1 00:00:01,840 --> 00:00:07,520 Speaker 1: Welcome to Brainstuff, a production of iHeartRadio, Hey brain Stuff, 2 00:00:07,560 --> 00:00:11,760 Speaker 1: Lauren Bogelbaum. Here in the United States, if you go 3 00:00:11,880 --> 00:00:14,760 Speaker 1: to a medical professional looking for help with mental health, 4 00:00:15,200 --> 00:00:17,000 Speaker 1: one of the guides they're going to turn to in 5 00:00:17,079 --> 00:00:20,159 Speaker 1: helping you identify what's going on is the Diagnostic and 6 00:00:20,160 --> 00:00:24,840 Speaker 1: Statistical Manual of Mental Disorders, or the DSM. The DSM 7 00:00:25,040 --> 00:00:28,240 Speaker 1: is a living document. It's currently in its fifth edition, 8 00:00:28,440 --> 00:00:31,920 Speaker 1: known appropriately as the DSM five, having been updated about 9 00:00:31,960 --> 00:00:34,840 Speaker 1: once every fifteen years by its governing body, the American 10 00:00:34,840 --> 00:00:38,600 Speaker 1: Psychiatric Association, since they first published it in nineteen fifty two. 11 00:00:40,360 --> 00:00:43,479 Speaker 1: It's updated so often because our understanding of the human 12 00:00:43,520 --> 00:00:47,800 Speaker 1: mind keeps updating based on science. For example, before the 13 00:00:47,880 --> 00:00:52,040 Speaker 1: nineteen seventies, homosexuality was often considered to be a mental illness. 14 00:00:52,640 --> 00:00:56,160 Speaker 1: The American Psychiatric Association, or APA, classified it as such 15 00:00:56,200 --> 00:00:59,640 Speaker 1: in the first iteration of the DSM. This held with 16 00:00:59,720 --> 00:01:04,320 Speaker 1: prevaill and cultural norms, but then activists started protesting at 17 00:01:04,319 --> 00:01:07,880 Speaker 1: annual meetings of the APA and presented scientific evidence opposing 18 00:01:07,880 --> 00:01:11,680 Speaker 1: those norms. In nineteen seventy three, it was put to 19 00:01:11,720 --> 00:01:14,360 Speaker 1: the vote and a majority of APA members agreed that 20 00:01:14,400 --> 00:01:17,440 Speaker 1: home sexuality should no longer be considered a mental disorder. 21 00:01:18,319 --> 00:01:20,760 Speaker 1: Although it took baby steps to get there, this change 22 00:01:20,840 --> 00:01:23,479 Speaker 1: was a huge leap for gay rights and helped shift 23 00:01:23,560 --> 00:01:27,600 Speaker 1: sidal thinking on home sexuality. It also demonstrated the power 24 00:01:27,680 --> 00:01:32,480 Speaker 1: of the DSM on public opinion. The DSM doesn't offer 25 00:01:32,560 --> 00:01:35,600 Speaker 1: advice on medications or other treatments for the one hundred 26 00:01:35,640 --> 00:01:39,520 Speaker 1: and fifty seven disorders currently described in its pages. Rather, 27 00:01:39,720 --> 00:01:43,080 Speaker 1: it was designed to help healthcare professionals identify and diagnose 28 00:01:43,200 --> 00:01:47,039 Speaker 1: mental health conditions, such as those that impact personality, cognition, 29 00:01:47,160 --> 00:01:51,920 Speaker 1: and mood. The manual also provides uniform diagnostic codes for 30 00:01:51,920 --> 00:01:54,880 Speaker 1: each issue, which are used to facilitate medical billing and 31 00:01:54,960 --> 00:01:58,480 Speaker 1: data collection. Often, if a condition isn't listed in the 32 00:01:58,560 --> 00:02:01,280 Speaker 1: DSM US, health and chure companies won't pay for the 33 00:02:01,320 --> 00:02:05,360 Speaker 1: treatment of it. The manual is primarily used in the 34 00:02:05,440 --> 00:02:07,680 Speaker 1: United States, with much of the rest of the world's 35 00:02:07,680 --> 00:02:11,200 Speaker 1: health professionals turning instead to the World Health Organization's International 36 00:02:11,240 --> 00:02:15,799 Speaker 1: Classification of Diseases or ICD, which covers all diseases, not 37 00:02:15,840 --> 00:02:20,560 Speaker 1: only those psychological in nature. The APA encourages healthcare professionals 38 00:02:20,560 --> 00:02:24,160 Speaker 1: to consider the DSM five and the ICD as companion 39 00:02:24,200 --> 00:02:28,239 Speaker 1: publications designed to be compatible with each other. The ICD 40 00:02:28,320 --> 00:02:30,680 Speaker 1: is currently in its eleventh edition, having started up in 41 00:02:30,680 --> 00:02:34,120 Speaker 1: the eighteen nineties and been updated about every ten years. 42 00:02:36,639 --> 00:02:39,240 Speaker 1: The history of the DSM goes back way further than 43 00:02:39,240 --> 00:02:42,600 Speaker 1: the nineteen fifties. It was developed in response to an 44 00:02:42,680 --> 00:02:46,160 Speaker 1: obvious need for systems by which to classify mental health. 45 00:02:47,200 --> 00:02:50,320 Speaker 1: The US Census of eighteen forty took small steps toward 46 00:02:50,360 --> 00:02:53,079 Speaker 1: the eventual development of the manual by adding a question 47 00:02:53,160 --> 00:02:56,440 Speaker 1: about incidents of what they called idiocy or insanity to 48 00:02:56,480 --> 00:03:01,119 Speaker 1: their survey. This was possibly the first attempt statistical information 49 00:03:01,200 --> 00:03:05,280 Speaker 1: gathering related to mental health. In eighteen eighty, the Census 50 00:03:05,320 --> 00:03:10,200 Speaker 1: flushed out the mental health category to include issues like dementia, melancholia, epilepsy, 51 00:03:10,280 --> 00:03:17,320 Speaker 1: and mania. In nineteen seventeen, the American Medico Psychological Association, 52 00:03:17,600 --> 00:03:20,640 Speaker 1: the forerunner of the APA, and the National Commission on 53 00:03:20,680 --> 00:03:23,800 Speaker 1: Mental Hygiene came up with a plan for gathering uniform 54 00:03:23,880 --> 00:03:27,080 Speaker 1: health statistics and mental hospitals, which was then adopted by 55 00:03:27,120 --> 00:03:31,280 Speaker 1: the Census Bureau in nineteen twenty one. The APA started 56 00:03:31,280 --> 00:03:36,480 Speaker 1: to develop psychiatric classifications for various severe psychiatric disorders. After 57 00:03:36,520 --> 00:03:39,520 Speaker 1: World War Two. They shifted to a bigger classification system 58 00:03:39,600 --> 00:03:42,240 Speaker 1: developed by the US Army as it was treating veterans 59 00:03:44,200 --> 00:03:47,000 Speaker 1: with these systems as guides. They released the first official 60 00:03:47,080 --> 00:03:50,680 Speaker 1: version of the DSM in nineteen fifty two. Each update 61 00:03:50,760 --> 00:03:53,800 Speaker 1: is the result of years of task force meetings, discussion 62 00:03:53,880 --> 00:03:57,040 Speaker 1: by work groups, and input by many psychiatric experts around 63 00:03:57,080 --> 00:04:03,160 Speaker 1: the world. Each listing the manual includes diagnostic criteria including 64 00:04:03,160 --> 00:04:06,840 Speaker 1: a disorder symptoms and their duration necessary for a diagnosis, 65 00:04:07,400 --> 00:04:10,360 Speaker 1: plus any other disorders to screen, four with common symptoms, 66 00:04:10,520 --> 00:04:15,200 Speaker 1: and any antithetical symptoms that can help rule a diagnosis out. 67 00:04:15,680 --> 00:04:19,080 Speaker 1: The listing also includes information about the prevalence, development, and 68 00:04:19,160 --> 00:04:22,440 Speaker 1: course of the disorder, the risk, the prognostic factors, and 69 00:04:22,600 --> 00:04:27,400 Speaker 1: other relevant information. Finally, each disorder has that diagnostic code 70 00:04:27,520 --> 00:04:30,000 Speaker 1: in common with the ICDs codes, which is helpful for 71 00:04:30,080 --> 00:04:32,479 Speaker 1: the collection of data as well as streamlining the billing 72 00:04:32,480 --> 00:04:38,159 Speaker 1: process for care providers and insurance agencies. It's no small 73 00:04:38,200 --> 00:04:40,159 Speaker 1: feat for a mental health issue to be added to 74 00:04:40,160 --> 00:04:44,000 Speaker 1: the DSM. The DSM four wasn't all that different from 75 00:04:44,040 --> 00:04:46,479 Speaker 1: the DSM five, but the changes that did make the 76 00:04:46,480 --> 00:04:49,359 Speaker 1: cut were thoroughly reviewed and discussed by some of the 77 00:04:49,400 --> 00:04:53,120 Speaker 1: foremost minds in the psychiatric field. The DSM four was 78 00:04:53,120 --> 00:04:56,320 Speaker 1: published in nineteen ninety four, so the DSM five Task 79 00:04:56,400 --> 00:04:59,640 Speaker 1: Force had to review all scientific studies published on psychiatric 80 00:04:59,680 --> 00:05:03,880 Speaker 1: disord orders since then. Since the DSM five wasn't published 81 00:05:03,920 --> 00:05:07,520 Speaker 1: until twenty thirteen, that's nearly twenty years worth of ongoing 82 00:05:07,560 --> 00:05:13,640 Speaker 1: research to look at. Following comprehensive review, proposals to modify 83 00:05:13,680 --> 00:05:17,599 Speaker 1: existing diagnoses were made, which required vigorous discussion and debate 84 00:05:17,680 --> 00:05:21,920 Speaker 1: among the committee members plus input from outside experts. All 85 00:05:21,920 --> 00:05:24,560 Speaker 1: proposals were examined by the Task Force, as well as 86 00:05:24,560 --> 00:05:28,479 Speaker 1: two additional committees created for a more independent opinion, being 87 00:05:28,560 --> 00:05:34,800 Speaker 1: the Scientific Review Committee and a Clinical and Public Health Committee. However, 88 00:05:34,920 --> 00:05:38,160 Speaker 1: since then, new changes to the process have streamlined it. 89 00:05:38,800 --> 00:05:42,320 Speaker 1: Rather than waiting decades between issues, experts can now submit 90 00:05:42,440 --> 00:05:45,760 Speaker 1: changes online, helping to make the manual more timely and current. 91 00:05:46,560 --> 00:05:49,919 Speaker 1: Once approved by the APA Board of Trustees, clinicians and 92 00:05:50,000 --> 00:05:53,560 Speaker 1: other DSM users are notified about the edit. Users can 93 00:05:53,640 --> 00:05:56,120 Speaker 1: hover over the change in the online version to find 94 00:05:56,120 --> 00:05:59,440 Speaker 1: out the pertinent details, what the previous material was, and 95 00:05:59,560 --> 00:06:04,760 Speaker 1: the support arding scientific evidence that inspired the edit. For 96 00:06:04,880 --> 00:06:07,039 Speaker 1: the article this episode is based on has to work, 97 00:06:07,080 --> 00:06:10,599 Speaker 1: spoke doctor Philip Wang, director of the APA's Research Division, 98 00:06:10,640 --> 00:06:14,640 Speaker 1: which supervises the DSM. He said, this has been a 99 00:06:14,760 --> 00:06:18,000 Speaker 1: major advance. Let's say there is enough scientific evidence, and 100 00:06:18,080 --> 00:06:20,520 Speaker 1: let's say there is a valid change. To have to 101 00:06:20,560 --> 00:06:23,440 Speaker 1: wait fifteen or twenty years for clinicians and patients to 102 00:06:23,480 --> 00:06:27,279 Speaker 1: benefit from that change is unconscionable. The new system is 103 00:06:27,320 --> 00:06:30,599 Speaker 1: completely transparent, continuous, and at the end of the day, 104 00:06:30,839 --> 00:06:36,320 Speaker 1: it hopefully is good for clinicians and benefits patients. The 105 00:06:36,480 --> 00:06:39,040 Speaker 1: changes from the fourth edition to the fifth edition were 106 00:06:39,200 --> 00:06:43,719 Speaker 1: small but significant to address advances in scientific research and 107 00:06:43,839 --> 00:06:47,839 Speaker 1: issues with diagnoses that clinicians had been reporting. The DSM 108 00:06:47,960 --> 00:06:52,640 Speaker 1: five combined nearly thirty disorders, eliminated two diagnoses entirely, and 109 00:06:52,720 --> 00:06:58,359 Speaker 1: added fifteen. The DSM five has also revamped disorders into 110 00:06:58,400 --> 00:07:02,800 Speaker 1: a lifespan approach. Instead of classifying certain issues as solely 111 00:07:03,040 --> 00:07:06,800 Speaker 1: childhood disorders, it discusses how they change and manifest at 112 00:07:06,800 --> 00:07:11,160 Speaker 1: all stages, and the DSM five emphasizes the importance of 113 00:07:11,200 --> 00:07:16,600 Speaker 1: parents in diagnosis and treatment. This new version also introduced 114 00:07:16,720 --> 00:07:20,320 Speaker 1: Section three, which is for conditions where there's not enough 115 00:07:20,320 --> 00:07:23,640 Speaker 1: scientific data yet to determine whether they should be classified 116 00:07:23,680 --> 00:07:27,600 Speaker 1: as psychiatric disorders. Among these conditions are things like Internet 117 00:07:27,640 --> 00:07:32,720 Speaker 1: gaming disorder and caffeine use disorder. Section three also contains 118 00:07:32,760 --> 00:07:35,800 Speaker 1: cross cutting measures and models that have potential to help 119 00:07:35,800 --> 00:07:38,920 Speaker 1: clinicians better evaluate patients when they show symptoms that could 120 00:07:38,920 --> 00:07:43,680 Speaker 1: be indicative of multiple disorders, and it also includes a 121 00:07:43,720 --> 00:07:47,800 Speaker 1: Cultural Formulation Interview guide with questions to help clinicians identify 122 00:07:47,920 --> 00:07:51,840 Speaker 1: how a patient's cultural background affects their perception and presentation 123 00:07:52,000 --> 00:07:57,240 Speaker 1: of psychiatric symptoms, treatment, and diagnosis. The APA's fact sheet 124 00:07:57,240 --> 00:08:00,240 Speaker 1: about it explains a quote the interview provides, it's an 125 00:08:00,240 --> 00:08:03,160 Speaker 1: opportunity for individuals to define their distress in their own 126 00:08:03,200 --> 00:08:05,720 Speaker 1: words and then relate this to how others who may 127 00:08:05,760 --> 00:08:08,960 Speaker 1: not share their culture see their problems. This gives the 128 00:08:09,000 --> 00:08:11,960 Speaker 1: clinician a more complete foundation on which to base both 129 00:08:12,000 --> 00:08:17,640 Speaker 1: diagnosis and care. Some key about faces that occurred in 130 00:08:17,680 --> 00:08:20,600 Speaker 1: this update are proof that the DSM isn't opposed to 131 00:08:20,680 --> 00:08:24,360 Speaker 1: changing with the times. Here's some examples of major turnarounds. 132 00:08:25,520 --> 00:08:29,960 Speaker 1: Consenting adults who enjoy relatively unconventional BDSM fetishes or cross 133 00:08:30,040 --> 00:08:33,240 Speaker 1: dressing need not fear being diagnosed with mental illness anymore. 134 00:08:34,040 --> 00:08:38,800 Speaker 1: The DSM five update depathologized kinky sex. They're now just 135 00:08:38,960 --> 00:08:43,000 Speaker 1: people with a preference. It also removed the diagnosis of 136 00:08:43,040 --> 00:08:46,480 Speaker 1: Asperger's syndrome and classified the symptoms associated with it and 137 00:08:46,600 --> 00:08:50,920 Speaker 1: three other previous diagnoses under the umbrella autism spectrum disorder, 138 00:08:52,360 --> 00:08:57,000 Speaker 1: and it codifies medical acceptance of transgender people. The DSM 139 00:08:57,080 --> 00:09:01,760 Speaker 1: five replaced the diagnosis of gender identity disorder with gender dysphoria, 140 00:09:02,679 --> 00:09:05,880 Speaker 1: so those who don't identify with their assigned sex at 141 00:09:05,920 --> 00:09:08,640 Speaker 1: birth are no longer considered to have a mental disorder. 142 00:09:09,520 --> 00:09:11,840 Speaker 1: The new diagnosis spells out some of the challenges of 143 00:09:11,880 --> 00:09:14,960 Speaker 1: living with gender dysphoria and the paths that people may 144 00:09:15,080 --> 00:09:21,240 Speaker 1: choose to resolve it. One complaint about the DSM is 145 00:09:21,280 --> 00:09:23,880 Speaker 1: that once a condition is included in the manual, it 146 00:09:23,920 --> 00:09:27,480 Speaker 1: may turn what once was considered normal behavior into a 147 00:09:27,559 --> 00:09:32,920 Speaker 1: pathological illness that must be treated, often with medication. But 148 00:09:33,160 --> 00:09:36,360 Speaker 1: Wang pointed out that the DSM five has incorporated an 149 00:09:36,400 --> 00:09:39,440 Speaker 1: acuity measure to help with that. Since so many disorders 150 00:09:39,559 --> 00:09:43,560 Speaker 1: range widely in their severity, these scales help clinicians better 151 00:09:43,559 --> 00:09:48,240 Speaker 1: evaluate symptoms and levels of impairment. For example, let's say 152 00:09:48,240 --> 00:09:50,960 Speaker 1: you're grieving the death of a loved one, are you 153 00:09:51,080 --> 00:09:53,680 Speaker 1: still able to cope with life? Or are you barely 154 00:09:53,720 --> 00:09:57,280 Speaker 1: able to get out of bed? Once assessed, clinicians will 155 00:09:57,320 --> 00:10:00,240 Speaker 1: be better able to land on the appropriate treatment, whether 156 00:10:00,280 --> 00:10:04,439 Speaker 1: that's medication, watchful waiting, talk, therapy, or a combination of these. 157 00:10:06,679 --> 00:10:10,160 Speaker 1: After all, the human mind is a marvelous thing, but 158 00:10:10,320 --> 00:10:14,400 Speaker 1: mental wellness doesn't come automatically or easily for all of us. 159 00:10:15,280 --> 00:10:17,360 Speaker 1: People dealing with that, and not to mention the loved 160 00:10:17,360 --> 00:10:20,320 Speaker 1: ones who support them deserve and up to date and 161 00:10:20,400 --> 00:10:23,400 Speaker 1: fully vetted guide to help them and their care providers 162 00:10:23,520 --> 00:10:27,600 Speaker 1: find the best treatments. The value in the decades of 163 00:10:27,640 --> 00:10:30,960 Speaker 1: research and intense consideration that have gone into the DSM 164 00:10:31,360 --> 00:10:33,760 Speaker 1: is one of the many reasons why the gold standard 165 00:10:33,800 --> 00:10:36,520 Speaker 1: advice for anyone who's concerned about the mental health of 166 00:10:36,559 --> 00:10:39,040 Speaker 1: themselves or a loved one is to reach out to 167 00:10:39,080 --> 00:10:43,199 Speaker 1: a healthcare professional. Access to tools like the DSM helps 168 00:10:43,200 --> 00:10:46,480 Speaker 1: those professionals help us on a path towards having a 169 00:10:46,480 --> 00:10:55,960 Speaker 1: better time in this sometimes difficult world. Today's episode is 170 00:10:55,960 --> 00:10:58,760 Speaker 1: based on the article how the Diagnostic and Statistical Manual 171 00:10:58,760 --> 00:11:01,440 Speaker 1: of Mental Disorders Works on how stufforks dot com, written 172 00:11:01,440 --> 00:11:04,040 Speaker 1: by A. Leah Hoyt brain Stuff is production by heart 173 00:11:04,080 --> 00:11:06,640 Speaker 1: Radio in partnership with HowStuffWorks dot Com and is produced 174 00:11:06,640 --> 00:11:10,000 Speaker 1: by Tyler Klang. Four more podcasts by heart Radio, visit 175 00:11:10,040 --> 00:11:12,839 Speaker 1: the heart Radio app, Apple Podcasts, or wherever you listen 176 00:11:12,880 --> 00:11:13,880 Speaker 1: to your favorite shows.