Friday, February 12, 2010

Friday DSM-V Post

Earlier this week the first draft of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was released for review and feedback. There are a number of issues in the DSM that are relevant to feminist concerns and, although it's hard to discuss them all here, the following is a brief overview.

Premenstrual Dysphoric Disorder, or PMDD, remains the subject of much debate. Recent research suggests that the percentage of women who would be diagnosed with PMDD if diagnostic guidelines were closely followed would be very tiny. Further, most of those who would rightly be diagnosed with PMDD have suffered serious trauma, abuse, or stress in their lives, suggesting that a diagnosis of PTSD might be more appropriate, and lending credence to the claim that the inclusion of this disorder amounts to a pharmaceutical fix of gendered social problems.

A number of changes in the definitions of gender identity "disorders" have been proposed. For the most part, there seems to be improvement in this area. For instance, the old diagnosis of "gender identity disorder" is replaced with "gender incongruence," which lacks the normative judgment and social stigma that the old label of "disorder" carried with it. Similarly, replacing "sex" with "assigned gender" looks to be a big improvement. This terminology is incredibly important in that it reflects and shapes the way we conceptualize various transgender and transsexual experiences. On the one hand, just including a description of one's gender identity in the DSM pathologizes the experience and behavior of a whole sector of the population, which is tragic when you think about the fact that it's our rigid, binary gender system that's the problem rather than the individuals who are unlucky enough to be born fitting into none of the pre-approved categories. But on the other hand medical treatments, and payment for treatments, and research, are all driven by or influenced by the DSM so that not including trans "conditions" in the DSM delegitimizes (in a way) the experiences of trans folk and makes it much harder for them to access the help and support they need. So the treatment of trans issues in the DSM is complex and problematic in a number of ways. For more discussion of this click here and here and here.

Also of interest in the latest version of the DSM is the way eating disorders are defined and diagnosed. One of the biggest changes would make Binge Eating Disorder a diagnosis independent of other disorders. As with gender identity issues, there is also some debate and progress made where word choice is concerned. Rather than characterizing anorexia as a "refusal" to maintain a healthy weight as it was in the DSM-IV, the move is to talk of an inability to maintain the weight, and there's a shift to focus on behaviors rather than choices. For more on these topics click here and here.

There was also an unsuccessful attempt to get a new eating disorder included in the DSM that's kind of interesting/disturbing to me. Orthorexia is the name for an excessive focus on eating healthy foods. Anyone who is obsessed with eating only healthy foods, or has such a strong compulsion to only eat healthy foods to the extent that it interferes with their social functioning or ability to live a normal life could be diagnosed with this. There are a number of things to consider here:
  1. Some of the descriptions of orthorexia make it hard to distinguish from anorexia, as the issue becomes low weight, skipping meals, obsessively counting calories, and spending hours thinking about and preparing meals.
  2. Obviously an obsessive behavioral element and some problem with normal functioning would be required to get a diagnosis here, but what counts as normal functioning, and how do we define compulsive behavior? I've known teens who decided to be vegetarian or limit other foods from their diets who experienced a lot of tension in their homes because of this. If a child learns about how meat is produced in factory farming and refuses to eat it, thereby angering/inconveniencing their omnivore parents, will this result in coercive diagnoses and treatments?
  3. I also wonder about the definition of compulsive behaviors given the marginalized position that eating healthy, or being a "granola" type has in our culture. I'm not obsessive about healthy eating, and my kids eat the occasional store bought birthday cake that's full of hydrogenated oil and artificial colors and flavors and high fructose corn syrup no matter how much it makes me want to cringe. We even for the sake of convenience occasionally eat meals in restaurants where I know these kinds of ingredients are used. OK, it's really not very often, but sometimes... But these concessions don't stop some people from viewing me as a wacky conspiracy-theory type who won't let her kid eat the extremely-healthy-and-delicious school lunch. I see the rolled eyes and the knowing looks. And quite honestly I don't give a fuck about the judgment and gossip of ignorant people who are all too eager to swallow the corporate (or ag-conglomorate) coolaid. But given our tendency to view people who are invested in healthy eating and who don't mindlessly accept every claim of the megacorporatocracy when it comes to food production as paranoid and over-sensitive, what really does count as an obsession and compulsive behavior in this area? I'm a tiny bit wary here.
  4. On the topic of compulsive behaviors...what looks like a compulsion from one perspective may be a perfectly rational behavior from another perspective. If I know that a particular substance is toxic and I therefore avoid it, this is a rational behavior. But what if I'm living in a culture where many fairly toxic things are widely believed to be healthy, or at least harmless, due to the lobbying power of the corporations who produce these toxic things? Then my behavior seems irrational and compulsive, right? OK, this was just a repeat of number 3. Sorry.
  5. But this brings me to the real root of my discomfort with the concept of orthorexia. We live in an environment that is pretty toxic when it comes to food. We know that things like hydrogenated oils and high fructose corn syrup and highly processed foods and various chemical additives contribute to real, widespread, devastating diseases like diabetes and heart disease and cancer. But we also have an incredibly powerful food industry and a complicit government that is unable or unwilling to bring about real change. And this leaves us adrift in a fairly toxic environment (where food is concerned). So some amount of suspicion and caution is called for. It is rational to take steps to defend yourself from toxins in your environment. This is what a normal, healthy person will do if they have the means to do it. But it is not a sign of health to be well-adjusted to a toxic environment, and to feel comfortable in it if you are aware of its toxicity. So what does "normal functioning" even mean here? Declining certain foods altogether and choosing not to eat in contexts where the only food available is unhealthy is listed as one symptom of orthorexia, but I think that eating something you know is toxic is a far better sign of mental illness. So here again we have a case where rather than acknowledging the sickness of the environment and the system you're living in, we pathologize the behaviors you develop in response to your environment. And that just seems ass-backwards to me. But maybe that's just me. And maybe it's just my neuroses speaking...

Have a good weekend y'all. Don't ingest any toxins out there...


  1. mayhem2/14/2010

    This is so right: "but I think that eating something you know is toxic is a far better sign of mental illness."

    I think this applies to lot of things in the DSM. Being well-adjusted to your environment is the end-all be-all in mental health, but what happens when your environment is fucked? You know, engaging in properly gendered behavior is a sign of mental health, but what if you see our gender binary as fucked up and toxic? Then you're technically mentally ill, even though you have good reason to object to our way of doing gender. And it wasn't that long ago that people were using diagnoses of mental illness as a way of enforcing adherence to gender roles on those who rebelled.

  2. Anonymous2/15/2010

    Thanks for giving thought to the 'orthorexia' dx. I've been mostly concerned about changes to the ADD to ADHD spectrum, so i really appreciate your take on this side of the DSM-V.

  3. Anonymous2/15/2010

    This isn't really a response to this article in particular but on the subject as a whole.

    Here's the truth: there are some really shitty therapists/counselors/psychologists/psychiatrists out there. Not everyone finishes in the top of their class, you know? You're bound to get a C student therapist if you don't do your homework. I saw this first hand when I was a substance abuse counselor. This is precisely why you should educate yourself on which therapies are empirically valid. You should know what therapy techniques your therapist will be using and why. DO YOUR HOMEWORK!

  4. Excellent advice, Anonymous. And great post, Rachel.