By David Joel Miller.
Are there more mental illnesses than we know about?
“Conditions for Further Study” is a chapter in the DSM-5 which describes some possible mental illnesses that have not yet gotten full official recognition. These are not something a clinician can diagnose, or one which insurance companies will pay to treat, not by these descriptions anyway.
You would think that by now we would have identified every possible mental, emotional or behavioral disorder, and come up with sure-fire treatments for each of them. Unfortunately, it doesn’t work that way.
Periodically a new disease comes along. It wasn’t all that long ago that no one had ever heard of AIDS or even HIV. The same thing, sort of, is happening in mental health. Researchers would like to be sure that when they tell you about the characteristics of and the treatment for a mental illness that everyone who was a subject in the research had the same disease.
Clinicians know that not everyone who has the same “diagnostic label” has the same symptoms. So you get a group of people who supposedly all have the same thing, say PTSD, and then you give them tests and assessments. For some things, personality characteristics like say introversion and extraversion, people will be on a continuum.
For other things like Posttraumatic Stress Disorder there will be clusters of people who all have similar symptoms and then clusters of other people who have different symptoms.
Lumpers and splitters.
Some people want only a few categories, like dogs and cats. The trouble with this is that Poodles are very different from Rottweilers. The house cat sitting on my desk is nowhere near like a Lion. So while we want to be specific about a mental, emotional or behavioral disorder someone might have, we also want to avoid creating several billion mental illness descriptions, one for each person.
Researchers and clinicians who notice these different clusters may become convinced that there are differences in symptoms that should be categorized as separate illnesses. For example, not all PTSD is alike. The PTSD that results from combat may show different features than the PTSD we see in battered women or abused children. Currently, they may all get a diagnosis of PTSD but there are different treatment approaches. Some clinicians have taken to referring to the form of PTSD that is the result of repeated abuse as “complex trauma” even though this is not officially a DSM diagnosis.
Are behavioral disorders a mental illness?
We see some similarities between drug and alcohol use disorders and some behaviors. Children and adolescents get some behavioral disorder diagnoses, things I sometimes refer to as “bad kid” diagnosis. But in adults not much in the way of behavior currently, meets criteria for a mental illness.
So far the only behavior that has gotten included in the Substance-Related and Addictive Disorders chapter is Gambling. Other behaviors, internet usage, compulsive gaming and pornography all have features that look like the loss of impulse control seen in Gambling.
Some of the major things that counselors treat are not diagnoses.
Anger is a huge reason for referrals to therapy, yet anger currently is not a specific diagnosis. While anger may be the reason for referral, currently it is seen as a symptom of some other problem, not a specific diagnosis. Despite the common practice of court-ordered Anger Management classes, Anger is not a diagnosis.
Suicidal behavior is not an official mental illness either.
Same problem with non-suicidal self-injury sometimes called cutting. Currently, the only place this fits is under Borderline Personality Disorder where it may be a symptom. This seems problematic. Does adding Non-Suicidal self-injury inflate the number of people with a diagnosis of Borderline Personality Disorder? Can you have one without the other? Shouldn’t someone who is thinking about killing themselves qualify for a diagnosis for that reason alone?
Disorders of special populations.
Several group-specific problems may be the focus of treatment but so far are not recognized as mental illnesses. This is a particularly acute problem for treatment of military personnel. Moral Injury is a situation in which you are required to do something that violates your sense of right and wrong. In civilian life, you may find ways to avoid this dilemma but in the military, there are few choices. Sometimes to do one good thing, following orders, you have to do something else that troubles your conscience.
Military sexual trauma is another non-DSM issue. In combat, you count on your comrades to keep you safe. Being raped by someone in your unit is a very traumatic incident. Having to continue to have good relationships with your abuser in order to stay alive is a tough situation.
Certainly, there are other problems, cultural or situational, that have not yet reached official disorder status but that require more research.
Do Conditions for further study make it to become a full diagnosis?
In each edition of the DSM, there are a number of proposed new diagnosis. Most do not make it as separate mental illness. After much research, they may get lumped in with existing disorders. Many of these proposed new disorders have long specific names. My observation is that the fewer words in the name the more likely it will get its own place in the DSM. Binge Eating Disorder made it. I have my doubts that Neurobiological Disorder Associated with Prenatal Alcohol Exposure will make it unless it gets a short name. (More on Fetal Alcohol Exposure Problems is coming up in future posts.)
Currently, there are 8 “Conditions for Further Study” listed in the DSM-5. The DSM-IV-TR had 16, most of which disappeared in this revision.
What are those Conditions for Further Study in the DSM-5?
- Attenuated Psychosis Syndrome.
- Depressive Episodes with Short-Duration Hypomania
- Persistent Complex Bereavement.
- Caffeine Use Disorder.
- Internet Gaming Disorder.
- Neurobiological Disorder Associated with Prenatal Alcohol Exposure.
- Suicidal Behavior Disorder.
- Non-Suicidal Self-Injury.
FYI These “What is” sometimes “What are” posts are my efforts to explain terms commonly used in Mental Health, Clinical Counseling, Substance Use Disorder Counseling, Psychology, Life Coaching and related disciplines in a plain language way. Many are based on the new DSM-5; some of the older posts were based on the DSM-IV-TR, both published by the APA. For the more technical versions please consult the DSM or other appropriate references.
Staying connected with David Joel Miller
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