A week ago the National Institute of Mental Health (NIMH) published its intention to work towards and devote research funding to a new system for mental health diagnoses as an alternative to the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association. The various incarnations of the DSM have been dubbed the “gold standard” of diagnostic criteria for mental disorders and have provided a common framework for practitioners, researchers and insurers to relate to.
The trouble is that the DSM has never been any good as a basis for understanding and treating mental disorders because it is built, as the NIMH announcement says, out of collections of symptoms rather than identifiable or understandable disorders.
The NIMH will be doing what has needed to be done for decades: to create a new set of diagnoses of mental disorders based on something real. In this way the new approach to diagnosing psychopathology will cut across previous descriptive domains and tie a diagnosis to growing knowledge of neurobiological, genetic and developmental processes.
I have been frustrated for many years by the DSM diagnoses’ evident lack of any connection to any underlying process or known etiologies (origins) of mental disorders. Much to my embarrassment, I have found myself while working for community mental health, diagnosing a youngster as having an “Oppositional Defiant Disorder” (113.81 in the DSM-4). Knowing a little about psychology, I was aware that oppositional behavior in kids is often related to the child’s experience of parental rejection. But in the DSM world (i.e. the world of billing and reimbursement) I could not treat the family system. I had to attempt to treat an emotionally dysregulated child as though he had some mysterious disease coming from who knows where.
The DSM and Sex Addiction
In the recent effort to find a way to include what we understand to be sex addiction in the DSM 5, the group attempting to satisfy the DSM evaluators proposed the term “hypersexual disorder” and specified basically the practical diagnostic criteria that have emerged over the last three decades of researching and and treating sexual addiction. The effort involved testing the characteristics of people actually undergoing treatment for sex addiction against the proposed criteria.
Reading the resulting diagnostic description one is struck by how closely they seem to mimic the terminology of the DSM while attempting to carve out a category not already included in another diagnosis. This is pretty fruitless. It suffers from all the deficiencies of the rest of the DSM including the fact that it is not tied to any underlying process or any scientific way of understanding such an addiction. However, for no logical reason, the DSM folks chose not to include hypersexual disorder in the DSM 5.
Perhaps it is for the best that we are not tethered to the term “hypersexual disorder” because the term is problematic. Hypersexual behavior is not really a disorder and is a symptom of many, many other existing DSM disorders. Furthermore, what we think of as “hypersexuality” in common language is not necessarily present in those who have compulsive sexual behaviors.
We need a new way of talking about addictive disorders
Researchers are in the beginning stages of identifying the neuropsychological, genetic and developmental factors that underlie all addictions, sex addiction included. They are even beginning to address the issue of which type of childhood attachment trauma leads to which kinds of addictions based on the individual’s developmental trajectory.
It has been clear for a while now that although we treat addictions, we are really treating an underlying problem that has its roots in childhood trauma that has affected brain development and brain chemistry and in which the addictions are only part of the overall picture.
In a new diagnostic schema that actually makes sense, addictions including addictions like sex, food and gambling, might end up as subtypes of a larger category such as disorders of the self (now called personality disorders) or dissociative disorder, or some new concept which contains the idea of childhood attachment trauma as the root cause, neurodevelopmental abnormalities impairing the formation of normal self-monitoring functions as the intermediary, and addictions as the end result.
This new schema may be a long time coming, but I am greatly relieved that it is now on the table. I think it offers hope for a rational approach to the treatment of all of what we now think of as addictive disorders. In the existing DSM the effort to find a logical place for them is doomed. Find Dr. Hatch on Facebook at Sex Addictions Counseling or Twitter @SAResource