Fear is a response to any threatening stimuli in the immediate present e.g., an out of control lorry is hurtling towards you. This is normal fear. Neurotic fear, on the other hand, is a response to anticipated, future dangers; something that might never happen. This neurotic fear is called anxiety. If the anxiety is mild and continuous, it is termed ‘worry’; if the anxiety is very intense and occasional, it is ‘panic’. ‘Panic attacks’ are a very common presenting problem. In reality panic attacks are episodes of negative trance states. The interpretations and possible future consequences of these episodes utilise a lot of disturbed thought processing.
“Patients often present to primary care settings with a complex mixture of anxiety, depression and somatic symptoms. However, relatively little is known about how somatic symptoms fit into existing dimensional models” (Simms et al. 2012). “Anxiety is a psychological experience, separated from syndromes with prominent physical symptoms. Yet it has long been known that internalising disorders often present with unexplained physical distress “(Gone, J, & Kirmayer, L. 2010).
Patients often present a mixture of both anxiety and depression. It is not known which is primary and which is secondary (Golberg, D. & Goodyer, I. (2005).
The name Generalised Anxiety Disorder has been re-named in DSM-5 as Generalised Anxiety and Worry Disorder (GAWD). This takes into account worry about events that are unlikely to happen. GAWD is not a precise diagnosis and has high levels of co-morbidity with phobias, depression and substance abuse (Stein, 2001).
The slight adjustment to the criteria in DSM-5 may mean in increase in ‘incidence’.
Psychoanalytic theory states that anxiety is caused by intrapsychic conflict, and we protect ourselves from this anxiety by developing defence mechanisms. Unfortunately, these mechanisms are not all that efficient and produce their own sets of problems. One defence mechanism is ‘repression’. When repressed, fear is transferred to a particular object (e.g., a spider) or situation (e.g., being in a lift), the resulting fear is called a phobia. All phobias are seemingly unreasonable fears.
A specific phobia may not lead to serious dysfunction. Consequently psychiatrists and psychologists rarely see individuals suffering from phobias.
Wittchen et al. (2010) addressed three core questions. “First, what is the evidence for agoraphobia as a diagnosis independent of panic disorder? Second, should agoraphobia be conceptualized as a subordinate form of panic disorder as currently stipulated in DSM-IV-TR? Third, is there evidence for modifying or changing the current diagnostic criteria?” He came to the conclusion that “agoraphobia should be conceptualized as an independent disorder with more specific criteria rather than a subordinate, residual form of panic disorder as currently stipulated in DSM-IV-TR. Among other issues, this conclusion was based on psychometric evaluations which show that agoraphobia can exist independently of panic disorder, and the impact of agoraphobic avoidance upon clinical course and outcome. . . The apparent advantages of a more straightforward, simpler classification without implicit hierarchies and insufficiently supported differential diagnostic considerations, plus the option for improved further research, led to favouring the separate diagnostic criteria for agoraphobia as a diagnosis independent of panic disorder”.
One change in DSM-5 is the removal of the requirement that patients who suffer from phobias regard them as irrational.
Wakefield et al. (2005) raised the question as to whether the high prevalence of social anxiety and shyness meant that it was too widely defined. He stated “Some social phobias are clearly genuine mental disorders. However, in just 2 decades, social phobia (or social anxiety disorder) went from “rare” (in the DSM-III) to “common”, amidst changing criteria and concern about caseness thresholds. The evidence suggests that social anxiety is a normal, species-typical, designed response to specific triggering situations, one that is roughly normally distributed in temperamental intensity. This raises the question, Is temperamentally high but nondisordered social anxiety being mislabelled a disorder? We argue that many, perhaps most, people whom the DSM-IV potentially classifies as suffering from social phobia are probably not …”
Lane (2007) even suggested that social phobia was invented specifically to market medication to a large number of people who were previously considered to be normally shy.
Paris (2000) considered the extent to which PTSD is a reaction to trauma, as opposed to the uncovering of a temperamental vulnerability to stress. He stated “It is well established that most people exposed to trauma, even severe trauma, never develop PTSD”.
“The diagnosis of PTSD remains controversial 30 years after its ratification in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. This is perhaps because, unusually among the anxiety disorders, PTSD implies categories of victim and perpetrator that often entangle moral and scientific discourse. When someone develops PTSD, there is usually someone to blame. When someone develops panic disorder, there is no one to blame. This entangling of the scientific, the political and the moral ensures that the diagnosis of post-traumatic stress disorder remains controversial” (Rosen, 2004).
“The authors of the PTSD diagnosis assumed that a circumscribed set of extraordinary stressors uniquely possessed the capacity to cause the symptomatic profile of the syndrome. These stressors were not merely the routine difficulties of everyday life. Rather, they were members of a class of events that fell outside the perimeter of usual human experience, causing distress in nearly anyone. The text provided examples of canonical traumatic stressors, including combat, rape, natural disasters, and torture. It also disqualified stressors falling within the ambit of ordinary life, such as simple bereavement, marital discord, or developing a chronic illness.
Yet surely establishing the stressors that do or do not possess the capability of causing PTSD is an empirical matter, not a conceptual one. In fact, many studies have reported that people can develop PTSD-like symptoms after exposure to stressors that fall short of the DSM definition of trauma (e.g. Mol et al., 2005). However, a person who meets all criteria for PTSD, but whose stressor does not qualify as traumatic, cannot receive the diagnosis. Concerns in the USA about denying these sufferers the diagnosis, and hence reimbursable treatment for PTSD, motivated a dramatic expansion of the concept of trauma in later DSM editions” (McNally, R. 2010).
However as Shephard (2004), the distinguished British historian of military trauma, concluded, “Any unit of classification that simultaneously encompasses the experience of surviving Auschwitz and that of being told rude jokes at work must, by any reasonable lay standard, be a nonsense, a patent absurdity” (p.57).
“The more we broaden the concept of trauma, the less convincingly we can award causal significance to the stressor itself, and the more we must emphasise vulnerability factors in the aetiology of PTSD. To put this issue in perspective, we must distinguish between risk for PTSD in general, and risk for PTSD among those exposed to trauma (i.e. vulnerability factors). The severity of the trauma itself is often the most important predictor of PTSD in general, as the dose-response effect implies” (March, 1993).
Exposure to trauma is more than a mere risk factor; it is logical requirement for the syndrome to emerge. Without a stressor to re-experience, one cannot suffer from re-experiencing symptoms, for example. This is why we cannot dispense with Criterion A1 entirely. Although exceptions abound, the more severe the trauma, the more likely someone will develop PTSD (McNally, R.2003).
“Conceptual bracket creep in the definition of trauma does not occur in the ICD-10 PTSD diagnosis. The ICD-10 conceptualises a traumatic event or situation as one that is ‘exceptionally threatening or catastrophic’ and one that ‘is likely to cause pervasive distress in almost anyone’. Importantly, ICD-10 requires a person to be present at the scene of the trauma to qualify as a trauma survivor” (McNally, R. 2010).
Clinical and epidemiologic studies have established that posttraumatic stress disorder (PTSD) is highly comorbid with other mental disorders. However, such studies have largely relied on adults’ retrospective reports to ascertain comorbidity. . . These data suggest PTSD almost always develops in the context of other mental disorders. Research on the aetiology of PTSD may benefit from taking lifetime developmental patterns of comorbidity into consideration. Juvenile mental-disorder histories may help indicate which individuals are most likely to develop PTSD in populations at high risk of trauma exposure” (Koenan, K. 2008).
McMally (2010) however comments “If risk factors overwhelmingly account for the emergence of PTSD in response to minor stressors, this seems to undermine the rationale for having a diagnosis of PTSD in the first place”.
Spitzer (2007) stated “At the very least, a person should be physically present at the scene of trauma to qualify as a trauma survivor. As in ICD-10, the person should be either a direct recipient of trauma or a personal witness to the trauma of another. Indirect exposure (e.g.via the media) should not certify someone as a trauma survivor. Anyone who does develop PTSD-like symptoms via such indirect exposure should receive a diagnosis of either anxiety disorder NOS (not otherwise specified) or a new V code diagnosis for acute nonpathological reactions to a stressor”.
Can Wittgenstein illuminate the concept of trauma? Attempts to provide necessary and sufficient criteria for defining the concept of trauma presuppose that we can formulate criteria for a unitary concept of trauma. Yet as Wittgenstein (1953) argued, “Most concepts resist definition in this way, instead having overlapping attributes with no single defining feature. At best, we may clarify correlated attributes often shared by traumatic stressors (e.g. life-threat, physical presence at the scene of trauma). Ultimately, facts may compel us to abandon the unitary concept of trauma”.
Roberts et al. (2012) considered the stressor criterion for DSM. He concluded that “The stressor criterion as defined by the DSM may not be informative in characterising PTSD symptoms and sequelae. In the context of ongoing DSM-5 revision, these results suggest that criterion A1 could be expanded in DSM-5 without much consequence for our understanding of PTSD phenomenology. Events not considered qualifying stressors under the DSM produced PTSD as consequential as PTSD following DSM-III events, suggesting PTSD may be an aberrantly severe but nonspecific stress response syndrome”.
The trauma is required to be exposure to actual or threatened death, serious injury or sexual violence.
The exposure needs to be:
There are four groups of symptoms that categorise the syndrome:
a) Intrusion (re-experiencing the trauma)
b) Avoidance (avoiding situations that elicit memories)
c) Negative alterations in cognition and mood
d) Marked alterations in arousal and reactivity
The duration of symptoms needs to be more that one month (if it is less – consider acute stress reaction).
Another very common presenting issue these days is that of Obsessive-Compulsive Disorder (OCD). An ‘obsession’ is a persistent, conscious idea or desire that the individual does recognise as being irrational. Such an individual is frequently heard to say: “I know it’s crazy, but I just can’t stop doing (or thinking) it”. The obsessed neurotic will often try to offset a frightening thought by a particular action, and this action is then a ‘compulsion’. This condition leads to significant dysfunction.
This is a condition that is difficult to treat (Stein & Fineberg. 2007).
Obsessive thoughts and compulsive acts, when explored therapeutically, are often found to be about normal, natural, but socially taboo subjects, such as sexuality, excretion and aggression.
OCD clients can be divided into ‘checkers’ and ‘washers’. Checkers check the switches of lights and other electrical appliances, doors, locks, over and over again, one hundred times may not be enough. Hours can be spent on producing unimportant symmetry, e.g., one woman kept plucking her eyebrows, and in an attempt to get each eyebrow exactly even, she eventually plucked out the final remaining hair. Washers may wash their hands over and over again until they are raw and bleeding, or they may repeatedly shower, or sit in a bath for up to two days. It is as though they cannot trust their own judgement. In fact, it could be seen that they are on the borderline of losing touch with reality.
O’Leary and Wilson (1975) proposed the superstition hypothesis to explain OCD. A behaviour has been associated with past success, e.g., putting a sock on inside out. The person then continues with the behaviour and feels anxious if this behaviour is prevented. Behaviourists believe that anxiety reduction is a strong reinforcer and explains why the behaviour is maintained. Therapists need to break the association between the compulsion and anxiety reduction.
“OCD lies in a spectrum that includes body dysmorphic disorder, trichotillomania, stereotypic movement disorder (tics), pediatric auto-immune neuropsychiatric disorders associated with streptococcal infections (PANDAS), as well as obsessive-compulsive personality disorder” (Fineberg et al. 2010).
The decision to add a new diagnosis of ‘hoarding disorder’ has attracted controversy (Maitax-Cols et al. 2010). Hoarding is common and may affect as many as 5% of the general population (Samuels et al. 2008). However to diagnose a mental disorder, patients need to be functionally disabled.
Some therapists find OCD easy to work with, others find it very difficult (or choose not to). Where do you fit on this continuum? What are your thoughts about the reason for this? Post a message to the forum.
DSM-5 does not show any categorical difference between substance use and addiction.
Paris (20130 states: “What determines the boundary between use and addiction? DSM, in its various editions, has focused on maladaptive patterns of use leading to ‘clinically significant impairment or distress’. But that concept lacks a precise definition. Less sensitive criteria such as ‘committing illegal acts’ have been removed, and a new criterion of ‘craving’ has been added to the definition. Even so, deciding what is or is not clinically significant requires a judgment call. Does impairment depend on losing one’s job and/or losing intimate relationships? Can one be sure that these outcomes would not have happened anyway? One is on safer ground in focusing on the physical effects of substance abuse. But those sequelae only emerge after years of abuse”.
Kessler (2005) stated that in the USA 13.2% met lifetime criteria for alcohol abuse and a further 5.4% for alcohol dependency. The total was more than 18%.
DSM-5 defines a substance use disorder as a maladaptive pattern leading to clinically significant impairment or distress for at least 12 months. Clinicians are also asked to specify whether physiological dependence is present.
Paris (2013) goes on to state “This brings us back to the same basic problem: the absence of a clear boundary between using too much and having an addiction problem. Everything depends on assessment of impairment”.
Substance abuse is considered within the framework of ego growth, with a particular focus on developmental deficits and compensatory actions. Alcohol, food, and drugs all serve as attempts to minimize the impact of ego deficits. In this regard, the function the substance serves is more crucial than the specific substance abused”.
Kessler (2008) quoted results from the US National Comorbidity Survey Replication. These showed 78.4% reported lifetime gambling, 2.3% showed at least one Criterion A symptom of Pathological Gambling (PG) and 0.6% had PG.
Gambling problems have a similar form and function to substance abuse. There is an attraction to addictive behavior, resulting in failure to perform major role obligations, as well as continuance despite negative consequences. DSM-5 has moved “Disordered Gambling” from the DSM-IV group of impulse disorders to the substance group, re-naming it as “Pathological Gambling”
Brisman (1984) stated: “There has been an epidemic rise recently in the number of women evidencing bulimia, an addictive cycle of binge eating and purging of food. A significant number of bulimics are reported to abuse alcohol and drugs as well. There is a need to account for the serious problem of symptom substitution in substance abusing populations.
Self-harm, common in borderline personality disorder, can be addictive because it provides immediate relief for dysphoric symptoms (Linehan 1993).
Its characteristic feature is a weight loss to at least 15% below standard norms, accompanied by a pursuit of thinness (Grilo & Mitchell 2010).
Sullivan (1995) stated that: “The aggregate estimated mortality rate for subjects with anorexia nervosa is substantially greater than that reported for female psychiatric inpatients and for the general population. The aggregate mortality rate was approximately 5.6% per decade”.
This was characterised by binge-eating, loss of control, and compensatory behaviour such as purging, at least twice a week for 3 months. DSM-5 has reduced the criteria of frequency to once a week.
This was in the appendix of DSM-IV but has now been moved into DSM-5. Wonderlich (2009) postulated that eating disorders lay on a spectrum with BED at the milder end.
A diagnosis of gender dysphoria describes people who, since childhood, have wanted to belong to the opposite sex (Zucker. 2010).
DSM-5 defines it as an incongruence between experienced gender and secondary sex characteristics, with a desire to be rid of these characteristics and to be the other gender (Manners. 2009).
DSM-I and DSM-II classified homosexuality as a mental disorder. The American Psychiatric Association (APA) meeting in San Francisco was interrupted by protests from the gay community. In 1973 the APA removed the category by a vote. The author presented the DSM-III controversy and a reformulation of the issues involved in the diagnostic status of homosexuality. He argued that what is at issue is a value judgment about heterosexuality, rather than a factual dispute about homosexuality (Spitzer. 1981). Almost everyone today agrees that diagnosing same-sex attraction as a mental disorder was a mistake.
Up to now, no one has seriously contemplated declaring pedophilia to be a normal variant. The obvious reason is that it is a crime, with victims who cannot consent. The same principle applies to exhibitionism. Yet fetishism, which hurts no-one, remains in DSM-5 (Paris. 2013).
Frances (2010) recommends that unusual sexual fantasies that affect no one but the person experiencing them should never be considered as mental disorders. DSM-5 fails to distinguish between paraphilias that present a social danger to other people and those that cause personal distress.
Autism was first described by Kanner (1943). The illness starts before the age of 3 and severely reduces social and cognitive functioning. It took years to establish that autism was heritable and associated with functional brain abnormalities (Mcgregor. 2008).
Asperger’s Syndrome is a variant of autism. In 1944 Hans Asperger described children with poor social functioning and stereotyped behaviors (Szatmari. 2004).
DSM-5 links autism and Asperger’s and uses the label ‘autistic spectrum’
This is a popular diagnosis because this diagnosis leads to treatment by medication that is effective. “ADHD is a common neuropsychiatric disorder that impairs social, academic, and occupational functioning in children, adolescents, and adults. In patients with ADHD, neurobiologic research has shown a lack of connectivity in key brain regions, inhibitory control deficits, delayed brain maturation, and noradrenergic and dopaminergic dysfunction in multiple brain regions. The prevalence of this disorder in the United States is 6-9% in youth (i.e., children and adolescents) and 3-5% in adults. Prevalence rates for youth are similar worldwide. . . Drug therapy is effective for all age groups, even preschoolers, and for late-onset ADHD in adults. Stimulants, such as methylphenidate and amphetamine, are the most effective therapy and have a good safety profile” (Dopheide 2009).
Fortunately long-term treatment with stimulants are much less serious (Cooper 2011) than for antipsychotics, a group for which prescriptions for pre-school children has increased (Olfson 2010).
“The essential element of a PD is that it is not an episodic condition in an otherwise well-functioning individual. Rather it is a chronic dysfunction that begins early in life and is slow to change” (Paris 2013).
Personality disorders account for 25% of attendances at psychiatric out-patient clinics (Zimmerman 2005).
Paris (2008) stated “The objective of this review is to examine clinical trials of the treatment of personality disorders (PDs). . . There is good support for well-structured methods of psychotherapy, mainly in borderline personality disorder (BPD), but evidence for the efficacy of pharmacotherapy is weak. Research on other PD categories is sparse”.
Only 6 names disorders are listed in DSM-5.
Antisocial personality disorder is characterised by manipulativeness, deceitfulness, callousness, and hostility, as well as by disinhibition (Robins 1966). These clients are not treatable at present.
Such individuals show a pattern of disregard for, and violation of, the rights of others. Most criminal behaviour is perpetrated by those who could be diagnosed as having this disorder.
Schizotypal personality disorder has a pattern of acute discomfort in close relationships, cognitive or perceptual distortions and eccentricities of behaviour.
It has long been known that patients can have psychotic-like symptoms without crossing into psychosis. However Siever stated (2007) “New studies of the boundaries of schizophrenia suggest that schizotypal personality disorder is biologically and genetically related to schizophrenia with alterations in brain structure/function related to deficit-like symptoms and increased dopaminergic function to psychotic-like symptoms”. He goes on to say “But because this condition rarely progresses to schizophrenia it is kept in the PD group rather than the psychosis group”.
Avoidant personality disorder. There is little research on this disorder. It has similarities to ‘anxious personality disorder’ and also a strong overlap with social phobia. Such individuals demonstrate a pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation.
“Obsessive-compulsive personality disorder should not be confused with OCD. It is associated with compulsivity (rigid perfectionism) and negative affectivity (perseveration) but may not present with any symptoms that are recognised by patients” (Paris 2013). These individuals show a pattern of preoccupation with orderliness, and control.
“Borderline personality disorder clients have dramatic behaviours that demand attention (e.g. cutting and taking overdoses). They have mood swings that are rapid, are environmentally sensitive. They demonstrate a pattern of instability in interpersonal relationships. This disorder does not respond well to pharmacological treatment.
It is not widely known that about half of BPD patients have quasi-psychotic symptoms, hearing voices under stress, suffering from depersonalisation, or showing paranoid thinking. Thus BPD is a complex disorder that reflects multiple endophenotypes and trait dimensions” (Paris 2013; Paris 2007)
Narcissistic personality disorder is again included in DSM-5. This is associated with excessive need for approval, a pattern of grandiosity, need for admiration and also poor empathy and intimacy. These characteristics make NPD patients uniquely difficult to treat.
The disorder had been dropped but has now been reinstated. (Russ 2008) stated that it remains a useful concept and that his study may help to bridge the gap in clinical research.
Each personality disorder is made up of between five and nine ‘traits’ rather than symptoms. We all have some of them. It is unusual to encounter a pure prototype of personality disorder. People more often present as a mix of at least two or three personality orientations.
Individuals with either Borderline or Narcissistic Disorder have the most fragility in their makeup and anyone with a ‘fragile sense of self’ needs very careful and skilful therapeutic intervention. Every therapist needs a thorough working knowledge of all the ‘traits’, in order to work effectively with clients by choosing the right approach. As therapists we are often called upon to carry out what is often referred to as: ‘Brief and Focal Therapy’, but some clients are so ‘damaged’ that what they really need is a long-term, healing and reparative relationship with an experienced and effective therapist, who has worked through his or her own pathology. Given that the client is willing to stay in therapy for a considerable time with a therapist, having the right qualities and skills, then it is possible totally to transform and become a complete, integrated, healthy, self-actualising personality.
This is a new label created by DSM-5. Neurocognitive disorders are by no means restricted to older adults (Ganguli 2011). This allows a broader and more neutral view about the course and disability than the previous label of dementia. For the diagnosis to be made there needs to be decline in one or more cognitive domains, confirmed by psychological testing, and deficits that interfere with independence.
The most common causes include:
b) Vascular disease
c) Fronto-temporal degeneration
d) Traumatic brain injury
e) Lewy body disease
g) HIV infection
h) The effects of substance abuse
i) Huntington’s disease
j) Prion disease
Somatic symptom disorder (SSD) were previously described as ‘hysteria’ – a term used since the time of Hippocrates. Freud used the term ‘conversion’.
a) Chronic fatigue
b) Chronic pain
c) Constant worrying about being sick (previously hypochondriasis)
This disorder no longer include the statement that psychological conflict lies behind these symptoms.
These are uncommon – so uncommon that they may not even exist (Lynn 2012). He states “Conventional wisdom holds that dissociation is a coping mechanism triggered by exposure to intense stressors. Drawing on recent research from multiple laboratories, we challenge this prevailing posttraumatic model of dissociation and dissociative disorders. Proponents of this model hold that dissociation and dissociative disorders are associated with (a) intense objective stressors (e.g., childhood trauma), (b) serious cognitive deficits that impede processing of emotionally laden information, and (c) an avoidant information-processing style characterized by a tendency to forget painful memories. We review findings that contradict these widely accepted assumptions and argue that a sociocognitive model better accounts for the extant data. We further propose a perspective on dissociation based on a recently established link between a labile sleep-wake cycle and memory errors, cognitive failures, problems in attentional control, and difficulties in distinguishing fantasy from reality. We conclude that this perspective may help to reconcile the posttraumatic and socicognitive models of dissociation and dissociative disorders”.
In the 1970s a theory that dissociation into multiple personalities results from child abuse was popularised in the best-seller “Sybil” (Schreiber 1973). It was believed that this book was, at least partly, responsible for an epidemic of diagnosis of multiple personality disorder and that dissociative identity disorder is an artifact brought on by suggestive therapy techniques (Piper & Merskey 2004). They stated “In this second part of our review, we continue to explore the illogical nature of the arguments offered to support the concept of dissociative identity disorder (DID). We also examine the harm done to patients by DID proponents’ diagnostic and treatment methods. It is shown that these practices reify the alters and thereby iatrogenically encourage patients to behave as if they have multiple selves. We next examine the factors that make impossible a reliable diagnosis of DID–for example, the unsatisfactory, vague, and elastic definition of ‘alter personality’. Because the diagnosis is unreliable, we believe that US and Canadian courts cannot responsibly accept testimony in favour of DID. Finally, we conclude with a guess about the condition’s status over the next 10 years”.
It was subsequently shown that the case history of Sybil (real name Shirley Mason) was a fabrication (Rieber 2006; Nathan 2011).
These are particularly of interest to those who run sleep clinics. They include:
a) Primary insomnia
c) Narcolepsy/hypocretin disorders
d) Obstructive sleep apnea hypopnea disorder
e) Central sleep apnea
f) Sleep-related hypoventilation
g) Circadian rhythm sleep disorder
h) Disorder of arousal
i) Nightmare disorder
j) Rapid eye movement sleep behavior disorder
k) Restless leg syndrome
l) Substance-induced sleep disorder.
Adjustment disorder is an exaggerated response to stress. However adjustment to stress is not an illness. The use of this category runs the risk of medicalising life itself (Paris 2013).