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April 20, 2014 / 20 Nisan, 5774
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Posts Tagged ‘American Psychiatric Association’

Diagnosing Mental Illness: How DSM-5 Will Change the Rules

Thursday, May 31st, 2012

Mental health specialists tend to speak about their patients according to a classification referred to as the DSM, which stands for the Diagnostic and Statistical Manual of Mental Disorders. This classification system was first published in 1952 by the American Psychiatric Association as a method to classify mental disorders and develop a statistical baseline through which disorders can be understood, studied and treated. It is not the only classification system available: the International Classification of Diseases, published by the World Health Organization, contains mental health diagnoses that parallel those of the DSM, but the DSM is most widely used in the mental health field, especially in the United States.

All classification systems evolve over time, and we are about to receive the latest iteration of the DSM in 2013. To understand why changes are made, one need only look at the changes made in each of the DSM revisions in the past. In the first DSM, which was based primarily on soldiers’ reactions to the stresses of World War II, all of the 106 diseases listed were termed reactive, or caused by reactions to social or environmental factors. This limited classification to traumas and environmental stressors.

In the DSM II, which contained 182 illnesses, the word reactive was removed, allowing for a broader approach to understanding possible biological or genetic contributions and other non-stress induced disorders.

DSM III, published in 1980, formulated a system that included a description of 265 diagnostic categories without any suggestion as to cause, unless it was very well documented, and conformed to very specific diagnostic criteria.

In 1994, the DSM IV added and deleted a variety of categories based on the research available at the time. In that version, which was further revised in 2000, only symptoms that caused clinically significant distress or impairment in functioning were included. Definitions of Attention Deficit Hyperactivity disorders and Autistic Spectrum disorders were expanded, and all of the disorders had a checklist of specific diagnostic criteria that had to be met in order to apply a diagnosis. This gave both clinicians and researchers a measurable way to classify their patients, the goal of which was to help find empirically validated treatments.

Every revision of the DSM causes a reaction among professionals and the public. Changes are often attributed to political considerations rather than research that supports the suggested changes. For example, in 1973, the DSM declassified homosexuality as a disorder, and the diagnosis was replaced by the category of Sexual Orientation Disturbance (SOD) because research failed to identify a specific abnormality caused by this sexual preference. Over the years, SOD has been modified and expanded to include a wider variety of sexual disorders and paraphilias. Some individuals still believe that gay activists advocating for their own agenda brought about this change, although that is highly unlikely.

The task force working on the DSM-5 was initially sworn to secrecy. This caused an uproar in the scientific community, which rightfully demanded an open process. Once the revision process was publicized and the recommendations for change became available, critics of the DSM-5 voiced three primary concerns. These include lowering of diagnostic thresholds that would increase the number of individuals who fit a diagnosis, introducing new disorders that are currently considered normal behavioral patterns, and questions regarding the scientific validity of certain categories.

If the DSM-5 goes forward as proposed, it could include changes such as a significantly broader definition of Attention Deficit Hyperactivity disorder; an Attenuated Psychosis Syndrome which would allow the diagnosis of individuals without a psychotic disorder to be classified as having one; and the categorization of shyness as a pathology.

Another proposed change would be a complete overhaul of the category now referred to as personality disorders. Perhaps the greatest concern of the scientific community is the neuro-biological emphasis of the DSM-5, and what some are calling the “over-medicalization” of disorders that are clearly a combination of biological, psychological, and social stressors. This is of great concern because it would provide justification for wider use of psychotropic medications, many of which have questionable utility, in vulnerable people who might benefit more from psychotherapy or counseling.

The need for practical interventions that are proven effective should be the primary motivator, but financial considerations are a pragmatic driving force. In the end, there is a great fear that the new criteria proposed in the DSM-5 will favor medical interventions, which may be seen by insurance companies as cheaper than therapy.

Uproar: Post Traumatic Embitterment Disorder?

Wednesday, September 30th, 2009

In a paper greeted enthusiastically at the May conference of the American Psychiatric Association, in San Francisco, a new name was given to a common problem, Post Traumatic Embitterment Disorder. My initial response: another excuse to drug people. However, upon thinking it over, I think that the word embittered does describe the essence of a serious problem. Many of us suffer from some degree of jealousy and bitterness about the injustices in our lives. But does that make us embittered? I would hope not. So, what characterizes embittered people? Here are some actual examples (the names have been changed):

Chedva was so happy at her vort last Motzei Shabbos. Finally, at the age of 23, she has found her bashert. She likes her future mother-in-law and her future husband is a gentle soul who loves to learn, and is also a musician – just perfect for her! Her mood changed swiftly the next morning when her mother angrily attacked her, “I was up the entire night crying because of you.” “What did I do?” asked Chedva, feeling the life drain out of her body. “I was so insulted,” said her mother. “You talked to your future mother-in-law almost the entire time and kept taking pictures with her! You have no kibud horim!” Feeling like a sinner who deserved the death sentence, Chedva listened submissively as her mother blamed her for being one more source of misery in her life.

For years, Mina has kept the family tradition of bringing her children to visit her parents every Shabbos. However, last week, the weather in B’nai Brak was unbearable. Desperate for sleep after giving birth to her 10th child, she decided to stay home and rest, although she dutifully sent her older children to visit their grandparents. The next day, one relative after another called to berate her, “How dare you? Daddy was furious and didn’t stop talking about how offended he was that you didn’t show up, like he was going to have a heart attack from grief. Call right away and make amends.”

Shlomo’s mother constantly berated him, calling daily to complain about his wife. “Why wasn’t I the first to know about the pregnancy?” she raged. “Why is she so cold to me?” Shlomo didn’t know what to say. He felt he had to listen for kibud horim. But her complaints were like poison, driving a wedge between him and his wife, who refused to go to his parents’ house for Shabbos. Caught between two angry women, his stomach turned in fear and shame.

These parents are embittered people, determined to make those closest to them feel unlovable, stupid and inadequate. Although they are often powerful, socially active people who are convinced that no one is as devoted and self-sacrificing as they are, they can erupt like a nuclear reactor, spewing bitterness at family members or workers who fail to live up to their expectations. In addition, they are:

Dependent Bullies: They act helpless yet bully others into subservience. As long as people are listening to them, giving them gifts or acting submissive, they seem happy and quite adoring. However, the minute the attention stops, they become spiteful and will harangue their victims – “No one cares/helps/loves me! The more time you spend with them, the longer the list gets, as you inevitably disappoint them hundreds of times each day by your very presence. Whatever you do, you cannot do it fast enough or well enough for them. In their eyes, you are a failure – unless they want something from you, at which point they can become surprisingly gracious and charming!

Touchy in the Extreme: They take everything others do personally. Thus, they constantly feel insulted, neglected and rejected, by the most innocent actions of others – the fact that you didn’t fold the napkins to their liking, didn’t call more often or didn’t stay longer, didn’t wrap the gift or left footprints on the rug, etc. They think your actions are deliberately hurtful.

Insanely Jealous: They are sure that everyone else is happier, more loved, more successful or getting more attention than they are. If you try to get them to focus on the good in their lives, they get angrier. If you avoid them, they spend hours crying to others that you have insulted and abandoned them, inciting people to hate you.

Empty: Because they suffer from intense feelings of emptiness, they become even more anxious when anyone is relaxed or happy. To fill the empty void within themselves, they focus on some flaw in others or make false accusations, causing a huge fight and a very distracting uproar, which ruins every Shabbos meal or simcha.

Filled with Blame: They blame others for not being loyal, attentive, respectful, quick or smart enough to please them and make them happy.

Paranoid: They see signs of betrayal or abandonment in the fact that you are successful or show love for anything or anyone else.

Unstable: You never know what to expect, whether they will kiss you or kick you. You can’t know what will set off a jealous rage or explosive tirade, repeating their refrain, “No one loves or appreciates me. No one is as devoted as I am.”

WHAT CAN YOU DO?

Like an anorexic who thinks she is fat, embittered people are sure that no one suffers as much as they do. Any attempt to even hint that they might not be seeing reality correctly will often cause them to attack you. You must focus on the three areas in which you do have choice, i.e., thought, speech and action. For example:

Avoid Shame: You can’t “fix” them. It is likely that they were abused or neglected in childhood, which resulted in an inability to trust people. Despite all your efforts to please, it will never be good enough. They can’t be pleased and will refuse all your helpful suggestions as to how they can feel less lonely, such as doing chesed, going to classes or seeking help.

Avoid False Hope: They will not change. Despite moments of passion and fun, especially when they want something from you, unless they make a firm commitment to change their thoughts and behaviors and without this intense effort the relationship will be like a “house of cards,” tumbling down the minute they feel hurt. Unfortunately, you are bound to do something that hurts them, even if it is simply not being available or tracking dirt onto the floor.

Disconnect: Research has shown that those who live or work with nasty-tempered people do suffer from more mental and physical illnesses, especially auto-immune diseases. Yet you may be addicted to them, thinking about them 24/7 – how to please them, how to avoid being attacked by them or how to recover from them. Avoid responding, and if possible, move away for sheer pikuach nefesh. Their lack of emotional maturity can cripple you.

Make Decisions: Create a sense of self-worth by being proud of your smallest decisions. State your individual opinions and take initiative. Form bonds with trustworthy people; otherwise your own ability to trust will be harmed. Do things that make you happy, even if they are terribly offended by your choices.

Spot Emotional Blackmail: They will use words like kibud horim or shalom bayis. This is emotional blackmail. Talking and trying to reason with them and make them understand will only pull you back into the web of deceit.

Remember, no matter what pain a person has experienced, an adult is responsible for his moods and middos. You are not to blame for the fact that they are bitter, lonely or depressed. This is a serious disorder that you did not create, cannot control and cannot cure. Healthy relationships are not built on guilt and fear.

Children With Oppositional Defiant Disorder (ODD): Assessing And Addressing The Problem

Wednesday, November 19th, 2008

Anyone who has been a parent for a while understands that children will most likely display imperfect behavior from time to time. But how do you determine if your child has a serious problem with her/his behavior, one that is more than just a passing phase of rebelliousness? And once you’ve properly assessed the condition, how do you go about treating it so that he/she can become a respectful and productive member of society?

According to the American Psychiatric Association, a child or teenager has ODD if he exhibits a pattern of negative, hostile and defiant behavior for at least six months. The anti-social behavior of youngsters with ODD would include at least four of the following behaviors: often losing their temper; often arguing with adults; often refusing to comply with adults’ requests or rules; often blaming other people for their own mistakes or aberrant behavior; often deliberately annoying people; often acting touchy or easily annoyed by others; often being angry and resentful; and often behaving in a spiteful or vindictive manner.

In a child with actual Oppositional Defiance Disorder, these difficult behaviors would occur at a rate and intensity much greater than among the child’s peers, and would be on such an exaggerated level as to create noticeable problems in the child’s social, academic and occupational functioning.

In order to know how to handle a child with ODD, a parent first needs to be aware of how the child’s thinking works. For one thing, a youngster who has this personality disorder actually believes that he is able to defeat all authority figures, and will defy or negate what he is told by his elders despite repeated punishments from them. Furthermore, this type of child operates with the firm conviction that elders such as parents or teachers must behave with total fairness towards the child regardless of how unfair the child may behave toward them.

Additionally, oppositional children believe: that if they ignore parents for a long enough amount of time, the parents will run out of strategies and they will win; that they are truly equal to their parents and thus have the right to do whatever they wish; and that they are not responsible for any behavior they engaged in.

After parents have come to understand the thinking process of their ODD child, the parents must recognize the importance of maintaining a proper and balanced level of structure with which to surround the youngster. A healthy structure is one wherein the parents convey reasonably strict expectations for their child’s behavior, while allowing some flexibility for the child to have a certain amount of independence.

There are a number of points that parents must keep in mind about their own behavior when they wish to successfully address and ultimately resolve the turmoil created by a child who consistently behaves in an oppositional and defiant fashion. The parents must not get too emotionally involved or overly angry when interacting with their child. Instead they must let their child know, in unambiguous terms, that inappropriate behavior will not be tolerated, and that repeated negative behavior on the part of the child will result in the parent taking strict measures in response.

Parents of children with Oppositional Defiant Disorder must make it clear that, in spite of what their child may think, that the child does not have the same authority as their parents. Moreover, the parents must not hesitate to act on their warnings, in order to reinforce their authority over the child.

It is important to note that before parents take this type of strong action, they should first discuss their plans with the defiant child. The parents should make the youngster realize the destructive effect of their behavior and offer their child suggestions of “replacement” behaviors that would reduce any consequent animosity and make the child’s life easier as a result.

Once these actions have stabilized the situation and you have gained basic control over your child, it is necessary to engage in longer-term strategies to train the child to act in a successful manner. These strategies include informing your child that she has to take responsibility for her actions and that she must anticipate real consequences for the things she does, and teaching your child that she can receive rewards from you, only by earning them through proper performance.

Furthermore, the parents need to insist on certain routine types of behavior from their historically oppositional children. These expected behaviors include exhibiting a positive attitude around the house; maintaining eye contact when speaking with their parents; avoiding negative nonverbal communications such as slouching, making derisive facial expressions or grunting noises while you are talking to them; offering appropriate verbal reciprocation when you are engaging them in conversation; guiding them to choose appropriate friends that will not serve as negative influences on them; training them to respond in a truthful and empathetic fashion when other people communicate with them; and insisting in a fair but firm manner that they must live up to their academic potential.

When you finally reach the point where you have successfully managed to control your child’s behavior, there are a number of methods you can use to ensure that this hard-earned progress will be maintained. To reinforce a child’s new spate of positive conduct, the parents can: “catch” their child doing a particular desirable behavior and “reward” them with verbal praise; give a younger child physical reinforcement through a warm hug or similar act of affection; or grant the youngster increased access to appropriate items and activities that give him or her special pleasure.

It is certainly not easy to have to endure an extended period of time wherein your child has Oppositional Defiant Disorder and routinely makes life difficult for others in the in the family, school or social situations. But through careful application of the methods outlined above – and with a lot of patience and faith – you as a parent should expect to eventually see the light at the end of the tunnel, and enjoy the change as your child transforms into a well-behaved young person who will be on the road to success in life.

Mrs. Rifka Schonfeld founded and directs the widely acclaimed educational program, SOS (Strategies for Optimum Success), servicing all grade levels in secular as well as Hebrew studies. She is a well-known and highly regarded educator, having served the community for close to 30 years. As a kriyah and reading specialist, she has successfully set up reading labs in many schools and yeshivas. In addition to her diversified teaching career she offers teacher training and educational consulting services. She has extensive expertise in the field of social skills training and focuses on working with the whole child. She can be reached at 718-382-5437 (KIDS).

Printed from: http://www.jewishpress.com/sections/family/parenting-our-children/children-with-oppositional-defiant-disorder-odd-assessing-and-addressing-the-problem/2008/11/19/

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