Non-Suicidal Self Injury in the DSM 5

As you likely already know, a draft of the DSM 5 came out Wednesday.
There’s a lot of interesting stuff to look through, but the part I had the biggest reaction to was the addition of Non-Suicidal Self Injury. Funny that this is what interested me, because in general research on self-injury bores me.

My initial reaction was entirely positive, but after some more thought I realized some potential problems. So, here’s a list of pros and cons.

Pros:
Too often people who self injure get stuck with the borderline personality disorder diagnosis who don’t meet the criteria only because they self injure. In the paper explaining the rationale for this addition (It’s a quick read. I recommend skimming through it if you’re at all interested) the authors mention that self injury occurs in many different disorders.

The specific wording in the title differentiates self injury from a suicide attempt. Hopefully this can help to cut down on some of the overreaction from practitioners about self injury.

Cons:
Does self injury really belong as its own disorder? Are there people who self injure on multiple occasions without any other diagnosis? Is there research on this? Seems strange to add a disorder that might only rarely be seen in isolation, increasing problems of co-morbidity.
But I understand that the way the DSM is set up, it has to be its own disorder or nothing at all. Possibly the benefits outweigh the negatives of added co-morbidity.
In the article (page 10-11) the authors justify self-injury as a separate phenomena by mentioning a longitudinal study showing that self injury decreased independent of other symptoms. This study was done only on patients with borderline diagnoses, not sure it is fair to generalize this to other patients especially because this new disorder plays a role to separate self injury away from only borderline personality disorder.

My largest problem is with section B: “The behavior and its consequences cause clinically significant distress or impairment in interpersonal, academic, or other important areas of functioning.
This seems like a benign thing to add. Similar qualifiers are in every disorder.

Here’s the problem: The way it is written right now, I don’t meet the criteria for this disorder. I don’t have impairment or distress from the self injury, but I have a lot of that from the feelings leading up to the self injury.

Seems silly. No one would try to argue with me that what I do is self injury. I’ve even participated in a number of studies researching non-suicidal self injury. Those studies could easily be used to support inclusion of this diagnosis, wouldn’t make sense for their participants to not all qualify.

Instead, I feel section B should be written something like this: “The behavior, its consequences and/or feelings precipitating the behavior cause clinically significant distress or impairment in interpersonal, academic, or other important areas of functioning.”

The current writing reflects an unfortunate trend to treat self-injury as the problem rather than the reasons for self injury. Certainly many people feel guilt over their self injury, but this is not the case with everyone.
The authors touched upon a similar idea in their section, “Placement in the system: A Mood or a Behavior Disorder?” (Pages 8-9). Much of their argument leads towards placing it in mood disorders, with a side note of similarity towards impulse control disorders, so it seems strange for the mood component to be omitted from the impairment part of the diagnostic criteria.

Psychology Scams

A handful of times I’ve learned of acquaintances falling for psychological diagnostic scams. The most notable are a urine test telling neurotransmitter deficiency and a brain scan to diagnose a mood disorder (Amen Clinic).

I can understand wanting a definitive diagnosis. I know how frustrating it is to go from doctor to doctor with a new diagnosis each time.
When hearing of these two scams, my initial reaction was skepticism and interest. Why had I never heard of them before? Why had no one ever recommended them for me? Quick searches for more information revealed why I’d not heard of these tests.

Neurotransmitter levels in urine do not necessarily reflect the amount of the neurotransmitter in the brain.

We don’t know enough to use brain scans for diagnosis of most psychiatric problems. There are a lot of studies finding differences between the brains of healthy controls and people with a specific problem, but a lot more research needs to be done to use it diagnostically.

Of course there are things that can be diagnosed with brain scans, which makes the Amen Clinic’s service seem legitimate. We can spot brain tumors for one. I even have a friend who had his schizophrenia diagnosis confirmed with an MRI. It’s important to realize that he would have still been diagnosed with schizophrenia regardless of what the the MRI scan showed, it just provided additional evidence for the diagnosis. Also, schizophrenia is a disorder with a larger body of MRI research.

We are no where near being ready to look at a persons brain and tell them they are bipolar.

Unfortunately one of my friends doesn’t realize this and shelled out a lot of money (looks like $3,375.00. according to the website) for this procedure. This clinic also takes a general history. I’m betting that’s where the bipolar diagnosis came from, not the overpriced photos of her brain.

If someone has a lot of money they don’t mind wasting they should go into the two different locations and tell different fake symptoms and then leave with two different diagnoses.

I wonder if the people running these know the science is shoddy? Maybe one person at the top knows and the underlings follow blindly.

If I thought these tests worked I’d get them done in a heartbeat. I want concrete answers. I want to know what is wrong and exactly how to fix it. The guesswork is exasperating. It’s unfortunate that this desire gets taken advantage of.

The people I know who bought into these scams to do not know the tests are bogus. They were given diagnoses and a recommended drug. What do I do? Do I educate them? Or maybe the damage is done and I should leave them be?
They were told in fancy sounding terms what FDA approved drug to take. The treatment plans they were told were nothing dangerous. It’s possible they are getting placebo benefit from this. I’d hate to ruin it if it’s helping them.

But, what if the drug isn’t the right fit? Are they going to feel trapped into taking it when alternatives might be preferable? Or feel hopeless/un-fixable if it doesn’t work?

I also have concern about them advocating the test to others. They share in common this enthusiasm about the test, thinking they’ve uncovered this secret hidden away by the medical community. Should they be told, so others are not dragged into this?

I’ve decided to mind my own business, but I feel a level of guilt over it. As a not-very-close-friend I feel saying more would cross a line.
I wonder how a therapist would/should handle a patient who begins therapy armed with this false information. It’s going to be hard to form a therapeutic alliance by shooting it down at the start. But if the information doesn’t fit with the best treatment plan then something needs to be done.

What do you think? Have you heard of other similar scams?