Having all the symptoms, but no "disorder." DSM and overdiagnosis

Statements from friends or clients about whether there is too much diagnosing: 

1. "I question my sexual identity, but it doesn't freak me out or depress me, why tell me I have Gender Identity 'Disorder.'"

2. "I am totally phobic of snakes, but there are no snakes where I live, so I never have any anxiety or freakouts, just let me have my fear." 

3. "I have compulsions and obsessive thoughts just like in OCD, but it doesn't ruin my day, I just ignore it and no one makes a make a big deal of it."

4.  "I have like 10 of those ADHD symptoms, but I run my own business now, get stuff done even if it's 12 projects at a time, I've always done well enough without medications or anything."

5. "Yeah, I get aroused by weird stuff, but I don't act on it, it doesn't hurt anyone, why is it a disorder." 

6. "I have Asperger's Syndrome, I even meet the new criteria for Autism Spectrum Disorder, but I do fine in life, I'm happy, I don't think I should be labeled as having a disorder."

7. "My brain can't do some things but I have a job and friends and I'm happy. Don't say I'm retarded"

In the psychiatric diagnostic manual used for the past two decades, the DSM IV-TR, many of these clients would indeed be correct:  you can have all the symptoms of a disorder, but still not being given the diagnostic label, because the DSM, for all of its reputation for encouraging overdiagnosis, does not allow you to make a diagnosis unless there is significant distress or functional impairment related directly to the symptoms.*  

The new diagnostic manual, the DSM-5 makes this even more clear, by clearing up some issue related to some of the examples above.  

1. Gender Identity issues are not automatically a disorder.  The new term is "Gender Dysphoria," with the idea that only if your Gender Identity issues led to chronic mood problems, as they might if you fully felt trapped in a body with the wrong sexual organs and sexual role and were misunderstood by others and didn't have access to, or comfort with, sexual reassignment surgery.   

2. Paraphilias, unusual arousal patterns such as transvestism arousal, fetishism, are not necessarily a disorder unless you act on your preferences with a nonconsenting partner, or otherwise act in a way that causes distress for yourself or others or interferes with family life or work. Pedophilia has stricter wording** and is the closest to being automatically a desire just for being aroused by children, but again truly becomes a disorder only when there is a risk of acting on it. But otherwise, being aroused by something unusual is no longer automatically a disorder. 

3. The "Mental Retardation" label is no longer in the manual, partly because its implication of merely delayed development is not accurate.  More importantly, Intellectual Disability/Intellectual Development Disorder (to use  DSM-5 terminology) is not defined by IQ, it's defined by the level of impairment in your social, occupational/academic, and other functioning. 

The point of not overdiagnosing a "difference" such as Asperger's/ASD as a "disorder" is not just to avoid stigmatizing people.  The point of the manual is to have a shorthand way of talking about the conditions which need to be treated.  So if there is no need for treatment, support, or intervention, it can still have a name like "Asperger's," but it's not a disorder. 

The DSM-5 has a lot more ways of describing mental health conditions than in the past; depending on whether all of those ways and specifiers count as separate diagnoses, it may have more diagnoses than ever. But in some cases, it's harder to get those labels than in the past, especially if you don't need treatment.  So don't blame the DSM-5 for overdiagnosis, blame the people who aren't reading the criteria.*** 

(Hmm:  Diagnostic labels mean that there is a need for treatment, not just that there is a disability, not just a reason for not functioning well. Sounds like the subject for another post/article.  I've already started it. )

* Examples of advancements in overdiagnosis prevention even before the DSM-5: : 

1) You can indeed have Asperger's Syndrome but do fine in life and be happy and thus you do not qualify for a diagnosis of Asperger's Disorder (for more on this:  http://autismspectra.blogspot.com/2014/01/aspies-still-have-home-identity.html).  

2) Homosexuality was dropped from this manual, in part because: even though being gay or lesbian may lead to distress, the distress is caused by bigotry or loneliness or hiding part of yourself, rather than by the sexual preference itself). 

** In Pedophilic Disorder you can have no distress and no functional impairment and still be diagnosed with that disorder due to the common risk of harm to people too young for their level of consent to be determined.

*** The wording which is left out of many popular psychology summaries of DSM disorders:  A collection of symptoms matching those for a disorder is still not a disorder unless it: "causes significant distress, or impairment, or, [in the case of disorders like pedophila] risk of harm to others."

Sleep problems: One of many mind-body challenges

If only sleep was always as easy and pleasant as it seems to be for this little charmer.

You or your clients or loved ones may:
1) be kept awake by worries and even headaches and stomach aches worsened by worry.
2) wake up in the middle of the night feeling scared, agitated, sweating and afraid
3) take hours to fall asleep and then take hours to become alert in the morning
4) sleep fitfully, up and down throughout the night as if never really falling into a deep sleep.

Although true biologically based sleep disorders are rare, sleep problems are common. Sleep is an arena where our bodies and minds interact; the new psychiatric diagnostic manual recognizes that it's hard to separate cause from effect when sleep, mood, thoughts, the body, and behavior are all not working smoothly.
You have probably heard that  reduced and disrupted sleep can lead to problems in the mind and body; research tells us that sleep loss can lead to problems in thinking/learning/concentration, physical illness, emotions, weight gain, premature aging, inflammation, and more.


This list of problems doesn't mean that forcing sleep through medication is the one correct pathway to get the whole sleep/mind/body system working smoothly again.  In fact, I've had clients become "immune" to all sleep inducing medications because there is an underlying problem leading to sleep avoidance.  These problems have included fear of nightmares, or simply not wanting to snore and disrupt a partner's sleep.

Dealing with sleep issues is also not a simple matter of just "dealing with what's on your mind."  People have genuine biologically-involved sleep problems such as narcolepsy, delayed or advanced sleep phases,, sleepwalking, and sleep terrors (not the same as nightmares, in fact they take place in deep sleep, not in REM sleep).  I say "biologically involved" because a problem that began as a lifestyle or anxiety issue can become a biological issue and vice versa.  Depression itself is a mix of emotional, cognitive, and whole-body effects including too much or too little or unrestful sleep. I've learned as a therapist to be flexible in realizing that sometimes the body (medications) are the first point of intervention, sometimes the mind or behavior should change first to bring the body back into balance.
Most often, in the case of sleep, depression, anxiety, anger, thought disorder, or attention and learning problems, getting on the road to health means making coordinated changes in body, thoughts, relationships, and lifestyle.
The new diagnostic manual of mental disorders makes special mention of how sleep issues are not just rooted in mind or brain or body alone; I am glad when medical and mental health professionals recognize this about many mind-body problems and work together with clients/patients on figuring out what's going on and making life better.