#dsm iv-tr

[mentalillnessmouse]

what is your opinion on the new DSM 5 vs DSM IV?

I think some of the changes were great, such as getting rid of amenorrhea for anorexia nervosa. More personally, the change from gender identity disorder to gender dysphoria is great. Now it addresses the distressing symptoms caused by being trans, rather than saying that being trans is a disorder.

That said, I don’t feel qualified to comment on most of the changes in the DSM, as I’m not a medical professional. 

--roboraptor

[directionofstories]

AHH MY MIND IS FULL OF DSM IV-TR AXIS I DISORDERS!!!! SOMEONE TELL ME THIS IS A GOOD THING. SOMEONE. ANYONE.

[modestsbert12]

For Christmas,

I want a DSM IV-TR.

[petrichorofperception-blog]

On Bob Wiley (What about Bob?)...

                           An analysis of Bob Wiley in “What about Bob?”

Bob Wiley is a male in his mid to late 30’s who lives in a metropolitan area of the United States.  Bob lives alone in his apartment with his pet goldfish Gil, who he talks to on a regular basis. When Bob was asked about romantic relationships he responded that he is divorced stating, “There are two people in this world: those who like Neil Diamond and those that don’t. She loved him.” Bob works from home where he clocks in and out during his work hours. The apartment Bob lives in has excess health care items such as tissues, humidifiers, and air purifiers. In his past interactions with therapists Bob is said to pay early and arrive on time. Bob says he has problems leaving the house and when he does leave and become stressed he will repeat to himself “I feel good. I feel great. I feel wonderful.” This phrase is also something he repeats when he wakes up in the morning. Bob worries about disease and touching things in public, including touching people. In his own words Bob gives an account of leaving the house. “I worry about diseases so I have trouble touching things in public places it’s almost impossible. I have a real big problem moving…as long as I’m in my apartment I’m ok, but when I want to go out I get weird. I get dizzy spells. Nausea. Cold sweats. Hot sweats. Fever blisters. Difficulty breathing. Difficulty swallowing. Blurred vision, involuntary trembling, dead hands, numb lips, fingernail sensitivity, pelvic discomfort…” When asked what he’s afraid of he responds that he’s afraid his heart might stop beating, or he might have to use the restroom and be unable to find one at which point his bladder might explode, also that he is afraid of shouting profanities. Bob also occasionally fakes having conditions such as Tourette syndrome or cardiac arrest because he believes if he feigns the condition, then he doesn’t have it.

Bob’s appearance is normal but slightly disheveled with messy hair. Bob seems very paranoid and looks keeps looking around the room, even after examining the therapist’s office when he first entered it. Bob’s mood appeared euthymic and he displayed exaggerated affect at times, though he was clearly distressed. Bob’s content of thought revolved around the obsession and fear of coming in contact germs or performing inappropriate actions. Bob’s intelligence seemed average and he was oriented X3.

Bob Wiley’s list of AXIS I symptoms include:

Panic Attacks

Touches items in public with tissue, not his hands.

 When he does leave the house he reports I get dizzy spells, nausea, cold sweats, hot sweats, fever blisters, difficulty breathing, difficulty swallowing, blurred vision, involuntary trembling, dead hands, numb lips (paresthesias), fingernail sensitivity, and pelvic discomfort.

Fear of death

Fear of losing control

According to DSM-IV-TR criteria one must meet four of the 13 symptoms listed, Bob meets 10.

Agrophobia

Stressed when leaving the house and in public.

Reports panic attack symptoms when he is in public.

Fear of doing or saying something embarrassing in public, or possibly going into cardiac arrest in public.

Takes his gold fish nearly everywhere with him.

Finds it difficult to leave the house and travel anywhere to the point that he would rather be knocked out than deal with the stress.

When an elevator was crowded he took the stairs up 44 flights

In public at a restaurant Bob announces to people what to do if he blacks out.

Fear of getting on buses, of going sailing, of thunder storms, and of death.

His lips got numb when he began talking about going sailing (somatic reaction).

According to DSM-IV-TR criteria Bob meets all sections (A, B and C criteria) for Agroaphobia.

Bob’s AXIS II symptoms include:

Creates bonds with most people he interacts with, wanting to know their name and personal information about them.

Once he believed the fish is angry at him because he’s been kept in a jar for so long so he made a frantic effort to get his fish a bigger jar so the fish wouldn’t get mad at him.

Attachment to both his gold fish and his therapist

Experiences relief when he sees his therapist.

When he became more comfortable around the therapists family he stopped using tissues to handle items around the house and eventually throws away his wad of tissues.

When his therapist is not able to be contacted he becomes anxious and takes drastic steps to get into contact with the therapist.

Clings to therapist and obeys everything therapist tells him to do (difficulty making decisions without excessive amount of advice and reassurance from others).

When therapist becomes angered with Bob, Bob takes back what is angering the therapist and will change his view to make it what the therapist believes it should be (fear of loss of support/approval).

Only starts doing things because it’s what his therapist tells him to do. His therapist told him to take baby steps in everything he does, so Bob lives his days through most of the movie repeating to himself to do things in baby steps, and because of this he experiences lots of things he would not normally do.

Goes to excessive lengths to obtain nurturance and support from others to the point of volunteering to do things that are unpleasant when he goes sailing with the therapist’s daughter Anna despite his fear, or traveling to see his therapist even though he hates buses.

When Bob realizes that he is alone, he becomes anxious and distressed to the point where a walk home becomes a run home from fear of being alone.

As his relationship with the therapist begins to fall apart Bob bonds with the therapist’s family. When the bond with the therapist’s family begins to dissipate he starts talking to the therapist’s sister and forming a bond with her who he then marries (seeks another relationship as a source of care and support when a close relationship ends).

According to DSM-IV-TR criteria one must meet five of the 8 symptoms listed, Bob meets six.

Bob’s other miscellaneous symptoms include:

Touches items in public with tissue, not his hands.

Repeats the phrase, “I feel good. I feel great. I feel wonderful” out loud.

Excessive worry about diseases.

Tendency to believe he is about to hyperventilate, then stops once he breathes into a bag.

Tenative Diagnosis:

AXIS I: 300.21 Panic Disorder (cued to leaving the house and germs) with Agoraphobia

AXIS II:  301.6  Dependent Personality Disorder

AXIS III:  Deferred

AXIS IV: Problems with primary support group: divorced. Problems related with social environment: living alone. Other psychosocial and environmental problems: clinicians do not keep working with Bob, but keep referring him elsewhere.

AXIS V: Current (first time in office during film): 37

            At discharge (end of the film): 82

Looking at Bob’s tentative diagnosis from a BioPsychoSocial prospective allows us acknowledge the circumstances that may have lead Bob to his condition beginning with AXIS I: 300.21 panic disorder with agoraphobia. Under the biological lens we do not have enough information to conclude if heredity or genes played a role in Bob’s acquisition of panic disorder with agoraphobia. In this case, the biological is not touched on however one could theorize that Bob’s symptoms of panic and his interpretations of somatic manifestations of stress could be related to the anxiety sensitivity theory. In this theory people interpret their anxiety symptoms in a catastrophic manner and are thought to have a hypersensitive suffocation mechanism. A person with this sensitivity might falsely hyperventilate which causes them to panic more. A few times in the movie “What about Bob?” Bob would begin to hyperventilate, pull out a bag, breath two or three times into it and then say, “False alarm” removing the bag from his face.

            From a psychological view we can find more reasons that may contribute to Bob’s tentative AXIS I diagnosis. It could be speculated that Bob has conditioned fear reactions that have trapped in him a cycle of panic. In conditioned fear reactions a person relates panic attacks with the way their body feels and what past panic attacks were like which in turn causes full blown panic attacks even if the way their body was initially feeling was not related with a panic attack. When this begins to happen to a person they star anticipating panic attacks, which may eventually lead to agoraphobia because they want to avoid the feelings associated with stress and panic attacks. Like Bob’s hyperventilation in the biological perspective we could theorized that Bob has conditioned fear reactions that have lead him to avoidance of feels that he knows will trigger a panic attack which has brought about agoraphobia. Bob has a good grasp on what worries him, his fears, and what he is trying to avoid in the world that bring about his panic attacks, and he makes efforts to avoid them and the feelings associated with the panic he gets when he is out in public knowing he is exposed to these fears.

            Bob’s AXIS II diagnosis of dependent personality disorder will be considered from the psychological perspective because in this particular case we do not know much of Bob’s background, his parents, siblings, or other circumstances that might give a biological or Socio-Cultural perspective. Under psychological causes of abnormality for dependent personality disorder we could highlight traumatic life experiences, learned associations, distorted perceptions, and faulty ways of thinking as a significant cause.

Under traumatic life experience we might want to consider Bob’s divorce. Though Bob’s divorce is only spoken of at the beginning of the film we could consider it a cause (and possibly effect) of his dependency. Bob rationalizes his divorce by saying she was a Neil Diamond lover and he was not, essentially that they were two different people. Bob’s therapist suggests that the divorce was due to Bob’s issues at which point Bob goes into a somatic fit of stomach pains, difficulty breathing, and chest clenching before calming down and feeling better. The reaction Bob had suggests that perhaps the divorce is more significant than he attempted to make it seem.

In lieu of distorted perceptions and faulty ways of thinking we are going to look specifically at Bob’s interactions with his therapist. Bob believes his therapist is completely supportive and committed to Bob’s well being and that everything he’s doing, even mean gestures, are for his own good (to the viewer it is obvious the therapist is trying to get rid of Bob). Bob faulty thinking may help lead to this distorted perception and is shown when Bob is speaking to Ana, the therapist’s daughter, about friendships. Bob says he treats friends like telephones, if they don’t like him he hangs up and tries again; they are temporarily out of order so you have to try and try again. Instead of thinking he is fine as he is Bob would rather keep trying to have or form that friendship.   

Under learned associations we should remember Gil the gold fish and agoraphobia. With agoraphobia people have feared situations that they meet with extreme stress, such as leaving the house for a day trip. This stress may be alleviated by the having a certain companion accompany them. Bob has a heavy dependency on his gold fish during the movie when he ventures out in search of his vacationing therapist. What Bob is displaying is a learned association that someone or something can diffuse a situation to make it better.  In dependent personality disorder the client has roots in dependency, for Bob it was Gil the gold fish but that switched to the therapist after they met. For Bob, it seems, like someone or some things is what can help make him feel safe which is a learned association that is part of dependent personality disorder.

    Cognitive-Behavioral therapy could help Bob with his Axis I and AXIS II disorders. For AXIS I: Panic disorder (cued) with agoraphobia I would first teach Bob some “covering” methods to help him manage his stress and cope with his issues off the bat. This would include relaxation training and breathing techniques. Then I would suggest working to uncover the underlying causes of his fears so that he could work through them, understand why he has these fears, and attempt to resolve the issues. Additionally, I would recommend systematic desensitization for his fear of germs and leaving his house. Bob’s amount of anxiety was enough to consider doing systematic desensitization imagery before moving on to desensitization in vivo. Further, since Bob seemed to have “false alarms” with anxiety I might suggest panic control therapy to help him become more aware of his body cues associated with panic attacks and how to manage them. Since anxiety disorders have physiological manifestations I would also prescribe a drug to help in a last ditch effort when covering and relaxation methods are not helping him. For anxiety a benzodiazepine such as Librium, Valium, Tranxene or Xanax would be most efficient.

            For Bob’s dependent personality disorder cognitive-behavioral therapy is also recommended. I think having Bob focus on gaining autonomy and reinforcing autonomous activities would be something to consider. We would also want to incorporate methods of raising self-esteem into therapy. Essentially we would want to lower Bob’s anxiety with making independent decisions and increasing his assertiveness. We would want to show Bob that he has personal power to control certain situations in his life on his own. I would want to see Bob start with small items that help create autonomy before moving on to bigger steps as suggested in the movie, “taking baby steps.”  While doing all this we would have to make sure that Bob was not becoming dependent on the clinician.

In addition to cognitive-behavioral therapy I would think psychotherapy could help Bob in the long haul. In terms of psychotherapy we would also want to find out where the underlying cause(s) of the dependency on others may have stemmed from, be it childhood conflict or traumatic experiences; perhaps into finding out if the impact of his divorce played a key role or if it was present before separation. By discovering what triggered the need to be dependent on others Bob will be able to recognize instances in his life where there is a possibility these feelings and tendencies might rise again. This cognitive awareness could possibly help prevent future relapse and assist in gaining control over dependent personality disorder.

Reference

Association, A. P. (2000). Quick Reference to the Diagnostic Criteria from DSM-IV-TR (1st ed.). Amer Psychiatric Pub.

Halgin, R., & Whitbourne, S. K. (2009). Abnormal Psychology: Clinical Perspectives on Psychological Disorders (6th ed.). McGraw-Hill Humanities/Social Sciences/Languages.

Oz, F. (2000). What About Bob? Buena Vista Home Entertainment.

[lagrandeentreprise-blog]

Prix Prescrire 2010 pour cet ouvrage.  La transformation de multiples états psychiques en troubles mentaux supposés avoir une base organique, ignorant tout lien avec le vécu de la personne, a ouvert la porte aux firmes pharmaceutiques.

Plusieurs firmes ont très largement contribué à universaliser et amplifier les dérives de la vision de l’homme et du psychisme sous-tendue par le DSM, notamment en faisant élargir les critères de diagnostic et en s’associant fortement aux travaux de l’Association américaine de psychiatrie.

L’auteur décrit le scénario qui s’est mis en place, et qui fonctionne encore en 2010 : « Première étape : prendre pour preuve les résultats d’un questionnaire ambigu afin de montrer que le nouveau trouble excède de loin les prévisions déjà alarmantes des psychiatres, en droit de penser qu’ils se trouvent face à un problème répandu et sous-diagnostiqué. Deuxième étape : inscrire le trouble dans le DSM, suggérant ainsi à l’industrie pharmaceutique de le traiter. Troisième étape : inonder les médecins d’échantillons gratuits ou de pilules toutes neuves, en bombardant simultanément les téléspectateurs de publicités sur mesure. Quatrième étape : confondre les dissidents en prétendant qu’ils nient l’évidence, à savoir la gravité de la maladie, ou bien qu’ils n’ont pas de scrupules à prolonger inutilement les souffrances des patients » (1). Selon ce même scénario, l’apathie et quelques autres nouveaux “troubles mentaux” devraient intégrer le DSM-V, attendu en 2012.