. And like many having Aspergers, he suffers several physical manifestations including morbid obesity and general clumsiness.



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