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- I'm really excited to be
talking about DSM-V today

2
00:00:04,712 --> 00:00:06,411
and I have a lot to
say about it, actually,

3
00:00:06,411 --> 00:00:10,504
so I'm gonna talk for about
50 minutes, 45, 50 minutes

4
00:00:10,504 --> 00:00:13,246
and then for the second half of our time

5
00:00:13,246 --> 00:00:15,112
we're going to break up into small groups

6
00:00:15,112 --> 00:00:18,419
and talk about some of
those questions that

7
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I gave you beforehand in the packets.

8
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There is so much diversity

9
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and difference of
opinion within this room,

10
00:00:32,568 --> 00:00:36,384
a lot of strong views
about the DSM in this room,

11
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I think, and so I'm really
excited to get to that,

12
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to hear where that conversation goes

13
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because I think that's really
important for our students

14
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and their experience.

15
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But the task that I was given for today

16
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was to present on some
of the changes to DSM-V

17
00:00:54,356 --> 00:00:56,990
that seem particularly meaningful
for clinical social work

18
00:00:56,990 --> 00:00:59,664
education across the curriculum,

19
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so that's in research, in practice,

20
00:01:01,734 --> 00:01:06,454
in faculty field advising,
in theory and in policy.

21
00:01:06,454 --> 00:01:09,129
The APA has released an official list of

22
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what they consider
highlights of the changes

23
00:01:11,283 --> 00:01:13,805
and I included that in
your packet as well.

24
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So I'm not gonna go through all of them,

25
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this is not gonna be
an exhaustive training

26
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of all of the changes in the DSM-V.

27
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Instead, what I'm going
to do is I'm going to

28
00:01:22,443 --> 00:01:25,692
really highlight five
conceptual changes that I think

29
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have particular meaning for
clinical social work education.

30
00:01:30,176 --> 00:01:32,583
Sometimes, especially relevant for Smith

31
00:01:32,583 --> 00:01:34,749
and sometimes more broadly.

32
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The five changes that I'm
gonna be focusing on are,

33
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first, this is the first
DSM that actually uses

34
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the word "racism", it's
the very first one.

35
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It acknowledges race and racism

36
00:01:48,577 --> 00:01:52,294
and it re-emphasises cultural formulation,

37
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so I'm going to be talking
about that in particular

38
00:01:54,810 --> 00:01:59,605
with reference to the PTSD diagnosis,

39
00:01:59,605 --> 00:02:02,456
I'm talking about, sort
of, more work to come.

40
00:02:02,456 --> 00:02:06,500
Secondly, new conceptualizations
of disability,

41
00:02:06,500 --> 00:02:10,001
there is the beginnings of
a reformulation happening,

42
00:02:10,001 --> 00:02:15,001
especially, I'll point your
attention to the new diagnosis

43
00:02:15,737 --> 00:02:19,514
of intellectual disability,
which replaces MR.

44
00:02:19,514 --> 00:02:22,020
Third, there's a further loosening of

45
00:02:22,020 --> 00:02:24,735
the definition of mental disorder.

46
00:02:24,735 --> 00:02:29,357
A lot of people are saying
with each new successive DSM

47
00:02:29,357 --> 00:02:31,458
they get bigger and more and more of us

48
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can find ourselves in it.

49
00:02:33,739 --> 00:02:34,837
(audience chuckles)

50
00:02:34,837 --> 00:02:37,963
This raises the question
as to what, really,

51
00:02:37,963 --> 00:02:40,844
is a mental disorder?

52
00:02:40,844 --> 00:02:45,844
Fourth, a very, very powerful
influence of biologism

53
00:02:45,952 --> 00:02:50,397
that I think is very
important for us in the field

54
00:02:50,397 --> 00:02:53,513
and us as educators to notice,

55
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in particular, the removal
of the multi-axial system

56
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which I'm going to
spend some time on today

57
00:02:58,986 --> 00:03:02,254
and also in some of the
changes to schizophrenia.

58
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And then fifth, there's the beginnings,

59
00:03:04,919 --> 00:03:07,473
it'll be interesting to look
at the beginnings of a shift

60
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from a categorical to a
dimensional model of diagnosis

61
00:03:11,141 --> 00:03:13,918
and I'll point your
direction specifically to

62
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Autism Spectrum Disorder,

63
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although there are other examples.

64
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So, I'm going to start off by situating

65
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these five changes
historically and conceptually

66
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and I think that the
history is really important.

67
00:03:30,932 --> 00:03:33,454
I'm going to be focusing on DSM-III

68
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but hopefully giving you
some rich history there.

69
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Then we'll talk about those five changes

70
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and then, fourth, I'm going
to talk about some conclusions

71
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that I'm taking from thinking about this,

72
00:03:46,986 --> 00:03:49,795
about what I think-- sort
of, the awkward position

73
00:03:49,795 --> 00:03:54,086
that many of our students
are in with regard to DSM-V.

74
00:03:54,086 --> 00:03:56,114
That's not just for Smith students but for

75
00:03:56,114 --> 00:03:58,024
social work students, broadly and perhaps

76
00:03:58,024 --> 00:03:59,987
in some specific ways for Smith students

77
00:03:59,987 --> 00:04:03,476
that the DSM can be a
very awkward tool to use.

78
00:04:05,962 --> 00:04:08,336
The British philosopher Ian Hacking,

79
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who you read for today,

80
00:04:09,874 --> 00:04:12,856
has famously argued that
psychiatric symptomatology

81
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is shaped and takes on new meaning

82
00:04:15,003 --> 00:04:17,562
once it is designated with a label.

83
00:04:17,562 --> 00:04:20,532
Others, such as Thomas Szasz,

84
00:04:20,532 --> 00:04:23,551
have said that labels create symptoms,

85
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but this is not what Hacking is saying.

86
00:04:25,744 --> 00:04:28,570
Hacking was saying that symptoms come

87
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to fit the boxes we built for them.

88
00:04:31,399 --> 00:04:35,371
In his 1998 book charting the invention

89
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of European understandings
of fugue states,

90
00:04:38,892 --> 00:04:41,727
Hacking observes that what had been

91
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a few isolated incidents of
people wandering the countryside

92
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became an epidemic of fugue states.

93
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After it made it into the
media and people began

94
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to try to understand it scientifically.

95
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He writes that Western belief in science

96
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"changes how we think of ourselves,

97
00:05:01,675 --> 00:05:04,025
"the possibilities that are open to us,

98
00:05:04,025 --> 00:05:06,297
"the kinds of people
that we take ourselves

99
00:05:06,297 --> 00:05:08,644
"and our fellows to be."

100
00:05:08,644 --> 00:05:11,369
For Hacking, the diagnosis
makes the type of variant

101
00:05:11,369 --> 00:05:14,261
experience intelligible
in the social realm,

102
00:05:16,450 --> 00:05:19,383
where it takes on some new life.

103
00:05:19,383 --> 00:05:21,069
In the essay you read for today,

104
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he referred to this theory
as "making up people"

105
00:05:24,567 --> 00:05:26,938
and applied it to
Dissociative Identity Disorder

106
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and to Autism.

107
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I really think that this could be applied

108
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to any of our descriptive diagnoses.

109
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All DSM-V diagnoses are
technically syndromes.

110
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This is to say, they're
not etiologically-based

111
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but rather describe clusters of symptoms

112
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that seem to go together.

113
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So I often encourage
students to think about this

114
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in terms of constellations of stars.

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From where we're sitting, they
look like they go together,

116
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they seem to move together
as time passes each night

117
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so their correlation appears obvious.

118
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Some stars are, indeed,
interrelated by forces of gravity

119
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but most only look close together

120
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because we see them in
a two-dimensional way.

121
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If we were looking from
another planet, for example,

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we might see the same stars

123
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but not the same constellations.

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Mental Disorder Syndromes
are even less convincing

125
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than constellations.

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The syndrome we call
schizophrenia, for example,

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includes clusters,
symptoms, positive symptoms

128
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like hallucinations and delusions

129
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and negative symptoms, like
the flattening of affect.

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I was first disillusioned
with descriptive diagnoses

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in my first year as a
clinical social worker

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just after I finished my MSW,

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when I worked in a program in Brooklyn

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running a very popular group for

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grandparents with schizophrenia

136
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and I remember gripping my DSM-IV

137
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and trying as hard as I could
to make accurate diagnoses

138
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for types of schizophrenia,

139
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trying to fit people into these types

140
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and there was so much
diversity within the types

141
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and within even the peoples'
experience of symptoms

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that the categories
themselves really proved

143
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meaningless to me,

144
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and this as a student--

145
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someone just having finished my MSW,

146
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this was incredibly frustrating to me

147
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that I couldn't actually make these work,

148
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these constructs that are
supposed to be natural.

149
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These descriptive diagnoses, nevertheless,

150
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have tremendous power.

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If you ask people if
schizophrenia is real,

152
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they're likely to say,
"Yes, of course it is,"

153
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and if you ask them what a syndrome is,

154
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they're not likely to know
what you're talking about

155
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or they don't know
exactly what that means.

156
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The DSM has not always relied
on this idea of syndromes

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and its aims were initially
much smaller in scope

158
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than it is presently.

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The APA published the first DSM in 1952.

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Its purpose was to bring
together, and standardize,

161
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disparate systems of psychiatric diagnosis

162
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developed by psychiatrists in
the military, veterans affairs

163
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and the National Committee
on Mental Hygiene.

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So before this, there were, really,

165
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three very different nomenclatures

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and one of the major problems

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is that it was impossible
to do epidemiological work.

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If you didn't have the same nomenclature

169
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then you couldn't be sure
that you are actually

170
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keeping statistics for
everyone that was diagnosed

171
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with something like schizophrenia.

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It was initially, one
of the main aims for it

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was to standardize so that you could keep

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accurate statistics.

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DSM-II is only a slight
revision over DSM-I in 1968.

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Both of them were primarily used

177
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in psychiatric hospitals in the military.

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They didn't have the same
pervasive or direct influence

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on social work that DSM-III
would later have in the 1980's.

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Part of that is because
they weren't considered

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exhaustive encyclopedias
of mental disorders.

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They were not supposed to fully explain

183
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how the disorder itself would
manifest in an individual.

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They were primarily informed
by psychoanalytic theory

185
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which put strong emphasis on
individualized manifestations

186
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of underlying conflict,

187
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so it was really just a
guide for how to think

188
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about individual manifestations.

189
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This had some advantages
and a lot of problems.

190
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The permeable definitions
of mental disorders

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led to many problems in
large scale practice.

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Many of you will be familiar
with David Rosenhan's

193
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very famous study on being
sane in insane places,

194
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published in the Journal
of Science in 1973.

195
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It received national
attention when he had eight

196
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research participants go
into psychiatric hospitals

197
00:10:04,033 --> 00:10:08,589
reporting once, or very
briefly, auditory hallucinations

198
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and I think all of them
were held inpatient

199
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for an average of 19 days

200
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and not allowed to leave until
they started on medication.

201
00:10:19,951 --> 00:10:21,983
None of them reported
any psychiatric problems

202
00:10:21,983 --> 00:10:24,280
after the initial complaints.

203
00:10:26,473 --> 00:10:28,085
The study, when it came out,

204
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the study has been critiqued
on a number of ways

205
00:10:30,688 --> 00:10:33,028
by a number of--

206
00:10:33,028 --> 00:10:34,626
a number of important ways

207
00:10:34,626 --> 00:10:36,951
but when the study came out in the 70's,

208
00:10:36,951 --> 00:10:41,784
it added a lot of power to
the anti-psychiatry movement

209
00:10:42,667 --> 00:10:46,306
and the 1970's was really a time

210
00:10:46,306 --> 00:10:49,592
when most people think of
psychiatry as under siege.

211
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In the same year that
Rosenhan's study came out,

212
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the APA voted to remove homosexuality

213
00:10:55,750 --> 00:10:58,224
as a diagnosis in DSM-II

214
00:10:58,224 --> 00:11:01,779
and then they voted to
revise DSM-II only five years

215
00:11:01,779 --> 00:11:03,810
after it was put out,

216
00:11:03,810 --> 00:11:06,570
so there was a sense of crisis,

217
00:11:06,570 --> 00:11:08,335
at least as people talk about it.

218
00:11:11,113 --> 00:11:14,329
DSM-III, released in 1980, was a triumph

219
00:11:14,329 --> 00:11:17,451
of the descriptive psychiatry movement.

220
00:11:17,451 --> 00:11:19,417
The modern descriptive psychiatry model

221
00:11:19,417 --> 00:11:23,577
has its roots with German
psychiatrist Emil Kraepelin,

222
00:11:23,577 --> 00:11:27,674
who in the late 19th century
identified dementia praecox

223
00:11:27,674 --> 00:11:30,776
and bipolar disorder
and differentiated them.

224
00:11:30,776 --> 00:11:33,092
Dementia praecox is what
would later be called

225
00:11:33,092 --> 00:11:35,257
by Bleuler, schizophrenia.

226
00:11:38,943 --> 00:11:40,775
But what Kraepelin did
was he distinguished

227
00:11:40,775 --> 00:11:43,845
these two syndromes as syndromes

228
00:11:43,845 --> 00:11:46,559
based on their symptoms.

229
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The descriptive model
developed slowly in the U.S.

230
00:11:50,362 --> 00:11:53,141
but very marginalized
over the 20th century,

231
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it developed mostly among a
small group of psychiatrists

232
00:11:55,873 --> 00:11:59,835
in the 1960's that were
called the St. Louis Group,

233
00:11:59,835 --> 00:12:02,401
they were all based at
Washington University.

234
00:12:03,720 --> 00:12:07,223
It can't be underscored,
really, how DSM-III

235
00:12:07,223 --> 00:12:09,058
seemed to come out of nowhere,

236
00:12:09,058 --> 00:12:13,617
at least if you talk to people
who were involved with it.

237
00:12:17,556 --> 00:12:20,107
It removed all ideological theory,

238
00:12:20,107 --> 00:12:23,192
focusing instead entirely
on clusters of symptoms

239
00:12:23,192 --> 00:12:26,128
that seemed to go together
to create syndromes.

240
00:12:26,128 --> 00:12:29,360
Concepts that didn't fit
this descriptive model,

241
00:12:29,360 --> 00:12:32,959
such as neuroses, were simply discarded.

242
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It revolutionized diagnostic work

243
00:12:35,377 --> 00:12:38,811
and very quickly pushed
other models to the margins.

244
00:12:38,811 --> 00:12:42,309
The system of descriptive
diagnosis seems so familiar now

245
00:12:42,309 --> 00:12:45,165
that it's hard to imagine
what it was like before.

246
00:12:48,122 --> 00:12:51,101
The explosive success of
DSM-III can be attributed,

247
00:12:51,101 --> 00:12:54,485
in large part, to the
work of task force chair,

248
00:12:54,485 --> 00:12:56,420
psychiatrist Robert Spitzer

249
00:12:56,420 --> 00:13:00,696
and social worker Janet
Williams, who would later marry.

250
00:13:00,696 --> 00:13:04,281
(audience laughs)

251
00:13:04,281 --> 00:13:07,103
Together they served on
almost every committee.

252
00:13:07,103 --> 00:13:10,982
Spitzer served on 12 of
the 18 DSM-III committees,

253
00:13:10,982 --> 00:13:12,778
Williams served on four,

254
00:13:12,778 --> 00:13:16,811
she was also the text editor
for the entire DSM-III

255
00:13:16,811 --> 00:13:21,309
and she was coordinator of
field trials for DSM-III.

256
00:13:21,309 --> 00:13:23,484
I got to meet Janet Williams recently

257
00:13:23,484 --> 00:13:25,657
at her home in Princeton

258
00:13:25,657 --> 00:13:27,771
and she explained to me
that part of the reason

259
00:13:27,771 --> 00:13:30,477
that they were able to make such

260
00:13:30,477 --> 00:13:32,616
significant changes with DSM-III,

261
00:13:33,877 --> 00:13:36,853
a really bold project,

262
00:13:36,853 --> 00:13:38,344
was because no one was paying attention

263
00:13:38,344 --> 00:13:39,900
to what they were doing.
(audience laughs)

264
00:13:39,900 --> 00:13:41,127
No one had any idea.

265
00:13:41,127 --> 00:13:42,788
She described just working,

266
00:13:42,788 --> 00:13:44,852
really in isolation, in their office

267
00:13:46,863 --> 00:13:48,789
at the Psychiatric Institute in New York

268
00:13:48,789 --> 00:13:52,775
and that she and Robert Spitzer were

269
00:13:52,775 --> 00:13:54,636
really allowed to do what they wanted.

270
00:13:57,057 --> 00:13:59,417
So she gave me permission to use

271
00:14:01,316 --> 00:14:04,318
bits of our conversation
I want to share with you.

272
00:14:04,318 --> 00:14:07,940
- [Janet] When we started
it, we had no idea

273
00:14:07,940 --> 00:14:10,184
how significant it was going to be,

274
00:14:10,184 --> 00:14:13,160
no idea whatsoever.

275
00:14:13,160 --> 00:14:16,602
And its significance even
seems to even seems to grow

276
00:14:16,602 --> 00:14:20,107
with every passing year

277
00:14:20,107 --> 00:14:22,431
as we get new findings and all,

278
00:14:22,431 --> 00:14:24,476
I mean, what a fabulous

279
00:14:27,759 --> 00:14:30,481
insight, I don't know
if insight is the word,

280
00:14:30,481 --> 00:14:33,654
vision, I think Bob had a vision

281
00:14:35,728 --> 00:14:39,205
to create,

282
00:14:39,205 --> 00:14:42,729
to define every mental
disorder so that people could

283
00:14:42,729 --> 00:14:46,112
at least agree on the
definitions and study them

284
00:14:46,112 --> 00:14:48,829
and then change them
based on the evidence,

285
00:14:48,829 --> 00:14:50,323
so that it was going to be--

286
00:14:50,323 --> 00:14:52,213
the diagnosis would be evidence-based

287
00:14:52,213 --> 00:14:53,842
instead of touchy-feely

288
00:14:55,416 --> 00:14:58,267
Oedipus complex and whatever else,

289
00:14:58,267 --> 00:15:00,130
underlying reactions.

290
00:15:01,841 --> 00:15:06,316
It was very important
that it was atheoritical

291
00:15:06,981 --> 00:15:09,649
so we realized people could agree

292
00:15:09,649 --> 00:15:11,680
on what these disorders look like,

293
00:15:11,680 --> 00:15:13,676
they couldn't agree on how they came about

294
00:15:13,676 --> 00:15:15,242
or how to treat them.

295
00:15:15,242 --> 00:15:17,257
So you don't have to have
an agreement on those things

296
00:15:17,257 --> 00:15:20,172
in order to define them.

297
00:15:20,172 --> 00:15:21,687
So that was really important

298
00:15:21,687 --> 00:15:25,027
and along the way,
involved a lot of struggles

299
00:15:25,027 --> 00:15:27,764
appeasing the psychoanalytic
community mainly,

300
00:15:27,764 --> 00:15:30,522
that was very powerful at the time.

301
00:15:30,522 --> 00:15:33,530
When we eliminated neurotic depression,

302
00:15:33,530 --> 00:15:35,231
they didn't care for that. (laughs)

303
00:15:37,568 --> 00:15:40,318
- As Hacking describes,
diagnostic constructs

304
00:15:40,318 --> 00:15:43,584
have organized difference
since the 19th century

305
00:15:43,584 --> 00:15:45,355
but I think this effect has become

306
00:15:45,355 --> 00:15:48,603
much more powerful since DSM-III.

307
00:15:48,603 --> 00:15:51,463
It was quickly tied to
insurance reimbursement

308
00:15:51,463 --> 00:15:54,249
and, not coincidentally,
became the standard diagnostic

309
00:15:54,249 --> 00:15:56,672
system, not only for psychiatry

310
00:15:56,672 --> 00:16:00,086
but also for psychology
and clinical social work.

311
00:16:00,086 --> 00:16:03,245
It also subsumed other
models of assessment.

312
00:16:03,245 --> 00:16:06,109
Since the release of
the DSM, social workers

313
00:16:06,109 --> 00:16:08,852
and others in related fields
have continued to develop

314
00:16:08,852 --> 00:16:10,914
other models of assessment,

315
00:16:10,914 --> 00:16:14,241
like contemporary,
psycho-dynamic inspired models,

316
00:16:14,241 --> 00:16:16,822
person-in-environment, for example,

317
00:16:16,822 --> 00:16:20,882
but none of these has had
the organizing influence

318
00:16:20,882 --> 00:16:24,406
or range of the DSM
since this third edition,

319
00:16:24,406 --> 00:16:26,177
and part of this is rhetorical.

320
00:16:26,177 --> 00:16:30,068
In part it's because the
DSM-III was represented as

321
00:16:30,068 --> 00:16:34,321
"atheoretical" and "all-encompassing".

322
00:16:34,321 --> 00:16:38,324
DSM-V released last
May is really, I think,

323
00:16:38,324 --> 00:16:41,319
an iteration of DSM-III.

324
00:16:41,319 --> 00:16:43,659
Many of the changes to diagnostic criteria

325
00:16:43,659 --> 00:16:46,749
simply reshuffle and recategorize.

326
00:16:46,749 --> 00:16:48,789
It was developed over
the course of six years

327
00:16:48,789 --> 00:16:50,562
with unprecedented effort to make

328
00:16:50,562 --> 00:16:52,940
the revision process transparent

329
00:16:52,940 --> 00:16:56,162
and open to public comment and scrutiny.

330
00:16:57,095 --> 00:17:00,007
But when it was released,
it met with little fanfare

331
00:17:00,007 --> 00:17:02,232
outside of the APA.

332
00:17:02,232 --> 00:17:03,659
One week before its release,

333
00:17:03,659 --> 00:17:05,926
the director, many of you must know this,

334
00:17:05,926 --> 00:17:09,989
the director of NIMH, Dr. Thomas Insel,

335
00:17:09,989 --> 00:17:14,180
called the DSM-V "scientifically invalid".

336
00:17:14,180 --> 00:17:16,684
According to Insel, DSM-V does not reflect

337
00:17:16,684 --> 00:17:19,179
the latest findings from neurobiology

338
00:17:19,179 --> 00:17:22,178
and research aimed at
validating DSM-V categories

339
00:17:22,178 --> 00:17:25,392
is just further misdirection.

340
00:17:25,392 --> 00:17:28,156
He therefore announced that NIMH

341
00:17:28,156 --> 00:17:32,651
would no longer fund research
guided by DSM-V categories.

342
00:17:32,651 --> 00:17:36,365
Other controversial charges
were also widely criticized

343
00:17:36,365 --> 00:17:38,705
by clinical researchers, advocacy groups

344
00:17:38,705 --> 00:17:40,154
and professional organizations

345
00:17:40,154 --> 00:17:42,700
in the U.S. and international

346
00:17:42,700 --> 00:17:46,369
but the APA is celebrating. (snickers)

347
00:17:46,369 --> 00:17:49,067
It's celebrating it as, I
think in realistic terms,

348
00:17:49,067 --> 00:17:51,304
as a pragmatic step forward.

349
00:17:55,047 --> 00:18:00,047
Here's an interesting
video that was released

350
00:18:00,144 --> 00:18:04,962
just after the annual program
meeting in San Francisco

351
00:18:04,962 --> 00:18:09,962
in May, 2013, as part of the
official launch of DSM-V.

352
00:18:11,589 --> 00:18:16,038
(silence)

353
00:18:19,167 --> 00:18:20,884
I'm gonna be a little mean about it,

354
00:18:20,884 --> 00:18:23,149
(audience laughs)
I just wanna preface that.

355
00:18:23,149 --> 00:18:25,410
- [Voiceover] Feel free.
(everyone laughs)

356
00:18:25,410 --> 00:18:30,410
Their song, "Hello DSM-V",
part of the official launch

357
00:18:30,421 --> 00:18:33,425
of the new edition

358
00:18:33,425 --> 00:18:35,822
raises a lot of questions for me.

359
00:18:35,822 --> 00:18:39,308
I'm gonna use a Freudian
analysis, of course,

360
00:18:40,470 --> 00:18:44,011
to suggest that the humor
here is repressing something.

361
00:18:44,011 --> 00:18:45,409
(audience laughs)

362
00:18:45,409 --> 00:18:49,137
They're clearly asking
us to forget the past,

363
00:18:49,137 --> 00:18:51,652
to forget previous editions of the DSM,

364
00:18:51,652 --> 00:18:55,323
to accept this new version as natural,

365
00:18:55,323 --> 00:18:58,355
to memorize it and to own it.

366
00:18:59,797 --> 00:19:02,370
I have a very different hope for DSM-V

367
00:19:02,370 --> 00:19:05,317
especially in social work education.

368
00:19:05,317 --> 00:19:07,565
I think that the new
edition brings with it

369
00:19:07,565 --> 00:19:09,869
a precious moment when the constructedness

370
00:19:09,869 --> 00:19:13,458
of the document is so plainly evident.

371
00:19:13,458 --> 00:19:15,762
Rather than saying, "Goodbye DSM-IV"

372
00:19:15,762 --> 00:19:17,761
and so-long to the controversy,

373
00:19:17,761 --> 00:19:20,021
which was quite intense and still is,

374
00:19:20,021 --> 00:19:22,401
I think, instead, we need
to use this opportunity

375
00:19:22,401 --> 00:19:26,084
to consider how the DSM has
been organizing our thinking

376
00:19:26,084 --> 00:19:28,358
and to demonstrate for
our students that the DSM

377
00:19:28,358 --> 00:19:31,579
is not a bible, and that it's not--

378
00:19:31,579 --> 00:19:33,508
just having the word "statistical" in it

379
00:19:33,508 --> 00:19:35,226
doesn't make it thoroughly scientific.

380
00:19:35,226 --> 00:19:36,385
(audience chuckles)

381
00:19:36,385 --> 00:19:39,238
At the same time, at the
present, this is the system

382
00:19:39,238 --> 00:19:41,928
that many of us need to
continue to work within

383
00:19:41,928 --> 00:19:44,658
and many of our students
need to work with it.

384
00:19:44,658 --> 00:19:47,847
The changes in the DSM-V,
whatever we think of them,

385
00:19:47,847 --> 00:19:51,117
inevitably have very far
reaching implications.

386
00:19:53,683 --> 00:19:58,683
So let me get to those five
major changes now in the DSM-V.

387
00:20:03,026 --> 00:20:05,191
Some of these changes
are widely talked about

388
00:20:05,191 --> 00:20:06,337
and I'll mention them when they are

389
00:20:06,337 --> 00:20:07,342
and some of them have received

390
00:20:07,342 --> 00:20:10,009
little to no attention so far.

391
00:20:10,009 --> 00:20:12,718
One that I can't find any mention of yet

392
00:20:12,718 --> 00:20:16,887
is the fact that, as I said
before, this is the first DSM

393
00:20:16,887 --> 00:20:20,267
to use the word "racism".

394
00:20:20,267 --> 00:20:23,970
It's the first, also, to
meaningfully acknowledge race

395
00:20:23,970 --> 00:20:26,735
at all, as a social identity.

396
00:20:26,735 --> 00:20:29,038
The change has received
no attention so far

397
00:20:29,038 --> 00:20:31,474
but it certainly has the
potential to make a difference,

398
00:20:31,474 --> 00:20:32,406
albeit symbolic.

399
00:20:33,690 --> 00:20:35,082
So I wanna

400
00:20:37,312 --> 00:20:38,900
show you a bit--

401
00:20:38,900 --> 00:20:43,094
this is part of what's included in DSM-V

402
00:20:43,094 --> 00:20:46,100
and I'm just going to
focus your attention to

403
00:20:46,100 --> 00:20:48,321
the last line here.

404
00:20:48,321 --> 00:20:50,611
"There is evidence that
racism can exacerbate

405
00:20:50,611 --> 00:20:54,934
"many psychiatric disorders,
contributing to poor outcome,

406
00:20:54,934 --> 00:20:58,536
"and that racial bias can
affect diagnostic assessment."

407
00:20:59,646 --> 00:21:01,198
This is not mind-blowing,

408
00:21:01,198 --> 00:21:03,322
this is not earth shattering

409
00:21:03,322 --> 00:21:06,969
but it has a big impact, I think,

410
00:21:06,969 --> 00:21:10,338
that this is suddenly, or not suddenly,

411
00:21:10,338 --> 00:21:15,338
after a lot of work it
is appearing in DSM-V.

412
00:21:18,419 --> 00:21:22,086
One thing to note, of course,
you'll notice it's Page 749

413
00:21:22,086 --> 00:21:26,677
and it's tucked away in the
long and often very thoughtful

414
00:21:26,677 --> 00:21:31,677
narrative pages of the DSM
that people don't often read

415
00:21:32,110 --> 00:21:34,874
and so I think it's important
that we be directing

416
00:21:34,874 --> 00:21:37,097
peoples' attention to those pages

417
00:21:37,097 --> 00:21:38,410
that people don't often
read because it's often

418
00:21:38,410 --> 00:21:43,410
where the writers are very
thoughtful and nuanced.

419
00:21:45,509 --> 00:21:48,001
Many clinicians had
hoped, though, that DSM-V

420
00:21:48,001 --> 00:21:51,707
would identify some version
of race-based trauma,

421
00:21:51,707 --> 00:21:54,564
to recognize when a
person develops symptoms

422
00:21:54,564 --> 00:21:57,214
consistent with PTSD

423
00:21:57,214 --> 00:22:01,902
following the insidious racist
microaggressions over time.

424
00:22:01,902 --> 00:22:05,167
One avenue for this might
have been, people say,

425
00:22:05,167 --> 00:22:08,626
through the recognition of complex PTSD.

426
00:22:08,626 --> 00:22:13,073
In complex PTSD there are
multiple life-threatening

427
00:22:13,073 --> 00:22:15,913
stressors in early life.

428
00:22:15,913 --> 00:22:20,030
Complex PTSD was not
accepted into DSM-V though

429
00:22:20,030 --> 00:22:24,380
and regardless, I don't think
that it would have taken

430
00:22:24,380 --> 00:22:27,316
well enough into account microaggressions,

431
00:22:27,316 --> 00:22:30,077
which are usually more subtle
than what Judith Herman

432
00:22:30,077 --> 00:22:33,080
was talking about with complex PTSD.

433
00:22:35,434 --> 00:22:38,752
Others are saying that
PTSD, the changes to PTSD

434
00:22:38,752 --> 00:22:42,540
are perhaps more inclusive
of what could be--

435
00:22:42,540 --> 00:22:45,039
of race-based trauma,

436
00:22:45,039 --> 00:22:49,835
it's pointing out that PTSD
itself is a bit more complex.

437
00:22:54,056 --> 00:22:58,027
In particular, the exposure
criterion can occur

438
00:22:58,027 --> 00:23:01,576
through repeated interaction
with aftermath of a trauma.

439
00:23:01,576 --> 00:23:04,516
This is intended, really,
for first responders

440
00:23:04,516 --> 00:23:08,060
who may, as a way of conceptualizing,

441
00:23:08,060 --> 00:23:12,756
how they have repeated exposure to

442
00:23:12,756 --> 00:23:14,537
the details of a trauma

443
00:23:14,537 --> 00:23:18,035
but it might be used more
broadly to talk about

444
00:23:18,035 --> 00:23:22,732
how children or adults live
with perpetual violence.

445
00:23:26,820 --> 00:23:31,308
The other, the subjective
reaction criteria,

446
00:23:31,308 --> 00:23:34,680
a reaction of fear, helplessness or horror

447
00:23:34,680 --> 00:23:37,108
has been removed in DSM-V

448
00:23:37,108 --> 00:23:41,115
because some of the studies say that

449
00:23:41,115 --> 00:23:43,411
professional responders might
not have those reactions,

450
00:23:43,411 --> 00:23:45,394
they've sort of been trained out of them.

451
00:23:48,184 --> 00:23:52,212
It's possible that this change
is also going to make PTSD

452
00:23:52,212 --> 00:23:55,257
more culturally sensitive and inclusive.

453
00:24:00,796 --> 00:24:03,376
DSM also contains a definition of culture

454
00:24:03,376 --> 00:24:04,627
for the very first time.

455
00:24:04,627 --> 00:24:08,000
The DSM-IV talked about
culture a great deal

456
00:24:08,000 --> 00:24:10,657
but, and there was a whole discussion of

457
00:24:10,657 --> 00:24:13,303
culture-bound syndromes
brought in by DSM-IV

458
00:24:13,303 --> 00:24:17,020
but this is the first one
that defines what culture is.

459
00:24:17,020 --> 00:24:20,127
I'm not going to go
through the whole thing

460
00:24:20,127 --> 00:24:22,926
but I'm going to just
point out two lines from it

461
00:24:22,926 --> 00:24:24,341
that I think are significant.

462
00:24:24,341 --> 00:24:28,225
One is that cultures are
open, dynamic systems

463
00:24:28,225 --> 00:24:31,655
that undergo continuous change over time,

464
00:24:31,655 --> 00:24:34,317
and secondly, most individuals are exposed

465
00:24:34,317 --> 00:24:36,514
to multiple cultures.

466
00:24:36,514 --> 00:24:40,660
So this is a very interesting language

467
00:24:40,660 --> 00:24:43,610
to talk about culture that
is, I think, much more nuanced

468
00:24:43,610 --> 00:24:46,557
and seems to convey some integration

469
00:24:46,557 --> 00:24:49,163
of post-colonial theory.

470
00:24:56,188 --> 00:24:59,219
There's also-- you see a
little corner of it here,

471
00:24:59,219 --> 00:25:02,039
there's also a new Cultural
Formulation Interview,

472
00:25:02,039 --> 00:25:03,738
which is an expression of the outline

473
00:25:03,738 --> 00:25:08,015
for cultural formulation,
which was in DSM-IV-TR.

474
00:25:08,701 --> 00:25:11,682
There's still a glossary
of culture-bound syndromes

475
00:25:11,682 --> 00:25:14,890
but it's been renamed "The
Glossary of Cultural Concepts

476
00:25:14,890 --> 00:25:17,152
"of Distress," but there
have been no changes

477
00:25:17,152 --> 00:25:19,635
other than the change in the title.

478
00:25:19,635 --> 00:25:23,182
It lists examples such
as ataque de nervious,

479
00:25:23,182 --> 00:25:25,413
which is an example of
trembling and screaming

480
00:25:25,413 --> 00:25:28,531
as it's understood in some
Latin-American contexts.

481
00:25:28,531 --> 00:25:32,351
Putting some diagnoses
such as ataque de nervious

482
00:25:32,351 --> 00:25:35,286
in a glossary separate
from panic disorder,

483
00:25:35,286 --> 00:25:37,793
which has a diagnostic
code, still suggests

484
00:25:37,793 --> 00:25:41,382
that one is based in culture
and the other in science.

485
00:25:41,382 --> 00:25:44,005
Still, the CFI, I think,

486
00:25:46,104 --> 00:25:48,741
it has some potential for
reconceptualizing culture

487
00:25:48,741 --> 00:25:52,891
in a more relational and dynamic way.

488
00:25:52,891 --> 00:25:55,951
It might help to complicate
the picture for clinicians

489
00:25:55,951 --> 00:25:57,752
and students in the field.

490
00:26:01,370 --> 00:26:04,123
The second change I want
to bring your attention to

491
00:26:04,123 --> 00:26:07,079
is a reconceptualization of disability.

492
00:26:10,464 --> 00:26:13,799
DSM-V articulates a new
understanding of disability,

493
00:26:13,799 --> 00:26:18,137
no longer referring only to a
discreet trait of impairment

494
00:26:18,137 --> 00:26:20,838
but now also to the psychosocial impacts

495
00:26:20,838 --> 00:26:23,347
of the impairment for the individual.

496
00:26:23,347 --> 00:26:25,506
I don't think many of the
members of the subcommittee

497
00:26:25,506 --> 00:26:28,035
were reading Judith Butler

498
00:26:28,035 --> 00:26:30,039
but the change reflects her point that,

499
00:26:30,039 --> 00:26:33,941
"Disability is the social
organization of impairment."

500
00:26:35,242 --> 00:26:37,660
The shift is demonstrated
most meaningfully

501
00:26:37,660 --> 00:26:40,752
in the new diagnosis of
intellectual disability,

502
00:26:40,752 --> 00:26:44,533
which has finally replaced
the old diagnosis of MR

503
00:26:44,533 --> 00:26:46,396
and advocacy for this
change has been happening

504
00:26:46,396 --> 00:26:48,919
for at least 20 years.

505
00:26:48,919 --> 00:26:53,474
The diagnosis of MR was based on IQ scores

506
00:26:53,474 --> 00:26:55,824
whereas the diagnosis of
intellectual disability

507
00:26:55,824 --> 00:26:57,224
is based on both IQ scores

508
00:26:57,224 --> 00:26:59,631
and adaptive functioning together.

509
00:26:59,631 --> 00:27:01,879
Further, the severity specifiers,

510
00:27:01,879 --> 00:27:03,875
mild, moderate and severe

511
00:27:03,875 --> 00:27:06,885
will no longer be based
on IQ scores at all,

512
00:27:06,885 --> 00:27:10,201
they'll be based on the
person's "adaptive functioning"

513
00:27:10,201 --> 00:27:11,732
in three different domains:

514
00:27:11,732 --> 00:27:14,415
Conceptual thinking,
such as problem solving,

515
00:27:14,415 --> 00:27:18,731
social interaction, such as
communicating with others

516
00:27:18,731 --> 00:27:21,936
and thirdly, practical
abilities such as navigating

517
00:27:21,936 --> 00:27:25,674
a grocery store, managing
money or attending school

518
00:27:25,674 --> 00:27:28,523
or going to a community program.

519
00:27:28,523 --> 00:27:31,157
The theoretical implications
of this shift should mean

520
00:27:31,157 --> 00:27:34,104
that disability broadly is
more and more recognized

521
00:27:34,104 --> 00:27:36,747
as informed by the social setting.

522
00:27:36,747 --> 00:27:39,980
Some groups and settings
will increase disabilities,

523
00:27:39,980 --> 00:27:42,488
some will expand abilities

524
00:27:42,488 --> 00:27:44,962
but a diagnosis should no longer be based

525
00:27:44,962 --> 00:27:47,364
on the individual alone.

526
00:27:47,364 --> 00:27:48,864
So I think that this has the potential

527
00:27:48,864 --> 00:27:50,668
to be a significant change.

528
00:27:54,886 --> 00:27:59,613
Change three, a further
broadening, or loosening,

529
00:27:59,613 --> 00:28:02,794
of the definition of mental disorder.

530
00:28:02,794 --> 00:28:05,618
This third change is one that has been

531
00:28:05,618 --> 00:28:07,710
pretty widely talked about within academia

532
00:28:07,710 --> 00:28:10,664
and a little bit in popular media.

533
00:28:10,664 --> 00:28:12,393
Rather than just calling it a change,

534
00:28:12,393 --> 00:28:14,244
it's probably more accurate to say that

535
00:28:14,244 --> 00:28:17,946
several small changes in
DSM-V that continue a trend

536
00:28:17,946 --> 00:28:21,651
that's been happening since DSM-III.

537
00:28:23,820 --> 00:28:26,901
It's largely the effect of APA's endeavor

538
00:28:26,901 --> 00:28:31,593
to be comprehensive, to
catalog all mental disorders.

539
00:28:32,520 --> 00:28:34,749
To use another space metaphor,

540
00:28:34,749 --> 00:28:39,218
this way of thinking is a little
bit like space cartography,

541
00:28:39,218 --> 00:28:43,468
it's like all you have to do is discover

542
00:28:43,468 --> 00:28:46,804
these new diagnoses, they're
out there if we can find them,

543
00:28:47,469 --> 00:28:49,907
because they are fixed and immutable.

544
00:28:50,849 --> 00:28:53,578
We just have to draw maps that are better.

545
00:28:55,667 --> 00:28:58,807
One example of a new discovery

546
00:28:58,807 --> 00:29:01,616
is Disruptive Mood Dysregulation Disorder,

547
00:29:01,616 --> 00:29:03,628
which is a diagnosis
that can now be assigned

548
00:29:03,628 --> 00:29:06,839
to children between
the ages of six and 18,

549
00:29:06,839 --> 00:29:10,382
when they demonstrate a
pattern over 12 months

550
00:29:10,382 --> 00:29:12,822
of outbursts of mood
that seem developmentally

551
00:29:12,822 --> 00:29:15,158
inappropriate, such as shouting

552
00:29:15,158 --> 00:29:17,277
at least three to five times per week,

553
00:29:17,277 --> 00:29:19,451
and also, irritability between outbursts

554
00:29:19,451 --> 00:29:21,502
in multiple settings.

555
00:29:21,502 --> 00:29:23,415
The new diagnosis is very similar to

556
00:29:23,415 --> 00:29:25,444
intermittent explosive disorder,

557
00:29:25,444 --> 00:29:27,528
which was added in DSM-III,

558
00:29:27,528 --> 00:29:29,242
except that intermittent
explosive disorder

559
00:29:29,242 --> 00:29:32,314
does not require irritability
between outbursts

560
00:29:32,314 --> 00:29:34,188
and only needs to be
observed for three months

561
00:29:34,188 --> 00:29:35,260
as opposed to 12 months.

562
00:29:35,260 --> 00:29:36,481
(audience snickers)

563
00:29:36,481 --> 00:29:39,516
It's also similar to
oppositional defiant disorder

564
00:29:39,516 --> 00:29:41,255
which is characterized more

565
00:29:41,255 --> 00:29:44,619
by angry resistance to authority.

566
00:29:44,619 --> 00:29:48,832
The new DSM-V diagnosis
has been very controversial

567
00:29:48,832 --> 00:29:50,191
because it's actually not based

568
00:29:50,191 --> 00:29:54,383
on any published findings
distinguishing it

569
00:29:54,383 --> 00:29:57,511
from the other childhood
behavioral disorders.

570
00:29:57,511 --> 00:29:59,280
The most prominent justification, in fact,

571
00:29:59,280 --> 00:30:01,051
has been a political one.

572
00:30:04,943 --> 00:30:08,860
Creating this new diagnosis is supposed to

573
00:30:08,860 --> 00:30:12,938
stop the tide of diagnosing
childhood bipolar disorder.

574
00:30:17,512 --> 00:30:21,229
Childhood bipolar disorder
exploded in the 1990's.

575
00:30:21,229 --> 00:30:22,722
It's gotten a huge amount of attention

576
00:30:22,722 --> 00:30:26,442
because the Harvard
psychiatrist who first published

577
00:30:26,442 --> 00:30:30,014
on the treatment of
childhood bipolar disorder,

578
00:30:30,014 --> 00:30:32,200
Biederman at Harvard,

579
00:30:32,200 --> 00:30:34,078
was later found to have
been receiving large sums

580
00:30:34,078 --> 00:30:35,827
of money from Johnson & Johnson,

581
00:30:35,827 --> 00:30:37,080
(sparse laughter in the audience)

582
00:30:37,080 --> 00:30:40,795
and not fully reporting
his earnings to the--

583
00:30:41,864 --> 00:30:44,420
or his consultation
fees, to the university.

584
00:30:45,395 --> 00:30:48,445
This has had enormous consequences.

585
00:30:50,160 --> 00:30:51,459
Just looking at--

586
00:30:51,459 --> 00:30:54,544
this is from a study, a 2007 study

587
00:30:54,544 --> 00:30:59,544
of rates of psychiatric
discharges for children,

588
00:31:03,723 --> 00:31:06,800
children who were
hospitalized for treatments

589
00:31:06,800 --> 00:31:09,038
related to bipolar disorder,

590
00:31:09,038 --> 00:31:13,389
so you'll see it in 1996,
the rates are fairly

591
00:31:13,389 --> 00:31:15,657
close together and quite low

592
00:31:15,657 --> 00:31:20,170
and by 2004, you'll see
that they have risen

593
00:31:20,170 --> 00:31:23,906
particularly for those blue lines,

594
00:31:23,906 --> 00:31:26,745
the solid blue lines are
African-American boys

595
00:31:26,745 --> 00:31:31,013
and the dotted blue line
is African-American girls.

596
00:31:31,013 --> 00:31:33,970
So the new diagnosis of
disruptive mood disregulation

597
00:31:33,970 --> 00:31:36,568
is supposed to correct this problem

598
00:31:36,568 --> 00:31:39,152
but I'm really not sure how.

599
00:31:39,152 --> 00:31:41,243
I don't think it's likely
to make a difference

600
00:31:41,243 --> 00:31:44,162
for psychotherapy treatments
with children and families

601
00:31:44,162 --> 00:31:46,732
and it's probably even less
likely that it will lead

602
00:31:46,732 --> 00:31:49,678
to changes in pharmaceuticals prescribed.

603
00:31:49,678 --> 00:31:52,714
If anything, the new
diagnosis lowers the threshold

604
00:31:52,714 --> 00:31:55,690
and will likely lead to even
more widespread prescribing.

605
00:31:59,568 --> 00:32:01,690
Another example of ADHD,

606
00:32:02,958 --> 00:32:07,958
ADHD has been expanded further in DSM-V.

607
00:32:08,373 --> 00:32:12,134
In DSM-IV, it required
onset of related symptoms

608
00:32:12,134 --> 00:32:14,030
by seven years old.

609
00:32:14,030 --> 00:32:17,731
DSM-V now requires it
only by 12 years old.

610
00:32:17,731 --> 00:32:21,804
Secondly, ADHD can now
be diagnosed in adults

611
00:32:21,804 --> 00:32:24,316
by meeting only five of
the symptom criteria,

612
00:32:24,316 --> 00:32:26,981
when six were required for children.

613
00:32:26,981 --> 00:32:28,659
In previous editions,

614
00:32:30,848 --> 00:32:33,675
adults were not really widely recognized

615
00:32:33,675 --> 00:32:37,059
by ADHD diagnoses.

616
00:32:37,059 --> 00:32:40,392
There was the residual type

617
00:32:41,461 --> 00:32:44,797
but DSM-V broadens
explanations of symptoms

618
00:32:44,797 --> 00:32:47,973
to include adult-specific presentations.

619
00:32:47,973 --> 00:32:49,745
So for example, they gave this ...

620
00:32:49,745 --> 00:32:51,115
(audience snickers)

621
00:32:51,115 --> 00:32:54,644
I think really cute example,

622
00:32:54,644 --> 00:32:55,930
the symptoms that--

623
00:32:55,930 --> 00:32:58,511
one symptom is that people lose things

624
00:32:58,511 --> 00:32:59,502
(audience laughs)

625
00:32:59,502 --> 00:33:01,661
and so, in DSM-IV it gave examples like,

626
00:33:01,661 --> 00:33:03,808
"You might lose your
toys, school assignments,

627
00:33:03,808 --> 00:33:05,864
pencils, books, tools",

628
00:33:05,864 --> 00:33:08,386
in DSM-V it just continues
the list to also,

629
00:33:08,386 --> 00:33:12,585
"wallets, keys, paperwork,
eyeglasses, mobile telephones",

630
00:33:13,146 --> 00:33:15,597
so it's a much more
inclusive diagnosis now.

631
00:33:15,597 --> 00:33:17,343
A lot of attention has
been given to the change

632
00:33:17,343 --> 00:33:20,751
in major depressive
disorder in the same way.

633
00:33:21,397 --> 00:33:25,148
DSM-IV specified that the
diagnoses was not indicated

634
00:33:25,148 --> 00:33:28,931
if the client had been grieving
for two months or less.

635
00:33:28,931 --> 00:33:31,194
DSM-III said that the
major depressive disorder

636
00:33:31,194 --> 00:33:33,096
is not indicated

637
00:33:33,096 --> 00:33:36,748
(pauses and repeats same words)

638
00:33:36,748 --> 00:33:40,467
if better accounted for in
uncomplicated bereavement,

639
00:33:40,467 --> 00:33:43,162
which was classified
as a V code in DSM-III,

640
00:33:43,162 --> 00:33:45,934
meaning that it was not
considered a disorder.

641
00:33:45,934 --> 00:33:48,514
Many feel this change will
lead to the pathologization

642
00:33:48,514 --> 00:33:49,504
of normal grief,

643
00:33:49,504 --> 00:33:51,458
basically what they've
done is they've removed

644
00:33:51,458 --> 00:33:53,700
the grief exclusion,
some people are worried

645
00:33:53,700 --> 00:33:56,197
that this is pathologizing normal grief.

646
00:33:56,197 --> 00:34:00,335
This might be true but I'm
not sure, entirely, about it.

647
00:34:00,335 --> 00:34:03,761
I think DSM-V still encourages
clinicians to differentiate

648
00:34:03,761 --> 00:34:07,040
between grief and a
major depressive episode.

649
00:34:07,040 --> 00:34:10,098
The change simply means
that you can be diagnosed

650
00:34:10,098 --> 00:34:14,091
with a depressive episode
when you are also grieving

651
00:34:14,502 --> 00:34:17,019
but it doesn't necessarily
mean that you should,

652
00:34:17,019 --> 00:34:20,238
and that might be a distinction
that we want to raise.

653
00:34:20,238 --> 00:34:21,852
(chuckles)

654
00:34:23,746 --> 00:34:27,155
This has been-- a lot around
this issue of expansion

655
00:34:27,155 --> 00:34:29,773
of diagnosis and expansion
of mental disorder

656
00:34:29,773 --> 00:34:33,222
is talked about by Jerome Wakefield,

657
00:34:33,222 --> 00:34:35,990
who is a professor at NYU
School of Social Work.

658
00:34:35,990 --> 00:34:38,375
He's written prolifically
on the problem of

659
00:34:38,375 --> 00:34:41,313
how APA defines mental disorder.

660
00:34:41,313 --> 00:34:45,230
Since the 1990's, he's famously
proposed a new definition

661
00:34:45,230 --> 00:34:47,352
of mental disorder, which is often cited

662
00:34:47,352 --> 00:34:49,357
in the medical and psychology literature

663
00:34:49,357 --> 00:34:52,413
but not very well engaged
with in social work.

664
00:34:53,755 --> 00:34:55,491
He calls it the disorder as

665
00:34:55,491 --> 00:34:57,864
harmful dysfunction definition.

666
00:35:01,116 --> 00:35:04,062
By harmful, he means it
has a negative impact

667
00:35:04,062 --> 00:35:06,964
on the person's adaptive functioning.

668
00:35:06,964 --> 00:35:09,963
By dysfunction, he means
it's a failure of an internal

669
00:35:09,963 --> 00:35:13,501
mechanism to perform a natural function

670
00:35:13,501 --> 00:35:15,555
for which it was assigned

671
00:35:15,555 --> 00:35:18,407
in the context of evolutionary biology.

672
00:35:19,680 --> 00:35:22,360
When Wakefield refers
to natural functioning,

673
00:35:22,360 --> 00:35:25,154
he means mental mechanisms
that he believes

674
00:35:25,154 --> 00:35:28,514
help humans to thrive
when operating naturally,

675
00:35:28,514 --> 00:35:31,716
such as cognitive abilities
and affective states.

676
00:35:31,716 --> 00:35:34,527
This is kind of similar to where a lot of

677
00:35:34,527 --> 00:35:36,093
attachment theory is going,

678
00:35:36,093 --> 00:35:40,047
like theories of healthy attachment.

679
00:35:40,047 --> 00:35:43,449
His broader point is that
real "mental disorders"

680
00:35:43,449 --> 00:35:46,324
indicated by gross dysfunction

681
00:35:46,324 --> 00:35:49,083
should be neatly and
clearly differentiated

682
00:35:49,083 --> 00:35:51,616
from normal difficulties of life,

683
00:35:51,616 --> 00:35:54,712
and that rather than trying
to classify more problems

684
00:35:54,712 --> 00:35:58,989
as disorders, which has
been sort of on the agenda,

685
00:35:58,989 --> 00:36:01,707
social workers should be trying
to get insurance companies

686
00:36:01,707 --> 00:36:04,865
to reimburse for counseling
for normal problems, too,

687
00:36:04,865 --> 00:36:07,590
such as grief counseling.

688
00:36:07,590 --> 00:36:10,079
It's interesting to me that
social workers don't engage more

689
00:36:10,079 --> 00:36:12,010
with Wakefield's argument.

690
00:36:12,010 --> 00:36:14,464
I understand where it's coming from

691
00:36:14,464 --> 00:36:17,726
but I think it should really
be raising controversy.

692
00:36:17,726 --> 00:36:20,623
Smith students often,
very forcefully reject

693
00:36:20,623 --> 00:36:23,920
these kinds of distinctions
between health and illness.

694
00:36:23,920 --> 00:36:26,667
This reflects the influence of classical

695
00:36:26,667 --> 00:36:30,090
psychodynamic theory, a
reverberation of Freud's arguments

696
00:36:30,090 --> 00:36:32,907
in psychopathology of every day life,

697
00:36:32,907 --> 00:36:35,496
that living in society
makes us all a bit neurotic

698
00:36:35,496 --> 00:36:37,963
and guilt-driven, and complicated

699
00:36:37,963 --> 00:36:39,564
and that the boundaries between the normal

700
00:36:39,564 --> 00:36:43,649
and the abnormal are unstable and dynamic.

701
00:36:43,649 --> 00:36:46,637
Joyce McDougall , who I adore,

702
00:36:46,637 --> 00:36:49,171
she's a French psychoanalyst,

703
00:36:49,171 --> 00:36:51,914
she elaborated on this
point most convincingly

704
00:36:51,914 --> 00:36:54,582
when in 1978 she wrote,

705
00:36:54,582 --> 00:36:58,671
"My colleagues have never
appeared to me eminently normal,

706
00:36:58,678 --> 00:37:00,161
(audience laughs)

707
00:37:00,161 --> 00:37:03,120
"as for myself, I feel
quite at home with them."

708
00:37:03,120 --> 00:37:04,425
(audience laughs)

709
00:37:04,425 --> 00:37:07,430
She went on, "For analysts
to speak of normality

710
00:37:07,430 --> 00:37:10,518
"is like trying to describe
the dark side of the moon,

711
00:37:10,518 --> 00:37:13,342
"we can imagine it, of
course, even send up a rocket

712
00:37:13,342 --> 00:37:16,348
"to take some photos, and on this basis,

713
00:37:16,348 --> 00:37:19,789
"build up some theories
about how it ought to look

714
00:37:19,789 --> 00:37:21,905
"but where does that lead us?

715
00:37:21,905 --> 00:37:24,968
"It's not our country,
scarcely our planet."

716
00:37:24,968 --> 00:37:27,515
it's actually not our planet,

717
00:37:27,515 --> 00:37:30,875
So I'll simply say that
the DSM continues to expand

718
00:37:30,875 --> 00:37:34,113
the boundaries of mental
disorder and mental illness

719
00:37:35,311 --> 00:37:37,036
and the boundaries between mental disorder

720
00:37:37,036 --> 00:37:39,444
and mental illness grow less clear.

721
00:37:39,444 --> 00:37:40,201
And as that's happening,

722
00:37:40,201 --> 00:37:43,793
it's ironically had some
radical implications

723
00:37:43,793 --> 00:37:46,142
reminiscent of what McDougall was saying

724
00:37:46,855 --> 00:37:49,375
but When the person is given a diagnosis

725
00:37:49,375 --> 00:37:51,328
in the current climate,

726
00:37:51,328 --> 00:37:53,116
it's much more likely
that they're going to be

727
00:37:53,116 --> 00:37:54,951
treated with medication,

728
00:37:54,951 --> 00:37:57,649
so we need to be puzzling it out.

729
00:38:02,307 --> 00:38:06,620
A fourth change, out
of five, is biologism.

730
00:38:10,761 --> 00:38:14,513
By biologism, I mean privileging
of biology-based theories

731
00:38:14,513 --> 00:38:18,032
over biopsychosocial perspectives.

732
00:38:18,032 --> 00:38:20,333
This, again, is a longer-term trend

733
00:38:20,333 --> 00:38:23,840
which is now even more evident in DSM-V.

734
00:38:23,840 --> 00:38:27,056
Take, for example, a simple
change in the wording:

735
00:38:27,056 --> 00:38:30,049
DSM-IV terms "general medical condition"

736
00:38:30,049 --> 00:38:33,101
has been replaced by
"another medical condition".

737
00:38:34,254 --> 00:38:36,437
This means that DSM-V diagnoses

738
00:38:36,437 --> 00:38:39,165
are supposed to be themselves
considered medical.

739
00:38:42,245 --> 00:38:44,980
The most drastic example of this, though,

740
00:38:44,980 --> 00:38:46,912
I think is the sudden--

741
00:38:46,912 --> 00:38:48,142
and it really is sudden in this case,

742
00:38:48,142 --> 00:38:50,469
removal of the multiaxial system,

743
00:38:51,363 --> 00:38:55,063
which was a format for
formatting diagnoses.

744
00:38:57,468 --> 00:38:59,578
Axis I was for Clinical Disorders,

745
00:38:59,578 --> 00:39:03,366
Axis II was Personality Disorders

746
00:39:03,366 --> 00:39:07,377
and also what's now thought of
as Intellectual Functioning,

747
00:39:07,377 --> 00:39:09,928
Axis III was General Medical Conditions,

748
00:39:09,928 --> 00:39:12,902
Axis IV was the Acuity
of Psychosocial Stressors

749
00:39:12,902 --> 00:39:16,142
and Axis V was an
Assessment of Functioning.

750
00:39:16,142 --> 00:39:18,767
Despite all of the
efforts to be transparent

751
00:39:18,767 --> 00:39:20,760
about their proceedings,
the multiaxial system

752
00:39:20,760 --> 00:39:24,119
was discarded without any
opportunity for public comment

753
00:39:24,119 --> 00:39:28,036
or even debate amongst
the DSM-V subcommittees.

754
00:39:28,036 --> 00:39:30,233
The APA justified this decision by saying

755
00:39:30,233 --> 00:39:32,964
that removing it would make
a psychiatric diagnosis

756
00:39:32,964 --> 00:39:35,616
conform to medical diagnostic formats,

757
00:39:35,616 --> 00:39:37,489
they were very plain about this,

758
00:39:37,489 --> 00:39:39,760
and correct the problem
of false distinctions

759
00:39:39,760 --> 00:39:43,052
between biomedical and
psychological domains.

760
00:39:43,052 --> 00:39:46,108
The new format merges Axes I through III

761
00:39:46,108 --> 00:39:47,849
into a single line,

762
00:39:47,849 --> 00:39:50,063
and they have suggested
that all that information

763
00:39:50,063 --> 00:39:51,844
about psychosocial stressors

764
00:39:51,844 --> 00:39:53,790
can go somewhere else in the record.

765
00:39:54,718 --> 00:39:56,902
But most importantly,
it's no longer considered

766
00:39:56,902 --> 00:40:00,751
part of the diagnosis,
that psychosocial stuff

767
00:40:00,751 --> 00:40:03,230
is not part of the diagnosis anymore.

768
00:40:08,983 --> 00:40:12,646
A lot of students have been writing to me

769
00:40:12,646 --> 00:40:16,051
over the year, former students from Smith,

770
00:40:16,051 --> 00:40:18,423
and asking, "What is this
supposed to look like?

771
00:40:18,423 --> 00:40:20,935
"I'm supposed to be using
DSM-V in my placement

772
00:40:20,935 --> 00:40:22,556
"and nobody at my placement actually knows

773
00:40:22,556 --> 00:40:26,488
"how to write a DSM diagnosis."

774
00:40:26,488 --> 00:40:31,400
So the answer is to simply put what you,

775
00:40:31,400 --> 00:40:34,708
as a social worker, are
treating the student for.

776
00:40:34,708 --> 00:40:36,769
If there's more than
one relevant diagnosis,

777
00:40:36,769 --> 00:40:40,239
list the one with the most
relevance for that day.

778
00:40:40,239 --> 00:40:44,495
As an example, this is what I would've--

779
00:40:44,495 --> 00:40:47,020
this is what I put for a client,

780
00:40:47,020 --> 00:40:48,287
who I was seeing--

781
00:40:48,287 --> 00:40:49,390
I was seeing somebody

782
00:40:49,390 --> 00:40:52,240
and this was my diagnosis for him

783
00:40:53,596 --> 00:40:55,192
before the summer

784
00:40:55,192 --> 00:40:57,612
and then when I returned to
work after my summer at Smith

785
00:40:57,612 --> 00:41:00,578
I had to submit a new diagnosis

786
00:41:00,578 --> 00:41:02,012
in the setting where I am,

787
00:41:02,012 --> 00:41:04,761
we changed quickly and this is what I put.

788
00:41:04,761 --> 00:41:07,615
Notice for schizophrenia
there's no more paranoid type,

789
00:41:07,615 --> 00:41:09,882
the types have been removed

790
00:41:09,882 --> 00:41:12,775
and there's none of the
psychosocial information

791
00:41:12,775 --> 00:41:13,810
included there.

792
00:41:16,306 --> 00:41:19,137
So I think that this is
probably the most drastic change

793
00:41:19,137 --> 00:41:21,863
in DSM-V and it has
significant implications

794
00:41:21,863 --> 00:41:24,104
for social work education.

795
00:41:24,104 --> 00:41:26,379
It's worth remembering
what the initial intention

796
00:41:26,379 --> 00:41:29,496
behind the multiaxial system was.

797
00:41:29,496 --> 00:41:32,297
DSM-IV-TR stated that
the multiaxial system

798
00:41:32,297 --> 00:41:36,293
"facilitates comprehensive
and systematic evaluations,

799
00:41:36,293 --> 00:41:40,137
"capturing complexity
of clinical situations

800
00:41:40,137 --> 00:41:42,850
"to describe the
heterogeneity of individuals

801
00:41:42,850 --> 00:41:45,709
"presenting with the same diagnosis."

802
00:41:45,709 --> 00:41:48,756
Its initial aims were even more bold.

803
00:41:50,273 --> 00:41:54,547
It was first introduced to
the APA by Dr. John Strauss,

804
00:41:54,547 --> 00:41:56,828
first in an article in 1975

805
00:41:56,828 --> 00:41:59,180
in the American Journal of Psychiatry

806
00:41:59,180 --> 00:42:03,030
and then with his formal
proposal to DSM-III

807
00:42:03,701 --> 00:42:05,444
task force.

808
00:42:05,710 --> 00:42:09,335
I met with Dr. John Strauss
recently at a cafe in New Haven.

809
00:42:10,020 --> 00:42:12,027
I asked him about what motivated him

810
00:42:12,027 --> 00:42:15,284
to suggest to the system that
would prove so significant

811
00:42:15,284 --> 00:42:18,923
to clinical practice and
theory for the next 33 years,

812
00:42:21,754 --> 00:42:25,146
and he also was eager to be a participant.

813
00:42:26,836 --> 00:42:28,957
- [John] This proves
that (audio distortion)

814
00:42:28,957 --> 00:42:33,689
face much more discrimination
(audio distortion)

815
00:42:35,629 --> 00:42:37,973
and what was gonna happen was that

816
00:42:37,973 --> 00:42:40,552
it was gonna be based on symptoms alone,

817
00:42:42,188 --> 00:42:44,194
so symptom complex.

818
00:42:44,997 --> 00:42:47,983
(audio distortion) a little
bit of grace thrown in

819
00:42:47,983 --> 00:42:52,174
then I was gonna be able
to make (audio distortion)

820
00:42:52,174 --> 00:42:56,975
local aspects if you (audio distortion).

821
00:42:58,417 --> 00:43:01,763
- It was initially referred
to as a multi-variable system

822
00:43:01,763 --> 00:43:06,047
in which each axis represented
a dependent variable

823
00:43:06,047 --> 00:43:09,053
influencing the person's
overall diagnosis.

824
00:43:09,053 --> 00:43:11,903
Strauss knew that you
could not simply tease out

825
00:43:11,903 --> 00:43:14,684
the different implications
of each axis, though.

826
00:43:14,684 --> 00:43:17,737
Each axis operated in dynamic ways

827
00:43:17,737 --> 00:43:20,340
in relation to the others.

828
00:43:20,340 --> 00:43:22,921
He ultimately worked with
social worker Janet Williams

829
00:43:22,921 --> 00:43:25,280
on the multiaxial system subcommittee

830
00:43:25,280 --> 00:43:27,045
to develop the system.

831
00:43:27,045 --> 00:43:29,491
Williams was also the chair
of the multiaxial system

832
00:43:29,491 --> 00:43:31,676
subcommittee for DSM-IV.

833
00:43:32,755 --> 00:43:35,290
When I met Strauss and
Williams, they both expressed

834
00:43:35,290 --> 00:43:39,296
extreme disappointment
about the multiaxial system

835
00:43:39,296 --> 00:43:41,502
and, really, they weren't
sure it was so bad

836
00:43:41,502 --> 00:43:43,296
that it was taken off, taken away,

837
00:43:43,296 --> 00:43:44,808
I was really surprised by that,

838
00:43:44,808 --> 00:43:47,033
I was kind of hoping
for a different story.

839
00:43:47,033 --> 00:43:50,784
But they both were pretty
disappointed in how it had worked.

840
00:43:50,784 --> 00:43:53,585
Strauss recalled that even
shortly after it was released

841
00:43:53,585 --> 00:43:55,792
as part of DSM-III,

842
00:43:55,792 --> 00:43:59,406
he would hear residents simply
listing information on the axes

843
00:43:59,406 --> 00:44:02,294
without thinking about
how the different domains

844
00:44:02,294 --> 00:44:04,429
were in interaction with each other.

845
00:44:04,429 --> 00:44:06,679
He reflected that over the three years

846
00:44:06,679 --> 00:44:08,445
he has noticed psychiatric residents more

847
00:44:08,445 --> 00:44:11,116
and more often conceptualizing
their diagnoses

848
00:44:11,116 --> 00:44:14,906
exclusively in terms of biology.

849
00:44:14,906 --> 00:44:17,766
Williams agreed that the
system had never worked

850
00:44:17,766 --> 00:44:19,550
as well as they had wanted,

851
00:44:19,550 --> 00:44:23,042
but said that at least
it pushed clinicians

852
00:44:23,042 --> 00:44:25,409
to use a biopsychosocial perspective

853
00:44:25,409 --> 00:44:27,412
at the diagnostic phase.

854
00:44:27,412 --> 00:44:31,233
When it comes down to it,
Williams really blames us.

855
00:44:31,233 --> 00:44:34,483
She blames social workers for
failing to advocate for it.

856
00:44:34,483 --> 00:44:37,848
- [Janet] And in part, it's our fault,

857
00:44:37,848 --> 00:44:39,186
in the mental health community,

858
00:44:39,186 --> 00:44:41,598
we didn't do enough with it.

859
00:44:43,271 --> 00:44:44,902
There weren't enough
people interested in it

860
00:44:44,902 --> 00:44:47,814
to really take it, and
I'm to blame as well,

861
00:44:47,814 --> 00:44:52,814
I could have done some
major research on multiaxial

862
00:44:53,540 --> 00:44:57,298
evaluation and maybe done some studies

863
00:44:57,298 --> 00:45:01,394
that would have demonstrated
how valuable it could be.

864
00:45:01,394 --> 00:45:03,826
I just didn't happen to
go in that direction.

865
00:45:05,175 --> 00:45:07,763
And social workers, I tried and tried

866
00:45:07,763 --> 00:45:10,006
but nobody seemed to be interested.

867
00:45:10,006 --> 00:45:13,594
It would have been a natural
area for social workers

868
00:45:13,594 --> 00:45:16,462
to step into and do research.

869
00:45:16,462 --> 00:45:18,928
- The influence of
biologism is also evidence

870
00:45:18,928 --> 00:45:21,972
in changes to the
conceptualization of schizophrenia

871
00:45:21,972 --> 00:45:26,070
and what is now in DSM-V
called Schizophrenia Spectrum.

872
00:45:26,070 --> 00:45:28,048
All of the subtypes of schizophrenia,

873
00:45:28,048 --> 00:45:30,661
paranoid, disorganized,
catatonic, undifferentiated,

874
00:45:30,661 --> 00:45:33,779
residual, have been removed in DSM-V

875
00:45:33,779 --> 00:45:35,658
because different
clinicians could never agree

876
00:45:35,658 --> 00:45:39,419
on which type a client really was.

877
00:45:39,419 --> 00:45:41,193
And because neuroimaging studies have been

878
00:45:41,193 --> 00:45:43,776
unable to show any consistent patterns

879
00:45:43,776 --> 00:45:47,762
of brain activation for people
within these subgroupings.

880
00:45:47,762 --> 00:45:50,393
Interestingly the whole idea
for schizophrenia subtypes

881
00:45:50,393 --> 00:45:52,878
began with Kraepelin's early work

882
00:45:52,878 --> 00:45:55,200
to distinguish categorical types using

883
00:45:55,200 --> 00:45:57,563
another biological construct.

884
00:45:57,563 --> 00:46:00,825
He and Bleuler, who would
later rename schizophrenia,

885
00:46:00,825 --> 00:46:03,567
were motivated to differentiate
forms of the syndrome

886
00:46:03,567 --> 00:46:06,108
because of their broader
belief that mental illness

887
00:46:06,108 --> 00:46:09,157
reflected racial degeneration.

888
00:46:09,157 --> 00:46:12,000
Both advocated for the
castration of people

889
00:46:12,000 --> 00:46:14,305
with some forms of schizophrenia

890
00:46:14,305 --> 00:46:17,257
and looked for examples of
their prototypical forms,

891
00:46:18,022 --> 00:46:21,871
these prototypical forms,
particularly among Jews,

892
00:46:21,871 --> 00:46:24,918
so this model of distinguishing
subtypes of schizophrenia

893
00:46:24,918 --> 00:46:28,285
continued all the way through DSM-IV-TR.

894
00:46:35,473 --> 00:46:37,211
With the new schizophrenia spectrum

895
00:46:37,211 --> 00:46:40,376
introduced in the DSM-V,
clinicians are encouraged

896
00:46:40,376 --> 00:46:43,028
to think across diagnostic categories

897
00:46:43,028 --> 00:46:44,907
associated with psychotic symptoms

898
00:46:44,907 --> 00:46:46,518
according to the following domains:

899
00:46:46,518 --> 00:46:49,481
Delusions, hallucinations,
disorganized thinking,

900
00:46:49,481 --> 00:46:51,334
grossly disorganized and abnormal,

901
00:46:51,334 --> 00:46:53,788
motor, behavior and negative symptoms.

902
00:46:53,788 --> 00:46:55,855
So students are going to be using a sheet

903
00:46:55,855 --> 00:46:57,489
that looks like this

904
00:46:58,944 --> 00:47:00,613
if their placements are using them,

905
00:47:01,612 --> 00:47:05,313
which they should be if
they're in compliance,

906
00:47:05,313 --> 00:47:07,576
so that they would actually be using this,

907
00:47:07,576 --> 00:47:12,576
right now it's in addition to
using a categorical diagnosis

908
00:47:13,331 --> 00:47:15,142
so you would diagnose the
person with schizophrenia

909
00:47:15,142 --> 00:47:17,437
but you'd have a somewhat
clearer picture of

910
00:47:17,437 --> 00:47:22,437
which symptoms are actually
prominent for the client.

911
00:47:23,555 --> 00:47:25,148
The addition recognizes, to some degree,

912
00:47:25,148 --> 00:47:27,404
that older categories
such as schizophrenia

913
00:47:27,404 --> 00:47:28,739
and schizoaffective disorder

914
00:47:28,739 --> 00:47:30,835
were always poorly differentiated

915
00:47:30,835 --> 00:47:32,572
and don't reflect new understandings

916
00:47:32,572 --> 00:47:35,297
from research and neurobiology,

917
00:47:35,297 --> 00:47:37,971
but it does not replace
old diagnostic categories.

918
00:47:38,960 --> 00:47:42,944
If clinicians use it, though,
it might make them obsolete.

919
00:47:42,944 --> 00:47:45,546
The fifth change that I
wanted to highlight is

920
00:47:45,546 --> 00:47:47,934
the beginnings of a
shift from a categorical

921
00:47:47,934 --> 00:47:50,215
to a dimensional diagnosis.

922
00:47:50,215 --> 00:47:53,253
Schizophrenia Spectrum
model is also an example

923
00:47:53,253 --> 00:47:55,221
of this fifth last change.

924
00:47:55,221 --> 00:47:57,477
The idea behind dimensional diagnosis

925
00:47:57,477 --> 00:47:59,994
is that each of us can be
assessed on different dimensions

926
00:47:59,994 --> 00:48:02,398
of cognitive and emotional functioning.

927
00:48:02,398 --> 00:48:05,546
While the categorical model
seeks to identify syndromes,

928
00:48:05,546 --> 00:48:08,791
or clusters of symptoms, for
example the schizophrenia

929
00:48:08,791 --> 00:48:13,382
cluster, a different dimensional diagnosis

930
00:48:13,382 --> 00:48:15,349
sidesteps the needs for syndromes

931
00:48:15,349 --> 00:48:18,363
by focusing on different
aspects of functioning.

932
00:48:18,363 --> 00:48:21,107
A really clear example of this is

933
00:48:21,107 --> 00:48:23,673
the Asperger's Spectrum Disorder

934
00:48:26,065 --> 00:48:29,375
which combines what
DSM-IV distinguished as

935
00:48:29,375 --> 00:48:31,738
Autistic Disorder, Asperger's Disorder,

936
00:48:31,738 --> 00:48:34,238
Childhood Disintegrative
Disorder, Rett's Disorder

937
00:48:34,238 --> 00:48:36,071
and Pervasive Developmental Disorder

938
00:48:36,071 --> 00:48:38,141
Not Otherwise Specified.

939
00:48:38,141 --> 00:48:40,377
The new diagnosis of
Autism Spectrum Disorder

940
00:48:40,377 --> 00:48:43,828
requires both deficits
in social communication

941
00:48:43,828 --> 00:48:48,201
and interaction and restricted
repetitive behaviors,

942
00:48:48,201 --> 00:48:50,673
interests and activities.

943
00:48:50,673 --> 00:48:54,695
Common APA explanations for
combining these diagnoses

944
00:48:54,695 --> 00:48:57,003
are that they are
inconsistently differentiated

945
00:48:57,003 --> 00:48:59,503
in clinical practice and
that child clinicians

946
00:48:59,503 --> 00:49:03,700
tended to overuse the diagnosis of PDDNOS.

947
00:49:03,700 --> 00:49:07,213
Removal of Asperger's
Disorder has been particulary

948
00:49:07,213 --> 00:49:09,838
charged, in part, because
many of the people

949
00:49:09,838 --> 00:49:12,362
have come to identify personally

950
00:49:12,362 --> 00:49:15,264
with that categorical distinction.

951
00:49:15,264 --> 00:49:17,413
I work in Boston,

952
00:49:18,872 --> 00:49:20,420
at a technical school in Boston,

953
00:49:20,420 --> 00:49:23,882
and work with a lot of
clients who were formerly

954
00:49:23,882 --> 00:49:25,748
diagnosed with Asperger's.

955
00:49:25,748 --> 00:49:27,899
A lot of them don't seem,
when I brought it up,

956
00:49:27,899 --> 00:49:30,024
a lot of them don't seem to care that much

957
00:49:30,024 --> 00:49:33,930
about the DSM-V, to be that
interested in the change,

958
00:49:33,930 --> 00:49:36,519
but they do take really, really seriously

959
00:49:36,519 --> 00:49:40,515
the possibility that their
new diagnosis would be autism.

960
00:49:40,515 --> 00:49:41,830
They've spent their whole lives,

961
00:49:41,830 --> 00:49:43,355
and their parents have
spent their whole lives

962
00:49:43,355 --> 00:49:46,330
telling people that they
do not have autism and now,

963
00:49:46,330 --> 00:49:48,728
because of this change,
they have something

964
00:49:48,728 --> 00:49:51,314
called Autism Spectrum Disorder

965
00:49:51,314 --> 00:49:53,780
so that's kind of an interesting shift.

966
00:49:57,902 --> 00:50:00,638
In addition to autism and psychosis,

967
00:50:00,638 --> 00:50:02,425
DSM-V includes dimensional models

968
00:50:02,425 --> 00:50:05,722
for diagnosing disability
and substance abuse.

969
00:50:05,722 --> 00:50:07,523
For a while it looked
like personality disorders

970
00:50:07,523 --> 00:50:09,317
were going to be reorganized

971
00:50:09,317 --> 00:50:12,050
with the dimensional
model in DSM-V as well,

972
00:50:12,050 --> 00:50:15,104
but they were faced with
very widespread criticism

973
00:50:15,104 --> 00:50:17,916
from the working group and
instead proposed a hybrid

974
00:50:17,916 --> 00:50:20,137
categorical dimensional model

975
00:50:20,137 --> 00:50:22,432
which then seemed too unwieldy

976
00:50:22,432 --> 00:50:24,406
and it was placed in
the section of the book

977
00:50:24,406 --> 00:50:26,163
designated for further study

978
00:50:26,163 --> 00:50:27,733
and no substantial changes were made

979
00:50:27,733 --> 00:50:30,624
to personality disorders this time.

980
00:50:30,624 --> 00:50:34,781
I think most people agree
that those changes are coming,

981
00:50:34,781 --> 00:50:39,042
and probably with DSM-V.I,
they seem to be soon.

982
00:50:45,997 --> 00:50:48,180
Taking into account all of these changes

983
00:50:48,180 --> 00:50:50,009
and the history of the DSM,

984
00:50:50,009 --> 00:50:53,060
we are ultimately left how to use it.

985
00:50:58,495 --> 00:51:01,893
When I spoke to Dr. Strauss,
he felt that neither accepting

986
00:51:01,893 --> 00:51:06,725
nor dismissing the DSM entirely
would solve any problems.

987
00:51:09,220 --> 00:51:11,520
- [David] So are you,

988
00:51:11,520 --> 00:51:14,034
do you consider yourself
anti-diagnosis now?

989
00:51:14,034 --> 00:51:18,124
- [John] No, I think that I understand,

990
00:51:18,124 --> 00:51:20,784
I mean I think there's a need for that.

991
00:51:22,966 --> 00:51:27,306
But my feeling for a lot
of concepts in psychiatry

992
00:51:27,306 --> 00:51:29,548
is that they're okay but you

993
00:51:29,548 --> 00:51:31,346
shouldn't believe them too much.

994
00:51:33,051 --> 00:51:36,329
It's all right to use them but not to make

995
00:51:36,329 --> 00:51:39,410
a lot of decisions based on them.

996
00:51:39,410 --> 00:51:41,635
And that they're the best we can do

997
00:51:41,635 --> 00:51:43,774
until we know more of what's going on.

998
00:51:43,774 --> 00:51:48,417
And that's what NIMH now
is doing with the biology,

999
00:51:48,417 --> 00:51:53,417
I think I'm not so naive
anymore, but I think they are.

1000
00:51:53,878 --> 00:51:56,142
They're saying, "Okay, we're
going to look at the brain

1001
00:51:56,142 --> 00:51:59,130
"because then we're going
to find the basic processes.

1002
00:51:59,130 --> 00:52:01,847
I don't think it's going to be that easy.

1003
00:52:05,266 --> 00:52:07,617
I think that's one of the
exciting things about the field,

1004
00:52:07,617 --> 00:52:12,342
and difficult things, is
that, in ways we don't even

1005
00:52:12,342 --> 00:52:16,756
suspect, it really is biopsychosocial.

1006
00:52:16,756 --> 00:52:21,756
And we're constantly trying
to find the one thing

1007
00:52:22,992 --> 00:52:24,932
that will sort out everything.

1008
00:52:24,932 --> 00:52:27,661
And I don't think we're going to find it.

1009
00:52:27,661 --> 00:52:32,478
We're dealing with a
complex interactive system.

1010
00:52:32,478 --> 00:52:35,666
- For Strauss, the
overreach of neurobiologists

1011
00:52:35,666 --> 00:52:38,817
parallels the reductive nature of the DSM

1012
00:52:38,817 --> 00:52:42,604
but we will need to think
critically about both, and more,

1013
00:52:42,604 --> 00:52:44,868
to make progress and provide better care

1014
00:52:44,868 --> 00:52:47,133
for our clients.

1015
00:52:47,133 --> 00:52:48,385
The approach that I was taught

1016
00:52:48,385 --> 00:52:50,993
when I was doing my MSW at NYU

1017
00:52:50,993 --> 00:52:53,804
was to quickly assign
the least stigmatizing

1018
00:52:53,804 --> 00:52:57,137
diagnosis that would still
get the client services

1019
00:52:57,137 --> 00:53:00,493
and then to never think about it again.

1020
00:53:00,493 --> 00:53:04,124
I learned DSM diagnosis
as a necessary evil

1021
00:53:04,124 --> 00:53:07,432
that should be systematically disavowed

1022
00:53:07,432 --> 00:53:10,516
but this isn't always so neatly achieved.

1023
00:53:10,516 --> 00:53:12,744
Social workers Kirk and Kutchins studied

1024
00:53:12,744 --> 00:53:16,665
how social workers used
the DSM in the 1990's

1025
00:53:16,665 --> 00:53:19,270
finding widespread and pervasive patterns

1026
00:53:19,270 --> 00:53:22,540
of underdiagnosis and overdiagnosis.

1027
00:53:22,540 --> 00:53:25,300
Clinicians justified
underdiagnosis by saying

1028
00:53:25,300 --> 00:53:28,476
they were protecting their
clients from labeling stigma.

1029
00:53:28,476 --> 00:53:31,157
At the same time, they also
seemed to underdiagnose

1030
00:53:31,157 --> 00:53:35,176
in order to limit admissions
to overburdened programs

1031
00:53:35,176 --> 00:53:37,973
or hospitals and otherwise
deny the obligation

1032
00:53:37,973 --> 00:53:39,802
to provide care.

1033
00:53:39,802 --> 00:53:42,422
They justified overdiagnosis,
on the other hand,

1034
00:53:42,422 --> 00:53:45,170
as helping their clients
to gain access to services

1035
00:53:45,170 --> 00:53:46,690
they thought they needed.

1036
00:53:46,690 --> 00:53:49,940
I suspect that these
patterns still persist.

1037
00:53:49,940 --> 00:53:52,736
Even students in their
first summers at Smith

1038
00:53:52,736 --> 00:53:56,013
often ask in my class
whether they should lie

1039
00:53:57,382 --> 00:54:01,523
about the symptoms that a
client is presenting with,

1040
00:54:01,523 --> 00:54:03,087
whether to protect them from labeling

1041
00:54:03,087 --> 00:54:05,587
or to get them services.

1042
00:54:05,587 --> 00:54:08,299
I hear in this temptation to cut corners

1043
00:54:09,346 --> 00:54:11,703
something developmental.

1044
00:54:11,703 --> 00:54:14,110
It seems to convey that the
frustration about the limits

1045
00:54:14,110 --> 00:54:15,812
of one's power

1046
00:54:15,812 --> 00:54:19,641
(repeats same words again)

1047
00:54:19,641 --> 00:54:21,299
in a very difficult system,

1048
00:54:21,299 --> 00:54:23,961
a kind of anxious grandiosity.

1049
00:54:23,961 --> 00:54:27,473
But lying, perhaps especially
when well-intentioned,

1050
00:54:27,473 --> 00:54:30,654
only perpetuates the
problem and prevents us

1051
00:54:30,654 --> 00:54:35,340
from developing integrative
approaches as a field.

1052
00:54:35,340 --> 00:54:38,590
Barbara Probst, who teaches
in the doctoral program here,

1053
00:54:38,590 --> 00:54:40,582
found in her recent qualitative study

1054
00:54:40,582 --> 00:54:43,340
that senior clinicians
today have a difficult time

1055
00:54:43,340 --> 00:54:46,988
balancing DSM diagnosis
in clinical practice.

1056
00:54:46,988 --> 00:54:49,894
They felt that that two-step
process of using the DSM

1057
00:54:49,894 --> 00:54:52,130
to give a diagnosis and then using their

1058
00:54:52,130 --> 00:54:54,201
theoretical training
to conceptualize a case

1059
00:54:54,201 --> 00:54:58,248
more holistically felt
like "walking a tightrope".

1060
00:54:58,248 --> 00:55:00,245
In another illuminating study, however,

1061
00:55:00,245 --> 00:55:02,855
Probst also found that
clinicians feel less conflicted

1062
00:55:02,855 --> 00:55:06,133
about using diagnoses in
cases of gross impairment,

1063
00:55:06,133 --> 00:55:07,894
such as schizophrenia.

1064
00:55:07,894 --> 00:55:10,379
For them, they don't feel so troubled.

1065
00:55:10,379 --> 00:55:12,962
This reminds me of Wakefield's
idea that we should distinguish

1066
00:55:12,962 --> 00:55:15,955
true mental illness from normal problems,

1067
00:55:15,955 --> 00:55:19,229
a distinction which I
find really troubling.

1068
00:55:19,229 --> 00:55:23,178
If senior clinicians find this
sort of balancing act hard,

1069
00:55:23,178 --> 00:55:27,105
I can only imagine what it
is like for our students.

1070
00:55:27,105 --> 00:55:30,595
In some cases, it might
contribute to a sense of splitting

1071
00:55:30,595 --> 00:55:33,579
between clinical internships
and the classroom.

1072
00:55:33,579 --> 00:55:35,404
Students are learning
sophisticated assessment

1073
00:55:35,404 --> 00:55:38,398
and practice models from
us but in the field,

1074
00:55:38,398 --> 00:55:41,372
they're rarely getting
to use these constructs

1075
00:55:41,372 --> 00:55:44,734
unless they're completing an
assignment with their FFA.

1076
00:55:44,734 --> 00:55:47,390
For many students, this
creates a disjunction

1077
00:55:47,390 --> 00:55:48,889
in their learning.

1078
00:55:48,889 --> 00:55:51,215
We hope that they find
ways to integrate them

1079
00:55:51,215 --> 00:55:53,743
but many may not and
their islands of learning

1080
00:55:53,743 --> 00:55:56,357
remain separate and
don't inform each other.

1081
00:56:00,266 --> 00:56:03,426
In the class that I teach on
Biopsychosocial Assessment,

1082
00:56:03,426 --> 00:56:06,676
we're constantly working
with Joan to think about

1083
00:56:06,676 --> 00:56:09,489
how to situate the DSM, and now the DSM-V,

1084
00:56:09,489 --> 00:56:12,099
next to biopsychosocial perspectives

1085
00:56:12,099 --> 00:56:14,006
and psychodynamic theory.

1086
00:56:14,006 --> 00:56:16,258
This is really difficult,
it's a very challenging

1087
00:56:16,258 --> 00:56:19,520
balancing act and a lot of
other people have important

1088
00:56:19,520 --> 00:56:22,550
feedback on how we should be doing it.

1089
00:56:22,550 --> 00:56:25,681
We're aiming for a comparative
and critical approach,

1090
00:56:25,681 --> 00:56:28,593
ultimately all theoretical
and research constructs

1091
00:56:28,593 --> 00:56:30,186
are problematic.

1092
00:56:30,186 --> 00:56:34,170
Comparison, reflexivity
and critique are integral

1093
00:56:34,170 --> 00:56:35,927
to good assessment work.

1094
00:56:35,927 --> 00:56:37,532
Teaching an integrative approach

1095
00:56:37,532 --> 00:56:39,408
has become all the more important

1096
00:56:39,408 --> 00:56:41,878
with the removal of the multiaxial system.

1097
00:56:45,201 --> 00:56:48,790
In conclusion, I think
although we might feel it less

1098
00:56:48,790 --> 00:56:51,496
on this campus, there's a lot
of pressure for clinicians

1099
00:56:51,496 --> 00:56:54,525
in hospitals, schools and
community based agencies

1100
00:56:54,525 --> 00:56:57,470
to passively accept DSM-V as a fact,

1101
00:56:57,470 --> 00:56:59,656
as something natural.

1102
00:56:59,656 --> 00:57:03,227
In engaging with the DSM-V,
we have the opportunity

1103
00:57:03,227 --> 00:57:07,496
to help students develop
a pragmatic approach

1104
00:57:07,496 --> 00:57:10,281
working within a difficult
system while maintaining

1105
00:57:10,281 --> 00:57:13,270
a critical perspective
informed by research

1106
00:57:13,270 --> 00:57:15,323
and clinical and social theory.

1107
00:57:17,536 --> 00:57:18,877
Thank you.

1108
00:57:18,877 --> 00:57:23,877
(audience applauds)