Substance-Abuse Disorder, Unclarity, and Confusion

Love Latte

Exploring the definitions for eating disorders in the Diagnostic and Statistical Manual (DSM-5) is an Alice-in-Wonderland type of experience, full of surprises and contradictions. Many hundreds of professionals worked tirelessly to formulate the book’s information, yet paradoxes abound. Many questions remain unanswered, with a ragtag collection of odds and ends that may or may not add up to something.

According to the checklist used to diagnose a substance-use disorder, there are 11 or 12 potential symptoms, depending on the substance. One of the signs – withdrawal – does not apply to hallucinogens or inhalants, while it does apply to the painful process of quitting a problem food. By that reckoning, food would appear to be even more addictive than some drugs.

Every one of the symptoms on the list has been experienced by a real-life, self-identified food addict, an idea that Childhood Obesity News played with by creating a hypothetical compulsive eater who showed all the hallmarks. A drug user with only 7 of the checklist items would qualify as “severe” – the highest rating. Yet a food addict could easily fulfill every one of the criteria for substance-abuse disorder, and create a new category of seriousness that is even above “severe.” Maybe, as some researchers and clinicians believe, what people describe as food addiction could be a substance-abuse disorder, unrecognized as such by DSM-5.

Coffee Break

Caffeine is the world’s most popular psychoactive drug, and DSM-5 allows for both caffeine intoxication and caffeine withdrawal, although not caffeine addiction. Regarding caffeine intoxication:

The official diagnosis can be made when any 5 of the following symptoms are present: restlessness, nervousness, excitement, insomnia, flushed face, diuresis (you keep passing urine), gastrointestinal disturbance (upset tummy, diarrhea), muscle twitching, rambling flow of thought and speech, tachycardia or cardiac arrhythmia, periods of inexhaustibility, or psychomotor agitation.

Characterizing caffeine withdrawal as “a very unpleasant experience,” the website CaffeineInformer.com lists ten symptoms: headache, sleepiness, irritability, lethargy, constipation, depression, muscle pain/stiffness, lack of concentration, flu-like symptoms, and insomnia.

That all sounds fairly serious, yet clinical psychologist Robin Rosenberg does not think either caffeine intoxication or caffeine withdrawal belongs on the roster of mental disorders. She says that the intoxication is temporary and,

The symptoms of caffeine withdrawal are transitory, they take care of themselves. It’s just a natural response to stopping caffeine, and it clears up on its own in short order.

The point is, Rosenberg specifically said she doesn’t understand why either one is included in the DSM-5. So, on the one hand, a substance (caffeine) with intoxicating effects and an uncomfortable withdrawal process is not categorized as addictive. Its proponents do not want it stigmatized by inclusion in the diagnostic manual as an addictive substance. Despite this, it appears in the DSM-5 as the cause of intoxication and withdrawal. On the other hand, a different substance (food) is accused by its adherents of being addictive according to every criterion, but does not appear in the DSM-5 section on addiction.

Things are kind of mixed up.

Your responses and feedback are welcome!

Source: “Caffeine Overdose Symptoms: Facts and Fiction,” CaffeineInformer.com, undated
Source: “Normal or Not? How Coffee Drinking May Brew a Mental Disorder
LiveScience.com, 05/28/13
Image by PoYang_博仰

Mysteries of the Feeding and Eating Disorders

Trilogy 4

Childhood Obesity News has discussed the change that took place in the latest edition of the Diagnostic and Statistical Manual, which now places Binge Eating Disorder (BED) in its own category, under Feeding and Eating Disorders. (The others are Pica, Rumination Disorder, Avoidant/Restrictive Food Intake Disorder, Anorexia Nervosa, Bulimia Nervosa, Other Specified Feeding or Eating Disorder, and Unspecified Feeding or Eating Disorder.)

Also mentioned was the distinction made by Dr. Vera Tarman between BED and food addiction. Along with her colleague Phil Wardell, Dr. Tarman was active in trying to get food addiction included in DSM-5, to no avail. She calls the omission “a poor reflection of our clinical reality.”

What are the diagnostic features of BED?  It’s not a one-time occurrence, but happens over and over again, and the habit causes great personal distress. Unlike the anorexic, the binge eater does not try to make up for all those extra calories by vomiting them up or exorcising them with exercise. As with other DSM-5 disorders, there is a checklist. When a patient shows up with 3, 4, or all 5 of these hallmarks, the clinician can be fairly confident of the diagnosis.

  • Eating until feeling uncomfortably full
  • Eating large amounts of food when not feeling physically hungry
  • Eating alone because of being embarrassed by how much one is eating
  • Feeling disgusted with oneself, depressed, or very guilty after overeating
  • Eating much more rapidly than normal

On the other hand, those guidelines leave some room for misinterpretation and error. Four of the elements are not scientifically verifiable, being based (necessarily) on self-reporting. Only one can be tested against observable reality: the rapid eating. How is anyone to know if they eat faster than other people? Sure, kids around the cafeteria table will make merciless fun of gobblers. But as people grow older and learn to dissemble, what they do in public is not always the same as what they do in private. On any given day, a person might meet ten closet binge eaters, and never know. Furthermore, according to Horace Fletcher, almost everybody eats too fast anyway, and even if it is normal, it shouldn’t be.

In “Why Are Children Overweight?” Dr. Pretlow’s 2010 presentation to the Royal College of Physicians National Obesity Forum, he hypothesized that binge eating might be an amalgam of comfort eating and a displacement activity.

A recent study published in the International Journal of Obesity reported that the brains of overweight and obese kids are hypersensitive to sugar.  There is, in the words of Prof. Kerri Boutelle, an “enhanced response” to the chemical. She explains:

This elevated sense of ‘food reward’ – which involves being motivated by food and deriving a good feeling from it could mean some children have brain circuitries which predispose them to crave more sugar throughout life….The brain images showed that obese children had heightened activity in the regions of brain involved in perception, emotion, awareness, taste, motivation and reward.

Some binge eaters specialize in sweets, and comfort eating very often involves sugar-intensive foods. In the realm of food addiction, sugar has been accused of being an addictive drug. How does this information fit in with all the rest? How does it conform with the long list of causes for obesity compiled by Lauren Rossen, PhD, in her book Obesity 101. Sometimes it seems as if an overarching yet elusive Unified Field Theory of obesity lies tantalizingly close but as yet unguessed-at.

Your responses and feedback are welcome!

Source: “New in the DSM-5: Binge Eating Disorder,” nationaleatingdisorders.org, 06/05/13
Source: “Why obese kids feel better than thin kids after eating food,” TheHealthSite, 12/12/14
Image by Fat Amy

The Food Addiction Institute Viewpoint

Trilogy 3

Last time, Childhood Obesity News referenced a quotation  by Dr. Vera Tarman to the effect that Binge Eating Disorder (BED) is related to “what is eating you” (emotional and psychological problems). In food addiction, “what you are eating” is the villain (highly processed food-like substances laced with chemicals and oodles of hidden sugar). The person gets hooked on one particular “problem food” (or maybe a few). That food is a problem because it has approximately the same effect on a food addict as cocaine does on a drug addict.

Dr. Tarman was very disappointed to find no Food Addiction diagnosis in the revised Diagnostic and Statistical Manual, DSM-5. She foresees this consequence:

We will have many food addicts funneled under the new categorization of Binge Eating disorder, and they will probably be given treatment that could ultimately undermine their recovery. Modified diets do not work for the food addict.

In other words, DSM-5, the “bible” that is meant to guide a clinician in formulating a diagnosis, appears to recommend a course of treatment that will worsen the patient’s condition. And yet history records that the venerable Hippocrates admonished physicians to “First, do no harm.”

Dr. Tarman and Phil Werdell of the Food Addiction Institute co-authored the book Food Junkies: The Truth About Food Addiction, scheduled for publication later this month. Werdall vigorously advocated the inclusion of food addiction in DSM-5 as a legitimate diagnosis, and Tarman calls him “a true pioneer: far sighted, dedicated and persistent.” Here are some words from the Food Addiction Institute:

Initial scientific estimates, according to Dr, David Kessler, former Commissioner of the U.S. Food And Drug Administration, are that about 50% of the obese, 30% of those overweight, and 20% who are at what we consider a healthy weight, are actually addicted to a specific food, combinations of foods or, in some cases, volume of food in general….At least half of the obesity crisis would be better understood and more suitably named the food addiction crisis.

That is a bold statement! If only more members of the medical establishment agreed with it, or were at least willing to consider the possibility.

Disappointing as the final DSM-5 lineup may have been, the manual did something right, or at least close enough to justify a Food Addiction Institute article titled “DSM-V Acknowledges Food Addiction.” In Werdell’s view, the inclusion of BED paves the way for the recognition, in future editions, of food addiction as a substance use disorder. To support this optimism he quotes the Feeding and Eating Disorder section of DSM-5 (page 329):

Some individuals with disorders described in this chapter report eating-related symptoms resembling those typically endorsed by individuals with substance-use disorders, such as strong craving and patterns of compulsive use.

This recognition….is of extreme importance. It gives clinicians encouragement to look for a psycho-socially caused eating disorder, a biochemically caused food addiction, or both.

Werdell makes the important point that both disorders should be acknowledged by health insurers, who seem a little too interested in avoiding anything that might cut into profits. Appropriate treatments for BED include therapy, mindfulness training, and medication, along with the modalities more often associated with addiction treatment – abstinence from the problem food, and education about dependency, along with “preparation for 12-Step-type aftercare.”

Your responses and feedback are welcome!

Source: “Binge Eating Disorder in the DSM 5: Good News or No News for the Food Addict?,” Addictionsunplugged.com, 01/30/13
Source: “Food Addiction as a part of the Obesity Epidemic,” foodaddictioninstitute.org/, undated
Source: “DSM-V Acknowledges Food Addiction,” FoodAddictionInstitute.org, 08/18/13
Image by 3 Twitter users: DearOvereaters, bossy-bootz, and ComicMikeV

 

DSM-5 and Binge Eating Disorder

Trilogy2

The acronym BED has nothing to do with sleep. It stands for Binge Eating Disorder, a condition that was found in the old DSM-IV only in its appendix. Since the 1994 publication of that edition of the DSM, nearly 1,000 papers about BED have been published. When changes for the revision of the manual were being discussed, some critics objected to its promotion to the main body of the book because, Sharon Kirkey wrote:

They wonder how reliably doctors who are not experts in eating disorders can distinguish between someone who binges for psychiatric reasons and someone who merely overeats.

The doubts were in part protective, because a lot of folks could be incorrectly branded with a mental disorder diagnosis or given psychiatric drugs when they didn’t need them. In the litigious United States, discontinuing an obese person’s employment under these circumstances could be interpreted as discrimination against the mentally ill.
The chair of the DSM-5 work group for eating disorders, whose job it was to decide what to include in that section of the manual and what to leave out, was psychiatry professor Dr. Timothy Walsh. Not all obese people have BED, and not all people with BED are necessarily obese. Compared to other varieties of obese people, those with BED have “substantially higher frequency of mood and anxiety problems,” Dr. Walsh explained to the reporter. The unhappiness is the difference.

“It is not what is eating you… but what you are eating”

Dr. Vera Tarman further noted that BED is not the same as food addiction, though the populations of the two disorders overlap. One difference she sees is that people suffer from BED in response to “what is eating them” – in other words, emotional trauma that they attempt to self-medicate by extreme consumption. What they need instead is healing for the PTSD, anxiety, or depression that drives the behavior. Tarman says,

Treatments include cognitive therapy, mindfulness and medications. They are taught how to eat all foods moderately, in the hopes that they were join “normal society” once their psychological conditions have been addressed, even resolved.

For the food addict, the problem is “what they are eating” – refined starches, sugar, or whatever problem food of which a single taste can trigger a cascade of unwise ingestion. She sees the cravings for these foods not as resulting from distressed emotional states, but from addictive qualities inherent in the foods themselves.

Certainly emotions can trigger a person to want to eat, but the control is lost truly when the food has ignited the reward pathway in the limbic brain….While psychological issues are important to sustain long term recovery, the essential first treatment for the food addict is to stop the drug that is creating the loop of addictive eating….Treatment includes abstinence from the triggering foods, peer support to encourage ongoing vigilance, and often a spiritual dimension needs to be tapped into to maintain long term recovery.

Food addiction was never recognized by the older DSM editions (nor is it acknowledged by the current DSM-5), which Dr. Tarman calls “a poor reflection of our clinical reality.” As with BED, there are pros and cons to official recognition of food addiction as a bona fide medical condition, and opinion is divided.

The lack of official recognition of food addiction means that insurance providers won’t pay for treatment, which Tarman describes as a “dire consequence.” Once a person is morbidly obese, bariatric surgery may be funded, but not treatment for the addiction that caused the weight to accumulate.

On the other hand, being labeled as an addict can have serious consequences for the patient. Taking a broader view, a fear also exists of the “overarching ambition” of some factions to medicalize everything that strays just a bit over the line drawn around normal behavior, for the purpose of selling another million pills and undeservedly enriching the pharmaceutical industry.


Source: “Binge eating to become bona fide entry in disorder bible,” Canada.com, 04/29/10
Source: “Binge Eating Disorder in the DSM 5: Good News or No News for the Food Addict?”
Addictionsunplugged.com, 01/30/13
Image by Fat Amy, ShotofCherye, pocahontas

 

Substance-Use Disorder in DSM-5

Borough Market, big cheese

If a clinician expects to use the label of substance-use disorder, and if the substance being used is a drug, the Diagnostic and Statistical Manual offers a list of symptoms to consider. The purpose of the list is to diagnose not only the presence, but the magnitude, of the substance-use disorder.

Two or three checkmarks means a mild disorder, four or five means moderate, and six or seven checkmarks means severe. Could any of these hallmark symptoms ever apply to a morbidly obese person who cannot stop overeating? Let’s call this person Wally, whose “drug of choice” is cheese, though he’s not that picky, really. In fact, he’ll eat anything that doesn’t run away. But let’s keep it simple.

Q. Does Wally continue to eat cheese, despite negative personal consequences?
A. Yes, he does.

Q. Is he messing up at work, at school, or in the domestic realm because of his cheese consumption?
A. Due at least in part to size discrimination, Wally has been unable to find work. He dropped out of college because the desks were too small. His mother is about to throw him out because her whole house smells of the cheese he hides everywhere.

Q. Does he recurrently use the substance in physically hazardous situations?
A. Crossing the street, Wally was nearly hit by a car because his attention was focused on unwrapping a package of cheese.

Q. Does he keep on doing it, even though it causes social and interpersonal problems or makes existing problems worse?
A. Sadly, the answer to this is also yes.

Q. Does he have to eat more to feel as happy as he used to feel with less?
A. You guessed it. Wally used to buy the 8-ounce packages, but now he buys cheese by the pound. The only reason he doesn’t buy a wheel is his mother’s temper.

Q. Does he avoid the possibility of experiencing withdrawal?
A. Indeed. Wally will no longer attend any social gathering that does not either provide cheese or allow him to bring his own supply and munch freely.

Q. Does he use greater amounts, or over a longer time period than he had intended?
A. Well just an ounce or two will not help Wally to feel better, will it? Of course he uses bigger amounts – he buys it by the pound, remember? And he’s been meaning to quit for years.

Q. Does he want to cut down or quit? Has he tried and tried and tried?
A. Yes, yes, and yes.

Q. And when he tries to quit, does he experience cravings for the substance?
A. Good heavens, affirmative. Cheese haunts his dreams.

Q. Does he spend a lot of time obtaining, using, or recovering from the substance?
A. If Wally sneaks some cheese into the shopping cart, his eagle-eyed mother puts it right back in the cooling case. He has to make an excuse that he’s going to the library, and return to the grocery store on his own. It takes up an enormous amount of time – though the walk does him some good.

Q. Has he quit or reduced his attendance at social, occupational, or recreational activities?
A. Obviously, unemployed Wally has no work-related functions to attend. Mostly, he stays in his room. Recreational – are you kidding?

Q. Does he consistently use the substance “despite acknowledgement of persistent or recurrent physical or psychological difficulties from it”?
A. Yes! That’s the frustrating part, he knows better! Wally isn’t stupid. He knows it’s not good for him and he’ll probably die young, and he just keeps on eating cheese!

In the official accounting, the “severe” rating only goes up to 7. There must be a category above “severe,” because we see how easy it is for an actual human to fulfill all the criteria for a substance-use disorder. And food is not even officially considered to be a substance of abuse.

Your responses and feedback are welcome!

Source: “DSM-5 Substance Use Disorder,” buppractice.com, Undated
Image by Stephanie Watson

 

DSM-5 and the A-Word

Doctor and Nurse Bears

Childhood Obesity News discussed how DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, backed off from using the word “addiction” and went to “substance use disorder” and “substance induced disorder.” The A-word appears in conjunction with gambling, “the only addictive disorder included in DSM-5 as a diagnosable condition.” Gambling disorder is in fact the lone member of the behavioral addiction category. The DSM’s “Substance-Related and Addictive Disorders” chapter says:

This new term and its location in the new manual reflect research findings that gambling disorder is similar to substance-related disorders in clinical expression, brain origin, comorbidity, physiology, and treatment.

But wait. Pathological overeating really is similar to substance-related disorders in clinical expression. It is similar in brain origin, and similar in how it ushers in co-morbidities. There are physiological similarities, and the most successful treatment modality is notably similar. Among alcoholics, hard drug addicts, and the obese, what works best is a 12-step program.

Unhealthy dependency on food and eating is a double whammy, because it involves both a behavioral component and a substance component. It sure sounds like a behavioral addiction.

More Resemblance

We mentioned previously how the DSM is not the only “bible” used to define and categorize certain psychological problems. WHO publishes the widely-used International Classification of Diseases, and the American Society of Addiction Medicine also publishes a guidebook. The RogersHospital.org website notes that according to both the ASAM manual and the DSM, gambling addiction is best understood as part of a spectrum of similar addictive disorders. Dr. Michael Miller explains:

The new ASAM criteria really focus on the treatment aspect of addiction, rather than making a diagnosis and trying to segment a diagnosis into a level of care….This change within the DSM reflects increasing evidence that some behaviors – like gambling – can activate the brain reward system with effects that are similar to those of drug use.

As we mentioned, one of the most exciting developments in the theory of food addiction was the discovery of its similarity to substance-related disorders like cocaine addiction. Also, the ASAM says that addiction is a “chronic disease of brain reward, motivation, memory and related circuitry.” The definition continues:

Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Dare we suggest that food might be one of those substances, and compulsive overeating might be one of those behaviors? The ASAM definition of addiction also speaks of the inability to consistently abstain, or to control one’s behavior, or to recognize how life problems are exacerbated by attachment to the substance or behavior. And a dysfunctional emotional response. And cravings. And cycles of relapse and remission. The nature of addiction is to be progressive, and to result in disability or early death.

Every one of those traits can be found in people whose relationship with food has gone off the rails. Why isn’t this recognized appropriately by DSM-5?

Your responses and feedback are welcome!

Source: “Substance-Related and Addictive Disorders,” DSM5.org, 2013
Source: “DSM-5 Now Categorizes Substance Use Disorders in a Single Continuum,” RogersHospital.org, 02/24/14
Image by Enokson

 

DSM-5 Shies Away from Addiction

5798335_sAccording to DSM-5, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, food is not something over which a person can develop a substance use disorder. The recognized disorder-causing substances are alcohol, caffeine, cannabis, hallucinogens, inhalants, opiods, sedatives, hypnotics, anxiolytics, stimulants, and tobacco.

This is straight from the horse’s mouth – a factsheet from American Psychiatric Publishing:

Each specific substance… is addressed as a separate use disorder (e.g., alcohol use disorder, stimulant use disorder, etc.), but nearly all substances are diagnosed based on the same overarching criteria….The revised substance use disorder, a single diagnosis, will better match the symptoms that patients experience.

Those lines contain two key phrases to keep in mind – “same overarching criteria” and “will better match the symptoms that patients experience,” and we will get back to them. But first, the picture becomes more complicated. DSM-5’s “Substance-Related and Addictive Disorders” category is sub-divided.

Disorders

A substance use disorder is characterized by the “negative consequences of continued and frequent use.” These are not immediate consequences, but ones that occur over time as addiction takes hold. (That being so, couldn’t overeating be considered a substance use disorder? The consequences build and multiply over time – with the continuous gain of weight and the increasing risk of developing an obesity-related morbidity.)

Then, there are substance induced disorders, characterized by the immediate effect of intoxication. If a person discontinues use of the substance, he or she experiences an immediate effect called withdrawal. (Can’t food be intoxicating? Feed a child a bunch of sugar and find out. When adults spend small fortunes at upscale restaurants, it isn’t just the wine getting them high.)

Intoxication is a temporary condition, about which it is useful to remember that the root word, toxic, means poisonous. If the central nervous system is affected, and there is a behavioral and/or psychological impact – but the effect is reversible after the substance has been processed through the body – that’s intoxication. (But wait – food can cause it. Also, abstinence from problem foods can cause withdrawal symptoms.)

Parallels Between Big Food and Big Tobacco

Now, here is a puzzling quotation from this article by Dr. Tom Horvath et al:

Substance intoxication applies to all classes of drugs except tobacco.

Really?  According to other sources, nicotine intoxication is definitely “a thing.” Why are so many humans hooked on it? Of course it is psychoactive. Many hundreds of people contributed to the making of this latest DSM, and it contains important information. But the tobacco section seems to show a certain bias.

Just to make sure there was no misunderstanding, another source was consulted. In a presentation created for doctors, to capsulize the new edition’s changes for them, there it is in Slide #9, “Substance intoxication does not apply to tobacco.” How did this happen? Since it did, may we expect DSM-6 to make a similar statement about food and overeating, excusing them from all culpability in the obesity epidemic?

When a child or adult eats for emotional comfort, part of the impact is psychological (intoxicating) – or else why do it? The whole purpose of comfort eating is to change the mental and emotional state – in other words, it is psychoactive. This descriptive article also says,

Substance withdrawal is diagnosed based upon the behavioral, physical, and cognitive symptoms that occur due to the abrupt reduction or cessation of substance use.

The severity of the patient’s withdrawal experience varies, depending on the specific substance and other factors. And yet the authors also note that, with some drugs, their use followed by discontinuation does not result in withdrawal. Accordingly, some things can be intoxicating and psychoactive, and even potentially addictive, without causing withdrawal pain. But then there is food, which, even though many people have shown definite indications of withdrawal, is not considered a candidate for addictiveness.

Consider the experiences people have with alcohol, caffeine, cannabis, hallucinogens, inhalants, opiods, sedatives, hypnotics, anxiolytics, stimulants, and tobacco – and the reactions that some patients have to food. Now, remember those two phrases – “same overarching criteria” and “will better match the symptoms that patients experience.” Yet food is not considered an addictive substance, and overeating is not seen as a behavioral addiction. Are we confused yet?

Your responses and feedback are welcome!

Source: “Substance-Related and Addictive Disorders,” DSM5.org, 2013
Source: “The Diagnostic Criteria of Substance-Induced Disorders
SevenCounties.org, undated
Image by 123RF/Goodday

 

The DSM and the ICD

untitled picture

We hear so much about the Diagnostic and Statistical Manual of Mental Disorders, we tend to forget that it is not the only “bible” or set of guidelines in use. The other major guide, the International Classification of Diseases and Related Health Problems, is produced by the World Health Organization (WHO).

A far-reaching study asked mental health professionals from everywhere to compare the current edition of that manual, familiarly known as ICD-10, with the 4th edition of DSM (since DSM-5 had not been published yet). This was in preparation for ICD’s 11th revision, expected to be finalized in 2017.

Each is a DCS

There is one more acronym central to this discussion: DCS, or Diagnostic Classification System. A diagnostic classification system needs to be simple, reliable, easy to use, and helpful toward making treatment and management decisions. A classification’s value is measured by its clinical utility, and most clinicians favor a system with fewer categories of disorder.

Classifications are needed so that medical professionals in different specialties, and from different countries, can communicate with each other regarding a patient or a disease. In some places, they are used to allot resources and support. Of course, when a patient is covered by insurance, the official diagnosis must always be selected from the available DCS choices and plugged into the paperwork. Additionally, within each category, there is plenty of room for disagreement over such matters as “whether or how to incorporate dimensional classification, functional impairment, and severity.”

Who Likes What?

Clinicians who primarily use either ICD or DSM were asked about what kinds of cases they saw most frequently. The most commonly seen problems are mood and anxiety disorders, along with stress-related and childhood disorders. Interestingly, the less frequently encountered conditions included “substance-related disorders, psychotic disorders, and eating disorders.” It should also be noted that a significant proportion of psychologists rarely or never use a diagnostic classification system. Prof. Graham Davey explains:

We should be clear that diagnostic systems are not a necessary requirement for helping people with mental health problems to recover, and many clinical psychologists prefer not to use diagnostic systems such as DSM-5, but instead prefer to treat each client as someone with a unique mental health problem that can best be described and treated using other means such as case formulation.

Around the world, 60% of psychologists use a formal classification system, with 51% routinely consulting ICD and 44% favoring DSM. In many places, mental health professionals are turned off by what they perceive as a cultural bias that gives more weight to the American and European way of doing things. Psychopathy is not seen in exactly the same way every in all parts of the world. There are “culturebound syndromes” and local differences in the delivery of mental health services.

When it comes to diagnostic and treatment guidelines, crosscultural applicability is, understandably, a significant issue. But some critics are not even satisfied with that goal – they want a national classification system relevant to their particular country, and this feeling is strongest in Latin America, Africa, and the Eastern Mediterranean. Both psychiatrists and psychologists vastly prefer flexible diagnostic guidelines, and that preference is equally true of those who mainly use either ICD or DSM. Traditionally, and quite logically, ICD has offered more leeway for cultural variation and clinical judgment.

Why Flexibility?

Flexibility matters because some basic assumptions are not universally shared. For instance, there is disagreement over the diagnosis of depression. If incidents in a patient’s life are clearly so horrific as to warrant major depression, is it fair to label that person as having a mental disorder? Of the professionals polled, a slight minority said no. Conversely, slightly more than half favor going with the depression diagnosis, even if the person’s distress is a “proportionate response to adverse life events” – in other words, if the depression has been earned by experiencing dreadful real-world horrors.

Your responses and feedback are welcome!

Source: “Psychologists’ perspectives on the diagnostic classification of mental disorders: Results from the WHO-IUPsyS Global Survey,” tandfonline.com, 06/10/13
Source: “Changes in DSM-5,” Blogspot.com, 02/13/13
Image by Premnath Thirumalaisamy

 

The Interesting Diagnostic and Statistical Manual

Doctor Lucy is REAL IN

Since the long-awaited publication of the 5th version of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, the dust has settled and many authorities have had a chance to weigh in and speak their minds. British psychology professor Graham Davey, for instance, notes several problems.

Among these is the fact that psychological/mental health problems are seen as dimensional, so the arbitrary establishment of a diagnostic cut-off point must necessarily be sketchy. Davey writes:

DSM-5 has attempted to recognize the importance of the dimensionality of symptoms by introducing dimensional severity rating scales for individual disorders. But… each iteration change in DSM diagnostic criteria changes the number and range of people who will receive a diagnosis, and this makes it increasingly hard to accept diagnostic categories as valid constructs.

Childhood Obesity News, naturally, takes a keen interest in the medical establishment’s view of food addiction, a frequent bone of contention both linguistically and conceptually. Back in the old days of DSM-IV, the terms “substance abuse” and “substance dependence” appeared in its pages. They have since been abandoned for the inclusive term “substance use disorder,” or SUD, which is further divided into three degrees of severity – mild, moderate, and severe.

The RogersHospital website explains that in many social circles, “abuse” is a stigmatizing label. If SUD is a real and significant health problem, then sufficient vocabulary, more professional and less judgmental, can be found to describe it. Also, the word “dependence” is no longer used because it was often applied inappropriately:

… “dependence” could be confusing to some clinicians and patients since the term is used medically to describe the body’s adaptation to a consumed substance.

They are saying that dependence is a normal body response. We all depend on Vitamin C to keep us from contracting scurvy, and some people depend on daily injections of insulin to keep them alive.

Mental problems that manifest as feeding and eating problems have always been difficult for the DSM compilers to deal with. The previous edition included anorexia nervosa, bulimia nervosa, and a slew of aberrant behaviors that got shoved into the category of EDNOS, or “eating disorder not otherwise specified.” Clinical psychologist Jennifer J. Thomas says:

Unfortunately, the pervasive myth that EDNOS was somehow less severe than anorexia or bulimia sometimes prevented people who fit into this category from seeking help, or insurance companies from covering costs.

DSM-5 shook up the organizational chart, kicked out EDNOS, and established OSFED, or “Other Specified Feeding or Eating Disorder,” a category with five members and some contenders:

  • Atypical Anorexia Nervosa (i.e., anorexic features without low weight)
  • Bulimia Nervosa (of low frequency and/or limited duration)
  • Binge Eating Disorder (of low frequency and/or limited duration)
  • Purging Disorder
  • Night Eating Syndrome

DSM-5 also includes a category called Unspecified Feeding or Eating Disorder (UFED) that is reserved for folks who don’t fit into any of these five categories, or for whom there is not enough information to make a specific OSFED diagnosis.

.
Binge Eating Disorder, with higher frequency and duration, but without purging, was awarded its very own category.

Your responses and feedback are welcome!

Source: “Changes in DSM-5,” Blogspot.com, 02/13/13
Source: “DSM-5 Now Categorizes Substance Use Disorders in a Single Continuum,”
RogersHospital.org, 02/24/14
Source: “Goodbye EDNOS, Hello OSFED,” JenniSchaefer.com, 08/21/13
Image by Kevin Dooley

 

Blame, Nuance, and the Fallacy of Choice

The largest one of the group

Psychologist Chris Crandall of the University of Kansas has noticed that the fundamental American values of individual choice and self-determination have a dark side:

We blame people for everything that happens to them – being poor, being obese. It’s the ‘just world’ idea that people get what they deserve.

According to this doctrine, failure occurs when a person does not work hard enough or practice enough self-discipline, and what could illustrate the allegation more visibly and publicly than an overweight body? A 2012 Reuters/Ipsos poll showed that 61 percent of the respondents blamed the obesity epidemic  on “personal choices about eating and exercising,” and 49 percent thought obese people should pay higher health insurance premiums.

Many critics object to the term “fat-shaming” because it implies that overweight people have chosen to do something of which they should rightfully feel ashamed. A study discovered that even children as young as 3 have been instilled with the idea that “overweight people are mean, stupid, ugly and have few friends.”

Who is Blameworthy?

If the obese individual in question is a child, the idea of blame is ridiculous – although maybe, in a just world, a relative or two might be due for some bad-parent-shaming.

An obese adult is different. A case might be made that blame could fairly be placed on not just one lousy choice, but on a multitude of small, seemingly minor choices, made day after day. But Dr. Christopher Ochner takes a more nuanced view, suggesting that a “point of no return” arrives, after which obesity is no longer a matter of choice. Here is his argument:

I have a problem with the assumption that individuals should just be able to simply adopt a healthy lifestyle sufficient to be lean. To be on par with your never-obese lean individual, this would mean their making significant changes to metabolism, neural dopamine levels, neural responsivity to food cues, gut-peptide profile and adipocyte count.

After a certain point, the standard advice to eat less and move more just doesn’t cut it, and he sees both educators and clinicians as remiss in their loyalty to the cliché. Of course, there is no doubt that practically everybody could benefit from more exercise, and for almost everyone, the most basic form of exercise should be pushing their chair away from the table.

While an adult can perhaps be assigned responsibility for every step of the way that led to obesity, that path cannot be easily retraced without solid professional help. The factors that cause obesity and the factors that maintain it are quite different, and once obesity has moved in and grabbed the reins of power, the game changes. This applies, says Dr. Ochner, to “all but very few exceptional individuals.” He continues:

Once someone has been obese for some time, the confluence of a number of extremely potent weight-maintenance mechanisms readily override even the most legitimate of attempts to will past it.

Your responses and feedback are welcome!

Source: “Insight: America’s hatred of fat hurts obesity fight,” Reuters.com, 05/11/12
Source: “The doctor replies again: Once obese, it’s tough to escape,” michaelprager.com, 08/01/14
Image by Gaulsstin

 

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