WEBVTT - How Does the Diagnostic and Statistical Manual of Mental Disorders (DSM) Work? 0:00:01.840 --> 0:00:07.520 Welcome to Brainstuff, a production of iHeartRadio, Hey brain Stuff, 0:00:07.560 --> 0:00:11.760 Lauren Bogelbaum. Here in the United States, if you go 0:00:11.880 --> 0:00:14.760 to a medical professional looking for help with mental health, 0:00:15.200 --> 0:00:17.000 one of the guides they're going to turn to in 0:00:17.079 --> 0:00:20.159 helping you identify what's going on is the Diagnostic and 0:00:20.160 --> 0:00:24.840 Statistical Manual of Mental Disorders, or the DSM. The DSM 0:00:25.040 --> 0:00:28.240 is a living document. It's currently in its fifth edition, 0:00:28.440 --> 0:00:31.920 known appropriately as the DSM five, having been updated about 0:00:31.960 --> 0:00:34.840 once every fifteen years by its governing body, the American 0:00:34.840 --> 0:00:38.600 Psychiatric Association, since they first published it in nineteen fifty two. 0:00:40.360 --> 0:00:43.479 It's updated so often because our understanding of the human 0:00:43.520 --> 0:00:47.800 mind keeps updating based on science. For example, before the 0:00:47.880 --> 0:00:52.040 nineteen seventies, homosexuality was often considered to be a mental illness. 0:00:52.640 --> 0:00:56.160 The American Psychiatric Association, or APA, classified it as such 0:00:56.200 --> 0:00:59.640 in the first iteration of the DSM. This held with 0:00:59.720 --> 0:01:04.320 prevaill and cultural norms, but then activists started protesting at 0:01:04.319 --> 0:01:07.880 annual meetings of the APA and presented scientific evidence opposing 0:01:07.880 --> 0:01:11.680 those norms. In nineteen seventy three, it was put to 0:01:11.720 --> 0:01:14.360 the vote and a majority of APA members agreed that 0:01:14.400 --> 0:01:17.440 home sexuality should no longer be considered a mental disorder. 0:01:18.319 --> 0:01:20.760 Although it took baby steps to get there, this change 0:01:20.840 --> 0:01:23.479 was a huge leap for gay rights and helped shift 0:01:23.560 --> 0:01:27.600 sidal thinking on home sexuality. It also demonstrated the power 0:01:27.680 --> 0:01:32.480 of the DSM on public opinion. The DSM doesn't offer 0:01:32.560 --> 0:01:35.600 advice on medications or other treatments for the one hundred 0:01:35.640 --> 0:01:39.520 and fifty seven disorders currently described in its pages. Rather, 0:01:39.720 --> 0:01:43.080 it was designed to help healthcare professionals identify and diagnose 0:01:43.200 --> 0:01:47.039 mental health conditions, such as those that impact personality, cognition, 0:01:47.160 --> 0:01:51.920 and mood. The manual also provides uniform diagnostic codes for 0:01:51.920 --> 0:01:54.880 each issue, which are used to facilitate medical billing and 0:01:54.960 --> 0:01:58.480 data collection. Often, if a condition isn't listed in the 0:01:58.560 --> 0:02:01.280 DSM US, health and chure companies won't pay for the 0:02:01.320 --> 0:02:05.360 treatment of it. The manual is primarily used in the 0:02:05.440 --> 0:02:07.680 United States, with much of the rest of the world's 0:02:07.680 --> 0:02:11.200 health professionals turning instead to the World Health Organization's International 0:02:11.240 --> 0:02:15.799 Classification of Diseases or ICD, which covers all diseases, not 0:02:15.840 --> 0:02:20.560 only those psychological in nature. The APA encourages healthcare professionals 0:02:20.560 --> 0:02:24.160 to consider the DSM five and the ICD as companion 0:02:24.200 --> 0:02:28.239 publications designed to be compatible with each other. The ICD 0:02:28.320 --> 0:02:30.680 is currently in its eleventh edition, having started up in 0:02:30.680 --> 0:02:34.120 the eighteen nineties and been updated about every ten years. 0:02:36.639 --> 0:02:39.240 The history of the DSM goes back way further than 0:02:39.240 --> 0:02:42.600 the nineteen fifties. It was developed in response to an 0:02:42.680 --> 0:02:46.160 obvious need for systems by which to classify mental health. 0:02:47.200 --> 0:02:50.320 The US Census of eighteen forty took small steps toward 0:02:50.360 --> 0:02:53.079 the eventual development of the manual by adding a question 0:02:53.160 --> 0:02:56.440 about incidents of what they called idiocy or insanity to 0:02:56.480 --> 0:03:01.119 their survey. This was possibly the first attempt statistical information 0:03:01.200 --> 0:03:05.280 gathering related to mental health. In eighteen eighty, the Census 0:03:05.320 --> 0:03:10.200 flushed out the mental health category to include issues like dementia, melancholia, epilepsy, 0:03:10.280 --> 0:03:17.320 and mania. In nineteen seventeen, the American Medico Psychological Association, 0:03:17.600 --> 0:03:20.640 the forerunner of the APA, and the National Commission on 0:03:20.680 --> 0:03:23.800 Mental Hygiene came up with a plan for gathering uniform 0:03:23.880 --> 0:03:27.080 health statistics and mental hospitals, which was then adopted by 0:03:27.120 --> 0:03:31.280 the Census Bureau in nineteen twenty one. The APA started 0:03:31.280 --> 0:03:36.480 to develop psychiatric classifications for various severe psychiatric disorders. After 0:03:36.520 --> 0:03:39.520 World War Two. They shifted to a bigger classification system 0:03:39.600 --> 0:03:42.240 developed by the US Army as it was treating veterans 0:03:44.200 --> 0:03:47.000 with these systems as guides. They released the first official 0:03:47.080 --> 0:03:50.680 version of the DSM in nineteen fifty two. Each update 0:03:50.760 --> 0:03:53.800 is the result of years of task force meetings, discussion 0:03:53.880 --> 0:03:57.040 by work groups, and input by many psychiatric experts around 0:03:57.080 --> 0:04:03.160 the world. Each listing the manual includes diagnostic criteria including 0:04:03.160 --> 0:04:06.840 a disorder symptoms and their duration necessary for a diagnosis, 0:04:07.400 --> 0:04:10.360 plus any other disorders to screen, four with common symptoms, 0:04:10.520 --> 0:04:15.200 and any antithetical symptoms that can help rule a diagnosis out. 0:04:15.680 --> 0:04:19.080 The listing also includes information about the prevalence, development, and 0:04:19.160 --> 0:04:22.440 course of the disorder, the risk, the prognostic factors, and 0:04:22.600 --> 0:04:27.400 other relevant information. Finally, each disorder has that diagnostic code 0:04:27.520 --> 0:04:30.000 in common with the ICDs codes, which is helpful for 0:04:30.080 --> 0:04:32.479 the collection of data as well as streamlining the billing 0:04:32.480 --> 0:04:38.159 process for care providers and insurance agencies. It's no small 0:04:38.200 --> 0:04:40.159 feat for a mental health issue to be added to 0:04:40.160 --> 0:04:44.000 the DSM. The DSM four wasn't all that different from 0:04:44.040 --> 0:04:46.479 the DSM five, but the changes that did make the 0:04:46.480 --> 0:04:49.359 cut were thoroughly reviewed and discussed by some of the 0:04:49.400 --> 0:04:53.120 foremost minds in the psychiatric field. The DSM four was 0:04:53.120 --> 0:04:56.320 published in nineteen ninety four, so the DSM five Task 0:04:56.400 --> 0:04:59.640 Force had to review all scientific studies published on psychiatric 0:04:59.680 --> 0:05:03.880 disord orders since then. Since the DSM five wasn't published 0:05:03.920 --> 0:05:07.520 until twenty thirteen, that's nearly twenty years worth of ongoing 0:05:07.560 --> 0:05:13.640 research to look at. Following comprehensive review, proposals to modify 0:05:13.680 --> 0:05:17.599 existing diagnoses were made, which required vigorous discussion and debate 0:05:17.680 --> 0:05:21.920 among the committee members plus input from outside experts. All 0:05:21.920 --> 0:05:24.560 proposals were examined by the Task Force, as well as 0:05:24.560 --> 0:05:28.479 two additional committees created for a more independent opinion, being 0:05:28.560 --> 0:05:34.800 the Scientific Review Committee and a Clinical and Public Health Committee. However, 0:05:34.920 --> 0:05:38.160 since then, new changes to the process have streamlined it. 0:05:38.800 --> 0:05:42.320 Rather than waiting decades between issues, experts can now submit 0:05:42.440 --> 0:05:45.760 changes online, helping to make the manual more timely and current. 0:05:46.560 --> 0:05:49.919 Once approved by the APA Board of Trustees, clinicians and 0:05:50.000 --> 0:05:53.560 other DSM users are notified about the edit. Users can 0:05:53.640 --> 0:05:56.120 hover over the change in the online version to find 0:05:56.120 --> 0:05:59.440 out the pertinent details, what the previous material was, and 0:05:59.560 --> 0:06:04.760 the support arding scientific evidence that inspired the edit. For 0:06:04.880 --> 0:06:07.039 the article this episode is based on has to work, 0:06:07.080 --> 0:06:10.599 spoke doctor Philip Wang, director of the APA's Research Division, 0:06:10.640 --> 0:06:14.640 which supervises the DSM. He said, this has been a 0:06:14.760 --> 0:06:18.000 major advance. Let's say there is enough scientific evidence, and 0:06:18.080 --> 0:06:20.520 let's say there is a valid change. To have to 0:06:20.560 --> 0:06:23.440 wait fifteen or twenty years for clinicians and patients to 0:06:23.480 --> 0:06:27.279 benefit from that change is unconscionable. The new system is 0:06:27.320 --> 0:06:30.599 completely transparent, continuous, and at the end of the day, 0:06:30.839 --> 0:06:36.320 it hopefully is good for clinicians and benefits patients. The 0:06:36.480 --> 0:06:39.040 changes from the fourth edition to the fifth edition were 0:06:39.200 --> 0:06:43.719 small but significant to address advances in scientific research and 0:06:43.839 --> 0:06:47.839 issues with diagnoses that clinicians had been reporting. The DSM 0:06:47.960 --> 0:06:52.640 five combined nearly thirty disorders, eliminated two diagnoses entirely, and 0:06:52.720 --> 0:06:58.359 added fifteen. The DSM five has also revamped disorders into 0:06:58.400 --> 0:07:02.800 a lifespan approach. Instead of classifying certain issues as solely 0:07:03.040 --> 0:07:06.800 childhood disorders, it discusses how they change and manifest at 0:07:06.800 --> 0:07:11.160 all stages, and the DSM five emphasizes the importance of 0:07:11.200 --> 0:07:16.600 parents in diagnosis and treatment. This new version also introduced 0:07:16.720 --> 0:07:20.320 Section three, which is for conditions where there's not enough 0:07:20.320 --> 0:07:23.640 scientific data yet to determine whether they should be classified 0:07:23.680 --> 0:07:27.600 as psychiatric disorders. Among these conditions are things like Internet 0:07:27.640 --> 0:07:32.720 gaming disorder and caffeine use disorder. Section three also contains 0:07:32.760 --> 0:07:35.800 cross cutting measures and models that have potential to help 0:07:35.800 --> 0:07:38.920 clinicians better evaluate patients when they show symptoms that could 0:07:38.920 --> 0:07:43.680 be indicative of multiple disorders, and it also includes a 0:07:43.720 --> 0:07:47.800 Cultural Formulation Interview guide with questions to help clinicians identify 0:07:47.920 --> 0:07:51.840 how a patient's cultural background affects their perception and presentation 0:07:52.000 --> 0:07:57.240 of psychiatric symptoms, treatment, and diagnosis. The APA's fact sheet 0:07:57.240 --> 0:08:00.240 about it explains a quote the interview provides, it's an 0:08:00.240 --> 0:08:03.160 opportunity for individuals to define their distress in their own 0:08:03.200 --> 0:08:05.720 words and then relate this to how others who may 0:08:05.760 --> 0:08:08.960 not share their culture see their problems. This gives the 0:08:09.000 --> 0:08:11.960 clinician a more complete foundation on which to base both 0:08:12.000 --> 0:08:17.640 diagnosis and care. Some key about faces that occurred in 0:08:17.680 --> 0:08:20.600 this update are proof that the DSM isn't opposed to 0:08:20.680 --> 0:08:24.360 changing with the times. Here's some examples of major turnarounds. 0:08:25.520 --> 0:08:29.960 Consenting adults who enjoy relatively unconventional BDSM fetishes or cross 0:08:30.040 --> 0:08:33.240 dressing need not fear being diagnosed with mental illness anymore. 0:08:34.040 --> 0:08:38.800 The DSM five update depathologized kinky sex. They're now just 0:08:38.960 --> 0:08:43.000 people with a preference. It also removed the diagnosis of 0:08:43.040 --> 0:08:46.480 Asperger's syndrome and classified the symptoms associated with it and 0:08:46.600 --> 0:08:50.920 three other previous diagnoses under the umbrella autism spectrum disorder, 0:08:52.360 --> 0:08:57.000 and it codifies medical acceptance of transgender people. The DSM 0:08:57.080 --> 0:09:01.760 five replaced the diagnosis of gender identity disorder with gender dysphoria, 0:09:02.679 --> 0:09:05.880 so those who don't identify with their assigned sex at 0:09:05.920 --> 0:09:08.640 birth are no longer considered to have a mental disorder. 0:09:09.520 --> 0:09:11.840 The new diagnosis spells out some of the challenges of 0:09:11.880 --> 0:09:14.960 living with gender dysphoria and the paths that people may 0:09:15.080 --> 0:09:21.240 choose to resolve it. One complaint about the DSM is 0:09:21.280 --> 0:09:23.880 that once a condition is included in the manual, it 0:09:23.920 --> 0:09:27.480 may turn what once was considered normal behavior into a 0:09:27.559 --> 0:09:32.920 pathological illness that must be treated, often with medication. But 0:09:33.160 --> 0:09:36.360 Wang pointed out that the DSM five has incorporated an 0:09:36.400 --> 0:09:39.440 acuity measure to help with that. Since so many disorders 0:09:39.559 --> 0:09:43.560 range widely in their severity, these scales help clinicians better 0:09:43.559 --> 0:09:48.240 evaluate symptoms and levels of impairment. For example, let's say 0:09:48.240 --> 0:09:50.960 you're grieving the death of a loved one, are you 0:09:51.080 --> 0:09:53.680 still able to cope with life? Or are you barely 0:09:53.720 --> 0:09:57.280 able to get out of bed? Once assessed, clinicians will 0:09:57.320 --> 0:10:00.240 be better able to land on the appropriate treatment, whether 0:10:00.280 --> 0:10:04.439 that's medication, watchful waiting, talk, therapy, or a combination of these. 0:10:06.679 --> 0:10:10.160 After all, the human mind is a marvelous thing, but 0:10:10.320 --> 0:10:14.400 mental wellness doesn't come automatically or easily for all of us. 0:10:15.280 --> 0:10:17.360 People dealing with that, and not to mention the loved 0:10:17.360 --> 0:10:20.320 ones who support them deserve and up to date and 0:10:20.400 --> 0:10:23.400 fully vetted guide to help them and their care providers 0:10:23.520 --> 0:10:27.600 find the best treatments. The value in the decades of 0:10:27.640 --> 0:10:30.960 research and intense consideration that have gone into the DSM 0:10:31.360 --> 0:10:33.760 is one of the many reasons why the gold standard 0:10:33.800 --> 0:10:36.520 advice for anyone who's concerned about the mental health of 0:10:36.559 --> 0:10:39.040 themselves or a loved one is to reach out to 0:10:39.080 --> 0:10:43.199 a healthcare professional. Access to tools like the DSM helps 0:10:43.200 --> 0:10:46.480 those professionals help us on a path towards having a 0:10:46.480 --> 0:10:55.960 better time in this sometimes difficult world. Today's episode is 0:10:55.960 --> 0:10:58.760 based on the article how the Diagnostic and Statistical Manual 0:10:58.760 --> 0:11:01.440 of Mental Disorders Works on how stufforks dot com, written 0:11:01.440 --> 0:11:04.040 by A. Leah Hoyt brain Stuff is production by heart 0:11:04.080 --> 0:11:06.640 Radio in partnership with HowStuffWorks dot Com and is produced 0:11:06.640 --> 0:11:10.000 by Tyler Klang. Four more podcasts by heart Radio, visit 0:11:10.040 --> 0:11:12.839 the heart Radio app, Apple Podcasts, or wherever you listen 0:11:12.880 --> 0:11:13.880 to your favorite shows.