Tag Archives: DSM5

45. Hosing out the caves of plenty.

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Celebrating the end of the cull.

Consider this: Celine Dion has sold over 200 million albums worldwide. Kodak sold over 70 million Instamatic cameras.  And more than 5 million ZX Sinclair computers were produced. Where have they all gone? The answer is: the house on Gladstone Street, the one with the twenty-foot-high overgrown garden and council notices pinned to the door.

There’s a new diagnosis in town and its name is Hoarding Disorder. Everyone’s talking about it, but no-one is doing much about it yet. That may be because there is no recommended drug therapy, and it’s even a bit dubious whether behaviour therapy will help, unless the sufferer wants to change.

I know, the word sufferer is politically incorrect, I’ve been on the disability and diversity courses. And in this case it is literally incorrect, as the people who suffer are neighbours, relatives and carers, rather than the hoarders themselves.

In DSM5, Hoarding Disorder escaped from the OCD section and was given its own little category. It’s significantly different from OCD, so, like South Sudan, though considerably more cluttered than that country, it has gone its own way.

There are a few other categories associated with squalor, including the so-called Diogenes Syndrome. And there are some similar scenarios which are not considered mental health problems, such as Collecting and Teenage Room Disorder.

Most psychiatrists will have visited homes like the one on Gladstone Street, and sat in sticky chairs, next to overflowing ash trays the size of buckets. We get pressurised by housing departments and public health officers to assess the people who live in these conditions.

In Diogenes Syndrome, which apparently is unfairly named, as Diogenes was a minimalist and lived in a barrel, the affected person simply gives up on the fight to organise, recycle and dispose of stuff, so that a rising tide of garbage fills their house, and finally flows out of the doors and windows, past the complicated row of empty recycling bins.

We could regard these problems as brain based, as in frontal lobe dementia, or part of some other problem, such as Depression, disorganised-type schizophrenia, or Compulsive. We could take a view that such habits are eccentric, or even just lazy. I prefer to look at environmental causes. Hoarders are basically overwhelmed by modern life. It’s not so much the quality of the environment as the quantity. They are victims of what should be called ‘Stuff Inflation’.

Whereas economic inflation leads to money losing its value, stuff inflation leads to manufactured items getting cheaper per cubic inch. Combining this effect with reduced living space – British homes are small on average – gives an ever increasing stuff to bloke ratio. There’s even a magazine called Stuff. And there’s a shop called Poundland, from which Stuff flows, like water from a fountain.

If the alcohol industry creates more product than people can consume, some of it will accumulate excessively in certain individuals. If the availability of alcohol is adjusted up or down, a lesser or greater number of people will consume it to excess.

Similarly, if the world’s factories create more stuff than can be recycled or land-filled, a pooling effect will occur.

Quite how these ‘trickle down’ effects affect particular individuals is the big question for clinicians. Like Magpies, humans have an innate urge to acquire items, and there is a whole industry directed toward persuasion. Why Magpies like shiny metal trinkets is a bit of a mystery. I have never seen a Magpie wearing jewellery, or queuing up in Cash Converters, or playing a slot machine.

I suspect that, like many mental health problems, Hoarding Disorder will turn out to lie on one end of a spectrum rather than behave as a discrete disease entity. I’d be surprised to find anyone who didn’t show some signs of hoarding, if we looked in their loft, car boot or Celine Dion collection.

People hate to lose things they already have, and retain an evolutionarily useful tendency to stock up in case of a bad winter or poor harvest. People need some token or another to explain why they have been at work all day.

Faced with a tsunami of disposabilia, some people just give up trying to cope with it. Hoarding may be just one of many ways people give up on dealing with modern life.. There are so many waiting for DIY SOS, or International Rescue, or the A Team to come, but sadly, there is no De-cluttering service in Yellow Pages. The time cost of sorting through piles of possessions far outweighs the value of any items unearthed, so it even costs money to have everything taken away.

The solution probably lies at political level, with more powerful Stuff Police and a new Ministry of Trinkets. A landfill windfall tax for Poundland would be a good start. NICE could come out officially in support of Minimalism. More of the plinths in Trafalgar Square could be kept empty. I think the NHS has already adopted the slogan Less is More. David Cameron could issue an official apology to Diogenes.

On a personal level I think we should recognise that we can all go down this road if we are not careful, so some attention to Stuff Hygiene is needed.

In previous EPs we destroyed any vinyl records or cassette tapes we had left. We invited the British Heart Foundation into our homes, as bailiffs of charity.

Beyond this, the solution may lie in The Cloud. Somewhere in the world there are some very untidy banks of computers, but, importantly, they are not in Gladstone Street.

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23. A little less conversation and a little more action. Please.

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I look good, don’t I? Unfortunately, it’s all I do.

There are more pictures about than ever before. The digital revolution means that an almost infinite number of images can be created, stored and accessed within seconds. Its easy to see that the introduction of video recording has proved to be a hazard for narcissists, being massively more versatile than mirrors or pond surfaces. People can video themselves all day long and send the videos to the friends they inevitably don’t have. Yet it is only 150 years or so since artists relied on watercolour and charcoal for a flattering self portrait. People who like to look at themselves have plenty more opportunity nowadays, plus Photoshop.

Narcissus himself fell in love with his own reflection and somehow died. There was no coroner’s inquest in those days, but legend has it that he was tricked into this by a vengeful goddess, after he spurned the advances of a local nymph.

Since then everyone knows ponds – and nymphs – can be dangerous. Shop windows and plate glass are also hazardous for those who like to gaze at themselves. Budgies know about this, locked as they are in an eternal battle with their mirrors, never seeming to realise they are just attacking themselves. Luckily they have millet and cuttlefish to distract them from their eternal struggle with their hated double.

More recently, narcissists have attracted a range of unflattering self-reflexive terms, such as being ‘up themself’ or ‘disappearing up their own arse’. The message seems to be that Narcissism is something to guard against and brings with it anatomically impossible challenges.

Some species, such as whiptail lizards, have succeeded in having sex with themselves, creating an all female population. Whiptails have been called – unkindly, it seems to me – ‘pseudocopulators’. There is very little political correctness in the lizard world.

If you are feeling a bit useless or redundant, imagine how a male whiptail must feel, particularly if it is made to attend diversity workshops.

In the DSM classification system, Narcissistic personality disorder (NPD) is included in the notorious Cluster B, whose other members include Sociopathic and Borderline personality disorders. Cluster B are known as the ‘dramatic, emotional and erratic’ characters, the ones who populate all TV soaps, most prisons and half the queue at A and E.

There is more to Narcissistic Personality Disorder than just liking the look of yourself reflected in Gap’s window among the Jeggings collection. There is more to it even than the ordinary vice of vanity. People with NPD are said to be arrogant, lacking in empathy, manipulative and constantly seeking attention and admiration. They could really use a new PR campaign. How about, ‘narcissists are lovely people, even if they do say so themselves’?

There are plenty of narcissists in politics or running large organisations, but there are also quite a few in prison. If they are lucky they will work as a presenter on a high number digital channel where all the programs are about dating.

Narcissists present a challenge to a therapist. On the plus side, they love talking about themselves; on the downside, this is liable to make them worse.

The danger is sending people even further up their own nether parts than they were before.

Therapists of various kinds are reluctant to accept that therapy carries the risk of negative change, something which is taken for granted with drug treatment, i.e. side effects.

In full sceptical mode, (something I should leave to the ‘neurobollocks’ website as I don’t like to appear negative) I read The Times this morning (8/7/13) and find an article called ‘How to become an optimist’.

To describe a ‘mindfulness’ technique the author, Michael Mosley, writes, ‘I sit in a quiet place and focus on physical sensations such as the weight of my body’.

And in describing what is called ‘Cognitive Bias Modification’ he looks at successive video screens containing blank, angry or smiley faces, ‘the idea is to train the brain to look for positive images’.

Probably best not to read the rest of the newspaper then. In particular don’t turn to page 27 and look under the headline: ‘referee who stabbed player is beheaded by fans’.

While keeping an open mind about the value of mindfulness etc I hear a shrill voice in the wilderness, shouting ‘get a life mate’.

The Horizon program version of the article will, no doubt, show people looking in wonderment at their own brain activity shown on scanners and scientists will say things like the left side of the brain likes Snickers and the right side likes a Mars Bar.

Contrast this introspective approach with the movement called ‘Random Acts of Kindness’ (RAK). It’s hard to know quite how it started. Probably it was born in California, in the mid-eighties. Interestingly the same kind of location and era as CBT. Although I’m pretty sure as far back as 1968 the Bonzo Dog Band were advising people to do things like leave a packet of fruit gums on London Bridge.

Now we have a ‘one million random acts of kindness campaign’: http://www.4000saturdays.com/rak/

This is a strategy designed to improve society by introducing new positive behaviours within the framework of a social movement. There is still a cognitive aspect to it though, which is deciding what constitutes Kindness.

Is it really being kind, for instance, to give a policeman a helium balloon, or might it just possibly encumber him from drawing his weapon, should the need arise?

Is it really a kindness to feed an expired parking meter, or are you depriving the council of useful revenue, and possibly another driver who is looking for a space?

People who paid toll charges for those behind them in a queue of cars apparently caused even greater tailbacks because of the ensuing surprise and confusion.

It usually feels good to let someone in from a side road, and the traffic system relies on this to function properly. On the other hand, people who scream down the right hand lane expecting to muscle in at the end of the queue should, like murderous Brazilian football referees, expect no mercy, let alone kindness.

Religions – they have all tried –   had quite a few problems sorting out the ‘treat others as you would like to be treated’ issue, especially if sadomasochism is thrown into the mix.

Could so called ‘tough love’ for instance be seen as a RAK?  Is it OK to chase cats away from birds, or is that kind of intervention in nature rather colonial? Some of these world policeman roles have got confusing post-Iraq.

Should overweight people be sent away from KFC? Should you give elephants cream buns while the zoo staff aren’t looking?

Should the queue of people about to buy lottery tickets be dispersed by water cannon? When is it kind to be cruel?

To answer all these questions you really need your own ethical committee.

Also, the question arises: could RAK have an opposition movement, Random Acts of Unkindness? If so, it’s important these people never infiltrate dentistry.

So which is better, CBT or RAK? Should we sort out our own thoughts and feelings or go and help an old lady across the road before the Stealth Renault gets her?

Or is RAK just another kind of CBT, more biased towards behaviour?

RAK tends to take place on Fridays, so there is time to do both. For starters, go to your local pond and put up a ‘Danger: Nymphs’ sign.

Put another one up in the park: ‘No Pseudocopulating’.

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5. Knowing what to call things

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An early classification system for depression, using cake.

Doctors and psychologists have invented a huge vocabulary of jargon. The downside of this enterprise is that non- experts are artificially excluded from participating. The upside is that at least we have a name for practically everything that might happen.

For instance – what do we call that thing – you know, in catatonic patients, where you pull their finger gently and you tell them to resist your pulling, but they follow your pull anyway without resistance, is there a word for that? How about mitgehen?

What about that thing where people mix up a coincidental event with a causal event? How about attribution error?

What’s that part of the wrist called at the base of the thumb? How about the anatomical snuff box?

How can we describe a loose pattern of findings that might include aspects of subjective history, observed behaviours and objective measurements, without necessarily implying a causal agent? How about a syndrome?

Depression has been described and categorised in so many different ways. We had reactive, endogenous, melancholia, major, minor, neurotic  and many more types. We have dysthymia and neurasthenia, we have bipolar 1 and 2. As stated by medical man, comedian and philosopher, Harry Hill, and an excellent catch phrase and running gag: ‘you’ve got to have a system’.

We are often accused of inventing diseases, for instance ‘medicalising’ ordinary human problems such as poor attention. More accurately though, we try and classify problems rather than invent them.

Classification is hugely important to doctors, partly because we have a geeky fondness for lists and tables, but mainly because all of medicine operates through a process of Pattern Recognition.

What we call each pattern doesn’t fundamentally matter, but it may matter a lot for social or political reasons. For instance if we diagnose ADHD or Asperger’s Syndrome, rather than identify a certain kind of character, that might mean extra funding and help at school for someone. Diagnosis could make the difference as to whether someone who offended got sent to jail or hospital.

These issues largely flow from the way society is organised and what part the medical community has come to play within the processes of maintaining social order, rather than whether the Pattern is a genuine entity.

There are lots of ways of describing Patterns of behaviour. If there is a recognisable Pattern then there are a few things we need to say about it. Take a simple example, no, lets take a really complicated example – Anorexia Nervosa.

Psychiatrists have defined this illness so that there are three necessary components -the person should have lost a lot of weight, stopped having menstrual periods (if they had them before), and have a certain set of views about their body size. Both the first two aspects are easy to measure, the third one not too difficult to find out if the person will speak to you.

Anorexia seems to be both a valid and reliable diagnosis. By valid, we mean there is a real problem that we can identify and measure, by reliable we mean that people would agree on whether someone suffered from Anorexia Nervosa.

But is there truly an illness called Anorexia Nervosa? Only perhaps in as far as that is what we agree to call a certain type of problem. Diagnoses in Psychiatry, for the most part, are conventions between us regarding what Patterns should be called.  Are there people we meet who seem to fit the criteria for Anorexia Nervosa? Yes.

Our health system, be it the NHS or private sector, will demand that we make a diagnosis. We have to use a system such as the International Classification of Disease or the Diagnostic and Statistical Manual. In the UK we tend to use the ICD10. That will give you a number code, such as F10, if you drink too much alcohol. The codes can be quite detailed if we use more digits, e.g. F10.4 if we drink too much alcohol, stop drinking for a day or two and get delirious. If we had an epileptic seizure during this we will get F10.41.

Are there people we meet who get Delirium Tremens some of whom have a seizure? Yes.

But why bother to label certain types of life problem and include them in a list of supposed Psychiatric conditions?’ I am not a number, I am a human being’, yelled Patrick McGoohan in The Prisoner. ‘Pigeon holing everyone’ – that is something Psychiatrists are accused of all the time, along with another favourite: ‘pumping people full of drugs’.

Ironically the interest in tightening up diagnosis in Psychiatry came as a result of a fascinating series of studies, the international pilot study of schizophrenia, or IPSS. The IPSS looked at the use of the term Schizophrenia in different countries including USA, USSR, UK, India and Nigeria.  This study seemed to find that a larger number of people were receiving the diagnosis of schizophrenia in certain countries (USA and USSR).  The American and Russian psychiatrists were calling a larger proportion of their patients schizophrenic.

At that time popular belief in the West was that the Soviets were falsely calling political dissidents mentally ill and locking them up in asylums. Whereas in the USA the disparity was put down to the way Psychiatrists traditionally understood the concept of schizophrenia.

It was soon recognized that it would be pretty difficult to do research into the causes or treatment of any disease if we could not even agree who suffered from it in the first place. Hence a huge amount of work sorting out a valid and reliable diagnostic system – DSM in the USA and ICD for the rest of world. The current versions – ICD10 and DSM4 are very similar in day to day use. So we can be reasonably sure that someone with Anorexia Nervosa in Milan has got a similar type of  problem to someone with Anorexia Nervosa in Birkenhead. So if we find Cause X or Therapy Y in one place, it might prove useful in any other place. Such is globalization.

Much  of the criticism of diagnosis in Psychiatry is based on what happens to people, and society, as a result of diagnosis happening. But criticizing diagnosis itself is as foolish as suggesting that it is impossible to classify colours of the rainbow or garden flowers.

The point is, sound diagnosis can be liberating as well as restrictive, it all depends on what we do with it. The danger is in poor quality diagnosis, or the misuse of diagnosis. These are the same dangers that occur with any tool, cordless curling tongs in particular.

How does this affect the depressed person in their kitchen?

Your subjective experience needs putting into words if you have to tell another person how you are feeling. You are free to create your own diagnostic scheme for Depression, but to be useful it needs to chime with someone else’s scheme.

In the case of Depression, even experts who normally know exactly what to call things, have failed to create much of a system. The ICD10 for instance gives up on classification much beyond the level of severity:  Mild/Moderate/Severe. Its unlikely that mass protest and civil disorder will break out in response to this categorisation.

There is only one thing worse than labelling people, as Oscar Wilde definitely didn’t say, and that’s not labelling people.

And there’s only one thing worse than pumping people full of drugs… (an inquiry was told).