Diagnonsense… or the DSM-V
In New Zealand, in order to receive ACC assistance, you need to have a diagnosed mental illness directly related to the abusive injury. I know from reading other blogs, that health insurers around the world, often require a recognised diagnosis in order to provide (or exclude) coverage. Depending on where you’re from, that diagnosis is determined by either the DSM (Diagnostic and Statistical Manual) or the ICD (International Statistical Classification of Diseases and Related Health Problems). In New Zealand, we use the DSM, and this is currently being substantially revised – some say rewritten, and is due for release in 2013. If you’re wondering why I’m worried about something that is so far away, well, this manual determines whether I will receive ongoing assistance, what that assistance will look like, I enjoy being an informed consumer, and I’m curious how mental health professionals perceive my various reactions to life.
At the moment, proposed revisions are being made to the DSM-5. There had been all sorts of rumours circulating that there would be a whole plethora of new diagnoses, and the removal of others – including DID. Based on my rather uneducated eye, the changes are “interesting” rather than sweeping. Running through the disorders that I’ve been labelled with over the years, there’s an interesting mix of tightening of the definitions, and what seems a desire to create a “catch-all” diagnosis. Here’s my take on a couple of them…
300.14 Dissociative Identity Disorder
My first concern is that they are now going to allow the disruption of identity states to be reported by the patient. Call me cynical and a worry wort, but if you’ve read tales of caution about the “attractiveness” of having DID (for example Tempy’s entry Lemme just say it), then this may open the way for some misguided people who have problems, but not necessarily DID, to “seek” the diagnosis.
Then we get onto the “experience of possession”… I think they need to clarify this wording somewhat. To me, it sounds like something associated with spiritual or religious possession. That again, could just be my cynical take on it. This could be saved by the wording of the last criteria, where the disturbance is not part of “accepted cultural or religious practice”. But still, the word “possession” conjures a certain image that isn’t positive!
There now seems to be some acknowledgement that abusive events can be repressed – “Inability to recall important personal information, for everyday events or traumatic events, that is inconsistent with ordinary forgetfulness.” I know this won’t eliminate the False Memory Syndrome (FMS doesn’t appear in the DSM as far as I can tell) supporters, but it gives an official nod to the research supported indications that traumatic events can be suppressed, or forgotten as part of a coping mechanism (and the crowd goes wild – insert by Mickie).
According to the rationale behind the changes, this new wording is aimed at reducing the use of DDNOS, the understanding that forgetting everyday events is common (i.e. mild dissociation is common) and an indication that conversion and somatic conditions need to be looked at when making any diagnosis. Personally, I think the wording could benefit from some further work. I rather like having DDNOS as a “fall-back” diagnosis when I’m faced with a mental health professional who doesn’t believe in DID. But overall, I can see some benefits to the changes – the big one for me is the inclusion of the inability to recall traumatic events.
309.81 Post Traumatic Stress Disorder
There seems to be further indication that dissociation is a normal response to trauma – something that the research has shown for years, with the wording “Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)”
Persistent distorted blame of self or others about the cause or consequences of the traumatic event(s)” – they’ve acknowledged that self-blame is an issue for survivors!
Irritable, angry, or aggressive behavior” – added aggressive behaviour, which is a great inclusion – I’m thinking in particular about my ex-husband with this one.
According to the rationale behind the changes, there appears to have been a great deal of input into this diagnosis, but little actually changed. The changes that have been made appear positive in broadening the scope of the reactions that those with PTSD can have, as well as defining the time frame associated with the onset and continuation of symptoms. I admit not to having as much of a vested interest in this diagnosis, as I think pretty much any survivor will fit this diagnosis. It’s more about how far reaching it goes. I appreciate that they’ve indicated the dissociative experiences that can occur – but it begs the question as to why DID is not on the PTSD spectrum?
301.83 Borderline Personality Disorder
I’ve heard of BPD being a diagnosis given when they don’t know what else to label you… Overall, I think that those with the diagnosis have an incredibly bad reputation which is undeserved. I’ve been labelled as having “Borderline traits”, but when reviewing the PTSD criteria, the behaviours that they describe as “borderline” could be PTSD. In many ways, the revisions still allow BPD to be a “catch all” diagnosis for when they’re not sure what else to do with you. It has aspects of PTSD, dissociation, psychosis, low self-esteem, impulsivity, etc. When you look at the different aspects on the surface, it is easy to see how many survivors could meet the criteria; it’s only when you do the diagnostic tests that you realise that the severity needed to meet the diagnostic criteria.
To me, this diagnosis seems to have been fleshed out substantially. This worries me when you consider the poor reputation and often poor treatment that those with BPD receive… When I was initially given a diagnosis of DID, I was told there were no treatment plans for that diagnosis in New Zealand, so they sent me through the system with a diagnosis of BPD… I was shocked, dismayed and victimised by some of the mental health professionals who treated me as “another borderline”. It’s taken many years for the public health system to remove BPD from my records. I can see with this revision, that many more people may receive the diagnosis and associated poor treatment. Mental health professionals really need to change their attitude to those with BPD.
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Overall, the revisions seem intent on minimising the use of the “NOS” diagnosis. But in some areas it won’t be possible – from my understanding of the criteria, I will still meet the EDNOS diagnosis. I’d encourage you to check out the proposed changes… it’s an interesting process they are undertaking. There has been criticism that the work is being rushed, so that means we have more of an obligation to check it out – especially mental health professionals!
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