Wednesday, March 21, 2018

The DSM-5: A Flawed Document

For all official purposes--including insurance claims--psychotherapists are required to use the diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth version (the DSM-5). Unfortunately, the DSM is a limited and even inaccurate text that in some areas reflects social and cultural biases. It has been written and revised by a team of psychiatrists who are mostly male, even though the majority of mental health clinicians are female and aren't psychiatrists. I and many other therapists find it to be of limited usefulness for diagnosis and assessment.

The DSM diagnoses were developed using the "medical model," which means they are symptom-based. The problem with this model is that although it describes what disorders look like, it does not describe their etiology--how they came to be. Although the DSM includes information about prevalence and prognosis, it doesn't describe how and why disorders develop.

The reason the DSM categories and descriptions are symptom-based is because that's what insurance companies and pharmaceutical companies want--they want to know how many symptoms a patient has because this can be fairly easily measured. Non-medical therapists and psychoanalysts are more interested in the underlying psychological structures and dynamics of a patient's illness, because our goal is not just symptom reduction, which can be temporary, but lasting change.

Perhaps the best example of a discrepancy between the DSM and other models are the different conceptions of Borderline Personality Disorder. The DSM description is a grab bag of symptoms that can also be found in people with Post Traumatic Stress Disorder. This can lead to diagnostic confusion. Psychoanalytically-oriented therapists, on the other hand, assess Borderline Personality Disorder based not just on symptoms but on factors such as which psychological defenses the patient uses, what type of interpersonal relationships they have, and how they manage stress. Ultimately this type of assessment allows us to differentiate between BPD and PTSD, to tailor treatment more effectively, and to better predict outcomes (prognosis).

Cultural biases are also found in the DSM. The criteria for Anti-Social Personality Disorder (sociopathy) include law-breaking. Whose laws? Laws vary from country to country and from state to state. Some laws may be unjust. This DSM criterion equates conformity and obedience with mental health. A psychoanalytically-oriented therapist is more interested in other criteria such as the patient's capacity for empathy, presence or lack of deceit, personal responsibility, presence or absence of aggression/sadism, and capacity for trust. The DSM criteria also do not address the fact that certain groups are more likely to come in contact with the police for reasons that have nothing to do with their personalities.

Similarly, the DSM criteria for Histrionic Personality Disorder includes "consistently uses physical appearance to draw attention to self." Women are encouraged to use physical appearance to draw attention to self, in Western cultures. This may have resulted in more women than men being diagnosed with HPD, although there is no evidence that women are more likely to have this disorder.

The influence of pharmaceutical companies is well-known among clinicians. A disorder originally called "Minimal Brain Dysfunction" was re-labeled as "Attention Deficit Hyperactivity Disorder" by the pharmaceutical industry, in order to better market their drugs. Many patients are unaware that "ADD" as many people call it, is a disorder invented by people who weren't acting on behalf of patients. Again, the listed symptoms of ADHD can overlap with other conditions, especially abuse and neglect of children. It's easier for a doctor to write a prescription than to call child welfare or to recommend parenting classes. It's the parents who are paying the doctor's bills, in most cases.

It's been said that "the winners write history." They also write the laws, the rules, and the diagnostic criteria.

Sunday, March 4, 2018

Are Movies Bad for your Daughter?

Perhaps the first answer I would give to this question would be "Not as bad as video games are for your son." At least most movies have story lines and characters that can be compared and discussed in relation to real life situations, rather than depicting enemies as mere targets. But the movies you and your children watch are filled with sexists messages that can have effects on young girls. 

With all the attention given to film content because of the "#Metoo" and "TimesUp" movements, I've been pondering what I was exposed to as a child. The sad conclusion I came to was that although what I was exposed to, in the 1970s, was bad, today's films aren't much better and possibly are worse.

I wasn't bothered by the "Bond girls," back when I was 12,  because they were mostly heroines and even action heroines in some circumstances: Think of "Pussy Galore," an air commander with a fleet of all-female pilots--almost a radical feminist statement! (if they hadn't been mostly 22- year old blondes). Or Tully Masterson, who tried to avenge her sister's death with a sniper rifle. Most of the sex was depicted by suggestion and innuendo. Today's action movies are either cartoon/comic adaptations that have no relationship to real life, or, they are live action movies with male heroes (Liam Neeson, Vin Diesel, Tom Cruise, Daniel Craig) in which the female roles aren't memorable. The last Bond movie I saw, "Skyfall," was execrable and featured females as failures and quick victims, but was dressed up with Judi Dench in the minor role of "M." And because Daniel Craig was tied up filming that movie and the next Bond film (which needless to say I did not see), the sequels to "Girl with a Dragon Tattoo"--an immensely popular story with an unusual heroine and a feminist message--did not get made. 

An insidious message that has persisted and perhaps even gotten worse is the message that women can't be friends with each other. I've noticed this even in recent,  so-called feminist films: Whereas in the "Hunger Games" books Katniss Everdeen had a female friend, this small role was excised from the films. The cinematic Katniss has no female friends. In "Maleficent," purportedly a feminist twist on the "Sleeping Beauty" fairy tale, Aurora plays with seemingly male forest creatures, Maleficent's companion is a male crow, and the three fairies who raise Aurora are depicted not as friends but as a group of catty, quarreling women who insult each other. As in the Hunger Games movies, the positive female relationships are family relationships--mother/daughter, stepmother/daughter, sister/sister. The message is that outside of the family, other women can't be trusted.

Parents might want to think about another message besides misogyny that their daughters might grasp from misogynistic films: The message that adults aren't role models. I'll never forget my response to the movie "M*A*S*H" when I was around 11 or 12: When the "heroes" humiliate the "Hot Lips" Houlihan character by ripping her shower curtain off and exposing her to a crowd, I realized this action was supposed to be cheered by the audience. Since I knew what they were doing was wrong, the message I received was that adults didn't care about the difference between right and wrong and were a bunch of hypocrites. These type of movies, which are still extremely common, should not be viewed by children under 15. In fact, they should not be viewed at all. 

What children need is to see are depictions of other children with whom they can identify, who have friends (including same-sex friends) and who solve problems,  and depictions of adults who are icons or role models. Today's movies and TV don't cut it. You can solve this problem by encouraging your children to read books.