Tag: DSM-5

The Dangers of Overpathologizing Behavioral Issues

Psychiatrists could do the profession—and their patients—a great service by resisting the urge to medicalize every behavioral problem, impulsive act, or mood fluctuation as a direct manifestation of psychiatric illness. While genuine psychiatric disorders exist and require careful diagnosis and treatment, many of the struggles patients face are deeply rooted in the complexities of life itself—financial stress, relationship conflicts, loss, trauma, and systemic issues that no DSM diagnosis can fully capture.

When Life Struggles Are Mistaken for Mental Illness

Certain behaviors and emotional responses are frequently overpathologized. For example:

  • A teenager acting out in school following their parents’ divorce may be labeled with oppositional defiant disorder, when their reaction is a predictable response to emotional distress.
  • A grieving spouse who experiences sadness, tearfulness, and withdrawal beyond a few weeks might be diagnosed with major depressive disorder, despite bereavement being a normal and deeply personal process.
  • A person engaging in impulsive spending or risky behaviors after a significant life change might be quickly categorized as having bipolar disorder, when in reality, they are struggling to cope with a sudden transition.

While these behaviors may be distressing, they do not always indicate the presence of a psychiatric disease requiring medication. Instead, they may reflect normal reactions to adversity that should be addressed through support, coping strategies, and time.

The Risks of Overpathologizing Human Experience

The trend of pathologizing problems of living carries significant consequences. Studies have shown that psychiatric overdiagnosis leads to unnecessary medication use, stigma, and a shift in focus away from addressing social determinants of health. For instance, research suggests that antidepressants are prescribed to 1 in 4 U.S. adults, often for mild or situational distress rather than true clinical depression. Moreover, children—particularly boys—are diagnosed with ADHD at disproportionately high rates, sometimes as a response to difficulties in structured classroom settings rather than a true neurodevelopmental disorder.

Overpathologizing also impacts the credibility of psychiatry. If every struggle is framed as a disorder, the public may begin to view psychiatric diagnoses with skepticism, undermining trust in the profession and the legitimacy of serious mental illnesses.

A Case That Stuck With Me

I once treated a young man who had been brought to the hospital by his family after he quit his job, broke up with his girlfriend, and started making impulsive purchases. His parents were convinced he had bipolar disorder, having read online that sudden life changes and spending sprees were signs of mania. However, after spending time with him, it became clear that his actions were rooted in profound dissatisfaction with his life, not a mood disorder. He was struggling with feelings of stagnation, a lack of purpose, and a desire to redefine himself—not symptoms of an illness, but a human experience.

Despite my clinical assessment, his family was frustrated. They wanted a diagnosis, a label, a treatment plan—something concrete. It was difficult for them to accept that not every distressing experience fits neatly into a medical framework.

How Can Psychiatry Do Better?

Psychiatrists and mental health professionals must be intentional in distinguishing true mental illness from the expected emotional and behavioral responses to life’s challenges. Some ways to do this include:

  • A thorough biopsychosocial assessment that considers the role of environmental, cultural, and situational factors in a patient’s presentation.
  • The judicious use of psychiatric diagnoses, ensuring that labels are assigned only when they accurately reflect a disorder rather than a reaction to stress.
  • Education for patients and families about the natural spectrum of human emotions, helping them understand that distress does not always equate to disease.
  • Advocating for systemic solutions, such as better social support networks, financial resources, and access to therapy, so that emotional struggles are not automatically funneled into the medical system.

Addressing the Counterarguments

Some might argue that withholding a diagnosis could prevent patients from accessing the care they need. While it’s true that a psychiatric label can sometimes be a gateway to services and support, misdiagnosis can be just as harmful. Providing the wrong diagnosis can lead to unnecessary medication, reinforce a sense of pathology where none exists, and obscure the real sources of distress. The challenge for psychiatrists is to walk this fine line carefully—validating suffering without automatically medicalizing it.

Conclusion: A Call for Thoughtful Psychiatry

As psychiatrists, our role is not simply to diagnose and medicate, but to thoughtfully assess and guide. True psychiatric illness must be identified and treated appropriately, but we must also be cautious not to medicalize the normal, albeit painful, struggles of life. The goal should always be to help patients find real, meaningful solutions—whether that means therapy, life changes, or, in some cases, just the reassurance that what they are feeling is part of the human experience.

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Does Everyone Have Autism or Is It Just Me? 

There is an ongoing fascination in the world of social media with regards to certain psychiatric diagnoses. It begins with the rise of self-diagnosing, which is rampant on social media these days and ends with a lot of individuals believing they have autism, tic disorder, or dissociative identity disorder (multiple personalities). I’ve also seen a rise in my patients suggesting they have autism as an explanation for symptoms clearly caused by other disorders. 

I can think of one specific example where an individual was convinced, they had autism. Later that day I observed the individual socializing with peers and staff making excellent eye contact, and all those symptoms they described in the diagnostic interview seemingly went away completely. It was clear at that point that autism was not the cause of this individual’s distress.

I feel like there is no better time to discuss autism spectrum disorders because we have a lot to clear up. 

Introduction

Autism spectrum disorder (ASD) was introduced in the diagnostic and statistical manual (DSM-5) to replace the category of pervasive developmental disorders (PDD) which previously included Asperger’s disorder, Autistic disorder, and PDD not otherwise specified (NOS). You might ask, why did they change the category in DSM-5 to just autism spectrum disorder? This was thought to improve the ability to make a diagnosis of ASD while maintaining the sensitivity of its criteria. In fact, research suggests that 91% of those who met the previous criteria would meet the new DSM-5 criteria. They also grandfathered in those with a previously well-established diagnosis of Asperger’s, autistic disorder, or PDD NOS. 

Epidemiology

In 2021, the CDC reported that approximately 1 in 44 children in the U.S. is diagnosed with ASD. The prevalence has been rising over the years, and this is largely thought to be related to better detection and awareness of the disorder not vaccinations or other environmental factors. ASD is 4.5 times more common in males than females. The median age when ASD is diagnosed in the U.S. is 50 months which is about 4 years of age. ASD can be found in all racial and ethnic groups although the prevalence does appear to be higher in Caucasian children. 

Clinical Features of ASD

The focus in DSM-5 was in two domains and not the three domains from the prior classification. These domains are social communication impairment and restricted/repetitive patterns of behavior, and an individual must have had these symptoms in early childhood. Specifiers were added to indicate the level of impairment, level 1: requiring support, level 2: requiring substantial support, and level 3: requiring very substantial support.

DSM-5 Criteria 

Persistent deficits in social communication and social interaction, as manifested by all 3 of the following:

-Deficits in social-emotional exchange: failure of back-and-forth communication, reduced sharing of interests, emotions, or affect, or failure to respond to social interactions. 

-Deficits in nonverbal communicative behaviors used for social interaction: difficulty understanding facial expressions, body language, or eye contact 

-Deficits in developing and maintaining relationships appropriate for the developmental level: difficulty adjusting behavior based on social context, difficult engaging in imaginative paly, or difficulty making friends 

These symptoms can be seen in other disorders in the adult population including social anxiety, OCD, schizoid personality disorder, schizotypal personality disorder, avoidant personality disorder, schizophrenia, bipolar disorder, and intellectual disability. Therefore, it’s important to establish that these deficits were present at an early age. 

Restricted, Repetitive Patterns of Behavior, Interests, or activities 

At least two of the following must be present:

  • Stereotyped or repetitive speech, motor movements, or use of objects (simple motor stereotypies, lining up toys, or repetitive use of objects). 
  • Insistence on sameness, inflexible adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change 
  • -Highly restricted, fixated interests that are abnormal in intensity or focus 
  • -Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment 

These individuals may have a rigid greeting ritual or struggle with small changes to normal activity. I had a case where the family took a different route to school one day and child became so upset that they jumped out of a moving car. This is the level of insistence on sameness and routine that we are talking about. 

Gender Impact on ASD

The prevalence of ASD is lower in females, but females are noted to have a greater impairment in social communication, lower cognitive abilities, and more difficulty externalizing problems than males. 

Causes of ASD

ASD is a complex neurodevelopmental disorder with both genetic and environmental factors. Family and genetic studies identified ASD as a highly heritable disorder. The heritability can range from 37% to more than 90% with only 15% of cases being attributed to a known genetic mutation. ASD is polygenic meaning there are multiple genes that contribute to the disease. Many inherited genetic variants contribute to a small additive risk of developing ASD. 

Neuroimaging research has found that ASD is often associated with atypical brain maturation. Children with autism usually have an excessive number of synapses in the cerebral cortex, this indicates abnormal pruning may be part of the etiology. Pruning occurs at a critical period in childhood where excess synapses are eliminated, it’s critical for proper cortical maturation. Other findings include abnormalities in neurotransmitter levels, immune dysfunction, and neuroinflammation. 

One of the greatest areas of controversy has focused on the impact on childhood vaccinations as a causative factor for ASD. The current evidence does not support this theory, and ASD is not associated with childhood vaccinations. 

Environmental factors including exposure to valproate, air pollution, low birth weight, and increased maternal and paternal age are all associated with increased risk for the development of ASD. 

Co-Morbidity

The most common co-morbid disorders in ASD include intellectual disability, ADHD, and seizure disorder. Approximately one-third of individuals with ASD meet criteria for intellectual disability. ADHD can be seen in 30% to 50% of individuals with ASD. Seizure disorders in these individuals can be difficult to treat, and often refractory to treatment. There is also increased risk of gastrointestinal disturbances such as constipation and restricted food intake.

Evaluating Someone with Suspected ASD

The assessment of ASD requires both an evaluation of the individual and collateral information from caregivers and teachers. ASD remains a clinical diagnosis, but there are several screening and diagnostic assessments that may help support the diagnosis. The most well-known is the ADOS autism diagnostic observation schedule, and the ADI-R autism diagnostic interview revised. 

A delay in spoken language is common first symptom that prompts referral in younger children for autism screening. The starting point is usually to check hearing and vision to be sure the individual is not suffering from deficit in either of these sensory domains. If there are dysmorphic characteristics, genetic testing for specific genetic disorders may also be completed prior to the evaluation. 

Treatment

There is no FDA approved medication for the treatment of ASD. The primary intervention is behavioral, and these interventions should be started as soon as possible. Applied behavioral analysis (ABA) is a type of therapy that focuses in developing specific behaviors such as social skills, communication, reading, and academics as well as fine motor dexterity, hygiene, grooming, domestic capabilities, and job competence. This should be the core of treatment and has good evidence to support its use. 

If medications are used, it’s important to note that they do change the underlying communication or social deficits seen in these children. They are used to target specific co-morbidities such as ADHD, or symptoms that include irritability and aggression. There are only two FDA approved medications for ASD-related symptoms. These medications are risperidone, and aripiprazole and they are approved to treat irritability in children. 

Conclusion

ASD is a complex disorder with multiple genetic and environmental factors contributing to the development of the disorder. Since it’s a neurodevelopmental disorder it’s often present at an early age and suspicion of ASD should be followed up with a proper diagnostic evaluation.  I think it’s important for people to avoid self-diagnosis and be careful what information they are consuming on social media. 

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