- I'm really excited to be talking about DSM-V today
and I have a lot to say about it, actually,
so I'm gonna talk for about 50 minutes, 45, 50 minutes
and then for the second half of our time
we're going to break up into small groups
and talk about some of those questions that
I gave you beforehand in the packets.
There is so much diversity
and difference of opinion within this room,
a lot of strong views about the DSM in this room,
I think, and so I'm really excited to get to that,
to hear where that conversation goes
because I think that's really important for our students
and their experience.
But the task that I was given for today
was to present on some of the changes to DSM-V
that seem particularly meaningful for clinical social work
education across the curriculum,
so that's in research, in practice,
in faculty field advising, in theory and in policy.
The APA has released an official list of
what they consider highlights of the changes
and I included that in your packet as well.
So I'm not gonna go through all of them,
this is not gonna be an exhaustive training
of all of the changes in the DSM-V.
Instead, what I'm going to do is I'm going to
really highlight five conceptual changes that I think
have particular meaning for clinical social work education.
Sometimes, especially relevant for Smith
and sometimes more broadly.
The five changes that I'm gonna be focusing on are,
first, this is the first DSM that actually uses
the word "racism", it's the very first one.
It acknowledges race and racism
and it re-emphasises cultural formulation,
so I'm going to be talking about that in particular
with reference to the PTSD diagnosis,
I'm talking about, sort of, more work to come.
Secondly, new conceptualizations of disability,
there is the beginnings of a reformulation happening,
especially, I'll point your attention to the new diagnosis
of intellectual disability, which replaces MR.
Third, there's a further loosening of
the definition of mental disorder.
A lot of people are saying with each new successive DSM
they get bigger and more and more of us
can find ourselves in it.
(audience chuckles)
This raises the question as to what, really,
is a mental disorder?
Fourth, a very, very powerful influence of biologism
that I think is very important for us in the field
and us as educators to notice,
in particular, the removal of the multi-axial system
which I'm going to spend some time on today
and also in some of the changes to schizophrenia.
And then fifth, there's the beginnings,
it'll be interesting to look at the beginnings of a shift
from a categorical to a dimensional model of diagnosis
and I'll point your direction specifically to
Autism Spectrum Disorder,
although there are other examples.
So, I'm going to start off by situating
these five changes historically and conceptually
and I think that the history is really important.
I'm going to be focusing on DSM-III
but hopefully giving you some rich history there.
Then we'll talk about those five changes
and then, fourth, I'm going to talk about some conclusions
that I'm taking from thinking about this,
about what I think-- sort of, the awkward position
that many of our students are in with regard to DSM-V.
That's not just for Smith students but for
social work students, broadly and perhaps
in some specific ways for Smith students
that the DSM can be a very awkward tool to use.
The British philosopher Ian Hacking,
who you read for today,
has famously argued that psychiatric symptomatology
is shaped and takes on new meaning
once it is designated with a label.
Others, such as Thomas Szasz,
have said that labels create symptoms,
but this is not what Hacking is saying.
Hacking was saying that symptoms come
to fit the boxes we built for them.
In his 1998 book charting the invention
of European understandings of fugue states,
Hacking observes that what had been
a few isolated incidents of people wandering the countryside
became an epidemic of fugue states.
After it made it into the media and people began
to try to understand it scientifically.
He writes that Western belief in science
"changes how we think of ourselves,
"the possibilities that are open to us,
"the kinds of people that we take ourselves
"and our fellows to be."
For Hacking, the diagnosis makes the type of variant
experience intelligible in the social realm,
where it takes on some new life.
In the essay you read for today,
he referred to this theory as "making up people"
and applied it to Dissociative Identity Disorder
and to Autism.
I really think that this could be applied
to any of our descriptive diagnoses.
All DSM-V diagnoses are technically syndromes.
This is to say, they're not etiologically-based
but rather describe clusters of symptoms
that seem to go together.
So I often encourage students to think about this
in terms of constellations of stars.
From where we're sitting, they look like they go together,
they seem to move together as time passes each night
so their correlation appears obvious.
Some stars are, indeed, interrelated by forces of gravity
but most only look close together
because we see them in a two-dimensional way.
If we were looking from another planet, for example,
we might see the same stars
but not the same constellations.
Mental Disorder Syndromes are even less convincing
than constellations.
The syndrome we call schizophrenia, for example,
includes clusters, symptoms, positive symptoms
like hallucinations and delusions
and negative symptoms, like the flattening of affect.
I was first disillusioned with descriptive diagnoses
in my first year as a clinical social worker
just after I finished my MSW,
when I worked in a program in Brooklyn
running a very popular group for
grandparents with schizophrenia
and I remember gripping my DSM-IV
and trying as hard as I could to make accurate diagnoses
for types of schizophrenia,
trying to fit people into these types
and there was so much diversity within the types
and within even the peoples' experience of symptoms
that the categories themselves really proved
meaningless to me,
and this as a student--
someone just having finished my MSW,
this was incredibly frustrating to me
that I couldn't actually make these work,
these constructs that are supposed to be natural.
These descriptive diagnoses, nevertheless,
have tremendous power.
If you ask people if schizophrenia is real,
they're likely to say, "Yes, of course it is,"
and if you ask them what a syndrome is,
they're not likely to know what you're talking about
or they don't know exactly what that means.
The DSM has not always relied on this idea of syndromes
and its aims were initially much smaller in scope
than it is presently.
The APA published the first DSM in 1952.
Its purpose was to bring together, and standardize,
disparate systems of psychiatric diagnosis
developed by psychiatrists in the military, veterans affairs
and the National Committee on Mental Hygiene.
So before this, there were, really,
three very different nomenclatures
and one of the major problems
is that it was impossible to do epidemiological work.
If you didn't have the same nomenclature
then you couldn't be sure that you are actually
keeping statistics for everyone that was diagnosed
with something like schizophrenia.
It was initially, one of the main aims for it
was to standardize so that you could keep
accurate statistics.
DSM-II is only a slight revision over DSM-I in 1968.
Both of them were primarily used
in psychiatric hospitals in the military.
They didn't have the same pervasive or direct influence
on social work that DSM-III would later have in the 1980's.
Part of that is because they weren't considered
exhaustive encyclopedias of mental disorders.
They were not supposed to fully explain
how the disorder itself would manifest in an individual.
They were primarily informed by psychoanalytic theory
which put strong emphasis on individualized manifestations
of underlying conflict,
so it was really just a guide for how to think
about individual manifestations.
This had some advantages and a lot of problems.
The permeable definitions of mental disorders
led to many problems in large scale practice.
Many of you will be familiar with David Rosenhan's
very famous study on being sane in insane places,
published in the Journal of Science in 1973.
It received national attention when he had eight
research participants go into psychiatric hospitals
reporting once, or very briefly, auditory hallucinations
and I think all of them were held inpatient
for an average of 19 days
and not allowed to leave until they started on medication.
None of them reported any psychiatric problems
after the initial complaints.
The study, when it came out,
the study has been critiqued on a number of ways
by a number of--
a number of important ways
but when the study came out in the 70's,
it added a lot of power to the anti-psychiatry movement
and the 1970's was really a time
when most people think of psychiatry as under siege.
In the same year that Rosenhan's study came out,
the APA voted to remove homosexuality
as a diagnosis in DSM-II
and then they voted to revise DSM-II only five years
after it was put out,
so there was a sense of crisis,
at least as people talk about it.
DSM-III, released in 1980, was a triumph
of the descriptive psychiatry movement.
The modern descriptive psychiatry model
has its roots with German psychiatrist Emil Kraepelin,
who in the late 19th century identified dementia praecox
and bipolar disorder and differentiated them.
Dementia praecox is what would later be called
by Bleuler, schizophrenia.
But what Kraepelin did was he distinguished
these two syndromes as syndromes
based on their symptoms.
The descriptive model developed slowly in the U.S.
but very marginalized over the 20th century,
it developed mostly among a small group of psychiatrists
in the 1960's that were called the St. Louis Group,
they were all based at Washington University.
It can't be underscored, really, how DSM-III
seemed to come out of nowhere,
at least if you talk to people who were involved with it.
It removed all ideological theory,
focusing instead entirely on clusters of symptoms
that seemed to go together to create syndromes.
Concepts that didn't fit this descriptive model,
such as neuroses, were simply discarded.
It revolutionized diagnostic work
and very quickly pushed other models to the margins.
The system of descriptive diagnosis seems so familiar now
that it's hard to imagine what it was like before.
The explosive success of DSM-III can be attributed,
in large part, to the work of task force chair,
psychiatrist Robert Spitzer
and social worker Janet Williams, who would later marry.
(audience laughs)
Together they served on almost every committee.
Spitzer served on 12 of the 18 DSM-III committees,
Williams served on four,
she was also the text editor for the entire DSM-III
and she was coordinator of field trials for DSM-III.
I got to meet Janet Williams recently
at her home in Princeton
and she explained to me that part of the reason
that they were able to make such
significant changes with DSM-III,
a really bold project,
was because no one was paying attention
to what they were doing. (audience laughs)
No one had any idea.
She described just working,
really in isolation, in their office
at the Psychiatric Institute in New York
and that she and Robert Spitzer were
really allowed to do what they wanted.
So she gave me permission to use
bits of our conversation I want to share with you.
- [Janet] When we started it, we had no idea
how significant it was going to be,
no idea whatsoever.
And its significance even seems to even seems to grow
with every passing year
as we get new findings and all,
I mean, what a fabulous
insight, I don't know if insight is the word,
vision, I think Bob had a vision
to create,
to define every mental disorder so that people could
at least agree on the definitions and study them
and then change them based on the evidence,
so that it was going to be--
the diagnosis would be evidence-based
instead of touchy-feely
Oedipus complex and whatever else,
underlying reactions.
It was very important that it was atheoritical
so we realized people could agree
on what these disorders look like,
they couldn't agree on how they came about
or how to treat them.
So you don't have to have an agreement on those things
in order to define them.
So that was really important
and along the way, involved a lot of struggles
appeasing the psychoanalytic community mainly,
that was very powerful at the time.
When we eliminated neurotic depression,
they didn't care for that. (laughs)
- As Hacking describes, diagnostic constructs
have organized difference since the 19th century
but I think this effect has become
much more powerful since DSM-III.
It was quickly tied to insurance reimbursement
and, not coincidentally, became the standard diagnostic
system, not only for psychiatry
but also for psychology and clinical social work.
It also subsumed other models of assessment.
Since the release of the DSM, social workers
and others in related fields have continued to develop
other models of assessment,
like contemporary, psycho-dynamic inspired models,
person-in-environment, for example,
but none of these has had the organizing influence
or range of the DSM since this third edition,
and part of this is rhetorical.
In part it's because the DSM-III was represented as
"atheoretical" and "all-encompassing".
DSM-V released last May is really, I think,
an iteration of DSM-III.
Many of the changes to diagnostic criteria
simply reshuffle and recategorize.
It was developed over the course of six years
with unprecedented effort to make
the revision process transparent
and open to public comment and scrutiny.
But when it was released, it met with little fanfare
outside of the APA.
One week before its release,
the director, many of you must know this,
the director of NIMH, Dr. Thomas Insel,
called the DSM-V "scientifically invalid".
According to Insel, DSM-V does not reflect
the latest findings from neurobiology
and research aimed at validating DSM-V categories
is just further misdirection.
He therefore announced that NIMH
would no longer fund research guided by DSM-V categories.
Other controversial charges were also widely criticized
by clinical researchers, advocacy groups
and professional organizations
in the U.S. and international
but the APA is celebrating. (snickers)
It's celebrating it as, I think in realistic terms,
as a pragmatic step forward.
Here's an interesting video that was released
just after the annual program meeting in San Francisco
in May, 2013, as part of the official launch of DSM-V.
(silence)
I'm gonna be a little mean about it,
(audience laughs) I just wanna preface that.
- [Voiceover] Feel free. (everyone laughs)
Their song, "Hello DSM-V", part of the official launch
of the new edition
raises a lot of questions for me.
I'm gonna use a Freudian analysis, of course,
to suggest that the humor here is repressing something.
(audience laughs)
They're clearly asking us to forget the past,
to forget previous editions of the DSM,
to accept this new version as natural,
to memorize it and to own it.
I have a very different hope for DSM-V
especially in social work education.
I think that the new edition brings with it
a precious moment when the constructedness
of the document is so plainly evident.
Rather than saying, "Goodbye DSM-IV"
and so-long to the controversy,
which was quite intense and still is,
I think, instead, we need to use this opportunity
to consider how the DSM has been organizing our thinking
and to demonstrate for our students that the DSM
is not a bible, and that it's not--
just having the word "statistical" in it
doesn't make it thoroughly scientific.
(audience chuckles)
At the same time, at the present, this is the system
that many of us need to continue to work within
and many of our students need to work with it.
The changes in the DSM-V, whatever we think of them,
inevitably have very far reaching implications.
So let me get to those five major changes now in the DSM-V.
Some of these changes are widely talked about
and I'll mention them when they are
and some of them have received
little to no attention so far.
One that I can't find any mention of yet
is the fact that, as I said before, this is the first DSM
to use the word "racism".
It's the first, also, to meaningfully acknowledge race
at all, as a social identity.
The change has received no attention so far
but it certainly has the potential to make a difference,
albeit symbolic.
So I wanna
show you a bit--
this is part of what's included in DSM-V
and I'm just going to focus your attention to
the last line here.
"There is evidence that racism can exacerbate
"many psychiatric disorders, contributing to poor outcome,
"and that racial bias can affect diagnostic assessment."
This is not mind-blowing,
this is not earth shattering
but it has a big impact, I think,
that this is suddenly, or not suddenly,
after a lot of work it is appearing in DSM-V.
One thing to note, of course, you'll notice it's Page 749
and it's tucked away in the long and often very thoughtful
narrative pages of the DSM that people don't often read
and so I think it's important that we be directing
peoples' attention to those pages
that people don't often read because it's often
where the writers are very thoughtful and nuanced.
Many clinicians had hoped, though, that DSM-V
would identify some version of race-based trauma,
to recognize when a person develops symptoms
consistent with PTSD
following the insidious racist microaggressions over time.
One avenue for this might have been, people say,
through the recognition of complex PTSD.
In complex PTSD there are multiple life-threatening
stressors in early life.
Complex PTSD was not accepted into DSM-V though
and regardless, I don't think that it would have taken
well enough into account microaggressions,
which are usually more subtle than what Judith Herman
was talking about with complex PTSD.
Others are saying that PTSD, the changes to PTSD
are perhaps more inclusive of what could be--
of race-based trauma,
it's pointing out that PTSD itself is a bit more complex.
In particular, the exposure criterion can occur
through repeated interaction with aftermath of a trauma.
This is intended, really, for first responders
who may, as a way of conceptualizing,
how they have repeated exposure to
the details of a trauma
but it might be used more broadly to talk about
how children or adults live with perpetual violence.
The other, the subjective reaction criteria,
a reaction of fear, helplessness or horror
has been removed in DSM-V
because some of the studies say that
professional responders might not have those reactions,
they've sort of been trained out of them.
It's possible that this change is also going to make PTSD
more culturally sensitive and inclusive.
DSM also contains a definition of culture
for the very first time.
The DSM-IV talked about culture a great deal
but, and there was a whole discussion of
culture-bound syndromes brought in by DSM-IV
but this is the first one that defines what culture is.
I'm not going to go through the whole thing
but I'm going to just point out two lines from it
that I think are significant.
One is that cultures are open, dynamic systems
that undergo continuous change over time,
and secondly, most individuals are exposed
to multiple cultures.
So this is a very interesting language
to talk about culture that is, I think, much more nuanced
and seems to convey some integration
of post-colonial theory.
There's also-- you see a little corner of it here,
there's also a new Cultural Formulation Interview,
which is an expression of the outline
for cultural formulation, which was in DSM-IV-TR.
There's still a glossary of culture-bound syndromes
but it's been renamed "The Glossary of Cultural Concepts
"of Distress," but there have been no changes
other than the change in the title.
It lists examples such as ataque de nervious,
which is an example of trembling and screaming
as it's understood in some Latin-American contexts.
Putting some diagnoses such as ataque de nervious
in a glossary separate from panic disorder,
which has a diagnostic code, still suggests
that one is based in culture and the other in science.
Still, the CFI, I think,
it has some potential for reconceptualizing culture
in a more relational and dynamic way.
It might help to complicate the picture for clinicians
and students in the field.
The second change I want to bring your attention to
is a reconceptualization of disability.
DSM-V articulates a new understanding of disability,
no longer referring only to a discreet trait of impairment
but now also to the psychosocial impacts
of the impairment for the individual.
I don't think many of the members of the subcommittee
were reading Judith Butler
but the change reflects her point that,
"Disability is the social organization of impairment."
The shift is demonstrated most meaningfully
in the new diagnosis of intellectual disability,
which has finally replaced the old diagnosis of MR
and advocacy for this change has been happening
for at least 20 years.
The diagnosis of MR was based on IQ scores
whereas the diagnosis of intellectual disability
is based on both IQ scores
and adaptive functioning together.
Further, the severity specifiers,
mild, moderate and severe
will no longer be based on IQ scores at all,
they'll be based on the person's "adaptive functioning"
in three different domains:
Conceptual thinking, such as problem solving,
social interaction, such as communicating with others
and thirdly, practical abilities such as navigating
a grocery store, managing money or attending school
or going to a community program.
The theoretical implications of this shift should mean
that disability broadly is more and more recognized
as informed by the social setting.
Some groups and settings will increase disabilities,
some will expand abilities
but a diagnosis should no longer be based
on the individual alone.
So I think that this has the potential
to be a significant change.
Change three, a further broadening, or loosening,
of the definition of mental disorder.
This third change is one that has been
pretty widely talked about within academia
and a little bit in popular media.
Rather than just calling it a change,
it's probably more accurate to say that
several small changes in DSM-V that continue a trend
that's been happening since DSM-III.
It's largely the effect of APA's endeavor
to be comprehensive, to catalog all mental disorders.
To use another space metaphor,
this way of thinking is a little bit like space cartography,
it's like all you have to do is discover
these new diagnoses, they're out there if we can find them,
because they are fixed and immutable.
We just have to draw maps that are better.
One example of a new discovery
is Disruptive Mood Dysregulation Disorder,
which is a diagnosis that can now be assigned
to children between the ages of six and 18,
when they demonstrate a pattern over 12 months
of outbursts of mood that seem developmentally
inappropriate, such as shouting
at least three to five times per week,
and also, irritability between outbursts
in multiple settings.
The new diagnosis is very similar to
intermittent explosive disorder,
which was added in DSM-III,
except that intermittent explosive disorder
does not require irritability between outbursts
and only needs to be observed for three months
as opposed to 12 months.
(audience snickers)
It's also similar to oppositional defiant disorder
which is characterized more
by angry resistance to authority.
The new DSM-V diagnosis has been very controversial
because it's actually not based
on any published findings distinguishing it
from the other childhood behavioral disorders.
The most prominent justification, in fact,
has been a political one.
Creating this new diagnosis is supposed to
stop the tide of diagnosing childhood bipolar disorder.
Childhood bipolar disorder exploded in the 1990's.
It's gotten a huge amount of attention
because the Harvard psychiatrist who first published
on the treatment of childhood bipolar disorder,
Biederman at Harvard,
was later found to have been receiving large sums
of money from Johnson & Johnson,
(sparse laughter in the audience)
and not fully reporting his earnings to the--
or his consultation fees, to the university.
This has had enormous consequences.
Just looking at--
this is from a study, a 2007 study
of rates of psychiatric discharges for children,
children who were hospitalized for treatments
related to bipolar disorder,
so you'll see it in 1996, the rates are fairly
close together and quite low
and by 2004, you'll see that they have risen
particularly for those blue lines,
the solid blue lines are African-American boys
and the dotted blue line is African-American girls.
So the new diagnosis of disruptive mood disregulation
is supposed to correct this problem
but I'm really not sure how.
I don't think it's likely to make a difference
for psychotherapy treatments with children and families
and it's probably even less likely that it will lead
to changes in pharmaceuticals prescribed.
If anything, the new diagnosis lowers the threshold
and will likely lead to even more widespread prescribing.
Another example of ADHD,
ADHD has been expanded further in DSM-V.
In DSM-IV, it required onset of related symptoms
by seven years old.
DSM-V now requires it only by 12 years old.
Secondly, ADHD can now be diagnosed in adults
by meeting only five of the symptom criteria,
when six were required for children.
In previous editions,
adults were not really widely recognized
by ADHD diagnoses.
There was the residual type
but DSM-V broadens explanations of symptoms
to include adult-specific presentations.
So for example, they gave this ...
(audience snickers)
I think really cute example,
the symptoms that--
one symptom is that people lose things
(audience laughs)
and so, in DSM-IV it gave examples like,
"You might lose your toys, school assignments,
pencils, books, tools",
in DSM-V it just continues the list to also,
"wallets, keys, paperwork, eyeglasses, mobile telephones",
so it's a much more inclusive diagnosis now.
A lot of attention has been given to the change
in major depressive disorder in the same way.
DSM-IV specified that the diagnoses was not indicated
if the client had been grieving for two months or less.
DSM-III said that the major depressive disorder
is not indicated
(pauses and repeats same words)
if better accounted for in uncomplicated bereavement,
which was classified as a V code in DSM-III,
meaning that it was not considered a disorder.
Many feel this change will lead to the pathologization
of normal grief,
basically what they've done is they've removed
the grief exclusion, some people are worried
that this is pathologizing normal grief.
This might be true but I'm not sure, entirely, about it.
I think DSM-V still encourages clinicians to differentiate
between grief and a major depressive episode.
The change simply means that you can be diagnosed
with a depressive episode when you are also grieving
but it doesn't necessarily mean that you should,
and that might be a distinction that we want to raise.
(chuckles)
This has been-- a lot around this issue of expansion
of diagnosis and expansion of mental disorder
is talked about by Jerome Wakefield,
who is a professor at NYU School of Social Work.
He's written prolifically on the problem of
how APA defines mental disorder.
Since the 1990's, he's famously proposed a new definition
of mental disorder, which is often cited
in the medical and psychology literature
but not very well engaged with in social work.
He calls it the disorder as
harmful dysfunction definition.
By harmful, he means it has a negative impact
on the person's adaptive functioning.
By dysfunction, he means it's a failure of an internal
mechanism to perform a natural function
for which it was assigned
in the context of evolutionary biology.
When Wakefield refers to natural functioning,
he means mental mechanisms that he believes
help humans to thrive when operating naturally,
such as cognitive abilities and affective states.
This is kind of similar to where a lot of
attachment theory is going,
like theories of healthy attachment.
His broader point is that real "mental disorders"
indicated by gross dysfunction
should be neatly and clearly differentiated
from normal difficulties of life,
and that rather than trying to classify more problems
as disorders, which has been sort of on the agenda,
social workers should be trying to get insurance companies
to reimburse for counseling for normal problems, too,
such as grief counseling.
It's interesting to me that social workers don't engage more
with Wakefield's argument.
I understand where it's coming from
but I think it should really be raising controversy.
Smith students often, very forcefully reject
these kinds of distinctions between health and illness.
This reflects the influence of classical
psychodynamic theory, a reverberation of Freud's arguments
in psychopathology of every day life,
that living in society makes us all a bit neurotic
and guilt-driven, and complicated
and that the boundaries between the normal
and the abnormal are unstable and dynamic.
Joyce McDougall , who I adore,
she's a French psychoanalyst,
she elaborated on this point most convincingly
when in 1978 she wrote,
"My colleagues have never appeared to me eminently normal,
(audience laughs)
"as for myself, I feel quite at home with them."
(audience laughs)
She went on, "For analysts to speak of normality
"is like trying to describe the dark side of the moon,
"we can imagine it, of course, even send up a rocket
"to take some photos, and on this basis,
"build up some theories about how it ought to look
"but where does that lead us?
"It's not our country, scarcely our planet."
it's actually not our planet,
So I'll simply say that the DSM continues to expand
the boundaries of mental disorder and mental illness
and the boundaries between mental disorder
and mental illness grow less clear.
And as that's happening,
it's ironically had some radical implications
reminiscent of what McDougall was saying
but When the person is given a diagnosis
in the current climate,
it's much more likely that they're going to be
treated with medication,
so we need to be puzzling it out.
A fourth change, out of five, is biologism.
By biologism, I mean privileging of biology-based theories
over biopsychosocial perspectives.
This, again, is a longer-term trend
which is now even more evident in DSM-V.
Take, for example, a simple change in the wording:
DSM-IV terms "general medical condition"
has been replaced by "another medical condition".
This means that DSM-V diagnoses
are supposed to be themselves considered medical.
The most drastic example of this, though,
I think is the sudden--
and it really is sudden in this case,
removal of the multiaxial system,
which was a format for formatting diagnoses.
Axis I was for Clinical Disorders,
Axis II was Personality Disorders
and also what's now thought of as Intellectual Functioning,
Axis III was General Medical Conditions,
Axis IV was the Acuity of Psychosocial Stressors
and Axis V was an Assessment of Functioning.
Despite all of the efforts to be transparent
about their proceedings, the multiaxial system
was discarded without any opportunity for public comment
or even debate amongst the DSM-V subcommittees.
The APA justified this decision by saying
that removing it would make a psychiatric diagnosis
conform to medical diagnostic formats,
they were very plain about this,
and correct the problem of false distinctions
between biomedical and psychological domains.
The new format merges Axes I through III
into a single line,
and they have suggested that all that information
about psychosocial stressors
can go somewhere else in the record.
But most importantly, it's no longer considered
part of the diagnosis, that psychosocial stuff
is not part of the diagnosis anymore.
A lot of students have been writing to me
over the year, former students from Smith,
and asking, "What is this supposed to look like?
"I'm supposed to be using DSM-V in my placement
"and nobody at my placement actually knows
"how to write a DSM diagnosis."
So the answer is to simply put what you,
as a social worker, are treating the student for.
If there's more than one relevant diagnosis,
list the one with the most relevance for that day.
As an example, this is what I would've--
this is what I put for a client,
who I was seeing--
I was seeing somebody
and this was my diagnosis for him
before the summer
and then when I returned to work after my summer at Smith
I had to submit a new diagnosis
in the setting where I am,
we changed quickly and this is what I put.
Notice for schizophrenia there's no more paranoid type,
the types have been removed
and there's none of the psychosocial information
included there.
So I think that this is probably the most drastic change
in DSM-V and it has significant implications
for social work education.
It's worth remembering what the initial intention
behind the multiaxial system was.
DSM-IV-TR stated that the multiaxial system
"facilitates comprehensive and systematic evaluations,
"capturing complexity of clinical situations
"to describe the heterogeneity of individuals
"presenting with the same diagnosis."
Its initial aims were even more bold.
It was first introduced to the APA by Dr. John Strauss,
first in an article in 1975
in the American Journal of Psychiatry
and then with his formal proposal to DSM-III
task force.
I met with Dr. John Strauss recently at a cafe in New Haven.
I asked him about what motivated him
to suggest to the system that would prove so significant
to clinical practice and theory for the next 33 years,
and he also was eager to be a participant.
- [John] This proves that (audio distortion)
face much more discrimination (audio distortion)
and what was gonna happen was that
it was gonna be based on symptoms alone,
so symptom complex.
(audio distortion) a little bit of grace thrown in
then I was gonna be able to make (audio distortion)
local aspects if you (audio distortion).
- It was initially referred to as a multi-variable system
in which each axis represented a dependent variable
influencing the person's overall diagnosis.
Strauss knew that you could not simply tease out
the different implications of each axis, though.
Each axis operated in dynamic ways
in relation to the others.
He ultimately worked with social worker Janet Williams
on the multiaxial system subcommittee
to develop the system.
Williams was also the chair of the multiaxial system
subcommittee for DSM-IV.
When I met Strauss and Williams, they both expressed
extreme disappointment about the multiaxial system
and, really, they weren't sure it was so bad
that it was taken off, taken away,
I was really surprised by that,
I was kind of hoping for a different story.
But they both were pretty disappointed in how it had worked.
Strauss recalled that even shortly after it was released
as part of DSM-III,
he would hear residents simply listing information on the axes
without thinking about how the different domains
were in interaction with each other.
He reflected that over the three years
he has noticed psychiatric residents more
and more often conceptualizing their diagnoses
exclusively in terms of biology.
Williams agreed that the system had never worked
as well as they had wanted,
but said that at least it pushed clinicians
to use a biopsychosocial perspective
at the diagnostic phase.
When it comes down to it, Williams really blames us.
She blames social workers for failing to advocate for it.
- [Janet] And in part, it's our fault,
in the mental health community,
we didn't do enough with it.
There weren't enough people interested in it
to really take it, and I'm to blame as well,
I could have done some major research on multiaxial
evaluation and maybe done some studies
that would have demonstrated how valuable it could be.
I just didn't happen to go in that direction.
And social workers, I tried and tried
but nobody seemed to be interested.
It would have been a natural area for social workers
to step into and do research.
- The influence of biologism is also evidence
in changes to the conceptualization of schizophrenia
and what is now in DSM-V called Schizophrenia Spectrum.
All of the subtypes of schizophrenia,
paranoid, disorganized, catatonic, undifferentiated,
residual, have been removed in DSM-V
because different clinicians could never agree
on which type a client really was.
And because neuroimaging studies have been
unable to show any consistent patterns
of brain activation for people within these subgroupings.
Interestingly the whole idea for schizophrenia subtypes
began with Kraepelin's early work
to distinguish categorical types using
another biological construct.
He and Bleuler, who would later rename schizophrenia,
were motivated to differentiate forms of the syndrome
because of their broader belief that mental illness
reflected racial degeneration.
Both advocated for the castration of people
with some forms of schizophrenia
and looked for examples of their prototypical forms,
these prototypical forms, particularly among Jews,
so this model of distinguishing subtypes of schizophrenia
continued all the way through DSM-IV-TR.
With the new schizophrenia spectrum
introduced in the DSM-V, clinicians are encouraged
to think across diagnostic categories
associated with psychotic symptoms
according to the following domains:
Delusions, hallucinations, disorganized thinking,
grossly disorganized and abnormal,
motor, behavior and negative symptoms.
So students are going to be using a sheet
that looks like this
if their placements are using them,
which they should be if they're in compliance,
so that they would actually be using this,
right now it's in addition to using a categorical diagnosis
so you would diagnose the person with schizophrenia
but you'd have a somewhat clearer picture of
which symptoms are actually prominent for the client.
The addition recognizes, to some degree,
that older categories such as schizophrenia
and schizoaffective disorder
were always poorly differentiated
and don't reflect new understandings
from research and neurobiology,
but it does not replace old diagnostic categories.
If clinicians use it, though, it might make them obsolete.
The fifth change that I wanted to highlight is
the beginnings of a shift from a categorical
to a dimensional diagnosis.
Schizophrenia Spectrum model is also an example
of this fifth last change.
The idea behind dimensional diagnosis
is that each of us can be assessed on different dimensions
of cognitive and emotional functioning.
While the categorical model seeks to identify syndromes,
or clusters of symptoms, for example the schizophrenia
cluster, a different dimensional diagnosis
sidesteps the needs for syndromes
by focusing on different aspects of functioning.
A really clear example of this is
the Asperger's Spectrum Disorder
which combines what DSM-IV distinguished as
Autistic Disorder, Asperger's Disorder,
Childhood Disintegrative Disorder, Rett's Disorder
and Pervasive Developmental Disorder
Not Otherwise Specified.
The new diagnosis of Autism Spectrum Disorder
requires both deficits in social communication
and interaction and restricted repetitive behaviors,
interests and activities.
Common APA explanations for combining these diagnoses
are that they are inconsistently differentiated
in clinical practice and that child clinicians
tended to overuse the diagnosis of PDDNOS.
Removal of Asperger's Disorder has been particulary
charged, in part, because many of the people
have come to identify personally
with that categorical distinction.
I work in Boston,
at a technical school in Boston,
and work with a lot of clients who were formerly
diagnosed with Asperger's.
A lot of them don't seem, when I brought it up,
a lot of them don't seem to care that much
about the DSM-V, to be that interested in the change,
but they do take really, really seriously
the possibility that their new diagnosis would be autism.
They've spent their whole lives,
and their parents have spent their whole lives
telling people that they do not have autism and now,
because of this change, they have something
called Autism Spectrum Disorder
so that's kind of an interesting shift.
In addition to autism and psychosis,
DSM-V includes dimensional models
for diagnosing disability and substance abuse.
For a while it looked like personality disorders
were going to be reorganized
with the dimensional model in DSM-V as well,
but they were faced with very widespread criticism
from the working group and instead proposed a hybrid
categorical dimensional model
which then seemed too unwieldy
and it was placed in the section of the book
designated for further study
and no substantial changes were made
to personality disorders this time.
I think most people agree that those changes are coming,
and probably with DSM-V.I, they seem to be soon.
Taking into account all of these changes
and the history of the DSM,
we are ultimately left how to use it.
When I spoke to Dr. Strauss, he felt that neither accepting
nor dismissing the DSM entirely would solve any problems.
- [David] So are you,
do you consider yourself anti-diagnosis now?
- [John] No, I think that I understand,
I mean I think there's a need for that.
But my feeling for a lot of concepts in psychiatry
is that they're okay but you
shouldn't believe them too much.
It's all right to use them but not to make
a lot of decisions based on them.
And that they're the best we can do
until we know more of what's going on.
And that's what NIMH now is doing with the biology,
I think I'm not so naive anymore, but I think they are.
They're saying, "Okay, we're going to look at the brain
"because then we're going to find the basic processes.
I don't think it's going to be that easy.
I think that's one of the exciting things about the field,
and difficult things, is that, in ways we don't even
suspect, it really is biopsychosocial.
And we're constantly trying to find the one thing
that will sort out everything.
And I don't think we're going to find it.
We're dealing with a complex interactive system.
- For Strauss, the overreach of neurobiologists
parallels the reductive nature of the DSM
but we will need to think critically about both, and more,
to make progress and provide better care
for our clients.
The approach that I was taught
when I was doing my MSW at NYU
was to quickly assign the least stigmatizing
diagnosis that would still get the client services
and then to never think about it again.
I learned DSM diagnosis as a necessary evil
that should be systematically disavowed
but this isn't always so neatly achieved.
Social workers Kirk and Kutchins studied
how social workers used the DSM in the 1990's
finding widespread and pervasive patterns
of underdiagnosis and overdiagnosis.
Clinicians justified underdiagnosis by saying
they were protecting their clients from labeling stigma.
At the same time, they also seemed to underdiagnose
in order to limit admissions to overburdened programs
or hospitals and otherwise deny the obligation
to provide care.
They justified overdiagnosis, on the other hand,
as helping their clients to gain access to services
they thought they needed.
I suspect that these patterns still persist.
Even students in their first summers at Smith
often ask in my class whether they should lie
about the symptoms that a client is presenting with,
whether to protect them from labeling
or to get them services.
I hear in this temptation to cut corners
something developmental.
It seems to convey that the frustration about the limits
of one's power
(repeats same words again)
in a very difficult system,
a kind of anxious grandiosity.
But lying, perhaps especially when well-intentioned,
only perpetuates the problem and prevents us
from developing integrative approaches as a field.
Barbara Probst, who teaches in the doctoral program here,
found in her recent qualitative study
that senior clinicians today have a difficult time
balancing DSM diagnosis in clinical practice.
They felt that that two-step process of using the DSM
to give a diagnosis and then using their
theoretical training to conceptualize a case
more holistically felt like "walking a tightrope".
In another illuminating study, however,
Probst also found that clinicians feel less conflicted
about using diagnoses in cases of gross impairment,
such as schizophrenia.
For them, they don't feel so troubled.
This reminds me of Wakefield's idea that we should distinguish
true mental illness from normal problems,
a distinction which I find really troubling.
If senior clinicians find this sort of balancing act hard,
I can only imagine what it is like for our students.
In some cases, it might contribute to a sense of splitting
between clinical internships and the classroom.
Students are learning sophisticated assessment
and practice models from us but in the field,
they're rarely getting to use these constructs
unless they're completing an assignment with their FFA.
For many students, this creates a disjunction
in their learning.
We hope that they find ways to integrate them
but many may not and their islands of learning
remain separate and don't inform each other.
In the class that I teach on Biopsychosocial Assessment,
we're constantly working with Joan to think about
how to situate the DSM, and now the DSM-V,
next to biopsychosocial perspectives
and psychodynamic theory.
This is really difficult, it's a very challenging
balancing act and a lot of other people have important
feedback on how we should be doing it.
We're aiming for a comparative and critical approach,
ultimately all theoretical and research constructs
are problematic.
Comparison, reflexivity and critique are integral
to good assessment work.
Teaching an integrative approach
has become all the more important
with the removal of the multiaxial system.
In conclusion, I think although we might feel it less
on this campus, there's a lot of pressure for clinicians
in hospitals, schools and community based agencies
to passively accept DSM-V as a fact,
as something natural.
In engaging with the DSM-V, we have the opportunity
to help students develop a pragmatic approach
working within a difficult system while maintaining
a critical perspective informed by research
and clinical and social theory.
Thank you.
(audience applauds)