DSMV

Hoorah!
I just received my new American Psychiatric Assocation, Diagnostic and Statistical Manual of Mental Disorders - DSM5 - 5th edition.  It's been a long awaited highly controversial text. I've just done the overview and really it's looking overall very good. The devil's in the details but first glance this is a great book.  A whole lot of terrific work.  Well done! 
July3, 2013
I got to read some more of DSM5
PTSD criteria has been broadened over all but has some more specific subcategories. I think it is more in line with the way it has been used clinically though I can see problems arising. Overall it's clear that some serious thinking has gone into this area of trauma related illness and it's well reflected in the clinical thinking inherrent in the changes since DSMIV. This is an area I work alot with and can see myself enjoying using the DSM5 without any overt concerns.
Bipolar Disorder II - the Bipolar Disorder I has remained much the same and hasn't had any controversy attached to it over the years.  Mania is a pretty drastic presentation so it's not one that gets overly misdiagnosed.  Bipolar II however has had serious flaws in diagnostic thinking lacking any real 'exclusion' criteria surrounding the term hypomania.  The idea that 'hypomania is irritability' is where the major crux is. If you're 'irritable' for 4 days now you can be diagnosed with a 'major' mental illness which can reflect on you 'freedom', 'work', 'income' and reputation.  However, a psychiatrist can safely prescribe a wide variety of medications that are likely to improve your mood.  Bipolar II and Bipolar Spectrum Disorders has been where drug companies have had their recent greatest influence as well reported in the book Unhinged, among other sources. That said there's really clear evidence that while the DSM folk might have still been overly influenced by the industry in this regard, there's an attempt to tighten up the diagnosis in specific areas. Therefore I'd say that the prescription pad psychiatrist won't be changed by this but a more concerned clinician with some diagnostic conscience will find this a better diagnosis than was available previously. 
Cyclothymia is well detailed in DSMV.
Substance Abuse - this was a very controversial area and it leaves a lot to be desired.  But it's far from as bad as some of us Addiction Psychiatry/Addiction Medicine sort thought.  It's only about 10years outdated in conceptualization but it's not 50 years out of date or on another planet like some feared.  It's really not changed much from DSMIV on first sight . Again the details will count.  There's some improvement in language. What I do like is that substance use depression is under depression. There was obviously a need for the Substance Use Disorder like this to be categorized under the headings and this has been done with Substance Use Psychotic disorder listed in the grouping for
Schizophrenia and Psychotic Disorders.  When all the chameleon colours of substance abuse disorders was listed separately novice practitioners and especially counsellors routinely misdiagnosed substance abuse psychosis and mood disorder and anxiety disorders because they were not listed under psychosis, mood or anxiety.  This is an improvement I think. The category of substance abuse itself in he desk reference is just fine, broad and specific as needed. Consistent with ICD9and 10 and not much different from DSMIV and probably easier to use clinically in the desk reference because the presentations of this category are often messy and overlapping. The specificity of the previous DSMIV was fairly academic and there's evidence this is more user friendly
The specific substance abuse areas are well documented too
Obviously I'll have more to say about this category when I go through the big book in detail but really it's not as crazy as people feared. I think everyone can work with it but appreciate that Addiction folk feel short changed as the opportunity for DSM5 to reflect the scientific advances in the field, as evidence by MRI, PET, blood urine, end organ damage etc and all the advanced knowleded now available in genetics and neurochemistry isn't clearly evidenced but that's possibly not the job of DSMV. 
Schizophrenia and Psychosis - I think this section is pretty damn good.  It's really well described schizophrenia, brief psychotic episodes, schizophreniform illness, schizoaffective disorder and substance induced psychosis. Can't see anything with first overview I'd disagree with.
 Personality Disorders- I'm really pleased that  the original Jungian categories of essentially odd, extrovert and introvert have been maintained.  There's been major advances in this field which are represented by more dimentionality but frankly I was concerned with clinically having to learn a whole new way of thinking about personality even if it's more scientific. I can see doctors working in this field being very disappointed but again I'm kind of happy it's not going to change the whole Axis II thinking radically. I suspect others that don't work in my areas of interest will like the conservative elements that have influenced DSM5 because while I individually as an addiction psychiatrist who works with trauma have specific concerns I'm pleased when I see that others broad areas have retained their overall basis.  DSM5 is a major undertaiking as much political as scientific, just getting all the doctors with competing agendas to sit at the table.
And this is looking overall like a really worthwhile undertaking.  An amazing contribution like a new encyclopedia Britanica.
The Neurocognitive Domains is a great section that really is an advance and reflects much of the new knowledge in traumatic and degenerative brain changes. Well done DSM5
The Sexual Dysfunction section in DSMIV was really well established and there's more of the same good thinking and work in this DSM5.
Eating disorders seems good too. No surprises, nothing off the wall. Just what we're concerned about clinically.
The Dissociative disorders were highly controversy but seem to be here in a very usable form. 
Somatic Sympton and related disorders seems on first glance to be better conceptualized overall and a very useful set of categories laid out the way clinicians think./
The sleep disorders are well established also with clear definitions and criteria. 

I''m going to say that again with first and second go round at this book, the DSM5 is a truly great work overall with naturally some areas of controversy. It's been a long time coming and a whole lot of very dedicated folk have done an overall amazing job at categorizing mental illness in a way that is clearly going to be useful to clinicians.  Having seen some 10 thousand psychiatric cases over a quarter century or so I think this new DSM5 is going to serve me well.  I'm looking forward to to the courses and controversy and discussions that will flow from this book and result in development of a likely even better DSMV.  It's only too bad that DSMV doesn't have a 'spiritual psychiatry" section.  A V code would have been nice. That would be asking the APA to raise the bar higher than it's usually used too though. Other V codes have been improved on in a major way with the addition of 'suspected and confirmed categories" in the case of 'abuse' which previously was 'assumed true' when indeed it's turned out that there's a real place in the world for the legal term 'alleged' and it's apparent that psychiatric diagnosis are demanding some 'boundaries' in this regard. 

There's a lot of little category changes and additions which will need specific review but again overall it's really an admirable work.

 I know DSMIII is a whole other animal than this DSMV. I'm looking at the advances in my life time a bit like the Star Trek series of enterprises over the centuries of that show and this is only in a matter of decades. The advances made in science and the clinical progression is truly amazing. 

The American Psychiatric Association deserves to be highly applauded for this major and extraordinary contribution to our collective medical knowledge.  Thank you to all involved in the production of DSM5. 

Narcissism

Narcissism is a psychiatric term referring excessive self interest. It's been equated with terms such as egoism, vanity, self conceit, and selfishness. Developmentally it is considered a normal stage in early childhood. It is thought that a baby simply focuses on itself and it's self interest at the earliest developmental stages.  Narcissists as adults have also been called 'King Baby".  or "Queen Baby".  Developmentally the journey of a person is seen as moving from excessive self interest to health interest in others.  The golden rule is 'do unto others as you would have them do unto you'.   Also spiritually the second greatest command of the Bible after Love God was "Love your neighbour as yourself."  Abnormal love of self is narcissism named after the Greek boy who drowned from falling in love with his mirror image in the lake. Altruism the opposite of narcissism is considered a healthy coping strategy and evidence of psychological maturity.  In lay language, a narcissist is a 'taker' .
Narcissism is an excessive trait in sociopaths and psychopaths and anti social personality disorders.  It is common and transitory in mood disorders in general but more prominent in Bipolar Mood Disorders.  People who suffer from Mania act and appear very Narcissistic.
Drug addiction and alcoholism are commonly associated with narcissism.  Social skills are commonly lost in addiction and people only care about themselves and getting their drugs.
Empathy is a mature depth of relation which a person can have with another. Narcissists commonly lack the capacity for empathy. Empathy is different from sympathy which is more superficial and less connecting.
Narcissism in general is equated with emotional immaturity and spiritual immaturity.  However, narcissists can be very smart and clever though they would not be wise.

Sad, Angry, or Anxious Depression

People commonly say that "I am depressed", thinking that they have accurately described something like a 'fever'.  "I am depressed, I have a fever".  Mood is seen as a scale going from zero to 10 or 1-10 positively and 1 to 10 negatively.  If a person has a fever, we can give them aspirin, a very good "anti fever" medication.  However fever can be caused by a 'myriad' of things and it is considered very bad medicine to treat a 'fever' without a 'cause'.  Yet commonly people will say "I am depressed" and be given an "anti depressive" medication and never delve into what is the 'cause'.  The discussion can quickly get into which antidepressant is better in much the same way that a person my discuss with a pharmacist technician whether to take aspirin, tylenol or advil for a fever.  There is often a 'collusion' between the doctor and patient as to not explore the 'cause'.  Indeed some doctors would say 'there's no money in that, it's just opening a can of worms'.

And yet the very expression of the word 'depression' can mean many different emotions.  HALT - hungry, angry, lonely, tired is just one acronym to help people to become 'emotionally aware".  Most people are 'emotionally illiterate'.  Their knowlege of 'emotional language' is rudimentary at best.  Yet if I ask a person is there 'depression" more 'irritability' or 'sadness' I learn an immense amount about cause and indeed that simple question should refine which of the antidepressant approaches is most likely to succeed.

One of the most important questions of all in regards to depression is to ask, 'when did you last not feel depressed."  One patients said "I think in the womb".  Now there's limits to this questions as there is 'emotional retrospective falsification'.  The severity of this cognitive distortion is seen mostly clearly in divorce proceedings where two very angry depressed people will insist "I never loved him", "I never loved her", yet a dozen little cherubs will be living in the soon to be divided home going from kindergarden to high school.  Yet if the person can't remember a time when they were not depressed this is a very different matter from a 'mild' 'acute' fever.  This is more likely a 'chronic' depression and the cause of 'chronic' depressions are even bigger cans of worms than 'acute' depressions.

A useful way to look for 'causal associations' in regards to depression is to look first for 'loss'.  It's common for a person to have depressed feelings when they lose someone or something important to them.  Indeed, some theorists have opined that depression is simply prolonged and pathological grief.  Loss of a job, a marriage, a home, a loved one all can cause grief but if it persists it may become depression.  This is the tradition "sweety boy and sweety girl' approach to looking at depression. Many clinicians like to assume this and everyone can 'play sweet' and no one gets hurt and there's no need to look further because we all collude in believing that this loss sometimes incredible minor can explain this ofttimes over reactive gargantuan depression ("I can't go back to work, I can't have sex, I can't get out of bed, since I broke my fingernail.)    That said, loss is common, especially in the family physicians office and this is a very good place for the use of antidepressants and indeed antidepressants work best in  this scenario.

The alternative loss however is 'failed expectation".  Expectations have been called "preformed resentments'.  Much of depression is 'resentment'.  It's also been described as narcissistic entitlement though this is a bit over the top for what more commonly comes into the office.  People may have had an expectation of having a job, all their lives they've been told if they are good people, and work hard, they will in fact have a job. One day through no fault of their own, really, they find themselves unemployed. There's loss, alright but the depression happens not in the 'grief' over the lost job but in the failure to find another. This commonly occurs after divorce. Many people celebrate divorce and are thoroughly relieved to no longer have to care for a drunken drug addicted chronically depressing whining complaining spouse with ugly family and friends.  However, if months or years go by and no Angelina Jolie or Brad Pitt has come along to fulfill there dreams this person may describe themselves as 'depressed'.  Antidepressants may work in these situations but more commonly atypical antipsychotics are the medication of choice because they get at the underlying irritability and anxiety.  This patient is often quite terrified that they are never going to work or love again.

Of course , no one really wants to look at whether their expectations are realistic and what they can do to change their life course so that they are more likely to have less depressing life in the future. In one case the person is 'depressed' whereas in the next case their life is 'depressed'.  Learning to see the good in what is obviously not so good takes more than medication or a pat on the shoulder and 'there, there' that classic mommy 'ego massage therapist' approach.  In this latter scenario it's best to take a 'hard' look at one's life with the help of someone who isn't afraid to ask 'tough questions'.  Alternatively a person can keep coming back to the doctor for life and keep not getting beyond that 'knot' or 'set back' that seemed to change 'their luck'.   Medications make both kinds of depression better but in one 'simple' case the person tends to 'self heal' whereas in the latter case there's a need for adjustment or actual 'psychic surgery'.  Chiropractics and surgery were the terms for the cognitive and analytic therapies which worked best in this group in combination with medication.
That said, there are even more forms of depression related to 'cause' and to the particular culture of an individual.  More often than not the word 'depression' is used for 'anxiety'.  Indeed many theorists accept depression as 'chronic anxiety'. The question then is 'what are you afraid of" and more importantly 'where did you learn to fear like this' and 'what do you need to protect yourself from your 'fear''.  Maybe a 'rabbits foot' in the pocket or a baseball bat at the door would make an antidepressant work a whole lot better. Certainly education has help chronic depression considerably.
I just mention this as a means to counteract the 'reductionist' approaches that so often have patients feeling 'belittled' when they are only offered a pill to 'all life's problems'.  Penicillin is a pill and it cures a myriad of infections but a variety of things are combined with penicillin for maximum benefit. This is the same with depression and antidepressant medication.

Bipolar Disorder

There is a lot of confusion these days when the term Bipolar Disorder is used. Historically Bipolar Disorder referred to one of the most serious psychiatric disorders and a relatively rare condition called "Manic Depressive". A normal 'mania' of the manic depressive disorder could last up to four months and lead to death from exhaustion and over activity. As one person who developed mania later said, it was "like being on constant cocaine without the cost of the drug." During frank mania the person is grandiose, experiences surreal highs, is delusional with hallucinations. They literally talk to God and can be extremely violent. The depression of Manic Depression was the most likely to be associated with suicide so was very dangerous. The Manic Depressive disorder was a hospital based disorder.
Today Bipolar Disorder refers to the idea that all mood disorders are part of a spectrum. Bipolar II refers to a person who has days of irritability and mood swings so that in fact Bipolar Spectrum Disorders may be any variation of mood from a steady state of euthymia or 'feeling okay'.
At the same time the whole idea of mood "disorder" must be considered in the context that Bereavement or Grief that persists longer than 6 weeks is considered pathological despite the fact that parents routinely say they never get over the depression of losing a child.
Today Bipolar Disorder can refer to the worst and the least of psychiatric conditions. Where once it was 'necessary' for a person with Bipolar disorder to be hospitalized and treated with medication there is no need for hospitalization or pharmaceutical treatment of the Bipolar Spectrum Disorders. In deed, it's been found that aerobic exercise can be equivalent to prozac in the treatment of depression and psychodynamic psychotherapy has long been shown to be equal if not better in the treatment of depressive disorders which are now subsumed by the Bipolar Spectrum Disorder definition. Further if medication is considered a wide range of medications can be used including the traditional antidepressants which explains why today it's more common to see medications used in common that once were considered 'uppers' or 'downers', the idea being that the medication is modulating the illness rather than changing it from one 'state' to another'. That said the vast majority of bipolar disorders today are not treated with hospitalizations and epidemiologically most who might fulfill the diagnosis of having a Bipolar Spectrum Disorder will not be on medications. There are indeed some who argue that the antidepressant medications in some cases caused bipolar disorder though most would not accept this.