Blue Line

The diagnoses they are a-changin’

October 26, 2012  By

1287 words – MR

HEAD: The diagnoses they are a-changin’

A new year is coming and we’re all overcome with a sense of wonderment and awe, anticipating new ideals and opportunities. Resolutions abound, we embrace change…

As if.

Enough of the whole “change” thing. I wish they would leave things alone. I’m not sure who “they” are but every now and then I wish people would stop changing things. While I am not sure DOS was the best thing since sliced bread, do we really need to move to Windows 8, which apparently is a totally different animal than Windows 7.

My new house has an outdoor plug the size of a breadbox because apparently the old outdoor plugs were going to kill us all. REALLY? Whatever happened to breadboxes anyhow? They are apparently no longer in vogue.

Then there is the whole fashion thing; bad enough that I am expected to get a whole new wardrobe every year but now I should change my kitchen cupboards because they’re no longer state of the “fashion” art? REALLY???

In your field, I suspect you sometimes shake your head, wondering what the bureaucrats and politicians are thinking as you head off for annual training to find out what laws and procedures have changed since your last annual training. Are all these changes going to make the world a better place for children and cute kittens?

In my world, which intersects with yours at times, we have this book called “The DSM;” our work is significantly affected by whatever version is currently in effect. DSM stands for “Don’t S*** Me.” OK, well, maybe not – but that’s how many of us feel when the inevitable revisions come out every decade or so.

The Diagnostic and Statistical Manual is the tome that instructs mental health practitioners how to decide what to call a particular mental disorder – and indeed, it decrees what is and what is not a mental disorder. Back in the day, for example, homosexuality was in the DSM. It’s long gone as it is apparent that homosexuality is not and never was a mental disorder.

Other disorders just get fine tuned or renamed but not overhauled wholesale. For example, what used to be called manic depression became “bipolar disorder” in the last revision. There are some disorders which vanished eons ago. I suspect none of you have heard of involutional melancholia or conversion hysteria. The DSM I talked about “Disorders of psychogenic origin or without clearly defined physical cause or structural change in the brain.” Schizophrenia used to be in that group – obviously before we knew much about its physiology.

The DSM is getting revised again; the new version is expected to be out in the spring. That means the folks you talk to about mental illness will suddenly be talking about things you haven’t heard of before and will appear to have changed their minds about who fits in which box, diagnostically speaking.

What used to be called a dementia is apparently going to be called a major neurocognitive disorder. Asperger’s syndrome is going to vanish as a separate disorder and become part of Autism (no one ever really agreed about this anyhow – and to a large extent they still don’t). Some people wanted a disorder called “sexual addiction” but that was voted off the island, as was Internet addiction. These may be problems, but apparently the Powers That Be are not convinced they are specific disorders in their own right. We will, however, have “hypersexual disorder.”

In some cases, the criteria for a disorder have changed. Take ADHD, for example. You probably run into lots of folks with ADHD in your work. They tend to act impulsively and not think things out very well, which can lead to close encounters of the police kind. It used to be an adult had to have symptoms before age 7 to be officially labelled ADHD. It looks like they are changing that to age 12. Instantaneously, over night even, people who did not have ADHD now will qualify – a dubious honour, I’ll admit.

Another diagnosis that has changed is Post Traumatic Stress Disorder (PTSD). Its definition has tightened up a bit in some areas, which I think appropriately reflects a gradual blurring of the lines between stress in general and post traumatic stress in particular. It was getting to the point that having a bad hair day (or worse, witnessing someone having a bad hair day) was classified as a traumatic event. Far be it for me to argue it is not stressful to have a bad hair day but stress and PTSD are not the same thing. I will not argue that one is worse than the other, but since they are different they need to be treated differently.

I have been reading up a lot on PTSD lately and it really poses some interesting issues in terms of diagnosis. One study reviewed the incidence of a variety of “critical incidents” in correctional officers. The identified “critical events” ranged from being held hostage to being sworn at by offenders. Having worked in prisons, I will be the first to say it can be extremely stressful and having offenders swear at you, pitch things at you, make threats etc can take a serious psychological toll – but not everything that causes stress is a critical or traumatic incident.

Since the last DSM came out, we have learned a lot about PTSD – and many other disorders; more about what causes them, their essential components and how to treat them. The old DSM said a traumatic event was one in which both of the following were present:

< 1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

  1. The person’s response involved intense fear, helplessness or horror. >

The new DSM (DSM 5) says a traumatic event is:

<Exposure to actual or threatened a) death b) serious injury or c) sexual violation in one or more of the following ways:

  1. Directly experiencing the traumatic event(s).

  2. Witnessing, in person, the traumatic event(s) as they occurred to others.

  3. Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental.

  4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies or pictures unless this exposure is work-related.>

The definition goes on to describe symptoms, etc – you can see the proposed changes for yourself at

Just a shade of difference really, but it does reflect the fact that we know more and can be more precise about the kinds of things that might lead to PTSD.

In the end, appropriate treatment is really the point of something like the DSM. In general, diagnosis dictates treatment. If you go in for a sore throat, you doctor has to figure out if it is a virus or bacterial infection. If the diagnosis is wrong, the treatment will also likely be wrong. The same sort of thing holds for mental illnesses and problems.

So maybe change is a good idea – or at least a necessary idea. In a few months, you might find the mental health people you deal with using different terms, changing people’s diagnoses, maybe even apparently contradicting things they might have said in the past. Take it as a good sign. We know more than we used to and are putting that new knowledge into practice.

Print this page


Stories continue below