Lay Guide to DSM Outlines Neurocognitive, Personality, and Paraphilic Disorders
Abstract
The inclusion of mild forms of neuro-cognitive disorders represents an effort by the field to identify and treat patients in the early stage of illness. This is the sixth in a series of articles.
Mild neurocognitive disorder is a new category for all of the nine neurocognitive disorders included in the DSM-5.
It’s a change that is bound to be of interest to patients—and to the families and caregivers of patients—who did not meet previous DSM-IV criteria for dementia but who are nevertheless clinically impaired. In Understanding Mental Disorders: Your Guide to DSM-5, published this month by American Psychiatric Publishing, mild neurocognitive disorder is defined like this: “A slight decline in at least one area of a person’s mental function—such as attention, ability to plan and make decisions, memory and learning, language, and motor skills—that causes concern from a loved one or a doctor, or is confirmed by testing.”
Maria’s Story
Maria, a single woman without a job, sought therapy at age 33 for treatment of depressed mood, chronic thoughts of killing herself, and having no social contact for many months. She had spent the last six months alone in her apartment, lying in bed, eating junk food, watching TV, and doing more online shopping than she could afford.
Maria was the middle of three children in a wealthy immigrant family. The father was said to value work success over all else. He often cursed at and hit all three children, Maria most of all. She felt alone through her school years and had bouts of feeling depressed. Within her family, she was known for angry outbursts. She had done well in high school but dropped out of college because of problems with a roommate and a professor. She had a series of jobs with the hope that she would return to college, but she kept quitting because “bosses are idiots.”
Maria sometimes cut herself (would make herself bleed using a knife on purpose) when she was feeling empty and depressed. She said that she was often “down and depressed,” but that dozens of times for one to two days, she would act on impulse with great risk to her safety. This involved drug abuse and reckless driving. Doing these things would often make her feel better.
She had been in psychiatric treatment since age 17 and had stayed in a psychiatric hospital three times after overdoses. During the session, Maria described shame at her lack of job success. She believed she was very able and simply didn’t know why she hadn’t done better in life. ... In terms of social contact, she said she knew people who lived in her building, but most of them had become “frauds or losers.” There were a few people from school who were “online friends” on social websites and were doing “big things all over the world.”
Maria was diagnosed with borderline personality disorder and major depressive disorder. ... [S]he was referred for a form of psychotherapy called dialectical behavior therapy, or DBT. It helps people know and manage their thoughts and feelings and teaches calming methods. DBT helped Maria learn how to feel more in control of her extreme feelings, as well as when she felt empty or paranoid. She learned skills to stop judging herself and others. After many months, she was able to get and keep a job. She was slowly able to have more healthy friendships with both women and men, but still struggled at times to get along with others.
Following the format and organization of the clinician’s version of DSM-5, the new layperson’s guide covers all of the mental disorders in DSM-5, explaining each in clear, concise language.
Neurocognitive disorders comprise the 17th chapter in the manual, followed by chapters on personality disorders and paraphilic disorders. The nine neurocognitive disorders covered in the chapter are Alzheimer’s disease (AD), frontotemporal degeneration, Lewy body disease, vascular disease, traumatic brain injury, HIV infection, prion disease, Parkinson’s disease, and Huntington’s disease. A 10th disorder, called delirium, which is defined as a short-term state of confusion and reduced attention, is also listed in this section.
In an interview with Psychiatric News last year, Dan Blazer, M.D., Ph.D., chair of the Neurocognitive Disorders Work Group, said that inclusion of mild neurocognitive disorder in DSM-5 reflects a body of research that has emerged since DSM-IV demonstrating that individuals with AD and other neurocognitive disorders may begin showing mild signs of cognitive impairment years before their diagnosis and may have neuropathological changes even before the onset of mild symptoms.
“In recent years, research across the entire field of neurocognitive disorders, but especially Alzheimer’s, is indicating that we need to move ‘upstream’ in terms of making a diagnosis,” he said.
All of the chapters include features that will be useful to patients and families, such as the following “Tips for Caregivers” included in the chapter on neurocognitive disorders:
Know what resources are available: Learn about the different levels of care your loved one will need depending on the stages of illness. Adult day programs, in-home assistance, and visiting nurses are just some of the services that can help you manage day-to-day tasks.
Get help: Don’t try to do everything yourself. Ask family and friends for support. The Alzheimer’s Association 24/7 Helpline at (800) 272-3900 and local support groups are also good sources for comfort.
Practice relaxation techniques: Meditation, breathing exercises, yoga, and visualization are just a few of the simple techniques that can help relieve stress.
Take time for yourself: Although it may be hard to find time to do things just for you, it’s important for your well-being to take time each week for an activity you enjoy or to stay connected to friends and family.
The chapter on personality disorders covers in detail the criteria for borderline, antisocial, and schizotypal personality disorders. Other personality disorders described in lesser detail are paranoid, schizoid, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive personality disorders.
“All people have personality traits that make them unique and different from others,” the manual explains. “These traits are lasting patterns of how someone tends to think about and relate to his or her own world, others, and self. … A personality disorder reflects deeper, more severe problems that can greatly impair how someone thinks, feels, lives, works, and perceives and loves others.”
Many of the chapters in the layperson’s guide include a patient story, drawn from real clinical vignettes with name and other identifying information changed (see sidebar).
Check Out the New Guide
While you are at APA’s 2015 annual meeting in Toronto, be sure to stop by the American Psychiatric Publishing Bookstore and page through Understanding Mental Disorders: Your Guide to DSM-5. This is the essential resource on mental illness you’ve been needing to recommend to patients, families, and community members.
APA members get a 20 percent discount on all APP purchases; resident-fellow members get a 25 percent discount. Enter to win an iPad Mini.
The most important change to the chapter on paraphilic disorders is the distinction between paraphilias—defined as atypical sexual interests—and “paraphilic disorders.” According to the manual, “[p]eople with paraphilic disorders have a paraphilia that causes distress; impairs work, social, or other key functions; or causes harm or risk of harm to self or others. These disorders often involve repeated, intense sexual fantasies and urges that the person then enacts in real life. … People with these disorders devote great time and energy to satisfying their sexual preference, and it may well cause problems in their job, marriage, and other aspects of life.”
The eight paraphilic disorders that appear in DSM-5 are discussed in this chapter: voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, and transvestic disorders.
“The change to the manual recognizes that you could practice sexual masochism or cross-dressing without having a mental disorder,” Ray Blanchard, Ph.D., chair of the Work Group on Paraphilic Disorders for DSM-5, told Psychiatric News in an interview last year. “The two routes to upgrading a paraphilia to a paraphilic disorder are either because it causes distress or impairment in functioning or because the paraphilia inherently involves individuals who are nonconsenting and who have been used to gratify the paraphilia in real life and not just in fantasy.” ■
More information on Understanding Mental Disorders, including ordering information and links to previous articles in Psychiatric News about the content, can be accessed here.
