The most basic critique of the DSM-5 is the same critique that has been levied against psychiatry for decades: that it does nil to a greater extent than than medicalize or pathologize normal behavior. So is it ever ok to say that someone isn’t normal? Are at that spot ever situations where giving a diagnosis is good? As it turns out, yes. And I’m non simply talking nigh diagnosis every bit a way to finance treatment. Yes, tertiary political party reimbursement hinges on diagnosis. But I’m talking nigh something less institutional together with to a greater extent than personal. There are people who similar labels, who uncovering comfort inward beingness able to call or label what is wrong. The label draws a boundary around an experience. Labels tin give the sack fifty-fifty describe upward boundaries around a grouping of people. According to psychologist Gary Greenberg, “[the label] Asperger’s syndrome gave people whose principal symptom was isolation a way to belong together with provided resources to those who were diagnosed” (episode 10 – uses labeling every bit a cardinal intervention. In IPT the therapist gives people the “sick role.” It goes something similar this (imagine I’m the therapist together with you’re the client. You consider criteria for major depressive disorder. I mightiness say something similar this: “The argue why you’ve been having difficulty is because you lot receive got an illness called depression. It is a treatable illness, but similar all illnesses, it makes it hard to do some things.” In the instance of IPT, the sick role draws a boundary around the sense of depression together with says “it is reasonable to do this together with non reasonable to that, until your depressive symptoms decrease.”
Labels tin give the sack fifty-fifty describe upward boundaries around a grouping of people. When you lot set upward boundaries, you lot separate. When separation systematically oppresses people nosotros telephone outcry upward that boundary segregation. But, when labels grouping people together, it tin give the sack also create community. Psychologist Gary Greenberg has suggested that 1 of the best examples of the powerfulness of a diagnosis to construct community is the diagnosis of Asperger’s Syndrome (which was established inward DSM-IV together with subsumed nether Autistic Spectrum Disorder inward DSM-5). According to Greenberg, “Asperger’s syndrome gave people whose principal symptom was isolation a way to belong together with provided resources to those who were diagnosed” (Reese, 2013).
So, I know what you lot are wondering - is DSM diagnosis goodness or bad? Well, today’s episode won’t last the definitive reply to that question. But, it volition give you lot crusade to interruption when you lot think nigh the role of DSM-5 inward the professional person life of social workers together with the people nosotros serve. My invitee is social piece of work faculty fellow member from Florida State University, Jeffrey Lacasse, Ph.D. Dr. Lacasse is an skillful inward psychiatric medications together with has published several critiques of the changes inward DSM-5. In today's episode, Dr. Lacasse critiques the Definition of mental illness, the empirical back upward for together with reliability of DSM-5 diagnoses, the politics associated amongst the creation together with publishing of the DSM, together with what it way for social workers to last the unmarried largest grouping of professionals who diagnose people amongst psychiatric disorders based on the DSM.
One quick notation nigh the interview: I spoke amongst Jeff inward Jan 2016 at the 20th annual Society for Social Work together with Research conference inward Washington DC. We did the interview inward his hotel room together with at 1 bespeak you lot tin give the sack hear music together with children inward the background. It’s non genuinely distracting, but since we’re talking nigh mental disorders, I thought it was solely fair to allow you lot know that you’re non hearing things.
And now, without farther ado, on to episode 101 of the Social Work Podcast: Critiques of the DSM-5: Interview amongst Jeffrey Lacasse, Ph.D.
Interview
[10:55]
Jonathan Singer: Jeff, thank you lot therefore much for beingness hither on the podcast together with talking amongst us nigh DSM 5.
[10:59]
Jeffrey Lacasse: Thanks for having me Jonathan!
[11:02]
Jonathan Singer: So 1 of the things that the DSM 5 was advertised every bit beingness was a pregnant improvement over the highly criticized DSM-IV. But you lot don’t genuinely consider it every bit an improvement, do you?
[11:14]
Jeffrey Lacasse: I do non consider it every bit an improvement. And I think that is what the information would show. I think 1 thing that nosotros receive got to remember, particularly every bit social workers, is that the DSM 5 is a production of a individual guild, who makes a profits yesteryear selling it. And it’s genuinely a real interesting thing if you lot think nigh it, that a individual guild gets to determine who is mentally sick together with who is not, inward our society. And every bit social workers, from a social jurist stand upward point, that is an awful, interesting, together with real sort of American sort of thing for us to think about, given the relationships betwixt drug companies together with psychiatrists, together with particularly those who are influential inward something similar the DSM 5. To last fair, I think there’s enough of academic psychiatrists out at that spot that would say that the DSM 5 is non an improvement. And, NIMH voted amongst their feet, proverb that they do non desire to last involved amongst the DSM 5.
[12:05]
Jonathan Singer: They said that they wanted to do the RDOCs.
[12:06]
Jeffrey Lacasse: And yeah, they wanted to do the RDOC criteria. And I hateful that’s a genuinely complicated split upward issue. But evidently the utility of DSM 5 is going to last inward clinical practice. That’s why social workers demand to last familiar amongst it for reimbursement purposes, etc. But every bit far every bit DSM 5 beingness an aspect of you lot know, improved science, I do non think that it true. And I think that is remarkable actually, if you lot think nigh it. Because DSM-IV is 1994, DSM-IV-TR is 2000 together with and therefore xv years after it would last reasonable to say okay therefore nosotros receive got improved this organization right? We got a niggling better. Actually some of the numbers for DSM 5 are worse than the tests for DSM-III inward 1980. And…
[12:50]
Jonathan Singer: What do you lot hateful yesteryear that? What numbers?
[12:51]
Jeffrey Lacasse: Yeah… Just to give you lot 1 illustration the Kappa value, the test-retest reliability for diagnoses is the principal variable used to mensurate accuracy. Which is somewhat primitive but it has some utility. So that way if a customer goes to consider ii split upward clinicians, together with around the same fourth dimension period, what pct of the fourth dimension do they handgrip that the customer has, let’s say, depression.
[13:12]
Jonathan Singer: So if they went to consider me together with they went to consider you.
[13:15]
Jeffrey Lacasse: Exactly. And therefore if you lot know there’s 100% understanding that’s great, but that does non be inward medicine. There is ever diagnostic ambiguity, but I was stunned at the bird of inaccuracy of the DSM 5. And that is why I am at this conference amongst you lot together with presenting a newspaper on this issue. It was 28% for major depression. It was 20% for generalized anxiety disorder.
And the interesting thing was the American Psychiatric Association, their piece of work group, they were genuinely trying to spin these results inward the scientific journals. And you lot know every bit researchers were used to that, the average consumer of enquiry results simply think these are scientists, this is going to last objective research. It is anything but. They spun these as, if non an improvement, at to the lowest degree every bit real positive results. They said, “We got goodness results. The DSM is pretty reliable.” 20% together with 28%? I mean, I am simply going to cutting to the chase. Those are abysmal results. And those are ii of the most, every bit you lot know, ii of the most mutual disorders diagnosed. And allow me last a niggling to a greater extent than specific. If there’s 100 clients, the way the report worked, if there’s 100 clients who had previously been diagnosed amongst generalized anxiety disorder nether DSM-IV-TR or real prominent symptoms of it, together with you lot together with I got trained specifically on how to portion diagnostic patterns. And together with therefore nosotros used instruments that are contained inward the DSM 5 which are oftentimes non used inward the community. And if nosotros did this report inward a position that has a lot of people who receive got generalized anxiety disorder, the prevalence is quite high together with and therefore the number at the halt of the report is 20%. It leads to questions, you lot know, that’s simply reliability yesteryear the way, that’s non validity which is a whole split upward discussion.
But DSM 5, the whole thought that the modern DSM system, the argue why you lot receive got checklists is to brand diagnosis at to the lowest degree reliable. And validity nosotros can’t genuinely larn to but reliable nosotros tin give the sack larn to, nosotros tin give the sack larn to…Reliable condition is supposed to last the point. 20-28%? Schizophrenia was 46%? Alcohol work disorder was 40%? But I receive got to say, it would last unrealistic to await numbers inward the 90s or possibly fifty-fifty the 80s. You know autism I think was 69% for illustration together with that’s something that because of the oculus contact together with how immature it happens it’s likely easier to diagnose. ADHD was fairly high, but some of these real commonly diagnosed mental disorders inward this bell jolt of an experiment where they’re trying real hard, had numbers of similar 20%. And of course, the American Psychiatric Association defined what a goodness value was for this together with they said unacceptable is 20% or lower, implying that anything higher upward 20% was okay, or at to the lowest degree acceptable if non goodness or excellent, etc. And it was interesting because, people may non last aware, but ii of the principal critic of the DSM 5 were Bob Spitzer, the editor of DSM-III together with DSM-III-R who wrote a alphabetic quality inward saying, certainly you're going to larn Kappa values every bit goodness every bit nosotros got inward 1980. I hateful he genuinely threw that on, it was real interesting. And together with therefore Allan Frances comes inward saying, you lot are trying to redefine accuracy therefore nosotros seem airheaded to the ease of medicine.
[16:21]
Jonathan Singer: Allen Frances, caput of the DSM-IV line force.
[16:24]
Jeffrey Lacasse: Yes, DSM-IV together with DSM-IV-TR, who has made a populace apology for the DSM-IV together with DSM-IV-TR. He came out of retirement to combat against the, you lot know the rhetoric around the DSM 5. So, I think it’s an of import number when it comes to informed consent together with some of the things you lot could combat from an ethical stand upward point. There’s a way that, every bit far every bit what clinicians would move out of something similar this. There is a way to utter to a customer nigh diagnosis, together with at that spot is pragmatic issues nigh reimbursement together with all that sort of stuff. But do clients know that. Imagine someone simply got out of a divorce or bad human relationship or had another sort of loss together with they’re diagnosed after 3 months of chronic symptoms amongst depression. That’s a dilemma for clinicians. You receive got to brand judgment calls, there’s the bereavement stuff, inward the DSM at that spot is a notation to clinicians. But does the customer who is beingness diagnosed know - seem if you lot saw someone else, on average 20% of the fourth dimension those ii people would handgrip that you lot are indeed depressed. Now the people could be, I hateful I think it’s genuinely of import to say, this doesn’t hateful nosotros don’t position people who are distressed or disturbed or receive got lots of symptoms that are inward this DSM checklist. But for social workers together with social piece of work academics similar us, the dilemma that is an unpleasant dilemma to raise, is nosotros receive got pushed all inward on this this thought of evidence based together with evidence informed practice, that handling guides are organized around these clusters, around these diagnoses. And inward this recent tutorial, I said handgrip on a second, if the diagnosis isn’t reliable, how do you lot fifty-fifty move along beyond that? And I think it’s frustrating to people because I don’t receive got a goodness reply to that query at all. But that’s a genuinely of import query together with it’s real convenient to skip that query I think, but I don’t think anyone has goodness answers to that query yet.
[18:09]
Jonathan Singer: That’s such a keen bespeak because for years, together with every bit for every bit long every bit I, you lot know I went to schoolhouse inward the mid-1990s for MSW. And for years the mantra has been that handling follows assessment together with diagnosis. And your right. If I am saying, “oh this is definitely major depressive disorder” together with I am non proverb “you know, you lot could larn a instant see together with they could totally disagree.” Like there’s, together with therefore the soul is non providing informed consent to this and, furthermore, my handling project design could real good last wrong, because I diagnosed it, does non necessarily hateful I am right.
[18:42]
Jeffrey Lacasse: Well luckily a lot of what nosotros do is non-specific. And luckily a lot of the mutual factor stuff would say possibly it doesn’t affair whether you lot receive got “generalized anxiety disorder” or its “depression amongst anxious features”. And through the therapeutic relationship, a lot of that stuff is going to piece of work regardless of the diagnosis. I report psychiatric medications every bit my principal thing, together with those are labeled yesteryear DSM category for what they’re approved for, that’s a niggling different. And I think together with at that spot is some non-specific stuff nigh the way drugs plant too obviously. But it’s called an anti-depressant because it’s used for depression, together with they’re also used for anxiety disorders together with they are pretty effective for, simply every bit effective for that every bit they are for depression, possibly fifty-fifty to a greater extent than so. To the grade that they are effective at all. I think every bit a field, together with this was inward an editorial, I said nosotros receive got to get-go rethinking this a niggling bit. Because it genuinely opens upward novel avenues of enquiry together with novel ways of looking at things. And also, we’re non psychiatrists. I hateful nosotros receive got a 100-year history of cooperating real closely amongst psychiatrists but we’re theoretically, to a greater extent than holistic, to a greater extent than committed social justice, the macro, the meso, the effects of things similar depression together with things that are related to depression that nosotros don’t think of every bit biological. And I think when you lot diagnose using the manual written yesteryear psychiatrists, I empathise it has to last done inward practice, I don’t receive got keen answers for that either. But, what I’d similar to consider is to consider an agency, a state, an area, experiment working without diagnoses. I learn psychopathology together with I would genuinely last curious to hear your see on this issue. In all the text books it says that diagnoses are essential for goodness clinical communication. So that clinicians tin give the sack communicate to each other. Just every bit an example. So I could write downward that John has major depression of a severe nature. I simply don’t understand, together with I’m non trying to last facetious here, but I don’t empathise how that is to a greater extent than helpful, than me telling you lot ‘Hey Jonathan, John simply got divorced. He is chronically lamentable together with suicidal. It’s been going on for twelve weeks, together with he is non doing good at all, together with he needs some help.” That took an extra 5 seconds to say that. I don’t understand, I literally don’t understand. I larn the reimbursement issues. I larn the medication issues. But inward damage of clinical communication, if you lot together with I are working inward an agency together, I think the latter description is much to a greater extent than descriptive together with I did it at an eighth grade bird of education, you lot know, but it sounds less medical. There is a lot of, therefore that’s something that I think nosotros all should think about. All the textbooks say this is essential for clinical communication together with I don’t know that it is.
[21:16]
Jonathan Singer: Well, together with what happens is that when I am saying, “Oh yeah. John has major depressive disorder,” historically it becomes to a greater extent than problematic when I am like, “Oh yeah, John, borderline personality disorder.” Right? I am non talking about, “yeah, therefore at that spot is some existent issues amongst emotion rule – he’s got some issues around self-harm, he’s got this, there’s some trauma background. All that stuff is genuinely of import clinical information. But, I’m like, “yeah, borderline,” together with you’re sitting at that spot similar “yeah, I don’t desire to piece of work amongst this guy.” And I think that is a keen illustration of how a diagnosis is terrible clinical communication.
[21:50]
Jeffrey Lacasse: Now I would agree. And nosotros sort of talked out of both sides of our oral fissure out of necessity inward that nosotros learn students to do inward depth psycho socials together with that is genuinely goodness clinical communication. But the diagnosis is supposed to last similar the summary statement. That whole borderline number though is real interesting, it is a fairly sexist diagnosis. And rather than proverb so-and-so was sexually traumatized every bit a kid together with has these acting out behaviors, etc., nosotros collapsed it into borderline. What is interesting is that at that spot was a report done where they looked at how many dissimilar types of borderlines you lot tin give the sack construct using the checklist inward the DSM 5, together with you lot create hundreds of clients - some of whom seem nil similar each other. And nosotros yet telephone outcry upward them all borderline because that is the disorder. That’s the call of the disorder. So fifty-fifty that thought that it communicates something, that you lot tin give the sack construct dissimilar looking depressive symptoms too.
[22:35]
Jonathan Singer: And it’s genuinely dissimilar yesteryear age.
[22:38]
Jeffrey Lacasse: Absolutely. I think this is the other thing nigh the DSM that nosotros mightiness desire to think nigh every bit far every bit the grade to which its scientific, is it was similar a medical textbook, you lot know. And it looks real authoritative, together with it’s from the American Psychiatric Association, which is you lot know nosotros receive got abide by for that profession together with therefore on together with therefore forth. So what happened is a bunch of people got around a tabular array together with decided this is a mental disorder together with hither are the together with at that spot are books written nigh this. Paula Caplan wrote a majority nigh the, I don’t desire to say the invention, but the creation of premenstrual dysphoric disorder or PMDD. She resigned from it inward disgust because she was therefore offended yesteryear the procedure because it was therefore subjective. But when you lot larn that majority inward the postal service or when you lot larn the online majority on Amazon or whatever together with you lot seem at it, you lot forget similar a bunch of people simply decided this. Now they may receive got used enquiry to do that together with it depends on which disorder were talking about, how good validated it is, how reliable it is. But Paula makes the bespeak that she wrote an entire majority nigh how human together with troubling she found the process. Speaking of DSM 5, nosotros halt upward amongst novel disorders similar binge eating disorder, similar little neurocognitive disorder, which some people say is medicalizing beingness inward your 50s together with early on 60s you lot know. And at that spot was simply a drug approved yesteryear the FDA for phemo hypoactive sexual dysfunction, which you lot know it’s slowly to critique that disorder on the basis, that it’s medicalizing what is a real relational issue. So if these things tin give the sack last reliable, if these kappa values could last genuinely high for all these entities, it’d last a dissimilar debate. They’re simply genuinely pitiful together with I don’t, it’s non similar I don’t empathise what American Psychiatric Association would say no these are goodness values, this was a rigorous essay because they are selling their majority amongst science. And at that spot are competitors nosotros could switch to ICD the International Classification of Diseases. It’s on the spider web for free. But I think people forget that they are buying, this is a production that they marketed together with you lot receive got to wonder if at that spot volition last a DSM 6. I hateful I’m sure you lot call upward all the furor on the Huffington Post. I hateful lay people inward the supermarket are familiar amongst the debates around the DSM 5, bereavement issues, together with you lot know ADHD beingness over diagnosed, all this sort of stuff. So, I don’t know if at that spot volition last a DSM 6. It’s the most mutual query I larn at the halt of my psychopathology class, do you lot think at that spot volition last a DSM 6? I hateful I receive got no idea, but from a PR stand upward point, it mightiness last improve to non receive got a DSM 6, it genuinely might.
[25:07]
Jonathan Singer: Yea or I could imagine them doing a DSM 5.1, .2. Like non proverb were going to completely re-haul again, were simply going to some updates.
[25:18]
Jeffrey Lacasse: Yea together with simply to give a little, this is a niggling chip inward contrary monastic tell but you lot know, DSM 5 took therefore long to come upward out because they were incredibly optimistic, I think it was the twelvemonth 2000 or 2001 when the white newspaper on DSM 5 comes out. And they said seem DSM 5 is going to integrate neuroscience together with categorical diagnosis. And it was interesting because I was inward my PhD computer program at that fourth dimension together with I’m studying the limits of what nosotros know nigh the brain, how complicated the encephalon is, what nosotros know about, together with lesions underlying a mental disorder, together with I was puzzled at the time, because I couldn’t imagine inward 10 years that nosotros would last able to, you lot know do that. But they were incredibly optimistic together with none of that materialized. I hateful null novel scientific discipline materialized that allowed them to map disorders onto the brain. You do wonder at what bespeak do you lot say seem this is non an sweat that is going to behave fruit to the clinician, together with the enquiry studies are different. I hateful they render information that would last useful to other scientists, but every bit far every bit for the clinician? I hateful a lot of times my students are nether the impression at whatsoever time, some of these disorders, that nosotros could uncovering the cause. And what is interesting is that happened betwixt DSM-IV together with 5 amongst 1 specific disorder that’s pretty rare called Rett's disorder, which is a sub type, it was classified nether Autism I believe. They found the genomic job that causes Rett's disorder. The etiology of these disorders is discussed inward the chapters, right, for each disorder. They removed it from the book. They said no DSM 5 is a majority of behavioral disorders, mental disorders, that way nosotros don’t know the crusade of them. Alzheimer’s is ever inward there, dementia is ever inward there, every bit these weird ones sort of inward between, but my students are commonly flabbergasted when I’ll say “wait a instant that got taken out of the majority crusade nosotros figured out what caused it therefore forthwith it’s a known medical disease, non a confusing mental disorder that takes all kinds of clinical judgment to sort out”. So that’s a fascinating illustration of, I think, what the DSM 5 genuinely is.
[27:15]
Jonathan Singer: That is amazing, I didn’t know that. I didn’t know that they took out Rett’s because they figured out what caused it, that’s bizarre.
[27:23]
Jeffrey Lacasse: Well what’s interesting is I think that, the fascinating thing nigh beingness a clinician or researcher regarding mental disorder is that it’s real mysterious, it’s real confusing, it takes keen clinical skills, together with it’s a detective flush to some degree. I hateful you’ve worked amongst people, you lot know what I am talking about. Often it gets presented to the populace every bit this is real simple. “We know what depression is, depression is a chemic imbalance inward your brain.” That’s gets, together with that’s simply yesteryear the way the DSM does non say that. But therefore the DSM should last a majority of things that are poorly understood, hard to assess for, together with possibly volition ever receive got pitiful reliability due to how hard those studies are to do. And that people’s clinical presentation change, or people lives change, together with the drugs they are taking change. So nosotros could attain a place, I think, where nosotros say good this is going to last sort of a, I don’t desire to say a disaster, but it’s ever going to last a real troubling, from a scientific standpoint, sort of book. So what’s the purpose of this book? It’s financial, it’s for reimbursement, it’s for bureaucratic coding, cool. But you lot consider it held upward every bit a slice of shining scientific discipline – yeah, that’s genuinely hard to support. And I think Allen Francis coming out of the woodwork, who is every bit conventional a psychiatric guy every bit you lot volition find. I hateful he was involved amongst the TMAP projection which was a Texas medication algorithm project, which was a real well-critiqued, conventional sort of project. Chair of psychiatry at Duke, I believe, or high upward at Duke. For him to come upward out of retirement to track against this, I think was genuinely an of import sort of thing. So rather than people thinking wow these social workers surely, “they sure critique the DSM a lot, and, those wacky hippy social workers…” It’s to a greater extent than similar if you lot hear to the psychiatrists real closely together with seem at their ain internal debates, they’d shell upward on the DSM 5 pretty bad too, but who’s using it mostly? Well nosotros outnumber psychiatrists, it’s got to last closed to 10 to 1 inward damage of mental wellness clinicians inward the United States. But I, if you lot move to the dorsum of the DSM 5 together with essay to find, non who participated inward the champaign trials but the scientific advisors that created the disorders together with all that sort of thing, seem for social workers. There are a few, but at that spot is non real many. So interesting that nosotros do an awful a lot of the piece of work together with and therefore every bit far every bit our representation, our voice, inward the actual creation of the manual, non genuinely there. And that’s of course of instruction assuming that our phonation would last dissimilar than their voice, I don’t know if that is true.
[29:49]
Jonathan Singer: So those are some keen critiques of the reliability of the disorder, nigh the internal fighting inward psychiatry, the role of social workers inward sort of perpetuating diagnosis every bit this thing nosotros should do because nosotros are the ones that are primarily doing… I hateful if nosotros seem simply inward damage of numbers, we’re doing it. Are at that spot other critiques that social workers should last aware of?
[30:15]
Jeffrey Lacasse: Well yeah, at that spot definitely are together with some of them are a niggling to a greater extent than conceptual inward nature. But they’re important. And at that spot pretty social worky, therefore to speak. I hateful 1 of them would last that the Definition of mental disorder has changed yet over again for DSM 5. It’s pretty inadequate scientifically. First of all it’s interesting that over the years the Definition of something similar a mental disorder has changed, which simply shows you lot how fuzzy this is together with how it hard it is to pivot down. Allen Francis said inward an article inward Wired yesteryear the journalist Gary Greenberger, who has written some goodness stuff on DSM 5. He says you lot can’t define it, you lot simply can’t define it. So you’re starting amongst something that the people who are engaged inward this are proverb that you lot can’t define it, where is that boundary betwixt normality together with disorder. So that’s a, that’s a problem. The other thing would be, this is a thought experiment. Couldn’t you lot utter nigh mental disorder without assuming that these are medical problems? You could utter nigh behavior. You could utter nigh a social, a sociological or deviance sort of approach. There’s a lot of dissimilar ways you lot could seem at these problems. But every bit they’re sorted inward the book, these are medical - sometimes they work the intelligence disease, sometimes they work syndrome, sometimes they work mental disorder. They work those damage sort of interchangeably. Those are genuinely real dissimilar things if we’re going to last technical nigh it. I simply work mental disorder to refer to something that’s inward the DSM. But fifty-fifty that concept, every bit I simply said, it’s a confusing concept. Now, DSM-IV had some genuinely interesting limitations noted inward the book.
[31:43]
There was a whole department called the “limitations of categorical diagnosis.” That was removed for DSM 5. So that is something of import for clinicians to know. It’s simply my opinion, but I think its important. The DSM 5 was a much to a greater extent than political document than the DSM-IV to me. Because I learn this class, because I am, I mightiness last the solely soul who sat downward together with read DSM 5 encompass to encompass to consider what was novel - that’s a bizarre thing to do I empathise that. But, I did that. And every bit I did that I noticed some changes that I thought were sort of disturbing. First of all, they deleted that department on the limitations of categorical diagnosis. DSM-IV-TR mentioned that the encephalon changes seen every bit schizophrenia may last related to handling amongst anti-psychotic medication. That’s gone now. It simply has a contestation nigh - I believe it says that - it simply to refers to the fact that at that spot is encephalon changes. That sort of advise its due to the schizophrenia. So at that spot is a debate inward the literature nigh that. But the DSM-IV said it mightiness last the drugs, DSM 5 says it hi the encephalon shrink over time, together with it is a heavily medicated population. I don’t think it nailed every unmarried 1 of them. There’s also stuff about, you lot know, some effects of meds similar akathisia. Where it looks to me to a greater extent than similar a majority written yesteryear people who diagnosis together with primarily medicate. And it’s political together with almost promotional nigh how they acquaint things. And DSM-IV certainly had components of things similar that. If you lot were someone who genuinely knew the literature deeply together with read it you lot would say at that spot was some politics here, there’s some spin hither together with there. But I think DSM 5 is worse objectively on these issues. See, this puts the thought that this is supposed to last a valuable resources for clinicians. Because my students are commonly real upset nigh this- yesteryear the way, I demo them on powerfulness points “this is what the DSM-IV said together with hither is what the DSM 5 said. Do you lot think this is a improve crusade they removed that information or removed that limitation?” And my students are similar “wow, why was that taken out?” Again, it is also possible no 1 reads this information too the billing codes together with it doesn’t matter, therefore I desire to last realistic nigh it. But I do think that’s an issue.
[33:50]
Jonathan Singer: So, given all of these critiques - which I think are genuinely of import for social workers to hold inward mind, together with you lot know, what you lot said before nigh social workers doing psycho social assessments… In DSM-IV, those genuinely mapped onto the Axis IV the environmental stressors together with those sorts of things. Social workers receive got to work the DSM 5 inward sure situations, together with since they do, together with since Axis IV is gone, how should social workers last using this responsibly?
[34:24]
Jeffrey Lacasse: Yes, that’s a keen query Jonathan. So two-part reply to that. First of all, the removal of axis iv nosotros should last to a greater extent than offended yesteryear that than I think nosotros are. Barbra Probst wrote an first-class slice of Research on Social Work Practice, which I invitee edited, nigh the demise of Axis IV. That was, you lot know, oftentimes called the social workers axis. And every bit far every bit nosotros tin give the sack tell, it simply sort of disappeared without them call for an entire profession nigh that. So your right. When I worked at a psychiatric hospice I spent a lot of fourth dimension writing things similar “homelessness” on Axis IV. And that mightiness last a way that the total 5 axis DSM-IV diagnosis mightiness receive got provided some goodness clinical communication inward that you lot larn a goodness thought of the client’s presenting problems pretty fast. You larn a GAF score, that sort of thing. So, GAS/GAF is gone. Axis IV is gone. We receive got Z codes forthwith instead of the previous V codes. And the Z codes listing almost every conceivable social worker job you lot could think of. So, 1 suggestions, together with I learn my pupil to do this, is to notation the Z codes to give a to a greater extent than consummate film of the client. You know if someone has a diagnosis of major depression, every bit nosotros receive got been discussing, together with that’s the solely thing on their chart, I think they move a depressive. You know, I think nosotros sort of pathologize it etcetera etcetera. And at that spot is a listing of 10 Z codes that listing simply what they are facing inward their life, that, I think, tin give the sack pigment a dissimilar picture. So I think that tin give the sack last important. As far every bit what nosotros do inward macro bird its a real elementary proffer together with I don’t know how you lot would implement it easily, together with likely impossible, but if you lot could reimburse for z codes, I’d similar to consider how many people would, given the choice: I tin give the sack diagnose you lot amongst this disorder, or I could simply listing these life problems your having. Which would you lot prefer? That’s an interesting though experiment at least. And Paula Caplan, 1 of her edited books - I think it was on a niggling rural wellness clinical - they stopped using the diagnosis every bit an deed of rebellion. And what they said was that nil happened. As far every bit I know, the touching on of it - every bit far every bit they could tell - it didn’t alter their practise real much. But those Z codes - I think students, I promise they larn taught inward DSM shape crusade I certainly learn them together with you lot know those receive got some utility. And inward actual practise when people convey the fourth dimension to create total those out. I promise so. I don’t know.
[36:38]
Jonathan Singer: Well Jeff, give thank you lot you therefore much for talking nigh DSM 5 critiques, things that social workers should last thinking nigh this novel document.
[36:46]
Jeffrey Lacasse: Thank you lot for having me Jonathan. I genuinely appreciate it.
Interview
[10:55]
Jonathan Singer: Jeff, thank you lot therefore much for beingness hither on the podcast together with talking amongst us nigh DSM 5.
[10:59]
Jeffrey Lacasse: Thanks for having me Jonathan!
[11:02]
Jonathan Singer: So 1 of the things that the DSM 5 was advertised every bit beingness was a pregnant improvement over the highly criticized DSM-IV. But you lot don’t genuinely consider it every bit an improvement, do you?
[11:14]
Jeffrey Lacasse: I do non consider it every bit an improvement. And I think that is what the information would show. I think 1 thing that nosotros receive got to remember, particularly every bit social workers, is that the DSM 5 is a production of a individual guild, who makes a profits yesteryear selling it. And it’s genuinely a real interesting thing if you lot think nigh it, that a individual guild gets to determine who is mentally sick together with who is not, inward our society. And every bit social workers, from a social jurist stand upward point, that is an awful, interesting, together with real sort of American sort of thing for us to think about, given the relationships betwixt drug companies together with psychiatrists, together with particularly those who are influential inward something similar the DSM 5. To last fair, I think there’s enough of academic psychiatrists out at that spot that would say that the DSM 5 is non an improvement. And, NIMH voted amongst their feet, proverb that they do non desire to last involved amongst the DSM 5.
[12:05]
Jonathan Singer: They said that they wanted to do the RDOCs.
[12:06]
Jeffrey Lacasse: And yeah, they wanted to do the RDOC criteria. And I hateful that’s a genuinely complicated split upward issue. But evidently the utility of DSM 5 is going to last inward clinical practice. That’s why social workers demand to last familiar amongst it for reimbursement purposes, etc. But every bit far every bit DSM 5 beingness an aspect of you lot know, improved science, I do non think that it true. And I think that is remarkable actually, if you lot think nigh it. Because DSM-IV is 1994, DSM-IV-TR is 2000 together with and therefore xv years after it would last reasonable to say okay therefore nosotros receive got improved this organization right? We got a niggling better. Actually some of the numbers for DSM 5 are worse than the tests for DSM-III inward 1980. And…
[12:50]
Jonathan Singer: What do you lot hateful yesteryear that? What numbers?
[12:51]
Jeffrey Lacasse: Yeah… Just to give you lot 1 illustration the Kappa value, the test-retest reliability for diagnoses is the principal variable used to mensurate accuracy. Which is somewhat primitive but it has some utility. So that way if a customer goes to consider ii split upward clinicians, together with around the same fourth dimension period, what pct of the fourth dimension do they handgrip that the customer has, let’s say, depression.
[13:12]
Jonathan Singer: So if they went to consider me together with they went to consider you.
[13:15]
Jeffrey Lacasse: Exactly. And therefore if you lot know there’s 100% understanding that’s great, but that does non be inward medicine. There is ever diagnostic ambiguity, but I was stunned at the bird of inaccuracy of the DSM 5. And that is why I am at this conference amongst you lot together with presenting a newspaper on this issue. It was 28% for major depression. It was 20% for generalized anxiety disorder.
And the interesting thing was the American Psychiatric Association, their piece of work group, they were genuinely trying to spin these results inward the scientific journals. And you lot know every bit researchers were used to that, the average consumer of enquiry results simply think these are scientists, this is going to last objective research. It is anything but. They spun these as, if non an improvement, at to the lowest degree every bit real positive results. They said, “We got goodness results. The DSM is pretty reliable.” 20% together with 28%? I mean, I am simply going to cutting to the chase. Those are abysmal results. And those are ii of the most, every bit you lot know, ii of the most mutual disorders diagnosed. And allow me last a niggling to a greater extent than specific. If there’s 100 clients, the way the report worked, if there’s 100 clients who had previously been diagnosed amongst generalized anxiety disorder nether DSM-IV-TR or real prominent symptoms of it, together with you lot together with I got trained specifically on how to portion diagnostic patterns. And together with therefore nosotros used instruments that are contained inward the DSM 5 which are oftentimes non used inward the community. And if nosotros did this report inward a position that has a lot of people who receive got generalized anxiety disorder, the prevalence is quite high together with and therefore the number at the halt of the report is 20%. It leads to questions, you lot know, that’s simply reliability yesteryear the way, that’s non validity which is a whole split upward discussion.
But DSM 5, the whole thought that the modern DSM system, the argue why you lot receive got checklists is to brand diagnosis at to the lowest degree reliable. And validity nosotros can’t genuinely larn to but reliable nosotros tin give the sack larn to, nosotros tin give the sack larn to…Reliable condition is supposed to last the point. 20-28%? Schizophrenia was 46%? Alcohol work disorder was 40%? But I receive got to say, it would last unrealistic to await numbers inward the 90s or possibly fifty-fifty the 80s. You know autism I think was 69% for illustration together with that’s something that because of the oculus contact together with how immature it happens it’s likely easier to diagnose. ADHD was fairly high, but some of these real commonly diagnosed mental disorders inward this bell jolt of an experiment where they’re trying real hard, had numbers of similar 20%. And of course, the American Psychiatric Association defined what a goodness value was for this together with they said unacceptable is 20% or lower, implying that anything higher upward 20% was okay, or at to the lowest degree acceptable if non goodness or excellent, etc. And it was interesting because, people may non last aware, but ii of the principal critic of the DSM 5 were Bob Spitzer, the editor of DSM-III together with DSM-III-R who wrote a alphabetic quality inward saying, certainly you're going to larn Kappa values every bit goodness every bit nosotros got inward 1980. I hateful he genuinely threw that on, it was real interesting. And together with therefore Allan Frances comes inward saying, you lot are trying to redefine accuracy therefore nosotros seem airheaded to the ease of medicine.
[16:21]
Jonathan Singer: Allen Frances, caput of the DSM-IV line force.
[16:24]
Jeffrey Lacasse: Yes, DSM-IV together with DSM-IV-TR, who has made a populace apology for the DSM-IV together with DSM-IV-TR. He came out of retirement to combat against the, you lot know the rhetoric around the DSM 5. So, I think it’s an of import number when it comes to informed consent together with some of the things you lot could combat from an ethical stand upward point. There’s a way that, every bit far every bit what clinicians would move out of something similar this. There is a way to utter to a customer nigh diagnosis, together with at that spot is pragmatic issues nigh reimbursement together with all that sort of stuff. But do clients know that. Imagine someone simply got out of a divorce or bad human relationship or had another sort of loss together with they’re diagnosed after 3 months of chronic symptoms amongst depression. That’s a dilemma for clinicians. You receive got to brand judgment calls, there’s the bereavement stuff, inward the DSM at that spot is a notation to clinicians. But does the customer who is beingness diagnosed know - seem if you lot saw someone else, on average 20% of the fourth dimension those ii people would handgrip that you lot are indeed depressed. Now the people could be, I hateful I think it’s genuinely of import to say, this doesn’t hateful nosotros don’t position people who are distressed or disturbed or receive got lots of symptoms that are inward this DSM checklist. But for social workers together with social piece of work academics similar us, the dilemma that is an unpleasant dilemma to raise, is nosotros receive got pushed all inward on this this thought of evidence based together with evidence informed practice, that handling guides are organized around these clusters, around these diagnoses. And inward this recent tutorial, I said handgrip on a second, if the diagnosis isn’t reliable, how do you lot fifty-fifty move along beyond that? And I think it’s frustrating to people because I don’t receive got a goodness reply to that query at all. But that’s a genuinely of import query together with it’s real convenient to skip that query I think, but I don’t think anyone has goodness answers to that query yet.
[18:09]
Jonathan Singer: That’s such a keen bespeak because for years, together with every bit for every bit long every bit I, you lot know I went to schoolhouse inward the mid-1990s for MSW. And for years the mantra has been that handling follows assessment together with diagnosis. And your right. If I am saying, “oh this is definitely major depressive disorder” together with I am non proverb “you know, you lot could larn a instant see together with they could totally disagree.” Like there’s, together with therefore the soul is non providing informed consent to this and, furthermore, my handling project design could real good last wrong, because I diagnosed it, does non necessarily hateful I am right.
[18:42]
Jeffrey Lacasse: Well luckily a lot of what nosotros do is non-specific. And luckily a lot of the mutual factor stuff would say possibly it doesn’t affair whether you lot receive got “generalized anxiety disorder” or its “depression amongst anxious features”. And through the therapeutic relationship, a lot of that stuff is going to piece of work regardless of the diagnosis. I report psychiatric medications every bit my principal thing, together with those are labeled yesteryear DSM category for what they’re approved for, that’s a niggling different. And I think together with at that spot is some non-specific stuff nigh the way drugs plant too obviously. But it’s called an anti-depressant because it’s used for depression, together with they’re also used for anxiety disorders together with they are pretty effective for, simply every bit effective for that every bit they are for depression, possibly fifty-fifty to a greater extent than so. To the grade that they are effective at all. I think every bit a field, together with this was inward an editorial, I said nosotros receive got to get-go rethinking this a niggling bit. Because it genuinely opens upward novel avenues of enquiry together with novel ways of looking at things. And also, we’re non psychiatrists. I hateful nosotros receive got a 100-year history of cooperating real closely amongst psychiatrists but we’re theoretically, to a greater extent than holistic, to a greater extent than committed social justice, the macro, the meso, the effects of things similar depression together with things that are related to depression that nosotros don’t think of every bit biological. And I think when you lot diagnose using the manual written yesteryear psychiatrists, I empathise it has to last done inward practice, I don’t receive got keen answers for that either. But, what I’d similar to consider is to consider an agency, a state, an area, experiment working without diagnoses. I learn psychopathology together with I would genuinely last curious to hear your see on this issue. In all the text books it says that diagnoses are essential for goodness clinical communication. So that clinicians tin give the sack communicate to each other. Just every bit an example. So I could write downward that John has major depression of a severe nature. I simply don’t understand, together with I’m non trying to last facetious here, but I don’t empathise how that is to a greater extent than helpful, than me telling you lot ‘Hey Jonathan, John simply got divorced. He is chronically lamentable together with suicidal. It’s been going on for twelve weeks, together with he is non doing good at all, together with he needs some help.” That took an extra 5 seconds to say that. I don’t understand, I literally don’t understand. I larn the reimbursement issues. I larn the medication issues. But inward damage of clinical communication, if you lot together with I are working inward an agency together, I think the latter description is much to a greater extent than descriptive together with I did it at an eighth grade bird of education, you lot know, but it sounds less medical. There is a lot of, therefore that’s something that I think nosotros all should think about. All the textbooks say this is essential for clinical communication together with I don’t know that it is.
[21:16]
Jonathan Singer: Well, together with what happens is that when I am saying, “Oh yeah. John has major depressive disorder,” historically it becomes to a greater extent than problematic when I am like, “Oh yeah, John, borderline personality disorder.” Right? I am non talking about, “yeah, therefore at that spot is some existent issues amongst emotion rule – he’s got some issues around self-harm, he’s got this, there’s some trauma background. All that stuff is genuinely of import clinical information. But, I’m like, “yeah, borderline,” together with you’re sitting at that spot similar “yeah, I don’t desire to piece of work amongst this guy.” And I think that is a keen illustration of how a diagnosis is terrible clinical communication.
[21:50]
Jeffrey Lacasse: Now I would agree. And nosotros sort of talked out of both sides of our oral fissure out of necessity inward that nosotros learn students to do inward depth psycho socials together with that is genuinely goodness clinical communication. But the diagnosis is supposed to last similar the summary statement. That whole borderline number though is real interesting, it is a fairly sexist diagnosis. And rather than proverb so-and-so was sexually traumatized every bit a kid together with has these acting out behaviors, etc., nosotros collapsed it into borderline. What is interesting is that at that spot was a report done where they looked at how many dissimilar types of borderlines you lot tin give the sack construct using the checklist inward the DSM 5, together with you lot create hundreds of clients - some of whom seem nil similar each other. And nosotros yet telephone outcry upward them all borderline because that is the disorder. That’s the call of the disorder. So fifty-fifty that thought that it communicates something, that you lot tin give the sack construct dissimilar looking depressive symptoms too.
[22:35]
Jonathan Singer: And it’s genuinely dissimilar yesteryear age.
[22:38]
Jeffrey Lacasse: Absolutely. I think this is the other thing nigh the DSM that nosotros mightiness desire to think nigh every bit far every bit the grade to which its scientific, is it was similar a medical textbook, you lot know. And it looks real authoritative, together with it’s from the American Psychiatric Association, which is you lot know nosotros receive got abide by for that profession together with therefore on together with therefore forth. So what happened is a bunch of people got around a tabular array together with decided this is a mental disorder together with hither are the together with at that spot are books written nigh this. Paula Caplan wrote a majority nigh the, I don’t desire to say the invention, but the creation of premenstrual dysphoric disorder or PMDD. She resigned from it inward disgust because she was therefore offended yesteryear the procedure because it was therefore subjective. But when you lot larn that majority inward the postal service or when you lot larn the online majority on Amazon or whatever together with you lot seem at it, you lot forget similar a bunch of people simply decided this. Now they may receive got used enquiry to do that together with it depends on which disorder were talking about, how good validated it is, how reliable it is. But Paula makes the bespeak that she wrote an entire majority nigh how human together with troubling she found the process. Speaking of DSM 5, nosotros halt upward amongst novel disorders similar binge eating disorder, similar little neurocognitive disorder, which some people say is medicalizing beingness inward your 50s together with early on 60s you lot know. And at that spot was simply a drug approved yesteryear the FDA for phemo hypoactive sexual dysfunction, which you lot know it’s slowly to critique that disorder on the basis, that it’s medicalizing what is a real relational issue. So if these things tin give the sack last reliable, if these kappa values could last genuinely high for all these entities, it’d last a dissimilar debate. They’re simply genuinely pitiful together with I don’t, it’s non similar I don’t empathise what American Psychiatric Association would say no these are goodness values, this was a rigorous essay because they are selling their majority amongst science. And at that spot are competitors nosotros could switch to ICD the International Classification of Diseases. It’s on the spider web for free. But I think people forget that they are buying, this is a production that they marketed together with you lot receive got to wonder if at that spot volition last a DSM 6. I hateful I’m sure you lot call upward all the furor on the Huffington Post. I hateful lay people inward the supermarket are familiar amongst the debates around the DSM 5, bereavement issues, together with you lot know ADHD beingness over diagnosed, all this sort of stuff. So, I don’t know if at that spot volition last a DSM 6. It’s the most mutual query I larn at the halt of my psychopathology class, do you lot think at that spot volition last a DSM 6? I hateful I receive got no idea, but from a PR stand upward point, it mightiness last improve to non receive got a DSM 6, it genuinely might.
[25:07]
Jonathan Singer: Yea or I could imagine them doing a DSM 5.1, .2. Like non proverb were going to completely re-haul again, were simply going to some updates.
[25:18]
Jeffrey Lacasse: Yea together with simply to give a little, this is a niggling chip inward contrary monastic tell but you lot know, DSM 5 took therefore long to come upward out because they were incredibly optimistic, I think it was the twelvemonth 2000 or 2001 when the white newspaper on DSM 5 comes out. And they said seem DSM 5 is going to integrate neuroscience together with categorical diagnosis. And it was interesting because I was inward my PhD computer program at that fourth dimension together with I’m studying the limits of what nosotros know nigh the brain, how complicated the encephalon is, what nosotros know about, together with lesions underlying a mental disorder, together with I was puzzled at the time, because I couldn’t imagine inward 10 years that nosotros would last able to, you lot know do that. But they were incredibly optimistic together with none of that materialized. I hateful null novel scientific discipline materialized that allowed them to map disorders onto the brain. You do wonder at what bespeak do you lot say seem this is non an sweat that is going to behave fruit to the clinician, together with the enquiry studies are different. I hateful they render information that would last useful to other scientists, but every bit far every bit for the clinician? I hateful a lot of times my students are nether the impression at whatsoever time, some of these disorders, that nosotros could uncovering the cause. And what is interesting is that happened betwixt DSM-IV together with 5 amongst 1 specific disorder that’s pretty rare called Rett's disorder, which is a sub type, it was classified nether Autism I believe. They found the genomic job that causes Rett's disorder. The etiology of these disorders is discussed inward the chapters, right, for each disorder. They removed it from the book. They said no DSM 5 is a majority of behavioral disorders, mental disorders, that way nosotros don’t know the crusade of them. Alzheimer’s is ever inward there, dementia is ever inward there, every bit these weird ones sort of inward between, but my students are commonly flabbergasted when I’ll say “wait a instant that got taken out of the majority crusade nosotros figured out what caused it therefore forthwith it’s a known medical disease, non a confusing mental disorder that takes all kinds of clinical judgment to sort out”. So that’s a fascinating illustration of, I think, what the DSM 5 genuinely is.
[27:15]
Jonathan Singer: That is amazing, I didn’t know that. I didn’t know that they took out Rett’s because they figured out what caused it, that’s bizarre.
[27:23]
Jeffrey Lacasse: Well what’s interesting is I think that, the fascinating thing nigh beingness a clinician or researcher regarding mental disorder is that it’s real mysterious, it’s real confusing, it takes keen clinical skills, together with it’s a detective flush to some degree. I hateful you’ve worked amongst people, you lot know what I am talking about. Often it gets presented to the populace every bit this is real simple. “We know what depression is, depression is a chemic imbalance inward your brain.” That’s gets, together with that’s simply yesteryear the way the DSM does non say that. But therefore the DSM should last a majority of things that are poorly understood, hard to assess for, together with possibly volition ever receive got pitiful reliability due to how hard those studies are to do. And that people’s clinical presentation change, or people lives change, together with the drugs they are taking change. So nosotros could attain a place, I think, where nosotros say good this is going to last sort of a, I don’t desire to say a disaster, but it’s ever going to last a real troubling, from a scientific standpoint, sort of book. So what’s the purpose of this book? It’s financial, it’s for reimbursement, it’s for bureaucratic coding, cool. But you lot consider it held upward every bit a slice of shining scientific discipline – yeah, that’s genuinely hard to support. And I think Allen Francis coming out of the woodwork, who is every bit conventional a psychiatric guy every bit you lot volition find. I hateful he was involved amongst the TMAP projection which was a Texas medication algorithm project, which was a real well-critiqued, conventional sort of project. Chair of psychiatry at Duke, I believe, or high upward at Duke. For him to come upward out of retirement to track against this, I think was genuinely an of import sort of thing. So rather than people thinking wow these social workers surely, “they sure critique the DSM a lot, and, those wacky hippy social workers…” It’s to a greater extent than similar if you lot hear to the psychiatrists real closely together with seem at their ain internal debates, they’d shell upward on the DSM 5 pretty bad too, but who’s using it mostly? Well nosotros outnumber psychiatrists, it’s got to last closed to 10 to 1 inward damage of mental wellness clinicians inward the United States. But I, if you lot move to the dorsum of the DSM 5 together with essay to find, non who participated inward the champaign trials but the scientific advisors that created the disorders together with all that sort of thing, seem for social workers. There are a few, but at that spot is non real many. So interesting that nosotros do an awful a lot of the piece of work together with and therefore every bit far every bit our representation, our voice, inward the actual creation of the manual, non genuinely there. And that’s of course of instruction assuming that our phonation would last dissimilar than their voice, I don’t know if that is true.
[29:49]
Jonathan Singer: So those are some keen critiques of the reliability of the disorder, nigh the internal fighting inward psychiatry, the role of social workers inward sort of perpetuating diagnosis every bit this thing nosotros should do because nosotros are the ones that are primarily doing… I hateful if nosotros seem simply inward damage of numbers, we’re doing it. Are at that spot other critiques that social workers should last aware of?
[30:15]
Jeffrey Lacasse: Well yeah, at that spot definitely are together with some of them are a niggling to a greater extent than conceptual inward nature. But they’re important. And at that spot pretty social worky, therefore to speak. I hateful 1 of them would last that the Definition of mental disorder has changed yet over again for DSM 5. It’s pretty inadequate scientifically. First of all it’s interesting that over the years the Definition of something similar a mental disorder has changed, which simply shows you lot how fuzzy this is together with how it hard it is to pivot down. Allen Francis said inward an article inward Wired yesteryear the journalist Gary Greenberger, who has written some goodness stuff on DSM 5. He says you lot can’t define it, you lot simply can’t define it. So you’re starting amongst something that the people who are engaged inward this are proverb that you lot can’t define it, where is that boundary betwixt normality together with disorder. So that’s a, that’s a problem. The other thing would be, this is a thought experiment. Couldn’t you lot utter nigh mental disorder without assuming that these are medical problems? You could utter nigh behavior. You could utter nigh a social, a sociological or deviance sort of approach. There’s a lot of dissimilar ways you lot could seem at these problems. But every bit they’re sorted inward the book, these are medical - sometimes they work the intelligence disease, sometimes they work syndrome, sometimes they work mental disorder. They work those damage sort of interchangeably. Those are genuinely real dissimilar things if we’re going to last technical nigh it. I simply work mental disorder to refer to something that’s inward the DSM. But fifty-fifty that concept, every bit I simply said, it’s a confusing concept. Now, DSM-IV had some genuinely interesting limitations noted inward the book.
[31:43]
There was a whole department called the “limitations of categorical diagnosis.” That was removed for DSM 5. So that is something of import for clinicians to know. It’s simply my opinion, but I think its important. The DSM 5 was a much to a greater extent than political document than the DSM-IV to me. Because I learn this class, because I am, I mightiness last the solely soul who sat downward together with read DSM 5 encompass to encompass to consider what was novel - that’s a bizarre thing to do I empathise that. But, I did that. And every bit I did that I noticed some changes that I thought were sort of disturbing. First of all, they deleted that department on the limitations of categorical diagnosis. DSM-IV-TR mentioned that the encephalon changes seen every bit schizophrenia may last related to handling amongst anti-psychotic medication. That’s gone now. It simply has a contestation nigh - I believe it says that - it simply to refers to the fact that at that spot is encephalon changes. That sort of advise its due to the schizophrenia. So at that spot is a debate inward the literature nigh that. But the DSM-IV said it mightiness last the drugs, DSM 5 says it hi the encephalon shrink over time, together with it is a heavily medicated population. I don’t think it nailed every unmarried 1 of them. There’s also stuff about, you lot know, some effects of meds similar akathisia. Where it looks to me to a greater extent than similar a majority written yesteryear people who diagnosis together with primarily medicate. And it’s political together with almost promotional nigh how they acquaint things. And DSM-IV certainly had components of things similar that. If you lot were someone who genuinely knew the literature deeply together with read it you lot would say at that spot was some politics here, there’s some spin hither together with there. But I think DSM 5 is worse objectively on these issues. See, this puts the thought that this is supposed to last a valuable resources for clinicians. Because my students are commonly real upset nigh this- yesteryear the way, I demo them on powerfulness points “this is what the DSM-IV said together with hither is what the DSM 5 said. Do you lot think this is a improve crusade they removed that information or removed that limitation?” And my students are similar “wow, why was that taken out?” Again, it is also possible no 1 reads this information too the billing codes together with it doesn’t matter, therefore I desire to last realistic nigh it. But I do think that’s an issue.
[33:50]
Jonathan Singer: So, given all of these critiques - which I think are genuinely of import for social workers to hold inward mind, together with you lot know, what you lot said before nigh social workers doing psycho social assessments… In DSM-IV, those genuinely mapped onto the Axis IV the environmental stressors together with those sorts of things. Social workers receive got to work the DSM 5 inward sure situations, together with since they do, together with since Axis IV is gone, how should social workers last using this responsibly?
[34:24]
Jeffrey Lacasse: Yes, that’s a keen query Jonathan. So two-part reply to that. First of all, the removal of axis iv nosotros should last to a greater extent than offended yesteryear that than I think nosotros are. Barbra Probst wrote an first-class slice of Research on Social Work Practice, which I invitee edited, nigh the demise of Axis IV. That was, you lot know, oftentimes called the social workers axis. And every bit far every bit nosotros tin give the sack tell, it simply sort of disappeared without them call for an entire profession nigh that. So your right. When I worked at a psychiatric hospice I spent a lot of fourth dimension writing things similar “homelessness” on Axis IV. And that mightiness last a way that the total 5 axis DSM-IV diagnosis mightiness receive got provided some goodness clinical communication inward that you lot larn a goodness thought of the client’s presenting problems pretty fast. You larn a GAF score, that sort of thing. So, GAS/GAF is gone. Axis IV is gone. We receive got Z codes forthwith instead of the previous V codes. And the Z codes listing almost every conceivable social worker job you lot could think of. So, 1 suggestions, together with I learn my pupil to do this, is to notation the Z codes to give a to a greater extent than consummate film of the client. You know if someone has a diagnosis of major depression, every bit nosotros receive got been discussing, together with that’s the solely thing on their chart, I think they move a depressive. You know, I think nosotros sort of pathologize it etcetera etcetera. And at that spot is a listing of 10 Z codes that listing simply what they are facing inward their life, that, I think, tin give the sack pigment a dissimilar picture. So I think that tin give the sack last important. As far every bit what nosotros do inward macro bird its a real elementary proffer together with I don’t know how you lot would implement it easily, together with likely impossible, but if you lot could reimburse for z codes, I’d similar to consider how many people would, given the choice: I tin give the sack diagnose you lot amongst this disorder, or I could simply listing these life problems your having. Which would you lot prefer? That’s an interesting though experiment at least. And Paula Caplan, 1 of her edited books - I think it was on a niggling rural wellness clinical - they stopped using the diagnosis every bit an deed of rebellion. And what they said was that nil happened. As far every bit I know, the touching on of it - every bit far every bit they could tell - it didn’t alter their practise real much. But those Z codes - I think students, I promise they larn taught inward DSM shape crusade I certainly learn them together with you lot know those receive got some utility. And inward actual practise when people convey the fourth dimension to create total those out. I promise so. I don’t know.
[36:38]
Jonathan Singer: Well Jeff, give thank you lot you therefore much for talking nigh DSM 5 critiques, things that social workers should last thinking nigh this novel document.
[36:46]
Jeffrey Lacasse: Thank you lot for having me Jonathan. I genuinely appreciate it.
