MORE ON DSM REVISIONS

I had mentioned in my previous Post that revisions are now being considered for the 5th edition of the Diagnostic and Statistical Manual (DSM V).

I have gone to the site where the proposals are put forth and discussed. You can access the general list here and the specific list of sexually-oriented diagnoses here.

I’d like to talk about a couple of these new proposed diagnoses, and then give some larger opinions as to the significance of all this for the SO community. It’s good to know this stuff, and there is room for ‘public comment’, they promise.

(Please note: When you go to this site, and you click on a particular proposed diagnosis, you will have a chance to click on several further bars: Proposed Revision, Rationale, Severity, and DSM-IV. Each of these bars will lead you to interesting material. It is readable and relatively forthright, and – just like in getting used to reading court filings and Opinions and Decisions – you get to see how professional folk think and work their way through a question. Always good to be able to look at this sort of thing yourself, especially since genuinely useful and accurate news reports are few and far between nowadays.)

It’s already interesting to note that the publication of DSM V has already been put off until May, 2013 – which gives you an idea that it’s already running into complications.

So, first to some of the new proposals.

A ‘hypersexual disorder’ is proposed. This will deal with adults who have constant sexual fantasies and cannot get rid of them; they may engage in masturbation, pornography, phone sex, cyber sex, strip club attendance, sex with consenting adults, or (ominously in a way) “other” manifestations. Further, such persons will engage in this constant sexual fantasy while disregarding the possibility of “physical or emotional harm” to themselves or others. There would be significant impairment to personal functioning in important areas like social or occupational activity. But none of this can be the result of the use of drugs (licit or illicit) or other factors outside the mental functioning and desire of the person.

You can see where “emotional harm” is hugely elastic. That’s good for a purely therapeutic concept – you want your therapist to be able to have as much space as possible to deal with (and help you deal with) such a problem. But – and I get to this in my own opinions later on in this Post – there is a whole world of trouble if an elastic term like this is taken over for court and prosecutorial purposes.

These out-of-control thoughts would however be ‘normal’ and not ‘odd’ or what they call “paraphilic” in the profession. There will be a specific section on paraphilia later on.

I also note that in the ‘Discussion’ of this proposed diagnosis, it is referred to as a “public health” concern since such sufferers are “risk takers” and can cause all sorts of pain and unhappiness all around them. Which is true enough, and a good clinical move in its way – but I have already noted in earlier Posts what happens if this sort of thing migrates into criminal justice and prosecutorial and court usage; and I have also discussed in earlier Posts what happens when the expansion of government police or coercive power is expanded under the rubric of “public health emergency” without serious thought as to the huge Constitutional implications.

There is also a proposed “paraphilic coercive disorder”. This refers to persons who have recurrent and very strong sexual fantasies involving sexual coercion – forcing somebody else to live out a role in their fantasy.

Nicely, the Rationale section notes that there is a difference between a paraphilia (where you might have the fantasies but they are not ‘out of control’ and they cause neither you nor anybody else any serious problems) and a paraphilic disorder (where the fantasies most certainly do cause you or others difficulty or cause physical or emotional harm). Whether this useful therapeutic distinction would survive prosecutorial usage is another question altogether.

The Rationale also notes that the more ‘normal’ the content of the fantasy is, then the more additional evidence would be required. Thus if you fantasized seeing adults you know naked you would be in less complication than if you fantasized and were aroused by the recurrent fantasy of hunting or killing strangers. Again, just how long this nuance would survive in prosecutorial usage is a big question.

There is a sizable section on paraphilias. I won’t go into all of them, but I will note the following.

Pedophilia is proposed as having recurrent fantasies of sex with prepubescent or pubescent children and those fantasies bring more sexual arousal or satisfaction than a fantasy of such sexual activity with an adult. Additionally, you would have to be at least 18 years old and at least five years older than the children you fantasize about.

Further, there is another axis of distinguishing the symptoms: attraction to males or to females or to both.

And another axis: attraction to prepubescent or pubescent children or both.

The age-parameters proposed are that “generally” a child is prepubescent if under 11 (in which case the diagnosis is for” pedophilic” attraction), and pubescent if between the ages of 11 and 14 (in which case the diagnosis is for “hebephilic” attraction). This distinction rescues the genuine meaning of “pedophile” from the inaccurate, though more sensational and expansive, meaning given in most news media. Whether that would actually do much to help slow down the mania is another question; careful thinking is not typical of a public mania, especially when the public is worked up and – as too often been the case – the government in its various branches and agencies is deliberately helping to keep the mania going.

Further, the Rationale takes a closer look at the involvement of “non-consenting persons”. A minimum number of separate victims would have to be identified in order to determine if the person is suffering from a psychologically genuine paraphilia or simply got caught once for doing it once. Again, a good clinical thought, but whether it would survive the blunt instrument of prosecutorial deployment is another question altogether.

And further, the Rationale acknowledges the difficulty for the clinician, especially if the patient is already charged with a sexual offense against a child, of determining the true depth and intensity of the patient’s attraction to children. The Rationale notes that persons so attracted – and now accused or charged – are not usually liable to give anybody an accurate picture of the scope, nature, and intensity of their sexual fantasies or desires. Which is largely true. But while this constitutes a genuine treatment challenge in the clinical forum, it may well create a ‘scientific’ inference for State action that will justify confinement (with or without conviction, perhaps) until things can be solidly established.

And there is a proposal for a “paraphilia not otherwise specified” which could include making obscene phone calls or necrophilia (having to do with corpses) or zoophilia (having to do with animals), and others having to do with excrement of one sort or the other.

In regard to these, I note that from a public-safety point of view such persons would not seem to constitute the threat usually claimed to justify inclusion in the various Registries. But two points can be made about that. First, the mania presumes that if somebody is attracted in that way, then he (yes, or she) may eventually ‘graduate’ to persons – which is not clinically or scientifically established.

Second, from a public-health point of view (and that is starting to pop up more often, especially as the public-safety view is discredited because the assumptions of its underlying Findings are being increasingly discredited) such persons may be considered ‘mentally ill’ in such a way as to justify State coercion (confinement not through criminal process but through ‘civil commitment’ procedures). And this starts to shade into a society that simply gets rid of and punishes its ‘weirdlings’ by – sensitively – confining them until they change, or are ‘cured’, or die off. Not so pretty a picture and an ominous straw in the wind.

But from a purely therapeutic point of view, some interesting distinctions indeed.

Lastly, there is a “sexual disorder not otherwise specified”. I’ve mentioned this ‘not otherwise specified’ (NOS) category in other recent Posting. From a clinical point of view, it leaves room for a provider to describe (and maybe get insurance coverage for) a problem afflicting a patient that does not fit into any of the standard DSM categories. And that’s useful and beneficial – if properly implemented.

But of course, in the hands of a prosecutorial intent, or a therapist with some sort of prosecutorial agenda, it can simply become a catch-all to label somebody with an ‘official’ diagnosis in order to secure conviction and/or confinement. Such is our modern American reality.

Well, just a few of my observations there and you are welcome to browse the DSM site yourself.
Now a couple of my own reflections.

First, there is a lot of professional controversy over the “secrecy” in the entire DSM V review process. See here and here.

But they’re most concerned with the Confidentiality Agreement that reviewers have to sign – ostensibly to protect intellectual property rights. Many worry about the researchers and clinicians (researchers don’t see patients – but rather conduct experimental research; the clinicians see patients – although this could be a full-scale psychiatrist or Ph. D. psychologist, or some cottage-industry ‘concerned helper’). A number of them have ties to drug companies and may have an interest in expanding official ‘diagnoses’ so as to make more possible profit for the drug companies.

Coming from an SO community angle, my concern is more that some researchers or clinicians may be ‘government’ or ‘prosecutor’ friendly, perhaps have a financial or status-interest in being quiet agents for a prosecutorial agenda that would also want to see the ‘sex’ diagnoses expanded to increase the number of possible ways to ‘get’ somebody charged with a sexual offense. The boundaries are blurring in these things now, and for quite some time the ‘sanctity of the therapy office’ has been legislatively dissolved, certainly when it comes to those accused of certain sexual offenses or simply those who discuss their sexual-attraction issues with a therapist.

Secondly, there are arguments that the researchers make up too many of the reviewers, and there aren’t enough clinicians among the reviewers. This would be a legitimate concern on its face, if clinicians only consisted of serious, well-trained professionals. But that is not necessarily the case. And even the American Psychological Association itself includes plenty of room on its roster of members for persons of far less competence and training. What I would not want to see is an influx of the type of ‘clinician’ whose basic stock-in-trade is something like the old 1980-1990s self-diagnosis paperbacks: If you are nervous around hot coffee then you were probably raped by your daddy because daddies drink hot coffee – see, it’s science! That sort of thing.

Third, there are reviewers who are supporting a very wide expansion of diagnoses because the ‘emergency’ of unmasking ‘true positives’ (those who are really afflicted with these sexual problems) outweighs the danger of creating many ‘false positives’ (those who are incorrectly labeled with the diagnosis). We’ve seen this emergency-outweighs-all-other-concerns approach in the SO mania from its very beginning. It’s bad in the genuine science and therapy forum, and it’s frighteningly bad (and Constitutionally lethal) in the legal and prosecutorial arena.

This expand-for-safety’s-sake approach is being touted as a new, major “paradigm shift” in the DSM philosophy of its purpose: expand the diagnoses to increase the possibility of identifying persons who will be cause “harm” to themselves or others (and “harm” is verrrry broadly defined).

As I’ve noted on both my sites, this is a lethal consequence of the development of the Regulatory-Preventive State. And it is not ‘new’: it is the old French Revolution concept (what we’re doing is sooo good that it cannot accept any limits on its power) against which the Framers carefully put together the American Revolution concept (government has so often proven dangerous that the People have to make sure they keep it under control at all times).

So all this ‘new paradigm’ stuff – in law and in therapeutic treatment – strikes me as simply a slide down into a very dark and dangerous civic abyss from which this country has already been saved once – by the Framers, whose insights are hardly “quaint”, as far too many government lawyers are saying nowadays (can you say John Yoo and Iraq War?) But – as I’ve also said – the radical feminist lawyers and law profs have been saying the same thing for a lot longer than G.W. Bush has been in politics.

Lastly, all the DSM proposals I’ve discussed have to be considered not simply in the isolated context of therapeutic knowledge, but also in the context of the increasing tendency in this country for the government conviction-confinement power to expand itself under the guise of ‘public safety’ or ‘public health’. You saw in the Comstock Posts what is going on.

It’s just too easy for an expanded number of sexual-disorder diagnoses (possibly good from a purely therapeutic context) to become that ‘sex offender mental illness’ diagnosis that for so long has eluded legislators and prosecutors.

And while even the best-intentioned and most competent DSM reviewers may simply want to expand the diagnostic categories so that therapists will have more insight into patients’ problems, there is every probability that such diagnostic categories will quickly wind up as arrows in the quiver of far too many eager prosecutors and (God knoweth full well) sex-offense-happy legislators.

Worse, it can’t be forgotten that the DSM is the most widely-known diagnostic manual in the world. The assumptions and science underlying its official diagnoses – whether strong or weak – will rapidly have an impact on researchers and clinicians around the world.

And so this mania may – to the extent that a mania would rely on ‘science’ – spread much more widely, piggy-backing itself on the good intentions of at least some of the DSM reviewing staffs.

But I don’t want to get too far ahead of events here. There is much that can happen.

I urge you to visit the site and see what you think.

ADDENDUM

If you go to the main site you will see on the master list of diagnostic categories a listing for 'Dissociative Disorders'. If you click on that you will get a list that includes 'Dissociative Amnesia', which is the professional term for those old deceivers 'repressed memory' and 'recovered memory'. At this point, there is almost no change considered for them, although as you saw in the recent Shanley Posts, even the US Supreme Court acknowledges that the current DSM reflects nothing so much as a huge amount of professional uncertainty as to whether such 'memories' exist at all, or even whether they can exist.