Welcome to PsychEd, the psychiatry podcast for medical learners, by medical learners.
In this episode, we present a focused summary of the latest changes in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) with our guest expert — Dr. Michael First, a Professor of Clinical Psychiatry at Columbia University, NY. Dr. First is an internationally recognized expert on psychiatric diagnosis and assessment issues. He is the editor and co-chair of the DSM-5 text revision project (DSM-5-TR), the editorial and coding Consultant for the DSM-5, the chief technical and editorial consultant on the World Health Organization ICD-11 revision project, and was an external consultant to the NIMH Research Domain Criteria project (RDoC).
The learning objectives for this episode are as follows:
Understand the rationale for undertaking a DSM-5-TR as well as the revision process itself
To become familiar with disorder, text, and symptom code additions and modifications to the DSM-5-TR
To understand the purpose and function of the DSM in its current form and be able to contemplate future directions
Guest Expert: Dr. Michael First – staff psychiatrist and professor of clinical psychiatry at Columbia University, USA
Produced and hosted by: Dr. Alex Raben (staff psychiatrist) and Saja Jaberi (international medical graduate)
Audio editing by: Dr. Alex Raben
Show notes by: Saja Jaberi
Interview Content:
2:53 - Learning objectives
3:34 - Brief description of the DSM and its history
4:54 - ICD vs. DSM
7:43 - Rationale behind the new revision
11:11 - Characteristics of the DSM-5-TR revision process and the people behind it
16:54 - Case presentation and differential diagnosis
23:07 - Prolonged grief disorder
27:04 - Most important changes to the terminology used in the manual
39:34 - Pros and cons of the DSM
44:30 - A brief comparison to the RDoC framework
49:04 - Future directions of the DSM
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. 2013.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th Text Revision ed. 2022.
DSM-5-TR Fact Sheets https://psychiatry.org/psychiatrists/practice/dsm/educational-resources/dsm-5-tr-fact-sheets
CPA Note: The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association.
For more PsychEd, follow us on Twitter (@psychedpodcast), Facebook (PsychEd Podcast), and Instagram (@psyched.podcast). You can provide feedback by email at psychedpodcast@gmail.com. For more information, visit our website at psychedpodcast.org.
PsychEd+episode+47+-+Understanding+the+DSM+V+TR+with+Dr.+Michael+First.mp3: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Alex:
Welcome to PsychED, the Psychiatry Podcast for Medical Learners by Medical Learners. This episode covers all you need to know about the new DSM five TR. I'm Alex Raben. I'm a staff psychiatrist at the Centre for Addiction and Mental Health in Toronto, and I'm also a lecturer at the University of Toronto. I'm joined today by my co-host Saja Jabri. She is a international medical graduate and a psychiatry enthusiast and this is her first episode. So welcome, Saja.
Saja:
Thank you. I'm very happy to be here.
Alex:
This was also such as brainchild. I should say so. Thank you, Saja, for picking a wonderful topic. We're also very pleased to be joined by our esteemed expert, Dr. Michael B first, and he is a professor of clinical psychiatry at Columbia University. Dr. First is also a internationally recognised expert on psychiatric diagnosis and assessment issues as a private practice in New York City and also conducts expert forensic psychiatric evaluations in both civil and criminal matters, including the 2026 trial of Zacharias Moussaoui.
Dr. First:
Sorry. Moussaoui.
Alex:
Moussaoui. Thanks, Doctor. First. And then especially important to this episode, Dr. First is the editor and co-chair of the DSM five Text Revision Project, the editorial and coding consultant for DSM five, the chief technical and editorial consultant of the World Health Organization ICD 11 Revision Project and was an external consultant to the NIMH Research Domain Criteria Project or RDOC. Dr. First is also the lead author of the Structural Structured Clinical Interview for DSM five, known as the SCID. More broadly, and this is a widely used or the most widely used structural diagnostic instrument for DSM five diagnoses and in research and in the clinical setting. He has also authored and co-edited a number of books, including a research agenda for DSM five, the DSM four TR Guidebook, the DSM five Handbook for Differential Diagnosis and Learning, DSM five by Case Example. So we could not be more pleased to have you here, Dr. First on the show to talk about this topic, which you are clearly a leading expert on. Welcome to the show.
Dr. First:
Thank you. A pleasure to be here.
Alex:
Now I'm going to just quickly talk about our learning objectives today, and then I'm going to hand it over to Saja, ask the first question. So by the end of the episode, the listener will be able to, number one, understand the rationale for undertaking a DSM five TR revision, as well as how that revision process looks. Number two, become familiar with disorders, the text and the symptom code additions and modifications to the DSM five TR. And number three, understand the purpose and function of the DSM generally and be able to contemplate what future directions are going to look like in this area. All right, Saja, I'm going to hand it over to you to take it away.
Saja:
Okay. So without further do, I'll jump into things to start with, Dr. First. Could you briefly describe to our listeners in simple words, what is the DSM and where did it come from and how did we get to the present edition?
Dr. First:
Okay, so the DSM that stands for the Diagnostic and Statistical Manual of Mental Disorders and the version that the subject of today's presentation is the DSM five. Tr So that means it's the fifth edition of the DSM, and the TR is the latest version, which is a version that focuses primarily on revising the text. So the DSM is basically a dictionary, so to speak, of all of the psychiatric diagnoses which are accepted as valid by the American Psychiatric Association. The fifth edition when the first edition came out in 1958 and the second 62 and DSM three, which is the one that is it's the first one to have diagnostic criteria for every disorder. That was the 1980, and then DSM four was in 1994, and now we're up to DSM five, which is in 2013. So we're now 11, eight years past the release of DSM five. So we felt that a revision was needed and that's what the DSM five text revision is.
Alex:
That's terrific. Thanks so much, Dr. First. No, we live in Canada. You live in America, but we have listeners from all over the world, certainly in North America. We turn to the DSM quite frequently in our clinical practice, as you said, as a dictionary for diagnosing. But our international listeners, I'm guessing they might use some other sources. So there's the ICD. So how do we differentiate the ICD from the DSM five? And could you take us through that?
Dr. First:
Sure. So the it's a little complicated. So the the version, the DSM, the ICD 11, which is the 11th revision, just got finished a couple of years ago, but no country is yet implemented yet. Eventually, every country in the world will have to use ICD 11 codes in the same way. Right now, the United States, Canada and all the countries of the world are using ICD ten codes. The DSM uses the ICD code. So when you open up the DSM and make a diagnosis and write down the code, you're actually fulfilling the obligation to use the ICD codes. But the definitions in ICD and DSM are very, very similar, but they're different. There's been attempts over the years to harmonies them, and I've been involved in that process. So they're pretty close. But there are still differences that have to do with some different historical traditions between the United States and other parts of the world and different levels of detail, different types of disorders. So they're pretty much the same, but not identical. It really depends upon where you live. Even though the DSM is produced by the American Psychiatric Association, there are a number of countries around the world which also use the DSM. It's been translated into different languages, and that got started basically after DSM three came out in 1980. DSM three had introduced diagnostic criteria for every disorder. The basically the rules you need what needs to be present in the patient duration and symptom wise in order to make the diagnosis at the time. The system which is affected in the rest of the world was ICD nine, which did not have those kinds of definitions. So a lot of countries decided to use the DSM three as their main system, mainly because of the sense that the diagnostic criteria were so useful. It was they preferred using the DSM. Since then, ICD has caught up. The ICD 11 does have something called clinical descriptions of diagnostic requirements, which are like criteria. So both systems now have criteria. So I think the usage of the ICD 11 has greatly increased over the years, and in many countries that's the only system that's used.
Alex:
Interesting. I didn't realise there was that sort of practical difference between the manuals historically and caused a lot of uptake of the DSM three. For that reason. It's quite interesting.
Saja:
Okay. So, Dr. First, thank you so much for that. Could you tell could you briefly describe to our listeners and tell us more about why was the DSM five are needed? What was the rationale behind it?
Dr. First:
Okay. So the as you can imagine, the DSMB is an amalgam of what we currently know about the mental disorders. And we luckily live in a world where what we know keeps changing as we learn more things. So know, like any textbook, you would not use a textbook of medicine from ten years ago. You would assume that a lot of things there would be out of date. So the same thing is kind of true too. There are two components to the DSM. There's the criteria which defined the disorders, but actually 95% of the words in the DSM are the text. That's the information about the disorders. It includes things like prevalence, sex ratio, familial pattern, all those aspects about the disorder, which are very important. And in more recent years we include things like risk factors and diagnostic markers. So this information, it's really become an authoritative source of information so that information could get out of date. As we know things happen. So the the version, the DSM five from 2013, all the texts there was based upon what we knew about mental disorders in 2012. So in the intervening eight or nine or ten years, a lot of the information in the DSM is really no longer up to date. So this is an attempt, since we don't know when the next big DSM six will be. We wanted to take the opportunity to revise the text to make it up to date. Now, one thing that's a little new this time around is in the previous DSM's, in between DSM editions, there were no changes, so you had to wait till the next big DSM to make changes.
Dr. First:
We finally got rid of that way of doing it, which is kind of bad to have to wait for some artificial period of time and changes can be made on a rolling basis. There's a process by which people could submit proposals for changes to the DSM five website, and then there's a whole process by which the proposals are evaluated. They have to be empirically based. You can't just write in and say, I think it would be a good idea to have this kind of disorder. You would say, I think we'll give you an example. A disorder that is becoming more and more popular around the world is Internet gaming disorder. People who have basically kind of like a gaming addiction. ICD 11, when they came out, has actually a disorder called gaming disorder, and DSM five doesn't yet. It's in the appendix. But it's very possible that in maybe the next ten years there's more and more data is collected. They'll feel that there's enough data to justify going into the DSM five. So new disorders could be added when there's enough data. There was one new disorder since DSM five came out that has been added, and that's prolonged grief disorder, which that's been much discussed already also in ICD 11. But the DSM group finally felt that there was enough data to justify being added to the DSM. So it is now in the text revision.
Alex:
I see. So a lot of years have passed. There's progress in science taking place all the time. And so there was this need to update the the DSM clearly, but it needs to be data driven. You can't just make an arbitrary change, as you were saying. You mentioned one of those changes, prolonged grief disorder. We are going to get into the meat of what these changes are very shortly. But I did want to talk about the process because you've been directly involved in that. So I was hoping with your personal perspective on that, what does that look like? How do these changes get approved? Who's sitting on these committees, how many committees, that kind of thing.
Dr. First:
So when the DSM five came out, that was the preparation for the DSM five was about seven or eight years. So that was a big process with different work groups working over that period of time to make all of the proposals. And once we've changed over to DSM five, post DSM five, this new ongoing revision model, we now have a different process. Now, for the first time, we have a website open up for proposals, and when a proposal comes in to the website, the website is very specific about what a proposal has to include. So for example, if you want to add a new disorder, which is probably the hardest thing to do, you have to show a lot of data about things like its validity and different kinds of validity. It's clinical utility, it's reliability, all the kinds of things you would want to know about before you make the decision to add a disorder. So a lot of data has to be collected, and it's pretty clear on the website what kind of data it needs to be. So this website has been open since 2013 and proposals have come in and some of the proposals are for tiny changes, but there have been a number of proposals that have been evaluated and have gotten through the process and that prolonged grief disorder is one of them.
Dr. First:
So now for that process, there's a steering committee that is the first line of when when a proposal comes in, they evaluate and see whether it looks like there's enough data in the proposal to even spend time considering it. If somebody just writes it, this should be this and. My data is I did a study of five people or whatever that would clearly not not immediately get sent back and say we need a lot more data. But so you would outline the proposal, kind of say what kind of data they're planning to give in. And then the committee would decide, okay, if they're in the ballpark of getting in, they would actually send it to a special committee that had expertise in whatever area it is that somebody had a proposal for a new mood disorder, the Mood disorder group would look at it and they would review a proposal and decide whether the data was sufficient, and if not, they would send it back to the submitter and say, you know, this is really good, but we still need more about this kind of validity, and then would go back to them and then it would be up to the person who submitted the proposal to provide that data.
Dr. First:
Then it would go back to the committee again. And if the committee feels like there's sufficient data, then the next step gets posted on the website for public comment for 45 days and then know notices are sent out to organisations saying there's a new proposal for such and such on the website. And then after 45 days we look at what comes in and then they get analysed and then that goes back to the steering committee to see whether or not any of the concerns that were raised by the public comments need to be addressed. And if everything's sort of taken care of and everybody's satisfied with how it looks, then it goes through the APA approval process. The APA has a board of trustees and an assembly. They also get to look at it and give a thumbs up or thumbs down on it. So by the time it's in there, it's got going through many, many layers of approval and the not so easy gets up at the end basically.
Alex:
Doesn't sound like it. So just to summarise that for our listeners, because it's harder to do visually, this would be, I think, a little bit easier, but it sounds like it goes to the steering committee first. If it passes a threshold, then it goes on to the individual committees that are experts in those areas or review committee. And then from there there's a public appraisal.
Dr. First:
Let's say it goes back to the steering committee first, because the steering committee has to approve. So the review committee would say, we think it's good. Then the steering committee debates whether to put it in. And when they're satisfied, like, okay, we really think it's solid and then it goes for public review and then then we'll see what the public has to say. And and hopefully it happened. It's been you know, the big one was the prolonged grief disorder. We got lots of very helpful comments. And the criteria that were proposed actually were changed after the public comments came in to address some of the problems that they pointed out.
Alex:
Interesting. And I think that's something. Yeah, Really? No, because I don't think a lot of people, myself included, realised there's this public component to it and and then after that back to the steering committee and then ultimately kind of APA for the final signoff. Okay.
Dr. First:
And that's what this is the first time we ever did that. There was never such an all the previous DSM's while people would write things into the APA and whenever there was never a formal process by which the public could make a proposal, that's that's new since DSM five.
Alex:
Gotcha. Okay. Very cool.
Saja:
Wonderful. Dr. First. Can I submit a proposal, let's say? Or who can submit these proposal for changes to the DSM? Is it open to the public?
Dr. First:
Well, the the hard part is fulfilling the requirements for the data. I mean, a regular person, a psychiatrist in practice might think there's a good idea for new disorder, but to get it in, a lot of data would be collected. And that's what that's what's laid out on the website, what that data is needed. So generally most of the people are either organizations or researchers or groups of researchers who can present all the data that is required to at least submit the proposal. But you're right. Theoretically, if an enterprising clinician collateral that data available, then then sure, you know that absolutely would be appropriate.
Alex:
Great. So I wonder if maybe we should go to the case now as a entryway into some of the changes in the DSM five, if you want to read that out.
Saja:
So for today's episode, we have a case presentation. Mariyam, she's a 56 year old female, married her daughter, completed suicide more than two years ago. She often feels depressed but does not think that she feels depressed most of the time, and she's unsure whether she feels depressed most of the day. Her appetite is normal. She sleeps very well. She often experiences fatigue and anhedonia. She experiences recurrent involuntary dreams and memories associated with her daughter's suicide. She used to avoid places and things that reminded her of her daughter outside the home rather than inside the home. But this is no longer the case. Her beliefs about the world have become negative and very pessimistic, and she struggles with substantial guilt associated with her daughter's suicide. She has invested. A great deal of time and effort to investigate and try to find answers and reasons for her daughter's suicide. She's not particularly angry, or hypervigilant, and she does not engage in reckless, self-destructive behaviours. She thinks about her daughter very frequently and longs for her daily. Since her daughter's death, she feels as though a part of herself has died. She has struggled to engage with friends or interest and experiences life as meaningless and feels intensely lonely and emotionally numb. So I don't know. Should we take a minute to think about the possible diagnoses?
Dr. First:
Yeah, I mean, you want me to comment on it.
Alex:
That'd be Great.
Dr. First:
So if you if her mother, Miriam, if you saw her mother one month after her daughter's suicide and she gave that story, you would say to her, you're going through a normal grieving process. It's painful, but there's then maybe counselling to help you get through the grief. But you would not consider her having a disorder because, you know, that's normal for people to grieve the loss of especially a child. The fact that it's two years later is what suggests that might be pathological. Another thing that's in the differential there. So normally when when there's a death like that, the two most common besides this, a grieving and abnormal grieving process could be depression. Major depression can be triggered by grief reaction, like any life stressor. But certainly if you're predisposed, have a family history of depression, you have a past history of depression that could trigger a depressive episode. But as was described in the case, she doesn't have the symptoms that would justify a diagnosis of major depression. The depression wasn't every day didn't include many of the required symptoms. So that was sort of ruled out. The only other diagnosis that sounds possible could be PTSD, avoiding things, you know, feeling nightmares that that's a symptom. So one of the questions which wasn't in the case was what was the nature of the suicide that the mother let's say the the she found her daughter had killed herself with a shotgun and the mother finds the body in the bedroom.
Dr. First:
That exposure to that traumatic experience could actually be enough to go for PTSD. But it doesn't sound like from the description that the typical symptoms of PTSD were, they're like things like re-experiencing the trauma. The only one that was a little bit like that were the dreams. But the doesn't sound like a picture of PTSD, but that would be in the differential. So and all three of these could happen together. So the three diagnoses I've mentioned in the differential would be major depression, PTSD, And then this new diagnosis, which has recently been added, which is called prolonged grief disorder. And the concept is simple. There's certain a certain amount of grieving. And some people, when they're grieving, become non-functional for a month or two after the death of a loved one. They really can't do anything but the normal grieving process. People at different paces slowly get over it. At a certain point in time, most people will have gotten pretty much back to normal, at least somewhat, and for that reason. So this the idea here, this is a diagnosis reserved for that subgroup of people who experience a loss, who never get over it. Now, that's a tricky state. When I use phrases like get over, a lot of people would say, Nobody, you never get over the death of your child, which is true.
Dr. First:
That's why getting over it is not the right word. But there's the way you get. If your grief is stuck at such a high level two years later, where it's preoccupying your life and it's interfering with your functioning, then we could say that that's not a normal grief reaction. When this diagnosis was put on the website for comment, there was a contingent of people who are very upset about the idea of labelling grief of any kind as disorder. And we're very we're very sensitive to that. We want to make it very clear that there's a normal grief and then there's abnormal prolonged grief disorder. And what made it even more compelling to add this diagnosis to the DSM is there's a treatment that has been shown to work. It's a cognitive therapy type treatment. There's no medication for this condition. It's a therapeutic therapeutic edition. And theoretically, you're supposed to wait a year until the death has occurred to be able to say you have prolonged grief disorder. So, I mean, I'm sure you could start the therapy earlier if you wanted. But as far as getting the label, you really need to wait a full year before you can conclude that the reaction to the grief and the person's life change is beyond what we would consider normal.
Alex:
That's really interesting to me that the way the public commentary kind of played into thinking about this as a disorder. And thank you for outlining your differential in the case. I couldn't agree more. And then you also let us nicely into this prolonged grief disorder discussion. You kind of outlined a bit of it for us, including even treatment. But I'm wondering, can we get a bit more specific? Like what are these criteria that clinicians will be looking out for? What's the sort of DSM version of this?
Dr. First:
As with the many DSM diagnoses, is symptoms which are core that are required for all cases. So for a manic episode, you must have elevated or expansive mood the rest of the symptoms, whether or not you don't need sleep, that's optional, that's variable. But you must have the elevated or irritable mood to have mania in the same way. Prolonged Grief disorder has two symptoms in particular, one of which must be present in all cases. The two cardinal symptoms. Either of them have to be present, usually both, or it's a yearning for the person and preoccupation with thoughts or memories of the person you can't get, Everything you think about has to do with the death of the person. So you have to have those. And as with many DSM definitions, you have to have it's not just every once in a while. It's got to be nearly every day for 12 months, very long period of time. That's the first part of it. So if you don't have either of those, you're not even in the ballpark. But once you have either the yearning or the preoccupation, then there's a bunch of other symptoms that you need. At least I believe it's three. There's a list of eight symptoms and three out of the eight are required. And let me tell you what the first is called identity disruption, which means that you feel like as though a part of yourself has died.
Dr. First:
A lot of people in right after the death of a level. And they feel that. But again, months later and again, that's why that itself would not be enough to make the diagnosis. That's why it's you need a whole cluster. It's a combination of the symptoms together. So that's one of them. Some one another one is a more sense of disbelief about the death. You really can't believe the person has died. Avoidance of reminders that the person is dead. Intense emotional pain, which includes anger or bitterness, difficulty reintegrating into one's relationship. So it's very common to kind of withdraw into yourself when you're grieving. But the part of the normal grieving process, you get back to your old life, you reconnect with your friends. In this condition, you really have a real hard time integrating with the way your life used to be. Some people are emotionally numb. They feel like they don't have any emotions at all. People will feel life is meaningless and there's an intense loneliness as a result of the death. So any one of these on their own may not be pathological. It's the three together, plus the yearning or preoccupation. All of that together is required. And like most DSM diagnoses, there's a requirement that that all of these symptoms together have to be severe enough to cause distress or impairment in occupational or social functioning. All that together is what makes it a disorder.
Alex:
Thank you so much for taking us through that doctor. First and looking at the list. I'm also kind of struck by, as you were mentioning before, like the overlap with PTSD, for instance, or some other conditions. Right. Identity disruption. You can think of that in other conditions, emotional numbness, avoidance. But to me, it seems like it's very oriented around the person you're grieving. That seems to be a very distinct difference here. And then the timing, as you were saying as well.
Dr. First:
That all of the symptoms, the identity disruption is as a result of the death. So, you know, people can have these symptoms chronically before the death happened. So you couldn't count that as part of prolonged grief disorder unless you could attribute it to as a result of the death of the loved one.
Alex:
It makes sense. Makes sense. Great. Thank you for taking us through that. I think now we'd like to turn to the other changes because prolonged grief disorder, that's the only new disorder added to DSM five TR. But there have been a number of other changes. Could we maybe go through?
Dr. First:
Well, actually, there are a couple of other new new in quotes. They're not completely I mean, this is the major one. There's no question. This is the one of the most clinical interest. It's three other disorders or conditions which have been added. One is something called unspecified mood disorder, which sounds it's a technical thing of sorts, but it's for real. When DSM five got rid of, you know, all of the categories in the DSM have an unspecified sort of a wastebasket for individuals who have presentations that don't meet the criteria for any of the disorders. And that actually is fairly common. A decent percentage of people who come for treatment don't actually meet the full criteria. So you really can't give them a diagnosis of one of the disorders in there because you don't meet the criteria. So you have to use one of these unspecified categories. So for someone who has like a subthreshold depression or subthreshold bipolar disorder, they would get a in the DSM five, bipolar, unspecified bipolar disorder or unspecified depressive disorder. But what is the mood category like something like irritability? Is that a depressive thing or is that a bipolar thing or agitation? Those certain mood symptoms aren't specific to either depression or mania. So one of the questions was what if somebody comes in and their main problem is irritability and agitation, but they don't meet the criteria for any of the disorders? What do you call that in the DSM five, you'd have to pick between decide whether is it really depressive or is it really bipolar.
Dr. First:
But the arbitrator, if you don't know anything, you have to pick like flipping a coin. The problem with that is then the person ends up having that wrong diagnosis stuck on their chart. So the solution is to take a step back and and reintroduce something which used to be in the DSM, which is an unspecified mood disorder. So we're now allowing the clinician to just say, hey, this is a mood problem. I'm not going to commit myself to whether it's bipolar or unipolar as of yet. So it's mood. So as you know, with all of these unspecified, there's more information comes in. You hope to be able to rewrite the diagnosis based upon new information. So you have to start somewhere. So this is sort of like a place to start for some unspecified general mood problem without committing yourself to bipolar versus unipolar. So that was one. There's a category called No Diagnosis. Believe it or not. So what? You know, when you work in a hospital, you have to write down a diagnosis or your practice. So sometimes you're going to get somebody who comes in, says, you know, I need to have a doctor's note saying I'm ready to go back to work.
Dr. First:
I've been on disability, everything's gotten better. So what would the diagnosis be for that person? There was really nothing in it. So we reintroduced another category that used to be in the DSM called No Diagnosis or Condition. So for somebody getting a wellness exam or sort of a duty to work thing that's been reintroduced for that reason. So these two are a little bit administrative, but they have real world implications. Another new thing was in the in the neurocognitive section, substance induced neurocognitive disorder. So that's a section of conditions that could cause dementia. Mostly dementia Drugs like alcohol, inhalants and sedatives can lead to a dementia that is very, very severe. The DSM five got rid of dementia, interestingly, and replaced it with a category called neurocognitive disorder. That comes in two levels of severity major, which is really the same as dementia. And this new thing that was added to DSM five, which is mild neurocognitive disorder. So it turns out the three drugs which cause dementia, which is inhalants, sedatives and alcohol, also cause mild neurocognitive to, I mean, the severity of the symptoms. If it's going to cause dementia, it should also cause less severe cognition.
Dr. First:
But it turns out there's one substance which only causes milder neurocognitive care, but not severe, and that's amphetamines. So amphetamines can present with a prolonged cognitive impairment that's not severe enough to call it a major neurocognitive disorder that was by accident, left out of the DSM five. So that's been now a new diagnosis, which is basically stimulant induced mild neurocognitive disorder. And the other new addition, which is a new thing for the DSM, which is to have codes for symptoms that are not disorders. And you can now add and the two that were added to DSM five was a code for suicidal behavior and non suicidal self injury. If suicidal behavior can occur in a wide variety of conditions that it's clearly very, very often it's going to be a focus of attention. It's something you really want to know. It's present and be able when you're referring the person to another clinician, know that that's on the table. So there was no way to indicate that suicide was part of the picture before. Now there's a special code that you can now write down the chart, which basically is for either current suicidal behaviour or past history of suicidal behaviour, and the same thing for non suicidal self injury, current and history. So those are all, those are new to.
Alex:
So is that diagnostically sort of agnostic in terms of the suicide behaviour and non suicidal self-harm behaviour, You could apply that to anything.
Dr. First:
You can apply to any diagnosis. You can also apply with no diagnosis. I mean there are people who make suicide attempts and you can't find any diagnosis at all. So you could write, you could use the code for that. But so there's so basically this categories for two uses. One, when those behaviours occur in the absence of a condition, but we expect that most cases of suicide or non suicidal self-injury will have a co-mental disorder diagnosis like depression, schizophrenia substitutes or whatever, they're usually going to use the codes that are code with an actual diagnosis.
Alex:
Right, Right. Makes sense.
Dr. First:
So that's those are the big changes with respect to new things. Some of that we've corrected some definitional problems or things that were unclear. Probably the biggest one is persistent depressive disorder. So persistent depressive disorder, which used to be known as Dysthymia in DSM five, is now any depression which lasts more days than not for at least two years, is now called persistent depressive disorder. So that includes the old dysthymia, which was. But if you have a major depressive episode every day for two years, that's also a persistent depressive disorder. If you have what used to be called double depression, there are chronic mild depression with occasional intermittent, serious depressive episodes. That's also if it's last at least two years. That's also called persistent depressive disorder. So you can indicate what waiver it is by using one of the subtypes. But the question was, do you also write down a diagnosis of major depressive disorder and persistent depressive disorder? So somebody, the double depression, get two diagnoses or just the the persistent depressive disorder. And the problem was that depending the two different spots of the DSM, which had the exact opposite thing, so it was really unclear what to do.
Dr. First:
It turns out that the actual it was supposed to be that you're supposed to use both diagnoses. You're supposed to use major depressive disorder and persistent depressive disorder. And the reason that's important, it's a little bit of a technical thing. It's a coding. So, for example, the coding for major depressive disorder allows you to see if the person's psychotic or mild, moderate, severe and psychotic are available in the diagnostic code. So if you write if that shows up in the chart, you could see immediately this person had a psychotic depression. The persistent depressive disorder, the code is is has nothing, nothing of severity, no anything. So if we only use the persistent depressive disorder code, you would have lost the information of the person had a psychotic depression. You need to use a code for major depression to get the psychosis in there, not plus the severity, which could also be relevant. So kind of technical reasons. We really want both codes there. And in a sense, the persistent depressive code really is used to say this is a chronic type of depression. And then the major depressive disorder codes indicate what the episode looks like.
Alex:
Makes sense.
Saja:
Okay. Shall we move on to the next question? So, Dr. first, as everybody knows, there are changes in regards to the terminology as well that's used in the manual. Could you briefly highlight the most important ones our listeners should be aware of?
Dr. First:
Sure. Some of them are extremely technical, which I won't even go into. It has to do with the most has to do with the people may have noticed that some of the diagnoses have parentheses next to them, which gets their alternate name. We kind of change some of the alternate names. The two most important ones are the use of the word neuroleptic. So Neuroleptic is a word from the fifties. I believe that's how the antipsychotics were referred to, and that word is still around. Neuroleptic malignant syndrome is still there. But through the DSM it appears in a number of different places that were term is really going out of disfavour and neuroleptic. If you look at the history of the word, basically focusing on the side effects of antipsychotics, that's what a neuroleptic is. So we decided to change it and get rid of it. Accepted in one spot. Neuroleptic malignant syndrome has been entrenched so much we sort of allow it there. But whenever we refer to the class of drugs, we call them antipsychotics and other dopamine blocking agents. Now, if in the text we refer to it as this is a drug for schizophrenia, we would call antipsychotic. The problem is that class of drugs is sometimes used for other medical uses, like nausea. You know, some of the dopamine blocking agents neuroleptic could be used to treat nausea. So we don't want to call them antipsychotic when they're not being used for that purpose. So we basically made the terminology throughout the whole book consistent. And we also got rid of the word neuroleptic wherever we could. The other area where there's significant changes of terminology was, perhaps not surprisingly in the gender dysphoria section, terminology about gender.
Dr. First:
If there's one area of the terminology, it's changing very, very rapidly. That's one of the a lot of terms become both. I don't say old fashion exactly, but they're just I guess they're let's let me tell you. So the key ones in in the gender dysphoria section, we used to say that the person you had your gender and the desired gender was the terminology that was original use. That's been changed now to the experienced gender, which is much more accurate. It's not just that you want it, you experience yourself as being that gender. Another the word phrase cross-sex as in the terms of a cross-sex medical procedure. That's another term, which is you can understand why the term was there. But that term is also going out of favour and it's been replaced by gender affirming medical procedure. And the other big one is the issue of being assigned Natal. So if you're considered a natal male, that means you were born male. That's, that's, that's also replaced because it's been replaced by assigned male at birth. It's really emphasizing the gender is what you were assigned with the doctor and the family thought you look like at birth. That's what gets you started. It's not that you're actually a male at birth, so it's really kind of highlighting the fact that gender is a social construct. And so the words have been changed to reflect that gender is not just a biological phenomenon. So they're basically basically bringing the text in line with current usage of these concepts.
Saja:
That's great. So just to summarise it, we've changed. Instead of saying desired gender to experienced gender and instead of saying cross-sex medical procedures, we use gender affirming medical procedures. And the third one would be instead of saying natal at birth, natal male at birth or natal female at birth, we say an individual assigned male at birth, and the fourth one us retiring the term neuroleptic and using antipsychotic. Amazing. Should we move on to the next question?
Alex:
I'm really curious to get your thoughts on this one Dr. First, for the DSM, as we've been talking about, used very widely, very highly regarded, and especially in North America. But I guess we're also wondering from your opinion, what does it do well, clinically and where where there's still some blind spots or weaknesses in your opinion, either from your own experience clinically or from what you've heard from other clinicians? And also you could speak to the research world if you feel there are pros and cons there to.
Dr. First:
Well, absolutely. The DSM has gotten an immense amount of criticism over the last 30, 40 years. There are very high hopes when the DSM in 1980, when DSM three came out, that these conditions actually were like diseases and that they were closer to medicine than they turned out to be. So it's turned out, for example, that it would have been nice if all if you had a diagnosis of depression, that drug that antidepressants would be the drugs to use and only they would work. But it's turned out that the relationship between a diagnosis and treatment is many to many. So many treatments work for the same diagnoses like SSRIs, work for like anxiety disorders, a compulsive disorder, and given a disorder that's many, many different treatments. So we were hoping it would be a better fit between making the diagnosis and knowing what the treatment is. And that didn't quite work out. So that in that sense the utility has been a problem. So when some people say, well, why use, you know, what's the point of using the DSM if it's not going to help me practice? Certainly one use of the DSM that I think everybody would agree on as a as a getting back to the dictionary term, that's the way we communicate with everyone, coalitions, family members, newspapers, everybody uses this terminology. And if you use the word major depression, the person hearing you, if they know how depression is defined, well, understand that I'm giving you I'm going to refer you a patient with major depression. If the person is using it correctly, you can expect when that person walks into your office what that person you'd expect to look like.
Dr. First:
You'd expect them not to have manic episodes, because if they had manic episodes, you would have said they were bipolar. So the terms both indicate what they have and what they don't have. So the terms are powerful as a communication. Beyond that, that's where it gets more controversy. The fact is that all of the treatments that have been developed in the past 50 years have been geared to some DSM diagnosis, like all of the medications on the market. To get approved for use in patients, you have to pick a drug indication to say this drug is indicated for depression. All that means is the studies have been done on patients with that diagnosis and it's been demonstrated that the medicine works better than placebo for that diagnosis. So as a clinician, if you're looking if your patient that you're seeing has a presentation that meets the criteria for social anxiety disorder, then if a drug is indicated for social anxiety disorder, you would expect it to work for that patient because that's where they date. So that all the treatment data and all the studies have been geared to the DSM system. So that's another. So it does tell you something, if we didn't have it, any system at all, you really be hard to get to get started about how how to think about how to plan the treatment. So it's been the framework for psychiatry for the past 50 years.
Dr. First:
It's far from perfect and people point that out all the time. You have this lack of specificity. The the other hope was, I think when DSM three came out that once we defined when we really didn't know the causes of any disorders and I'm I was in practice back then and I and I the belief was that now that we have a system of criteria that makes it clear what the patient's conditions look like and we do the work and the studies will find out what the causes are now that we at least have a language we all agree on. You know, here we are 50 years later, we still don't know what the cause of virtually any of the mental disorders are. That's been a really big disappointment. In fact, some researchers have blamed the DSM for our not being able to find the cause. I think that's a little over, but I could see they make some points. It's the DSM drives research funding and drives drug development, and the system itself is has no validity. Then you're really in a hole. I think there's some problems with validity, but I still think it does. Have a considerable amount of validity, enough validity to make it useful, but it's far from what we would have liked it to be. So I think that I'm I'm the first to admit that it's an imperfect system. But when people start harping on I said, Well, what should we replace it with? And then nobody has an answer.
Alex:
All right. An imperfect system is better than no system. As you were saying. Okay. So I think that that leads us in nicely, though, to Saja's, I think our last question for today. And so I'll hand it over to Sasha.
Saja:
Yeah. So when thinking about the DSM and this whole system, if we are to replace it, what can we replace it with? And there has been increasing, increasing evidence about the Rdoc framework that the APA is working on. Could you tell us if it's going to replace the DSM and what are the differences between those two systems?
Dr. First:
If Rdoc is not really a replacement. I mean, the ICD ICD is the only system in existence which is trying to do the same thing the DSM does. So, I mean, you know, you could argue maybe they really should only be one system, but I think it's safe to say that the ICD and the DSM will continue to co-exist indefinitely. But the other newer hopes, like Rdoc is basically a framework for doing research. That was an attempt. It kind of got started with the idea you should you shouldn't be doing a study looking recruiting patients for major depression because there's no doubt and schizophrenia is the same way that the people who have major depression probably have many different things going on biologically. It's a huge amount of heterogeneity. That's the big problem you have to people who meet the criteria for major depression, they're completely different, nothing in common other. Then you even have depressed mood in common necessarily because either depressed mood or loss of interest. So there's a huge variability for all of these diagnostic categories, which is a real problem. So Rdoc partly said, you know, if we're going to try to find the cause, the underlying biological cause of mental disorder, we should be recruiting patients based on whether they meet the criteria for a DSM disorder. We should be recruiting patients because they have some biological factor or pathway in common.
Dr. First:
And that's what Rdoc. Rdoc has broken things down into domains of functioning. And so and they they break them down into they're based on known neurocircuitry. For example, there's a whole group of domains which are called negative valence systems, and they correspond to symptoms that people have that are negative like fear, anxiety, loss. These correspond to actual brain circuitry. So the idea is if we recruit somebody, a group of patients that all share in common the same domain, which is linked to the biology, we're much more likely to be able to have a homogeneous group of patients to be studied. So that's another one called Positive Valence, which is where mania and stuff comes in and substance use disorders as a cognitive one. And so so these are broken down, not diagnostic. And that's the whole idea that Rdoc it's cross diagnostic. It kind of ignores the entire DSM system and recruits patients based upon these common symptom factors which are connected to the neurobiology. It's a sensible approach. So it's almost like, say, the the DSM, we know we're not going to find the cause of mental disorders if we just use the DSM. I think everybody would agree very strongly. The question is what would help us find the cause? And Ladakh was a proposal by the NIMH for a completely different approach, much more tied to the biology.
Dr. First:
And since a lot of the treatments they were looking for a biological and since we all know there is a biological basis for most mental disorders, that was very promising and continues to be a very promising approach. It's you can see it's not ready to replace anything. I mean, I think the reality is it will help us improve the DSM and the ICD as information comes in, we maybe will be grouping the categories differently. For example, once we determine that OCD and anxiety disorders have the same neuro circuitry. So we would reorganise maybe the disorders by the neuro circuitry, That approach is very appealing, but we're still far from getting there. So I don't think we see the Rdoc as a very, very useful replacement for basing science on a system, but it's also completely not practical for clinicians. That's the other thing. I mean, the DSM having a system which is symptom base that corresponds to the symptoms you see, that's very valuable. And also the Rdoc approach doesn't do well with things like delusions. What, what neurobiological is a delusion. I mean, the circuits, it's way too complicated. So it really works really well for anxiety, depression, addiction, not so well for a lot of the psychotic disorders.
Alex:
That's super interesting. And I know I said that was our last question, but that discussion that just now raised one more for me, if that's okay with you Dr. First, which is that you said and I think nice line why Rdoc is not a DSM replacement. I know you don't have a crystal ball, but where do you see the future of the DSM going, like in DSM six, for instance, and beyond?
Dr. First:
That's I think there's been a push on the DSM five. When they started work on DSM five, there was this hope for a paradigm shift, partly because of the frustration with the DSM. And that was not very I think it was very clear during the DSM process that we weren't ready to get rid of the current approach. One thing that another criticism of the DSM is the fact that it's a categorical system. You either have a diagnosis or you don't know which is not the world. Everything is not. Yes, no, it's like the shades of things. So everything's dementia, like blood pressure. One of the best examples of hypertension is a category. You either have hypertension or you don't. But in fact is it's a continuous measure of blood pressure. So any place you cut it, that's where you could call hypertension. So the same idea could work for mental disorders where you could have different possible cut points across the spectrum. And then and there's some reflection of that in the DSM five itself. So, substance, in fact, what I mentioned earlier, they got rid of dementia that was replaced by this neurocognitive impairment spectrum and autism. They got rid of Asperger's and autistic disorder, and that's now been replaced by an autistic spectrum disorder. And they did that with substance use and dependence. Now it's substance use disorder. So they're trying to move towards having some broader dimensions with cut points within them to define. So that's certainly a very, very important direction and that's already been started. And I think it will continue as we move forward. I'm not sure if this what the next big paradigm shift is, because if I knew that, I would have to know what's going on. I mean, I have a really amazing crystal ball to know that.
Alex:
Or what proposals might come through that. The new website.
Dr. First:
Yeah, right.
Alex:
Well, thank you so much, Dr. First, for joining us today. We really appreciate it. I know I learned a lot. And so thanks for being here. And Saja, thanks so much for the great first episode and this idea. And I hope you come back for another. Take care, everyone, and we'll see you next time.
Dr. First:
Okay. Thank you.
Saja:
Thank you.
Alex:
Psyched is a resident driven initiative led by residents at the University of Toronto, where affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organization. This episode was produced and hosted by Saja Jabari and myself, Alex Rabin. The audio editing was done by Alex Raben. Our theme song is Working Solutions by all live music. Special thanks to our incredible guest, Dr. Michael B, first for serving as our expert for this episode. You can contact us at psychedpodcast@gmail.com or visit us at PsychED Podcas.org Thank you so much for listening.
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