Redefining Crazy: Changes to the Bible of Psychiatric Disorders

What the new version of psychiatry's bible means for you

  • Share
  • Read Later
image: A sofa in a psychoanalyst's office, Paris, France.
Patrick Tourneboeuf / tendance floue

A sofa in a psychoanalyst's office, Paris, France.

On Saturday, the American Psychiatric Association (APA) finalized a 13-year process of revising the Diagnostic and Statistical Manual of Mental Disorders, commonly known as the DSM, the most important book in the field of mental illness. The DSM attempts to designate and code all the ways our minds can go awry. It defines depression, anxiety, schizophrenia — as well as more than 300 other problems from obsessive-compulsive disorder to stuttering to fetishism. Insurance companies require DSM codes for reimbursement, and the National Institutes of Health require them for research grants. It’s no exaggeration to say that the new DSM — the fifth full edition, one that more than 1,500 mental-health experts help write — will change the world of mental health.

Here are some of the biggest changes:

1. Autistic disorder will become autism-spectrum disorder. That spectrum will incorporate Asperger’s syndrome, which generally involves milder forms of autism’s social impairments and previously had its own code number (299.80). To guide clinicians, the DSM will include specific examples of patients meeting criteria for the different disorders making up the spectrum, from autistic disorder to Asperger’s, childhood-disintegrative disorder and pervasive developmental disorder (not otherwise specified). Combining autism and Asperger’s is especially controversial partly because autism can be so much more serious than Asperger’s. Although some autistic people function extremely well (the livestock expert Temple Grandin has helped change her field), others affected by the disorder need lifelong care for basic needs. The change will likely cause considerable debate, however, since the diagnosis is a requirement for access to some of the educational and social services that make up this care, and it’s not clear yet how the change in definition will affect such eligibility in the future.

(MORE: DSM-5 Debate: Committee Backs Off Some Changes, Reopens Comments)

2. Binge-eating disorder will be moved from DSM‘s Appendix B — a category of proposed conditions that require “further study” — to a full-blown illness in the main part of the book. The shift will create a significant new market for mental-health professionals who will now be able to apply for insurance reimbursement for patients who binge eat. A major criticism of considering binge eating a distinct disorder is the difficulty in distinguishing whether consuming an entire pint of Ben & Jerry’s could be a sign of depression or anxiety rather than an illness of its own. But in recognizing recent research that suggests that there are unique features to binge eating involving distorted-body-image issues, the APA in its press release on the DSM changes says that “the [binge-eating-disorder] change is intended to better represent the symptoms and behaviors of people with this condition.”

3. The new DSM will remove the exception for bereavement from the definition of depression, which means psychiatrists will be able to diagnose depressive disorder even among those who have just lost a loved one. For years, skeptics have criticized the APA for its expansive meaning of depression; now that definition is even broader.

4. Continuing the expansion of diagnostic criteria, the new DSM will also include a controversial new diagnosis called “disruptive mood dysregulation disorder (DMDD),” a label that can be attached to “children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.” Earlier this year, the Huffington Post called DMDD the “tantrum diagnosis,” and a blogger for Wired warned that the new disorder “could be anything, like the meltdown when the shoes can’t be found, the homework got lost, or the braids aren’t quite right.” But the APA says the new diagnosis “is intended to address concerns about potential over-diagnosis and over-treatment of bipolar disorder in children.”

(MORE: The Trouble with Talk Therapy)

5. DSM-5 will also incorporate the extremely rare disorders of excoriation (skin picking) and hoarding. The current DSM does list trichotillomania (obsessive hair pulling), but adding reality-show problems such as skin picking and hoarding has bolstered criticisms of diagnosis creep. Hoarding was previously considered a form of obsessive-compulsive disorder.

What will not be added to the DSM is hypersexual disorder — sex addiction — even though many APA members argued for its inclusion. According to one member of the APA’s board of trustees: “The evidence just wasn’t there.” Other mental-health professionals note that the DSM is subject to political influence. “This is a huge moneymaker for the American Psychiatric Association,” says Marsha Linehan, a University of Washington professor and a leading expert on personality disorders. The decisions reflect the votes of the APA’s board of trustees; the entire membership will vote on the revisions later in the spring, but experts don’t expect additional alterations. Which means that the approval this weekend of DSM-5 ends years of editing but begins years of debate.

MORE: What Counts as Crazy?

190 comments
SaraBehnke
SaraBehnke

I don't think you understand how incredibly offensive your article is. I have dermatillomania, and I literally spend hours doing nothing but scratching at my skin until I bleed. I am not exagerating at all. Literally hours. It causes me so much self consciousness and anxiety. It's on par with severe OCD, but it actually and literally operates similar to drug addiction. I know it sounds weird, or maybe as you'd like to say, "crazy", but it's real and it affects so many.

tij
tij

John Cloud, you know someday you will become CRAZY when you get older. You do not know it, yet. Karma is the reality show.

MichelleRavensCzarnecki
MichelleRavensCzarnecki

I refuse to take this article seriously. Trichotillomania and dermatillomania are real disorders. I should know, as I have both disorders.

marilynroxie
marilynroxie

Hearing skin picking referred to as a "reality show" problem makes me feel sick...it is already difficult enough for people to understand and be supportive about. It is not some kind of a vanity issue, it can actually be both physically painful and emotionally distressing. I've been suffering from this since I was 12 and I'm doing my utmost to recover in a mostly private battle (since many people will suggest that I "just stop", not knowing how the impulse follows me everywhere, no matter what I'm doing or how long I've stopped). Your article does nothing to help people become more compassionate towards their friends and family who are dealing with dermatillomania or any of the other topics you've treated here with such dismissiveness.

Kristen Szabo LePrevost
Kristen Szabo LePrevost

This really was an ignorantly titled article...hard to take any writer seriously when they start it out like that...I expect much more from a well known media source and Time should be embarrassed!

sabah4eva2009
sabah4eva2009

This article is horrific. There's not much that can be said to such ignorance.

shleet
shleet

This article is completely, completely, offensive and ignorant. Reality show problems? I've dealt with dermatillomania (csp) my whole life and the stigma that comes with it, and to dismiss it like that, is so ridiculous that I can't even articulate it. 

Marty McCann Davis
Marty McCann Davis

Shame on TIME for allowing such callous, ignorant articles to be printed in their magazine. For TIME to continue to ignore the comments from so many is unprofessional. This article lacks knowledge, respect & compassion - just as Mr Cloud does.

MartyDavis
MartyDavis

After only a few minutes of web search, John Cloud is reportedly known for his ignorant and misguided articles.  For a respectable magazine such as TIME, it is very disappointing that they allow writers who are ignorant and heartless to represent them.  Mr Cloud, you have overstepped your boundary when you used he term crazy to define mental illness sufferers.  On a more personal level, skin picking has been an issue long before reality tv became what it is today.  I have suffered for more than 33 years with this disorder. To compare the two is absurd.  If you could live a single day in the life of a person suffering from this illness, I guarantee you will change your opinion.  I suggest you broaden your resources before putting your knowledge - or lack thereof - to print.  You have only proven your naysayers to be right on!

Jennifer Forte
Jennifer Forte

Reality-show problem? I find that highly offensive. What i find even more disturbing is Mr. Cloud's is known for writing articles that involve the same topic(psychological), yet the editors of time magazine as well as Mr. Cloud found it okay to publish an article with such an insensitive title that makes a mockery of legitimate disorders. I thought Time was better than this article, but I was wrong. It is people like Mr. Cloud casually tossing around the word crazy that made me think for so long that I truly was crazy before finally realize I had a genetic disorder and was not crazy. This article is sending the wrong message and telling people that they are crazy when they in fact are far from crazy. I also can assure Mr. Cloud that skin-picking is not a rare disorder but many people choose not to discuss it, because people like him are so quick to brush it off as not a big deal. It in fact is a very big deal.

Lynn Merrick O'Brien
Lynn Merrick O'Brien

If you read through the comments on the article you will find that many people gave very compelling reasons that title was in such poor taste. Time magazine needs to address this issue.

Paula Lafferty
Paula Lafferty

This title is cruel to people living with mental illnesses. The stereotypes in the article are likewise not helpful.

LauraBarton
LauraBarton

Maybe if we all take to commenting on their facebook page instead they'll start to notice our complaints with this article, since apparently commenting here, tweeting Mr. Cloud and sending them an e-mail (all of which I have done to try and get SOME response) is only to be met with silence. http://www.facebook.com/TIMEHealthland/posts/207538579381438

Laura Barton
Laura Barton

I'd just like to say that I find the lack of response in regards to the plethora complaints on this article is absolutely astonishing. Not even a hint of maybe some sort of response coming from either TIME or Mr. Cloud addressing people's concerns or the flagrant use of the word "crazy" and the insulting tone of the article in general, using terms such as "reality-show problems" and suggesting that these real disorders are only trivial matters that shouldn't even be paid attention to. Not only that, but an e-mail I sent to TIME expressing my concerns about this article has also been ignored. I think the complete silence from the author of the article as well as the magazine is only adding further insult to injury. This is completely unacceptable, and I know that I'm not the only one who is interested in seeing a response, if not an apology for this article. This is my last-ditch effort to get some sort of response from TIME about this, although I fear that this will likely be ignored as well.

AndrewJ.Rózsa
AndrewJ.Rózsa

Thank you for using the word CRAZY. As if there weren't enough stigma already attached to the notion of mental illness. Millions of people, especially men, don't seek help because they believe that admitting they are crazy, they admit to being weak. Thousands of macho veterans who bought into your type of mentality have committed suicide, instead of getting help. Congratulations! Now you can add thousands more, just because you put the work "crazy" in the title. I hope that you and your moron "editor" sleep well tonight, Mr. Cloud.

KMTC
KMTC

I am disappointed by the dismissive, ugly tone of this article. I am offended by the flippant use of the word crazy. Like it's not hard enough to contend with mental illness without more stigma? Bad call, Time.

BethMurray
BethMurray

As someone who has suffered from skin picking for over 22 years, this is one of the most insulting articles I have ever read. How dare Mr. Cloud mock the legitimate suffering of so many by dismissing the new DSM-V inclusions as "reality show disorders." 

This article is equally offensive to me as a student of psychology who has conducted research on emerging disorders within the impulse control and obsessive compulsive spectra and has read numerous peer-reviewed journals on these topics.  Based on empirical confidence--rather than titillating speculation--I can say that these disorders are far more common and more destructive than Mr. Cloud intimates.

Thank you very much, Lynn, for posting the e-mail address for the editors of TIME.  I will be writing to them shortly.

LynnMerrick
LynnMerrick

It's disappointing that neither Time Magazine or Mr. Cloud have responded to any of these comments made since the article was published.

Reading back through them they  present compelling reasons why this needs to be addressed.

Contact information for the editors:  letters@time.com  or  212-522-8949

NateMcLean
NateMcLean

I have yet to hear Mr. St. Cloud comment on this series of comments, or in any other way apologize or retract any of his statements, including the choice for a title.  The time is now.  

LauraBarton
LauraBarton

I can understand having an opinion about something, but suggesting that something is a farce by calling it a "reality show problem" is just insulting. You're basically telling me that the problem, skin picking, I've dealt with since the age of five (over seventeen years now) is nothing but an entertainment grab on a television show. You should check your ignorance at the door when writing a professional article and actually do some research before you call common disorders such as dermatillomania (skin picking) and hoarding rare. There are so many skin pickers out there that it's astounding, even to those of us who deal with this disorder. Often we don't talk about or mention our disorder because of how people, including those in the professional field, treat us. Speaking for myself, although I think other pickers feel the same, we've been waiting for it to be admitted into the DSM so that we might be taken more seriously and have a chance at some specific research being done about it. Maybe then we can finally get treatment. But when you post nonsense like this, it's extremely disheartening. How dare you trivialize a disorder simply because you haven't heard much about it.

And as others have said, the title of this article is atrocious. I have a feeling it's supposed to be a lighthearted thing, but really, people have been fighting against the negative stigma of the term crazy for centuries. Why perpetuate it, especially when writing an article about mental health disorders? It further suggests that you feel that our problems are not real and shouldn't be taken seriously. There's enough invalidation in this world that we don't need people who write for a well respected magazine on "psychological issues" to add to it.

It baffles me that this even got published with all the backhanded comments and stigma seeping through the words.

JheriBashen
JheriBashen

Redefining "crazy"??? As a mental health professional terms like this do not help people that are truly suffering with mental health issues. It fuels the stigma associated with mental illness. I agree there is a flaw, in that some people will try to "make money" via billing insurance companies or over prescribing. I think the revisions are trying to be more specific to minimize this from happening so that people with mental health issues can be accurately diagnosed and treated.

CraigHamilton
CraigHamilton

I believe that there are metaphysical elements within the brain, or moreso, the realm of the mind. We still know so little of our own consciousness, that these parameters will always somewhat vague and obscure.What does this say of the legitimacy of our own reality?What defines "reality" and "insanity", this?

adelf252
adelf252

You have no idea.  Skin picking is SO COMMON as is hair pulling.  It's just that no one comes out about it.  I've struggled since I was 5 (I'm 17 now).  I work so hard every day to have skin free of scarring, sores, and infections.  And I have friends with hair pulling.  It's a very emotional disorder, and while it isn't curable, it is completely possible to overcome with enough work.  Go check out the Trichotillomania Learning Center (TLC) before you judge.  Yes, some people make a big deal out of it when they're not really struggling very much, but it is amazingly common.  Go check out TLC's annual conferences too.  I'm just SPEECHLESS right now.  I thought we were in the 2010s, not the 1960s...

gpera
gpera

"Defining Crazy?"Referring to the DSM as a "Bible"?This isn't helping to mitigate stigma around mental-health issues, folks!

StefanieDAngelo
StefanieDAngelo

I'm not as much offended by the title as I am about the selectiveness of information as well as the joking manner in which it is presented. I appreciate humor. What I don't appreciate is having a condition I've struggled with for thirteen years (skin picking) be referred to as "a reality show disorder." That is exactly the kind of mentality that has had sufferers of skin picking crossing all of their fingers in hopes that this disorder would make it into the DSM 5. 

I'm not sure if you can understand how frustrating it is to be diagnosed with something by a psychologist only to find out that because your disorder is not defined in some book, you will have to pay out-of-pocket for treatment or forego treatment entirely. I also don't believe you truly understand this disorder, or other disorders related to impulsivity and compulsion, and I encourage you(and perhaps beg you, if you intend to continue writing psychological commentary) to do some research into the neurological findings in recent studies so you can avoid offending those who may be suffering from "extremely rare" conditions. Also worth noting, and I know it's been posted already, but none of those compulsive disorders are extremely rare. Perhaps you meant to say extremely undocumented. Or extremely poorly reported on. But do not confused that with rarity.

It really doesn't surprise me that TIME would publish such drivel. I realize your target audience is a huge group of people who probably read TIME, and only TIME, and haven't read any other publication--be it periodical or book--in a very long time, if ever. But knowing that your readership is so large, I would expect any decent publication, with any kind of interest in educating the public, to at least report quality information instead of simplifying everything for mass-media-drone to understand; you're just removing the good information and turning it into a colloquial circus so people don't have to do the brainwork to keep up.  I imagine it won't be too long before TIME is all-digital a la Newsweek. Keep up the good work...

YellowBirch
YellowBirch

I'm not crazy... My mother had me tested.

ChatoBStewart
ChatoBStewart

Hate the title - I'm not sure if you post was meant to be funny or offensives...  I feel bad the will not be added to the DSM is hypersexual disorder as a real disorder.  Does that mean people are just faking it? The new “disruptive mood dysregulation disorder (DMDD) i can understand the debate...  I rather have that disorder be the bipolar extra light then see kids get the wrong diagnosis.

Yankeegirl2012
Yankeegirl2012

John Ashley Cloud,  "Redefining Crazy" Really?  Did one of  Time's editors come up with that gem or did you?  If it was you, how on earth did you get assigned to write articles about mental health? Your lack of senstivity is apalling.

LauraBarton
LauraBarton

@JoshuaAllen I have been trying to contact Time ever since this article was posted and have received no response at all. I've e-mailed, tweeted and posted on their facebook several times, but they seem content to ignore everyone. Which is a real big disappointment and only serves to reflect even more poorly upon them.

tryingdownstream
tryingdownstream

@FletcherTherapy Thank you for posting this and addressing the problems with the Time article and heading that people have brought up in comments. The lack of response from Time to our concerns has been disappointing, but I appreciate your response and the responses of others.  

LauraBarton
LauraBarton

@LynnMerrick Thanks for this e-mail. Never really thought to e-mail the editors directly because I figured these people would have the decency to address the matter considering the number of comments, but I suppose they don't.

Mkp22red
Mkp22red

It just goes to show you that TIME magazine is  becoming much like the trashy gossip magazines that have to come up with a ridiculous article titles to get any attention. 

LauraBarton
LauraBarton

@NateMcLean I was even just looking on Twitter to see if he's made any comment and nothing.

adelf252
adelf252

I do agree about bereavement though.  It is a natural part of life.  However, depression could result from a difficult recovery process.

AND ONCE AGAIN:   Skin picking is NOT extremely rare.  They're simply expanding the OCD-anxiety spectrum, so grow up,.

By the way, EXCORCIATION is not the same as skin picking.

tryingdownstream
tryingdownstream

@LauraBarton @NateMcLean I too have been checking. Most articles on health get 0 - 20 comments. You would think there would be a retraction. The petition has over 200 signatures. 

CraigHamilton
CraigHamilton

@adelf252 intense abrasive behavior to the skin, by means of physical abrasion or rubbing.

adelf252
adelf252

@CraigHamilton @adelf252 And I am NEVER looking for sympathy.  I NEVER want to be defined by my disorders.  But I DO want the disorder to be recognized especially for those who are not as functional as me.

adelf252
adelf252

@CraigHamilton @adelf252 Rubbing is not how it's done, and I suppose that abrasion could be used to describe scratching, but it's really more methodical than that.  But I guess I'm just trying to get across the point that people really don't understand.  It's so hard.  I spend so much money on bandaids and coverup makeup and spend time out of class on stressful days picking, and then I cry sometimes because I don't WANT to pick... I just can't help it.  I'm successful everywhere else- I have supportive friends, I'm generally good at school... it's just rough.