So, with a title like the DSM, Psychiatry's Deadliest Scam, you're probably not surprised that that documentary is not very complimentry about the diagnostic and statistical manual of mental disorders. And if you watch the entire hour and twenty minutes, you will see that they have a lot of people with a lot of beefs about how the DSM is put together and how it's used, etc., etc., etc. So a part of what I think is interesting about this documentary is it does actually it does actually present the facts, in some way, in terms of how the DSM is put together. But then, with its image, imagery of shadowy figures, with poker chips and cards and the house of cards and then the circus music in the background, they really do a good job of making it all seem very ridiculous. [LAUGH] So, part of what we're going to do in the next segment here is demystify or may be demythify what it, the DSM is, how it's put together and how it's supposed to be used and then, you could make your own judgments about whether you think this is a circus trick or actually something that is useful in understanding people's experiences of mental distress. The DSM is the Diagnostic and Statistical Manual of Mental Disorders. The roman numerals IV indicate that it is in its fourth edition and the letters TR indicate that the fourth and, the fourth edition underwent some text revisions. The TR stands for text revision. As it says here, it is published by the American Psychiatric Association. A fifth edition of the DSM is expected later this year in May 2013. The DSM is used in North America. But as was indicated in the documentary clip you watched, it is also connected to the International Classification of Diseases that is used all over the world. The DSM is used to provide guidelines for making psychiatric diagnoses. It doesn't claim to be able to account for every single possible expression of metal distress or disorder. Instead, it attempts to share what has been most consistently observed as the presentation for different disorders so that trained clinicians can reliable assign diagnosis and communicate with each other with confidence that they are discussing the same thing. The documentary suggests that DSM is not based on research, but that is completely untrue. Every diagnosis in the manual is the outcome of years of clinical research by trained clinical researchers at multiple sites. The people who do the research to validate these diagnoses are leaders in the field who have a strong track record of doing research in various areas of their expertise. The research is held to a very high scientific and ethical standard and is done under extremenly high level of scientifc scrutiny. Now, what if this claim that there is no evidence or science underlining the DSM. I think that a claim that some people think that they can make because the research that's involved in developing this manual doesn't involve blood tests or science in the way that many people think of. But psychiatric research is based on careful observation and documentation of the experiences that people are having. There needs to be wide agreement about what is observed and its effect on people's abilities to function effectively and its place in a manual of mental disorder. If there is not enough agreement or there's not enough evidence to support the identification of a particular type of experience as a type of pathology, it does not go into the manual. But the key check of the proposed diagnosis that are considered and rejected so they can be transparent about the process and leave the door open for further consideration by future panels. The documentary makes much of the idea that any type of life problem can be included in the DSM. It's quite true that it's a very comprehensive document and you can find almost anything you can think of attached with diagnostic name and code. If you reflect on what we've already discussed about the history of psychiatry, you might agree with the documentarian who was suggesting that this is psychiatry's way of pathologizing everything possible in order to increase psychiatric power and priviledge. You can also consider however, that if something is unnamed and we have no way of identifying a type of human problem, then we may be very limited in the ways we can respond to it as well. The DSM is set up so that clinicians can make what is called a multiaxial assessment. There are five axes for assessment, and this is one way in which the diagnostic process gives a nod to the biopsychosocial perspective that we discussed in the previous lecture. There are two axes that cover psychiatric diagnoses. Axis 1 is where you identify clinical disorders. For example, things like depression, schizophrenia, and bipolar disorder. Axis 2 is for identifying personality disorders or mental retardation. Mental retardation is a now outdated term for intellectual disabilities and I expect that this will be updated to a more contemporary term in the upcoming fifth edition. Personality disorders refers to a group of diagnoses that describe enduring personality and relational style that affects people's abilities to function socially. These two will probably be addressed differently in the upcoming edition. One of the issues with the way that personality disorders is described in the fourth edition is that there's tremendous overlap between the description of various disorders. This may be what the documentary is refering to when it claims that you can give twenty diagnoses to a single patient although that is a huge exxageration. Part of the research that has gone into the new edition has been to make the identification of these types of disorders more percise. Axis 3 is for identifying general medical conditions. This is important to note because physical illness or other physical problems can have an impact on someone's mental health. In fact, we understand more and more that physical illnesses can have an effect, sorry, that physical illnesses can have affects that affect mental functioning, and physical illness can also affect mental health and well-being. For example, it is common to have depression associated with cardiovascular illness. Noting both the physical and mental conditions as part of the multiaxial assessment, assures that both are taken into consideration in making a diagnosis and determining a treatment plan. Axis 4, psychosocial and environmental problems is used to indicate anything that is going on in the patient's life that may be a source of stress, and may help explain why they're presenting with a mental health problem at the moment. I'll say more about that on the next slide. But I want to know that this is probably the axis that is most indicative of the enduring influence of Adolf Meyer's position that you cannot understand an individual's presentation of mental illness without knowing that person and their environment. Axis 5 is used to assign a number that gives some indication of how capable this person is of functioning in the social environment. I'll say more about that on the next slide as well. So, let's take a closer look at Axis 4 and 5 because they are the most social of the axes used in the DSM. Axis 4, psychosocial and environmental problems is included because things that are causing stress in a person's life can shed light on whether they, whether what they are experiencing mentally is connected to some environmental or psychosocial stressor. Social workers focus on this axis because it represents areas in which we may be able to intervene to diminish stress that is having an impact on someone's mental health. The fourth axis covers a wide range of psychological, social, and environmental stressors that can range from things like a recent divorce or death in the family to issues like job loss, financial problems, problems with the justice system, and all the way to quite extreme things like natural disasters, terrorist attacks, or wars. The fifth axis asks clinicians to assign a score between 0 and 100 that gives some indication of how well a person is functioning in the social environment. To give you an indication of the range, somebody could get a score of 100 if they are described in the following way. Superior functioning in a wide range of activities. Life's problems never seem to get out of hand. This person is sought out by others because of his or her many positive qualities. No symptoms. That does, indeed, sound pretty good. Now, if we go down to the other end of the scale, for somebody who is going to receive a score between 1 and 10, that person is described as being a persistent danger, in persistent danger of severely hurting self or others. Or a persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of health. So, that gives you some sorry, [LAUGH] with clear expectation of death, not health. So, that gives you some indication of the kind of range that you see on the global assessment of functioning scale. The global assessment of functioning score is a way of assessing someone's ability to function in that exact moment. It can be very useful for being able to evaluate whether someone's ability to function has improved or declined over a period of time. One of the things that some people don't like about the DSM is that despite its attempt of being comprehensive through the use of multiple axes, it does not have any access that isn't focused on problems and pathology. Aside from assigning a higher score on the Global Assessment of Functioning scale from Axis 5, there's really nowhere that you can indicate what kind of strengths or resources that someone brings to a situation. For example, a person may be dealing with a mental illness but they may also have tremendous personal capabilities. They may be a confident person, an accomplished person, a person who has a positive outlook on life. These are all things that will have an influence on their experience of mental disorder. They may also have a great social support network, or be financially secure. These are also things that experience. These are also things that affect the experience of mental disorder. In social work assessments, we describe these strengths and resources as protective factors and they are part of our assessments because they have a huge impact on what kind of help or supports are appropriate for a person in a given situation. They may also point to things that a person already has in place that can be a great help in the recovery from a mental illness. The DSM also has several appendicies that address things like how to use the manual, what codes to use for insurance, or how to align it with the international classification of diseases. I already mentioned that they document things like additions and deletions that represent changes from the previous edition. The fourth edition of the DSM also has an access for what they call cultural formulation and culture bound syndromes. We'll be discussing these in detail in our lecture on culture, mental health, and mental illness. So, that's the DSM. So, why do people hate the DSM? So, why do people hate the DSM? Look, I've got my pocket edition right here. It doesn't look so dangerous. But I think the thing is, you know, that it can be dangerous, not the DSM specifically, but we know that psychiatric diagnoses have been used in harmful ways in the past, and we worry about them being used in harmful ways in the present and the future. And that can be as extreme as diagnoses being used to, to interfere with people's ability to just be the people they are, or as extreme as psychiatric diagnoses being used to silence and control people that are somehow inconvenient to us, or as not extreme but still dangerous as somebody like the clinician that I was enacting in the, in the introduction to the lecture. Somebody who takes the fullness of your human experience and try to shut it into a box with little bit great for what you think about it. The DSM and other diagnostic tools, psychiatric diagnostic manuals are like many tools that we have. They can be harmful or helpful depending on the person who is using them and the intention they have. And while we may focus on the ways that it can be harmful, I would like to talk briefly about a way that diagnosis has been helpful in the past. you do know, of course, that we have talked about shell shock as something that people were experiencing after the First World War. And certainly this phenomenon of, of soldiers going into battle and then coming back in heightened states of distress and unable to function, is something that we've known about for a very long time. And used before, before we had a diagnosis for it, we used terms like battle fatigue and shell shock to describe it. And the expectation was that this person who was experiencing these, these distressing symptoms, I'm going to use the word symptoms, was somebody who just needed to settle themselves down and then get back out there. They had to get back out onto the battle field or if we were talking about soldiers that were returning home, they had to get back out there and go into their jobs and their families and just pull it together. It wasn't until a group of advocates both from with in and outside psychiatry, really pushed for us to have a name for this phenomenon, to understand that as a diagnosis called post-traumatic stress disorder that required treatment, that required help, that required support in the form of social support and financial support for soldiers that were dealing with it. Before we had that name and that diagnosis, people could not get the help that they needed. So sometimes, we have to think about the fact that diagnosis can be very helpful for various reasons and it's not just a thing that tries to force people into a box. The other thought I want to leave you with before we move on to the next section is we have a very negative lens that we bring to psychiatric diagnosis. But it always occurred to me that it's strange we don't bring the same lens to medical, general medical diagnoses. It's equally true that they are developed and discovered and maybe invented on the basis of people's opinions about what's going on with people. They similarly take human experience and channel it into some kind of specific box so that we can understand it and they similarly predict a set of actions that will follow that we call treatment. And yet, we don't have the same concerns about it in the same way. I'd like you to think about why there's that difference and you'll see that it's one of those discussion questions that we have at the end of the lecture. I look forward to hearing what you think about it.
