Mental Disorders

In psychiatry the Diagnostic and Statistical Manual of Mental Disorders(DSM–5) is the authoritative guide to mental disorders. To have a specific disorder certain criteria must be met. With each revision new disorders are identified. The original DSM-1 had 105. The latest DSM-5 has 297. There has been concern about the increasing number of mental health disorders identified. I would like to suggest two disorders that I feel should be in the next DSM. One is currently seen as a medical disorder and the other is a hypothetical disorder that needs exploring.

Vasovagal syncope or neurocardiogenic syncope is also known commonly as fainting.

Fainting is harmless in itself , but can be fatal if occurring while driving or if one hits their head. While it can be a rare event, some patients suffer from frequent vasovagal episodes. One is usually referred to cardiologist for evaluation and treatment. I propose that it should listed in the DSM as a psychiatric disorder and treated by psychiatry. It has many similarities to other psychiatric disorders as panic disorder and there is evidence that psychiatric treatment can be beneficial. Similar to panic attacks vasovagal syncope can occur after exposure to a trigger or “out of the blue”. Visual stimuli or cognitions can lead to both a panic attack and a faint. A person having a panic attack will get dizzy, sweat ,and have the feeling of faintness, dying or going “crazy” but does not proceed to a loss of consciousness. These feelings also can be present in fainting episode that results to a loss of consciousness. The treatment of frequent vaso-vagal episodes in the past has been beta blockers and pacemaker insertion with mixed results. The beta-bocker effect may be secondary to decreasing the heart rate and reducing anxiety. Studies have shown medications as antidepressants , including SSRIs and tricyclics, may aid vasovagal syncope similar to theirtheir effect of blocking panic attacks. Some studies have shown benzodiazepines can be effective in avoiding a syncopal episode if administered prior to an event that previously caused an episode such as dental work. There is also evidence that cognitive behavior therapy can reduce the negative cognitions that can lead to a fainting
episode similar to the reductions seen in depressive and anxiety disorders.1

To summarize, I suggest vasovagal syncope should be listed as a psychological disorder given it’s similarity to other psychiatric disorders as phobias, panic and other anxiety disorders. Many patients with vasovagal syncope have comorbid psychiatric disorders that need treatment. Given that psychiatric treatments are more effective shouldn’t treatment be in the domain of psychiatry especially if a medical cause has been ruled out?

The second disorder is more hypothetical, I would call it the Unresolved personal fable. Imaginary audience developmental stage. Imaginary audience is the belief in early adolescence that many people are enthusiastically observing, listening to, and interested in them. The personal fable is a stage where the teen thinks he is unique, and due to this others cannot possibly know how they feel.2 It usually occurs between the age of 11-13 and peaks around age 14.It declines as teens go through adolescence. BUT what if it doesn’t? The teen may proceed into another mental health category. Up until age 18 behaviors such as stealing, lying, and run ins with the police in teens are called a conduct disorder. After age 18 we will begin diagnosing this person as an antisocial personality disorder.

What if an 18 year old still feels everyone is watching him, feels he is the center of attention, or is unique and special? We might see the beginning of several psychiatric disorders. Everyone watching him could be seen as symptoms of paranoia or social anxiety. Unique and special could be signs of a narcissistic personality disorder or the grandiosity seen in Bipolar disorder.

Of course a person must meet a full set of criteria to be diagnosed a specific disorder.

My suggestion is that the imaginary audience and personal fable stage of development may not resolve in some adolescents resulting in the beginning of several psychiatric disorders. We should spend more awareness of the the age group between 10 years old and 15 as a developmental period that may be the precursor to many mental health disorders that occur in the late teens or early adulthood. Problems with self esteem or identity at this time can result in early interventions to resolve this stage into healthy thoughts, feeling and cognition as they proceed through later adolescence.

I have proposed 2 disorders I feel belong in the DSM -one a current medical diagnosis and the other a hypothesis. Hopefully more research and discussion will answer the question of whether seeing these as psychiatric disorders would benefit patients and improve treatment.

1. LaFerney M. PEARLS A psychiatric approach to vasovagal syncope Current Psychiatry. 2011 August;10(8):53-54 taken for the www. at:

2. LaFerney,M. 2018 Advance for Nurses,, Imaginary Audience and Personal Fable. Taken for the WWW at: