Study Summary | To protect students who self-injure, focus on helping them manage emotions

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Research from the University of Washington Medical School suggests how to improve treatments for college students struggling with non-suicidal self-injury (NSSI). Treatments which develop people’s practical skill in managing emotions may be more effective than the current therapies that increase people’s confidence in their ability to cope with events.

The study involved 187 students with a history of self-injury. The students provided information about their experiences with NSSI, including the age at which they first self-injured and the reasons behind their self-injury.

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Personality Disorders 101: Obsessive-Compulsive PD

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The final personality disorder in the current diagnostic system is Obsessive-Compulsive Personality Disorder (OCPD). First, I’ll explain why OCPD is not the same as Obsessive-Compulsive Disorder (OCD).

In OCD, someone’s obsessions and compulsions are entirely subjective, and individual to them. While the person knows their obsessions and fears are irrational, they feel forced to listen to those fears. At the core of OCD are ingrained if-then loops: if the person does not listen to those fears, something bad will happen to them or people they care about. If the person carries out their compulsions – either activities or rituals of specific thoughts – then they have briefly stopped those negative things from happening

As a stereotypical example, consider a person with OCD whose particular obsession and compulsion centres on locking doors. The person may need to spend an hour checking that every door in their house is locked before leaving, to prevent the overwhelming consequences of leaving one unlocked. However, they will not think differently of their family members for being able to leave after checking once. They may envy their family for being free from that worry and may feel guilty over how the time spent checking intrudes upon other family members.

In OCPD, the person’s rules and beliefs are not subjective and personal. They see their rules and methods as “objectively” correct, regardless of how complex, rigid or time consuming their approach may appear to others. Someone with OCPD who had specific rules about the correct location of every item in their house would require everyone else to abide by those rules exactly. If a housemate wanted to do things differently, the person with OCPD would see them as incorrect, illogical, or even morally wrong.

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Personality Disorders 101: Dependent PD

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Dependent Personality Disorder was introduced in the first version of the DSM in 1952. Originally, it was seen as a subtype of an now-unused condition named “Passive-Aggressive Personality Disorder”, but it was quickly changed to being a separate condition.

The core symptom of DPD is a person’s belief that they are unable to function independently. A person with DPD is compelled to rely excessively on either one person (often a significant other) or multiple people (such as a close group of friends) to help them navigate most or all parts of their life. This reliance is not out of laziness, nor a wish to delegate responsibility. Instead, it is to escape a primal fear of inability. A person with DPD sees the world as a cold, dangerous place, and usually believes that they are deficient and unable to survive on their own. Therefore, they will seek out others who they view as stronger and more capable to help them navigate through life. They are terrified of losing that support or angering their support network, as they believe they cannot function alone.

The DSM-5 describes DPD as a pervasive and excessive need to be taken care of, which leads to submissive and clinging behaviour and fears of separation. To be diagnosed with DPD, someone needs to have at least 5 of these criteria:

  • They have difficulty making everyday decisions without excessive advice and reassurance from others
  • They need others to assume responsibility for most major areas of his or her life
  • They struggle to disagree with others because they fear a loss of support or approval.
  • They have difficulty initiating projects or doing things on their own. because they lack self-confidence in their own judgment or abilities (Not because of lacking motivation/energy etc)
  • They go to extremes to get nurture and support from others, even to the point of volunteering for uncomfortable or dangerous situations
  • They feel uncomfortable or helpless when alone, as they are convinced they cannot care for themselves
  • They must urgently seek out new relationships to provide care and support when a relationship ends
  • They are unrealistically preoccupied with fears about being left to take care of themself alone
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Personality Disorders 101: Avoidant PD

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Today we move on to the Cluster C personality disorders, which are known as the “anxious” or “fearful” disorders. The first of these is Avoidant Personality Disorder (AvPD).

In 1911, Swiss psychiatrist Bleuler wrote about people who shied away from most social contact and activities. Bleuler is better-known for coining the words schizophrenia and schizoid, and he interpreted people’s avoidance through that lens; he assumed severe social avoidance was part of an unnoticed type of schizophrenia. However, this opinion was not widely accepted, and within ten years others described severe social avoidance as a separate condition.

AvPD is leagues beyond being shy and introverted. Instead, it is a deep-rooted and severe fear of rejection and criticism which impacts almost every aspect of a person’s life. While someone with AvPD will want to connect with and develop friendships with others, their fear of being criticised and disapproved of can be so painful that they are unable to take part in social activities. Their self-loathing and feelings of inferiority may be so strong that they assume others would not want to interact with them. As a result, they often interpret neutral statements as containing hidden rejections or reminders of their perceived social inability, which reinforces their perception of being socially inadequate.

The DSM-5 describes AvPD as a widespread pattern of being inhibited around people, feeling inadequate, and being very sensitive to any negative judgements. To be diagnosed with AvPD, someone must meet 4 of these criteria:

  • They avoid occupational activities that involve significant interpersonal contact because they fear criticism, disapproval, or rejection.
  • They are unwilling to get involved with people unless they can be certain of being liked.
  • They show restraint within close relationships because of the fear of being shamed or ridiculed
  • They are preoccupied with being criticized or rejected in social situations.
  • They are inhibited in new social situations because they feel inadequate
  • They seem themselves as socially inept, personally unappealing, or inferior to others
  • They are unusually reluctant to take personal risks or to engage in new activities in case they embarass themseleves.
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Personality Disorders 101: Borderline PD/ Emotionally Unstable PD

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Today’s topic, Borderline Personality Disorder, is perhaps the third most argued-about psychiatric disorder (with first and second place going to Dissociative Identity Disorder and ADHD/ADD).

One of the many contentious points is its name. When the DSM was first developed during the 1950s, psychiatrists divided mental health issues into “neurotic” and “psychotic”. People with “neurotic” illnesses were in distress but still aware of reality and that they were ill, while people with “psychotic” illnesses were detached from reality and often unaware that they were ill. Borderline personality disorder received its name because psychiatrists saw the symptoms as being on the border of both categories. However, that method of categorising mental health conditions is no longer used, so “borderline” now doesn’t mean anything. It can also be actively unhelpful, because people can assume it means that someone is on the border of having a mental health condition and not having one. The ICD-10 instead uses the name “Emotionally Unstable Personality Disorder”, which better reflects the condition’s core symptom.

A person with EUPD experiences much more intense and changeable emotions than a typical person, and the overwhelming nature of those emotions underpins the other EUPD symptoms. To be diagnosed with EUPD in the DSM-5, someone must meet 5 of the 9 criteria:

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Personality Disorders 101: Narcissistic PD

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The term “Narcissism” comes from the Greek myth of Narkissos, a demigod famed for his beauty. Although everybody admired Narkissos, he scorned and rejected everyone who loved him. Eventually Nemesis, the goddess of revenge, led Narkissos to a pool of water where he fell in love with the image he saw. When Narkissos realised the image was himself, and understood that he could never love anyone else in the same way, he died.

Psychologists first used the word narcissism to mean vanity and self-admiration. Now, people often call an arrogant or over-confident person a narcissist. But the disorder covers far more areas than vanity or confidence. The DSM-5 describes Narcissistic PD as a pattern of having an unrealistic sense of greatness or uniqueness, a need for admiration, and a lack of empathy. The person needs to have at least 5 of the following criteria:

  • They have a grandiose sense of self-importance. They exaggerate their achievements and talents, and they expect to be recognized as superior without reason.
  • They are preoccupied with fantasies of unlimited success, power, brilliance, or beauty, or of ideal love.
  • They believe they are “special” and unique, and that they can only be understood by other special, high-status people.
  • They require excessive admiration.
  • They have a sense of entitlement. They expect especially favourable treatment or automatic obedience to their expectations.
  • They take advantage of others to achieve their own goals.
  • They lack empathy and are unwilling to recognize or identify others’ feelings and needs.
  • They are envious of others, and believe others are envious of them.
  • They are arrogant and haughty to others.
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Personality Disorders 101: Histrionic PD

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The word histrionic comes from the Latin word “histrio”, which means both “actor” and “excessively dramatic or emotional”. People with HPD struggle to be genuinely intimate in relationships, so often maintain relationships through acting out a role. Yet they are skilled at setting up situations which force specific emotions from others, often by using their appearance to attract others. Their reliance on seduction can generate many shallow friendships but spark distrust from longer-term friends or partners.

In the DSM-5 Histrionic Personality Disorder is a long-term pattern of being excessively emotional, dramatic, and attention-seeking, which is true across multiple areas of life. To be diagnosed with HPD, a person must meet 5 or more of these criteria:

  • They are uncomfortable whenever they are not the center of attention
  • They use inappropriate sexually seductive or provocative behavior to interact with others
  • They express rapidly shifting and shallow emotions
  • They consistently use their physical appearance to draw attention
  • They speak in an excessively impressionistic way which lacks detail
  • They are dramatic and theatrical, showing exaggerated expressions of emotion
  • They are suggestible – easily influenced by others or circumstances
  • considers relationships to be more intimate than they actually are Continue reading

Personality Disorders 101: Antisocial PD

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Today we move on to the Cluster B disorders, which are known as the “dramatic” or “erratic” disorders. The first of these is Antisocial Personality Disorder (ASPD).

The stereotypical understanding of ASPD is of a criminal with little-to-no empathy or regard for others; someone who will break things and break people “just because they can”. While elements of that are true for some people with ASPD, this stereotype is more influenced by sensationalism and crime-based media than reality.

In the DSM-5, ASPD is considered to be a long-term pattern of disregard for and violation of other people’s rights, which has occurred since the age of 15. To be diagnosed with ASPD, someone must meet at least three of these criteria:

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Personality Disorders 101: Schizotypal PD

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Previously, I talked about the relationship between schizophrenia, Schizoid PD (SPD) and Schizotypal PD (SzPD). Continuing on from that, today’s topic is SzPD.

Schizotypal PD (SzPD) overlaps with some symptoms of schizophrenia, such as disordered thoughts and perceptions. However, someone with SzPD will not experience reduced motivation or catatonia, and they will have fewer difficulties in thinking and working than someone with schizophrenia. Instead, many SzPD symptoms link back to social situations and social performance. While people with SzPD desire social interaction, they are often anxious in social situations regardless of who they are with. Delusional or paranoid beliefs, such as that others can hear their thoughts, may be behind their anxiety. Alternately, their anxiety may be from the pressure of communicating with minds which work on very different wavelengths to their own.

The DSM-5 describes SzPD as a long-term pattern of being uncomfortable with and unsuccessful at maintaining close relationships, as well as experiencing distorted thoughts and perceptions and odd behaviors. To be diagnosed with SzPD, someone must meet 5 of the following criteria:

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Personality Disorders 101: Schizoid PD

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Today’s topic is Schizoid Personality Disorder, and the first step with this one is explaining why both a Schizoid and a Schizotypal PD exist. Both names are derived from the Greek prefix skhizein, which means “split”. They are both part of the schizophrenia spectrum, and they are more common in people who have relatives with schizophrenia. However, their symptoms oppose each other.

A common way to explain symptoms of schizophrenia is by sorting them into “positive” and “negative”. Positive symptoms refer to when something atypical is added, such as when a person experiences hallucinations or delusions. Negative symptoms refer to when something typical is lost, such as when a person is unable to feel happy or unable to motivate themselves. (Think of positive and negative as representing plus and minus, rather than good and bad).

Schizotypal PD (SzPD)  lies inbetween a personality disorder and a schizophrenic disorder, as some people who have SzPD later develop schizophrenia while others only ever have SzPD. SzPD includes many positive symptoms of schizophrenia, including disordered thoughts, disordered speech, and near-psychotic experiences. However, it doesn’t feature any negative symptoms of schizophrenia.

Schizoid PD (SPD), in contrast, is solely a personality disorder. Its diagnostic criteria include many negative symptoms of schizophrenia, but none of the positive symptoms. To be diagnosed with Schizoid PD, a person needs to meet 4 of these criteria:

  • They are emotionally cold and detached, and do not seem to experience strong emotions.
  • They do not often express emotions towards others or react strongly to others.
  • They consistently prefer to work alone and have solitary hobbies.
  • They have few or no close friends or relationships (due to not wanting them rather than anxiety or fear).
  • They don’t care about being praised or criticised.
  • They find few or no activities pleasurable.
  • They are indifferent to social norms and conventions.
  • They are preoccupied with fantasy and introspection; they may seem “in their own world” or absent-minded.
  • They do not desire or care about having sexual experiences with another person.

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Personality Disorders 101: Paranoid PD

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The first in the series of personality disoders is Paranoid Personality Disorder (PPD). Although experiencing paranoia in a stressful situation is common, PPD refers to a much bigger idea; a permanent fear that someone or something is trying to cause you harm, and that you are in almost-constant danger.

A person with PPD will treat every experience, however neutral or friendly, as a personal attack and a sign of their “put-upon” status. They will feel like they always need to be on guard to defend themselves. Someone with PPD will struggle to trustanything, as they fear (or expect) that everything in their world could be revealed as a lie or trick at any moment. This uncertainty may drive someone with PPD towards anger and constant arguments with other people, who they assume are lying or hiding information. Alternately, the person may isolate themselves from the world and from others so they cannot be decieved.

To be diagnosed with PPD in the DSM-5, someone must meet 4 of these criteria;

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Personality Disorders 101 : How are PDs diagnosed?

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The study of psychological differences and “abnormal” behaviour has received more public attention than many other branches of psychology, but this attention isn’t always beneficial. “Abnormal” behaviour – is associated with sensationalist news headlines more than sensible conversation. As a result, people often know about psychological through their portrayals in mass media, rather than from factual explanations.

Of the many psychological differences, the category of personality disorders is most frequently misunderstood. The individual personality disorders (PDs) are often mis-represented, while the idea of a “disordered personality” sparks criticism from anti-psychiatry groups and people diagnosed with PDs.

So what are PDs, and what do they mean by “personality”?

Currently, personality disorders are defined as groups of traits, experiences and behaviours that are significantly different from the majority of people; that affect someone’s thinking, emotions and impulses; and are associated with personal distress and dysfunction. These general criteria needs to be met for any PD diagnosis.

So to be diagnosed with a PD, someone needs to have a collection of unusal behaviours and traits which affects a large portion of their everyday life. Those behaviours and traits must start before early adulthood. They need to cause negative consequences for the person, who should be upset by or annoyed at those behaviours.  The name “personality disorder” attempts to represent how far-reaching and impactful those behaviours and experiences are upon almost every aspect of the person’s understanding of themselves and their ability to relate to others.

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Mental Health Online: Forums

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In 1994, Dr Phillip Long founded www.mentalhealth.com aiming to create a cross-cultural encyclopaedia of mental health conditions. The site is looking a little archaic now, using older DSM categories not commonly used now, and containing diagnostic ideas that didn’t really catch on, such as analysing all mental health symptoms through Greek personality dimensions.

mentalhealth.com post

While the site may not be entirely relevant these days, it’s a fascinating and detailed read. Moreover, it’s attached forum has been consistently running since 2005. In internet terms, this is an incredibly long time. Imagining friendships possibly extending for 10 years, its easy to see the best part of forums; their ability to connect people with others across time and space, providing friendships built on common experience and support.

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Mental Health Online: Tumblr

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Of all the major social networks, Tumblr is the one I wanted to write about the most, because its a dramatic difference from the stoicism of Twitter and the envy-inducing highlight reel of Facebook. Just like most of its users, its young, bold, and easily misunderstood.

#History

For the uninitiated, Tumblr is a microblogging site with a very “anything goes” attitude towards content: drawings, videos, music, gifs, longform text, links and pretty much anything else you can think of are all found there. Its major feature is reblogging, which is reposting someone else’s content onto your own feed and adding commentary, opinions, or a visual response- a cross between a Twitter retweet and a standard blog’s comment chain. Content is organised and collected using hashtags, which are essential for posts being discovered and read.

Part of Tumblr’s appeal is how it conveys the impression of a private, almost clandestine association. Continue reading

Mental Health Online: Twitter

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Compared to Facebook, I didn’t think of Twitter as a useful place for discussing mental health issues. This was partly due to the 140 character limit; I couldn’t see the use of tweets for in-depth discussion compared to something like a blog post or video.

However, when I looked through my twitter feed more closely, there was a lot of talk about mental health. Most of the people talking were advocates; either they wanted to start conversations, to support mental health organisations, or start their own campaigns. And most of these advocates were survivors, using their experiences with mental health to show others why researching mental health matters.

#Academia

Twitter doesn’t have the same kind of scare-headline news stories as Facebook, and there isn’t any research saying it affects people negatively. However, there is some research on  responses to individual hashtags. Shepherd et al studied the #DearMentalHealthProfessionals thread, a conversation set up by Amanda O’Connell in August 2013, and found there were four main types of discussion:
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Mental Health Online: Facebook

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Everyone, their mum, and their cat has Facebook, or so it can often seem.  As one of the most subscribed-to places online, and perhaps some people’s only online connection, looking at what Facebook has to do with mental health could be important on a large scale.

Simply searching for “Facebook” flags up a New Yorker headline- “How Facebook Makes Us Unhappy”. Narrowing it down to “facebook and mental health” adds BrainBlogger’s  “Facebook is no friend to mental health”, and “7 Ways Facebook is Bad For Your Mental Health, from Psychology Today.

The BrainBlogger and Psychology Today articles were almost uniformly negative, showing research that connects Facebook use to envious friendships, jealous relationships and decreased life satisfaction.

The New Yorker article included its fair share of research on the unhappy consequences of Facebook usage, but also included some optimistic findings. Their best answer was: it depends what people are actually doing on Facebook. People actively using Facebook to keep in contact and engage with loved ones benefit from the social connection. People passively browsing their timelines, however, are often left feeling worse after using Facebook.

Facebook as a mental health resource

If actively participating on Facebook is generally beneficial, does that make Facebook a good resource for people with mental health issues?

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Treating Mental Health Issues: Definitions

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When talking about treating mental health issues, it’s important to look at what medical staff, researchers, and people with mental health issues consider to be successful treatment. As its a lot harder to measure and accurately define mental health symptoms than physical ones, it is harder to accurately judge treating them. To show what kind of terms are used when treating mental health conditions, I’m  using some hypothetical case studies. Imagine that each of these patients has just been diagnosed as being in their first Major Depressive Episode, and this is their first mental health issue. Each patient starts with a score of 18 on the PHQ-9, representing moderately severe depression using that system, is treated with an antidepressant, and is followed up six months later.

Response

After a six-week course of medication, Patient A retakes the PHQ-9 and scores 14. Six months later, their score is 15. Because their score has stayed lower, Patient A has had a treatment response. Their diagnosis would not change. In a purely medical sense, this is progress. An academic study testing the effectiveness of patient A’s antidepressant would be happy with a 3-point response, and would consider this a successful response. However, the patient themselves won’t see it that way.
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My Diagnosis Experience, Part 4

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Background

Despite having sat through my fair share of mental health assessments, I don’t know much about them. As I don’t personally know anyone who has experienced one, and don’t really have many people I could ask about how they work, my knowledge is entirely from what people have said online.

Out of everything I’ve written about in the last few posts, one meeting has always remained in my mind, because it was simultaneously the worst and the best experience I had with mental health professionals.

Having never had anyone to “compare notes” with, I’m going to explain it here, in case it comes in useful for future reference or for anyone else. Again, personal information has been removed.
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Diagnosing Mental Health Issues: What is Mental Health?

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There is currently more published information about mental health than ever before, and it has never been so easy to connect with experts, health workers and charities supporting mental health issues. Yet misinformation, stereotypes and stigma still exist, and often people still don’t know where to turn. The problem isn’t a lack of information, but in communicating what information we currently have, and what we need to have. One of the most basic pieces of information would be a clear description of exactly what people mean when they talk about mental health and mental health issues. Definitions are often expressed differently depending on who the target audience is; articles written for a general audience will often focus on a single problem or dysfunction, while medical articles get more of the complexity across. Here are some examples of different online resources, and their definitions.

Layman’s definitions

Mind: “problems that affect they way you think, feel, or behave”.
Wikipedia: a mental or behavioural pattern or anomaly that causes either suffering or an impaired ability to function in ordinary life (disability), and which is not a developmental or social norm.
BBC Science: symptoms  that go beyond typical responses, and are severe enough to interfere with a person’s ability to function.

Diagnostic Manuals

Now for the big one, the DSM- IV. As you might expect, this is a comprehensive and rigid explanation:

  • A clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.
  • [This] must not be merely an expectable and culturally sanctioned response to a particular event.
  • A manifestation of a behavioural, psychological, or biological dysfunction in the individual.
  • Neither deviant behaviour (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above.”

Breaking this down, the DSM requires a mental health condition to be a pattern of symptoms that cause suffering to the person, go beyond culturally normal experiences, and are caused by a biological or psychological difference in that person. The ICD- 10  definition is a common research basis, striking a good balance between comprehension and simplicity. They define a mental illness as “a clinically recognizable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions.”

From Illness to Wellness

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Diagnosing Mental Health Issues: What is the DSM?

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The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the official instruction book for diagnosing and treating mental health conditions in the US. It is used by psychiatrists, medical staff and academic researchers.

The DSM works based on the principle that psychological symptoms can be objectively classified and observed in the same way as physical symptoms, so psychiatric illness can be diagnosed and studied as medical illnesses. Emil Kraepelin, one of the first psychiatrists, pioneered this idea, which is why systems like the DSM are sometimes described as neo-Kraepelinian methods.

In Kraepelin’s time (1883), people were diagnosed haphazardly, based on their most obvious symptoms. Most doctors also believed in Unitary Psychosis, the idea that all symptoms of mental illness were variants of one overall illness. Kraepelin instead looked for syndromes – patterns and trajectories of symptoms. He wrote an encyclopaedia of psychiatry which contained case histories and trajectories of specific syndromes and also promoted his diagnostic system.

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