SWM-006: Social Work and the DSM-5, with Michael First and Janet Williams (1/2)

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When the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, abbreviated as DSM-5, was released last year by the American Psychiatric Association, mental health professionals had to get used to a new set of diagnostic criteria for the first time in 19 years. The clinical faculty in the Columbia School of Social Work hosted a day-long conference on the DSM-5 this past December targeted at social workers in the mental health field: which of the new criteria will have the most impact on their interactions with clients? On this podcast we hear from the conference’s two keynote speakers: Dr. Michael First, a professor of clinical psychiatry at the Columbia University Medical Center and a research psychiatrist at the New York State Psychiatric Institute, and Dr. Janet Williams (MS'74, PhD’81), professor emerita of Clinical Psychiatric Social Work at the Columbia University College of Physicians and Surgeons. Both speakers have played key roles in developing DSM contents over the years. Also on this podcast is second-year student David Forman (MS'14), who is specializing in advanced clinical practice. He poses some questions from a social work perspective.


Background information & key points:

DSM-5 podcast speakers

  • Michael First was involved in the research planning of DSM-5 and was one of the co-authors of the research agenda. He was called in as a coding and editorial consultant in the final phases before publication.

  • Janet Williams, an alumna of the School of Social Work, was the text editor of DSM-III and –IIIR.

  • The DSM is commonly referred to as a “bible” of mental health disorders, but according to Dr. First, this analogy is a misnomer as it suggests it was handed down from a divine source when in fact it is the work of researchers who are “doing their best.” That said, it will never be a crowd-sourced document or a series of Wikipedia articles. It is a “body of professional information intended for use by professionals,” which is issued under the imprimatur of the American Psychiatric Association. The DSM is “evidence based”—but the word “based” is important, he notes, as there is opinion built in as well.

  • The DSM has become a fixture of American culture. The general public is now familiar with it, and there is a huge number of articles about it in the media. People find it “fascinating” as well as “terrifying" (First).

  • With every revision of the DSM, a strong effort has been made to reach consensus, but for the DSM-5, this goal was more challenging, perhaps because of the explosion of diagnostic research that has taken place since the DSM-III (Williams). That said, from the APA’s point of view, any controversy surrounding the DSM-5 is due to the fact that it was easier for people to get involved via the Internet (the criteria were posted online while being worked on). In addition, “some of the decisions they made in DSM-5 were in fact more controversial.” (First)

  • When it comes to mental health disorders, there is a “loose relationship” between diagnosis and treatment. Many health professionals are frustrated that the DSM doesn’t do more. Much of its contents are “descriptive”—but that is because people are very good at observing patients. Thus the DSM supports the ability of two different DSM users to agree on a diagnosis. Treatment, however, is “more of an art than a science.” (First) There is a tendency to use the same psychopharmological drugs to treat various mental health disorders; to target symptoms rather than treat specific disorders. (Williams)

  • The Research Domain Criteria (RDoC) project—which calls for the development of new ways of classifying psychopathology based on dimensions of observable behavior and neurobiological measures—has reached a dead end. “We don’t know what’s going on, and what little we know doesn’t match DSM categories." Would we be better off starting again? (First)

  • Subtle and minor changes in the DSM can have major impacts on clients and clinicians. For example, the decision to change the onset of ADHD from seven to 12 years old means that means that new people will get diagnosed and medicated. The change was made because of recall problems: it is hard for people to remember what they were like at 7. But as a consequence, some will now get medicated and labeled as ADHD who are actually normal. There is always a trade-off. (First)

  • While it is reasonable to assume that insurance companies lobby to shape the DSM, there is no evidence that they get involved. In fact, it is more likely to be the other way around: mental health researchers will make a decision on a diagnostic based on the need for patients to get reimbursed. For instance, there is no reimbursement for “oppositional defiant disorder” in children, so some creative researchers came up with a diagnostic home for this condition. (First)

  • As to cultural factors (all the “-isms”) that moderate the expression of disorders, the DSM-5 has added a section called “culture features” and has an even bigger appendix on these topics than found in the DSM-IV. (First)

  • Is DSM used all over the world? Not exactly. Researchers everywhere tend to use it, but clinicians outside the U.S. use ICD-10, a medical classification list issued by the World Health Organization. But it may be worth noting that nearly a fifth of the work groups for the DSM-5 included people from Europe and other countries, providing an “outside the US” perspective. “This is something new—the opening up of the DSM beyond the northern US-centric view." (First)

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