Frustrations with the DSM

I live in a very psych oriented world. I work for a nonprofit that provides services to kids with autism and developmental disabilities and general mental health problems. I spent at least five hours a week in therapy. I talk a lot about mental health, I care a lot about mental health, and a few of my friends and I just started throwing around the idea of creating a skepticism and psychology conference (SO EXCITED). So I’m thinking (as per usual) about mental health.

One of the talks at SkepTech (by the fabulous Stephanie Zvan) was about psychometrics, which is “The science of measuring mental capacities and processes.” She talked a fair amount about how we often define certain disorders based on our stereotypes: we view autism as a boy’s disorder, so the diagnostic criteria are slanted towards how autism presents in boys. I think this is a very important thing to address (especially in terms of race. UGH), and I think the place to start is with the DSM (the psychology diagnostic manual). The DSM is very much a quantitative measure. For eating disorders for example, it lists particular weights, numbers of binges and purges per week, and length of the persistence of the disorder as diagnostic criteria. In many ways, these concrete diagnostic tools are incredibly helpful: they allow insurance to see who to treat or not and they allow clinicians to have something more solid than personal judgment to use in their diagnoses. That’s important. We do need some element of consistency, we need some science in our diagnostic tools.

The problem shows up in the fact that many of these diagnoses are written around what is considered the typical case and doesn’t necessarily allow for any variation. It also doesn’t address the fact that many people have lots of symptoms that don’t quite fit into a neat diagnostic category. In many ways it’s far too rigid. Diagnoses that involve NOS (not otherwise specified) often aren’t covered by insurance, aren’t included in research, and aren’t afforded as much respect as serious problems by clinicians or the individuals diagnosed.

This is a really big deal because it limits who can access mental health care based upon demographic or personal variation. Males with depression generally exhibit it in very different ways from females, and they are not diagnosed as often because they aren’t viewed as the typical depression sufferers. People of color are not diagnosed with eating disorders nearly as often as white girls (particularly teens).

So how can we both create helpful categories AND capture the wild diversity of mental illness? How can we approach mental illness not as a checklist of symptoms that we address and move the individual back to the neurotypical end of the spectrum? First and foremost, insurance needs to NOT be tied to strict diagnosis. That is not fair to individuals who might need preventative therapy or interventions, or those who want to catch a disorder before it becomes so serious that it interferes with their life. It is also not fair to those individuals who have a serious mental illness that is wreaking havoc on them, but who don’t fall neatly into a category. But it’s also unfair to those who DO fall into the category, because it might ignore any other symptoms or problems that could be contributing to their diagnosis. OF COURSE labeling some patterns and similarities can be helpful because it allows us to conduct research and to develop treatments that work for people with similar issues. But these labels should not be considered so strict, should not be the only guide we have in treatment, should not have such harsh boundaries, and should allow more movement between diagnoses. They should be guidelines (the code is more like guidelines than actual rules).

There should also simply be more cross-cultural research. Right now we have very Western-centric views of psychology as well as very white, male views of psychology (thanks Freud). We need to focus on evidence based treatments, and we also need to simply be willing to have MANY types of treatment available for people who are exhibiting different symptoms because of their demographic. We need to have psychologists who are social justice aware: personally I think that sociology, women’s studies, and race studies classes should be required of every psychology major. It is SO important to improve our mental healthcare system, and the first place we need to turn is how we determine who needs mental healthcare.

If we’re being honest? EVERYONE. Mental healthcare isn’t about turning people into the neurotypical. It is about improving functioning. Everyone could use a mental health checkup, just like they have a physical health checkup to make sure they’re functioning like they should and to catch any worries or glitches before they turn into something serious. We need a paradigm shift that no longer sees diagnoses as identifying problematic difference to seeing diagnoses as identifying problems with functioning that require help.

NOTE: they are trying to adjust some of these problems in the latest update of the DSM, the DSM-V which is coming out in May.

How Do We Talk About Eating Disorders?

I’m currently working on a post for Teen Skepchick about eating disorders in a cross cultural perspective. At the moment, I’m just in the research stage of this post, so I’m reading a lot about the research that’s been done about cross cultural eating disorders and about the differences in symptoms, causes, and etiology of eating disorders in different cultures.

And I have to say that I am deeply upset by the way we talk about eating disorders. I am particularly upset because I’ve been reading academic articles, pieces by graduate students studying psychology, and other articles that are surveys of the literature on eating disorders. These should be held to the best standards we have. Unfortunately, no matter where I look (except for in very particular blogs written by people with eating disorders, particularly Science of Eating Disorders), I hear the same things over and over and over again:

“When we expose our girls to thin models and beauty ideals they develop eating disorders”

“Girls of African American descent aren’t likely to get an eating disorder because their culture values voluptuous bodies”

“Eating disorders only crop up in other countries as they become infiltrated by Western beauty ideals”

I am SO sick of the conversation around eating disorders being dominated by conversations about models and images of women in the media and the desire to be thinner. It cannot be that difficult for people to understand this, but I’ll say it again: an eating disorder is a mental illness. It is not a diet. It is not even an extreme diet. It is not a desire to lose weight. It is a coping mechanism to deal with difficult things in your life that you can’t cope with otherwise.

There is VERY little evidence that eating disorders are caused by skinny models. What there IS evidence of is that eating disorders are caused by low self-esteem, family disruption, trauma, other mental illnesses (depression, anxiety, OCD, BPD, bipolar, and addiction are common), abuse, or other difficult situations that you need a way out of. It is such a cliche by now that eating disorders aren’t about food, but I cannot stress it enough: eating disorders aren’t about food! They aren’t about looking pretty or beautiful. I have YET to meet someone with an eating disorder who says they just want to be pretty. I hear them say that they’re depressed, that they can’t cope, that they’re lonely, that they don’t feel acceptable when they’ve eaten, that they feel out of control around food, or that they use food to numb out emotions and manage other parts of their lives.

It is not helpful to keep refocusing the conversation on how someone’s body looks and the beauty ideals. This continues to reinforce them as what’s important, and it focuses the issues on the body again, instead of addressing whatever mental stress has occurred. It simplifies the matter to a point that is unhelpful, and makes treatment and self-understanding very difficult because it doesn’t allow us to reach the real etiology of the disease. It even reinforces those negative suggestions that a woman’s worth is in the beauty standards she does or does not strive to live up to.

Instead of these things, it would be far more helpful to talk about the sexism that makes women feel inadequate no matter what they do, or the bad family systems that don’t allow for good communication or healthy emotions, or the abusive relationships that many women are in, or the trauma and depression of daily life, or the failure of our mental health system to provide us with good coping techniques for when we do start to feel over our heads. If we want to talk about cross cultural eating disorders, maybe we should talk about the different family roles that exist, the different expectations of women in different cultures, the common mental illnesses in those cultures, the differences in guilt and shame in different culture (these feelings are huge in eating disorders), and the relationship that these cultures have to food as symbolic, relational, or positive.

Eating disorders are mental illnesses. They are not an attempt to be skinny. They are not a reaction to the media. They are not the desire to look like a model. They are serious. They are life-threatening. They are painful. They come with depression, constant mental stress, trauma, self-hatred, difficulty with relationships, isolation, loneliness, feelings of guilt and inadequacy, and all sorts of things that ARE NOT simply reactions to the media, but are about how we relate to ourselves and how we relate to others. Can we please start talking about them in terms of the mental situation of the individual suffering, because that is what makes something a mental illness?