Wednesday, February 24, 2010


The DSM (Diagnostic and Statistical Manual of Mental Disorders) is on version IV, but they are preparing changes for version V.  It turns out this manual is very important for diagnosing mental disorders, both to the clinician, and to the insurance and pharmaceutical companies. Given the money involved, you would expect economists to to be interested in the political economy of how disorders are defined. There is an excellent discussion of the changes being made to the diagnostic criteria for Autism here
5. The headline-making but most predictable--and most predictably responded to--change is the loss of Asperger's and PDD-NOS, which have both always been considered part of the autistic spectrum, as distinct-from-autism diagnoses. Whatever their shortcomings, the loss of these diagnoses is another signal that autism is, officially and more so than ever, merely a series of deficits in overt typical behaviour.

6. At the very least, the DSM-V strongly discourages any view of autism as an atypical cognitive phenotype involving relative (to nonautistics) cognitive strengths and weaknesses.

7. The changed criteria, which collapse the DSM-IV social and communication domains, overlook any role for manual and oral motor abilities in these two areas. And whose definition of the now-mandatory social reciprocity criterion will prevail? Here is John Constantino'sone-way-street definition:

Reciprocal social behavior refers to the extent to which a child engages in emotionally appropriate turn-taking social interaction with others.
The closer-to-equal time, so to speak, now granted the previously-relegated RIRB (restricted interests and repetitive behaviours) domain could be seen as progress, ditto the disappearance of the "nonfunctional" assumption. But autistics will no longer have DSM-IV unusually focused and intense interests (a strength), we will instead be pathologically fixated.
And here is a discussion of some suggestions that appear to be making it into the proposed changes being made to female sexual dysfunction (FSD). I received an email from the SSSS, looking for people to comment on the following proposals:

Currently the FSD subcommittee has proposed four changes from the DSM IV-TR as follows:

Change 1: deletion of sexual aversion disorder and capturing it as an anxiety disorder

Change 2: redefining female orgasmic disorder as delay in or absence of orgasm and/or markedly reduced intensity of orgasm that must be present for at least 6 months and experience on at least 75% of occasions of sexual activity that causes distress

Change 3: merging desire and arousal diagnosis into one entity, replaced by SIAD, sexual interest arousal disorder. SIAD would be defined as a lack of sexual interest/arousal for 6 month duration as manifested by at least 4 fo the following:
a. absent/reduced interest in sexual activity
b. absent/reduced sexual/erotic thoughts and fantasies
c. no initiation of sexual activity and not receptive to partner's attempts to initiate
d. absent/reduced sexual excitement/pleasure during sexual activation at least 75% of occasions of sexual activity
e. desire not triggered by sexual/erotic stimulous
f. absent/reduced genital or non-genital physical changes during sexual activity at least 75% of occasions of sexual activity
which causes distress and is not due to a physiological substance or general medical condition.

Change 4: merge vaginismus and dyspareunia into genito-pelvic pain disorder defined as persistent or recurrent difficulties for 6 months or more with at least one of the following:
This obviously increases the standards to get a diagnosis, thus reducing the demand or potential insurance coverage for those marginal patients. You can imagine who would be against this, those clinicians who serve the marginal patients. (By marginal here I mean the people that met the DSM IV criteria but will not meet the DSM V criteria.)

1 comment:

ACH said...

Allen Frances, in a number of his editorials regarding DSM-V, has said that one big problem with the way the DSM works is that people, by and large, are much more interested in reducing the number of false negatives, but tend to be a lot less interested in reducing false positives. This worries me regarding SIAD especially.

What does "impairment" mean anyway? I know that it means someone can be diagnosed as having this "disorder" in the absence of distress (perhaps because their partner is distressed?)

And is not being interested in sex because one's partner is a jerk really a mental disorder? The specifiers seems to suggest yes.

How about having accepting the cultural beliefs about sexuality someone is raised with? Another one of the specifiers suggest that that too can be a mental disorder.

There are a lot of us who are very much worried about how the pharmacutical industry will use (and has already been using for years) HSDD/SIAD (or whatever DSM-V will have) to create distress surrounding lack of interest in sex.