What’s New in the DSM-5-TR?
Curt and Katie interview Dr. Michael B. First, MD, editor and co-chair of the American Psychiatric Associations’ DSM-5 Text revision, coming out March 2022. We explore: What are the differences between a full update and a text revision? What changes have been made (and how were these changes decided)? What new diagnoses can we expect? Can clinicians continue to use the older DSM-5? How can clinicians advocate for changes in future versions of the DSM? All of this and more in the episode.
Click here to scroll to the podcast transcript.
Click here to scroll to the podcast transcript.
Interview with Dr. Michael B. First, MD
Michael B. First, M.D, is a Professor of Clinical Psychiatry at Columbia University, a Research Psychiatrist in the Division of Behavioral Health Sciences and Policy Research, Diagnosis and Assessment Unit at the New York State Psychiatric Institute, and maintains a schematherapy and psychopharmacology practice in Manhattan. Dr. First is a nationally and internationally recognized expert on psychiatric diagnosis and assessment issues and has conducted expert forensic psychiatric evaluations in both civil and criminal matters, including the 2006 trail of the 9/11 terrorist Zacarias Moussaoui. Dr. First is the Editor and Co-chair of the American Psychiatric Associations’ DSM-5 text revision, Editorial and Coding Consultant for the DSM-5, and the chief technical and editorial consultant on the World Health Organization’s ICD-11 revision project. Dr. First was the Editor of the DSM-IV-TR, and the Editor of Text and Criteria for DSM-IV and the American Psychiatric Associations’ Handbook on Psychiatric Measures. He has co-authored and co-edited a number of books, including the fourth edition of the two-volume psychiatry textbook, A Research Agenda for DSM-V, the DSM-5 Handbook for Differential Diagnosis, the Structured Clinical Interview for DSM-F (SCID-5) and Learning DSM-5 by Case Example. He has trained thousands of clinicians and researchers in diagnostic assessment and differential diagnosis.
In this podcast episode we talk about latest updates for the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5-TR.
With the upcoming release of the new DSM-5-TR, Curt and Katie reached out to Dr. First, the editor and co-chair of the American Psychiatric Association’s DSM-5-TR, to find out what’s new and how the DSM committee works.
“During the development of [DSM-5-]TR, George Floyd happened, and our entire consciousness about systemic racism became sort of raised. Then the question was, are there things in the DSM that are reflective of this kind of systemic racism? So, we actually created a committee that went through the entire DSM.” – Dr. Michael First
What changes have been made in the new DSM-5-TR?
- Text revisions occur to avoid letting the text become stale while supporting ongoing updates.
- New disorders, specifically Prolonged Grief Disorder, have been added.
- New codes, modeled off symptom codes, created for documenting suicidality and non-suicidal self-injury with another diagnosis.
- New categories of Unspecified Mood Disorder.
- New Criteria set for Autism Spectrum Disorder which is more conservative.
How are cultural differences addressed in the DSM-5-TR?
- Starting with DSM-IV, there has been a special committee created for culture and culture related issues
- Hypothetically, the criteria sets should apply to everyone, but in the text, there is a section on Culture Related Features which is more specific.
- The impact of the George Floyd protests inspired the creation of a new committee to look for systemic racism, lack of nuances, and prevalence issues within the DSM.
- There are conflicting opinions if “transness” should be included in the DSM and if it’s even a mental disorder.
- As the DSM is a diagnostic tool to code for insurance, the DSM takes the stance that the Gender Dysphoria diagnosis stay included so individuals can have access to medical intervention and treatment.
- The Steering Committee for new diagnosis is small, but there is diversity.
- Before a diagnosis is approved, it is posted for 45 days on the DSM website for all, including people with lived experience, to comment and advocate for diversity
What is the Process for Accepting New Diagnose?
- The Steering Committee accepts proposals through the DSM portal for new diagnosis
- Some diagnoses are qualified based on the United States’ continued use of ICD-10, whereas the ICD-11 is more progressive.
- With Complex Post Traumatic Stress Disorder, some of the criteria from the ICD have been incorporated into the DSM diagnosis of PTSD
- Proposals are floated around often, but they often don’t have enough empirical research yet.
- Proposals need to show a pool of patients who don’t fit other diagnoses, a gap in treatment, and a difference from other possible similar diagnoses.
- New diagnoses will be approved on a continuum, making the electronic DSM-V-TR the most up to date resource.
- The committee is more conservative in adding a new diagnosis to the DSM because it is hard to remove a diagnosis once it is included.
“I’d say the biggest [change] is Prolonged Grief Disorder… Now for a number of years, the concept of Prolonged Grief Disorder was really a hole in the diagnostic system… patients were out there that… were suffering, so they had some kind of mental disorder… That’s not Major Depression, you can have Major Depression, and Prolonged Grief Disorder. But they’re not the same at all. Hardly any overlap. So there’s a big hole in the system that allows people to come into your office and not have any place for them.” – Dr. Michael First
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Relevant Episodes of MTSG Podcast:
Antiracist Practices in the Room with Dr. Allen Lipscomb
Trans Resilience and Gender Euphoria
Death, Dying, and Grief with Jill Johnson-Young, LCSW
On the APA Guidelines for Boys and Men
What to Know When Providing Therapy to Elite Athletes
Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
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Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Curt and Katie 00:00
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You’re listening to the Modern Therapist Survival Guide where therapists live, breathe and practice as human beings to support you as a whole person and a therapist. Here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 00:58
Welcome back modern therapists. This is the Modern Therapist Survival Guide. I’m Curt Widhalm with Katie Vernoy. And this is the podcast for therapists about all the things that we do. And we have a pretty big milestone coming up in our profession here where the DSM-5 is transforming into the DSM-5-TR. And we are joined today by one of the very instrumental people behind the updates to this Dr. Michael First. He’s professor of psychiatry at Columbia University and editor and co-chair of the DSM-5 talking to us about some of the exciting updates that are happening and a little bit of the process behind it. So thank you very much for joining us here today Dr. First.
Dr. Michael First 01:44
Really, it’s a pleasure to be here.
Katie Vernoy 01:46
We’re so excited to have you and to have this conversation, we had reached out to our audience for some questions. So we’ll try to get to some of those. But our first question that we ask all of our guests is, who are you and what are you putting out into the world?
Dr. Michael First 02:00
Okay, so um, I have a position at Columbia University. I also work at the New York state psychiatric institute. I also have a private practice in New York City, and also a forensic practice. That’s pretty pretty busy. And I’ve my main thing to my life has been DSM, I actually got involved all the way back first at the VA that year, DSM-3 came out in 1986, because I did my residency at Columbia, where Robert Spitzer, who is the king, or whatever, he said, he created the DSM, he put it on the map, so I got to work with him. And I’ve been working with him and also with the person who did DSM for Alan Francis. And so I’ve been had my finger in some way, shape, or form every DSM. Oh, and I also work on the ICD 11, who has their own classification. And they’re just recently updated theirs as well. So I asked to work on that project.
Katie Vernoy 02:54
Wow, that’s awesome.
Curt Widhalm 02:56
So some of us have been practicing a while, my grad school we were on the DSM-4-TR. So I got to see through the transition of DSM-5, but can you maybe provide a little bit of context for what’s the goal of a text revision as opposed to a full update and looking at, you know, just kind of jumping into the next number here.
Dr. Michael First 03:18
Let me give you a background of how the text, the 4-TR came about, there was those 3-TR, for example, was the first TR. So it’s all started way back in 1980, with DSM-3, which was the first version that had diagnostic criteria. When they were working on it, they had this idea that it was just something that psychiatrist would be interested in. When they publish it, it became this huge hit, you know, it’s sold millions of copies really transformed the field, people found that very, very useful. And so, seven years later, they did the DSM-3 are now why that wasn’t called DSM-4 simply because the DSM are actually linked to the ICD. And ICD 10 was supposed to be coming out in 1992 or so. Here we were in 1987 today, so we’re actually this is an in between DSM-3, DSM 4- revision, so that’s why it was called the three R, then DSM-4 comes out in 1994. And then after DSM-4 came out, there was a lot of pushback in the field about APA grinding out a new DSM, every seven years, everybody had to learn it. So things really put the brakes on the DSM. So APA made a decision that we’re not going to seven years from now, I’ll do with the DSM-5 we’re gonna wait and see. What the downside of doing that is the text which is 90 something percent of the book is actually text not just the criteria detects is a really good resource for mental health professionals about diagnosis and prevalence doesn’t know anything but treatment, but it’s kind of like a super textbook in the sense that it’s got the top people in the world working on it. They’ve kept waiting, waiting, waiting DSM-5, which was clearly going to be at least 10 years if not more away. It ended up being closer to 20 years, the text would have gotten very stale. So that was the motivation to do the DSM-4-TR. Or when they did the 4-TR, or they made the decision, so people wouldn’t be bent out of shape about yet another DSM only to revise the text, the diagnostic criteria will go into be unchanged, it turned out there for very, very small changes, because a couple of errors has been found in the DSM 4 like, for example, Tourette’s, tic disorders had requirement that the, in order to call somebody diagnose somebody with Tourette’s, it had to cause clinically significant impairment and distress. That’s a standard DSM phrase. So you’re trying to differentiate things that aren’t problems, from things that are problems, the neurologist got all bent out of shape about that ticks a tick whether or not it causes impairment, it’s still a tick. So we, for example, we deleted that, that criteria, but it’s very small stuff like that. So that’s why the TR really was just a text revision. So DSM-5 didn’t come out until 2013. So with DSM-5 came out, it was a complete redo of all the criteria and the text. And then moving forward, what happened was, is the DSM-5-TR, now, now DSM-5-TR is actually different than the 4-TR, because it is this time, the criteria have changed, they’ve been changing the criteria. And the way that was accomplished was the fact that we now have APA as a process in place to allow changes to be made on an ongoing basis. That was one of the reasons why the DSM-4 criteria were changed was every time they do a revision, it’s a huge expensive, you know, hundreds of people involved process and it because you really want to every time there’s a change, you want to make sure that changes, it’s been well researched, you consider the pros and cons. So it’s a big process. So they realized that moving forward, they APA realized that now that we’re not stuck using just books, they could actually have changes made in the DSM on an ongoing basis. And that’s what happened since DSM-5 came out. In 2013, there’s been a number of changes in the criteria set. So the criteria sets in there five to about 70 of them have some changes, most of them are very, very minor, you’re correcting tiny errors, but there’s some that are significant. So one of the differences, of course, is that when 4-TR are came out, you could say I want to buy that still say that about five here, but you can say I care about the criteria that he diagnoses, I don’t really need to see the text. That’s not true. This time, the actual definitions have changed. There’s a new disorder in the DSM-5-TR.
Katie Vernoy 07:39
What are the big important changes that we should know about in DSM-5-TR?
Dr. Michael First 07:40
So we’ve added a disorder it’s Prolonged Grief Disorder. So it’s much more clinically relevant. The DSM-5-TR, really than the 4-TR was I’d say the biggest is Prolonged Grief Disorder. So you know, when you whenever a new disorders, DSM, that’s big news, I’ve been going through many, many DSM, the press always gets what’s the new disorder. So this is a this disorder was has been researched. Now for a number of years, let me the concept of Prolonged Grief Disorder is really a hole in the diagnostic system. So there are individuals who after losing a loved one, normally, you basically adjust at some point, it’s always painful maybe to think about the loved one, but you move on with your life. And in that that’s a very important part of the grieving process. There are individuals where they’re unable to do that they’re basically stuck in a grief reaction, month after month. So after a year has elapsed in the person’s grieving and preoccupied with grieving, then you could meet the criteria for Prolonged Grief Disorder. So it’s can be given until at least a year has elapsed. And these are individuals or a number of individuals who have that problem. And it was really unrecognized, wasn’t in the system at all. Now in DSM-5 came out, and there’s a pending research appendix in the back. So when DSM-5 was was in preparation, we already knew about this condition, and there was some controversy about how best to define it. So they actually put something in the research appendix called persistent, complex bereavement disorder in the back that is the precursor to what’s now called Prolonged Grief Disorder. So it’s been around but, So now, after this, we finally got to the point, we felt that the research was clear enough, the case was compelling enough that it would do more harm than good to put it in there. And it went through all the processes within the APA for approval, and it was approved and added to the online version, and now that’s going it’s in the hardcopy version as well. That’s by far the biggest change. Probably the next biggest change has to do with suicide. Now suicide. If you look at the DSM now, suicide is basically a criterion in major depressive episodes, criterion number nine, that’s like the biggest suicide of course, as a therapist, what are the most important things that we have to deal with very, very important but the DSM has a little sidelight so to speak. So we felt it was very important for therapists and clinicians and researchers to have a way to indicate the presence of suicidal behavior, independent of depression. Suicidal behavior can occur in a wide variety of mental disorders including no mental disorder at all. So we wanted to have a way to indicate that. So it turns out that there’s a mechanism within the ICD 10, which is the coding system. You everybody know that when you write down the diagnostic code, you get paid. That’s your that’s how the DSM code, that’s the code from the International Classification of Diseases, which is a government controlled system, we realize that there are these things called symptom codes in the ICD 10, which are not disorders, but they allow you to list a particular symptom, that is of particular importance. So we actually went and requested from the NCHS, the National Center for Health Statistics to have a new code created for suicidal behavior, current and history of suicidal behavior, and also current non suicidal self injury and history of non suicidal self injury. So there’s four separate codes that are now in the book that will allow you, it’s optional, obviously, to list those along with the diagnosis. So if you have somebody with Major Depressive Disorder, who’s suicidal, you would list both major depressive disorder as a diagnosis. And we also list this special code. In addition, that’s so that’s a really nice addition. The rest are not quite… so one of them is there’s a category that’s been added actually restored, called unspecified mood disorder. And what’s that? Why is that a big deal? It turns out that, you know, when you first see somebody who has a mixture of mood symptoms, you have to right, you’re one of the things about getting paid is you need every time you see the patient or his client, you need to write down a diagnosis.
Katie Vernoy 08:32
Dr. Michael First 08:32
What the person look like during that meeting. So let’s say you have your first meeting with a client, and they have this, you know, mix of irritability and agitation and a little sad, what would you call that? And you say, Well, you know, I’m going to have to look into maybe I’ll check their history more speak to some other previous treaters, we got to write something down. So what the DSM does in general, when you see someone and you don’t know what the diagnosis is yet, either because it doesn’t fit into any of the diagnoses, or because you simply don’t have enough information. That’s where these unspecified codes come from. So they typically do you see somebody who is psychotic, and either you don’t have enough time to figure out what diagnosis it is, or there simply doesn’t fit in the type of psychosis doesn’t fit into any diagnosis, you would write down Psychotic Disorder, unspecified. So for mood, there is Bipolar Disorder, unspecified, and Depressive Disorder unspecified. The question is that person who is agitated and irritable, what is it? What would you call that? And there’s some implication, if you wrote down Bipolar Disorder, unspecified, then in their record their medical record, the rest of their life will be something that says Bipolar disorder, when in fact, this may simply morph into a case of Major Depressive Disorder, because irritability and agitation is commonly seen in depression. So the real what we had to do, we introduced a new unspecified category that allows you to be neutral about whether it’s bipolar or depression. So that’s why it’s called Unspecified Mood Disorder, which you can use that you’re saying no, I don’t know what it is. And I’m not I know it’s a mood problem, because the symptom is a mood symptom. But I’m not going to commit myself to say whether it’s either depressive or bipolar. So it’s a new parking place, so to speak, to put your client before you figure out what’s going on in a way that’s going to be less stigmatized. And that’s great. And if it’s a couple of corrections to problems in the criteria, that’s one of the ones is Autism Spectrum Disorder. So Autism Spectrum, so if you were called in, when we went from DSM-4 to five, that was a new category that was created that used to be autism, autistic disorder, and Asperger’s disorder, there are several different and pdds are different types of autism disorders. For DSM-5, they decided to consider the entire thing a spectrum of conditions. So it’s now Autism Spectrum Disorder. And it comes with three levels of severity. So Autism Spectrum Disorder is defined, there are two clusters of symptoms. There’s the social interaction, social engagement, awkward social reading, social cue, cues, piece of autism, and then there’s this preoccupation with unusual interests or repeating words. So there’s two separate dimensions of autism, the autism spectrum, so the criteria set was reformulated. And we had to come up with a new algorithm. Now, the challenge here is Autism Spectrum Disorder is really had a huge amount of interest for the past 10, 15 years because of what appears to be this explosion in cases of Autism Spectrum Disorder. And part of that has been argued that people are recognizing it more, and that’s why there’s more cases, but part of it is over recognizing anyway, that’s the kind of little weird and awkward Oh, they’re on the spectrum, that’s become a common phrase in the English language. Now, if you watch movies and TV start hearing, Oh, that guy’s on the spectrum. So it’s become incorporated into language. But it also shows that it’s been overused and over diagnosed. So when you.. the diagnostic criteria sets, the prevalence often depends upon how you construct the criteria set. So when you have a criteria set, for example, the test five out of 10, if you were to make the requirement three out of 10, the prevalence would go up a lot. If you were to go up to eight out of 10, you would shrink the prevalence. So those kinds of criteria that give you a number out of a larger number has a big effect on prevalence. So when they reformulated the autism criteria set, they wanted to make sure that the the new criteria set was conservative. So that so the way it works is there are three items for the social impairment piece of it, and four of the interest restricted interests problem, the restricted interest is two out of four, the social one was supposed to be three out of three. But if you look at the criteria itself, it just says, including the following wasn’t clear if you had to have all the following or any of the following, or whatever it was intended to be all the following because they were very worried about not inflating the rates of Autism Spectrum Disorder. So the new version now has very clearly all of the following. So that I think is good. I don’t know how many people were making that error, but certainly was there to be made. And you opened up to different interpretation. I think those are some of the bigger ones. There’s lots of small number of small tinkering around. But I think those are probably the most one of the greatest political interest.
Curt Widhalm 16:47
We received a lot of listener feedback and some specific questions as far as some diagnostics that may not be appearing and specifically, some things like Complex PTSD, Developmental Trauma Disorder, Orthorexia, can you explain to our audience a little bit here, as far as what your process is for inclusion, or further research into maybe an inclusion of these in the future? These are things that are being discussed with the APA, and kind of how the decision is made, as far as what do we include? What we kind of continue to just monitor and see what’s out there.
Dr. Michael First 17:21
So that’s another a change in process when the DSM-5 was done over, however, eight years, they had all these committees, and they would would look what’s out there in the literature, and people would write in suggestions. So there’s a whole process during the DSM-5 to make lots of major major changes, those committees don’t exist anymore. Instead, there’s a steering committee. And what the steering committee does is we entertain proposals for new new disorder. So the Prolonged Grief Disorder, even though it was in the appendix, somebody had to come and propose that it be added to DSM-5. But when you put together the proposal, that is, on the DSM portal, there’s a whole complicated… we they give an indication of what kind of empirical information is required you and submit your evidence of validity, reliability will make your cost benefit analysis is the harm versus the advantages is balanced in the right direction. So yeah, there’s some hurt hurdles to go through to get one of these things in there. And the website lays out what those hurdles are. So now, the system is more reacting to what people suggest rather than coming up with diagnoses on our own. So he says, a little bit of a change. So that’s now the process. All the changes you’ve just mentioned so far were suggested, and then ultimately approved, but let’s cover some of the ones you met. So right now, there’s really no unless somebody were to write in and say I want Complex PTSD in there. We’re not going to be considered unless somebody actually outside the system proposes it and makes it formal proposals. Now, complex PTSD is interesting, because the ICD 11 I mentioned in the beginning that I worked on the ICD 11. On past Complex PTSD, they both PTSD and complex PTSD, in ICD 11. So they made the decision to include that condition. Now, the DSM, turns out that the DSM version of PTSD if you compare it to the ICD, PTSD and complex PTSD, they’re elements in the complex PTSD, much of that has been incorporated to the criteria set for PTSD. So it’s kind of a little blurry with what’s and what’s not emphasized, is it typically when Complex PTSD was first proposed, it was a type of PTSD that happened in response to chronic early traumatic experiences often ongoing. That was the original concept, but it turns out, this is from the ICD 11. If you look at the ICD 11 definition, even though they say that’s often the kind of trauma that causes Complex PTSD, that’s not required. That defines Complex PTSD, at least in the ICD. It’s like PTSD, plus some chronic changes in the person to soon have a chronic sense of disconnection, chronic inability to social impairments, they basically been changed, the trauma is so extensive, it’s almost like change them as a person. So you have more typical symptoms of PTSD like re experiencing, and avoiding things plus these more fundamental differences in the person. Now, some of those complex PTSD symptoms are now in the PTSD criteria set. So that’s what I meant by saying that we sort of took some of the complex and added it to the regular one. So that so here’s an example where there are a number of examples where the ICD 11 and the DSM-5 differ. And that’s one of them, you know, DSM-5 decided to have a single PTSD category that was a little bit more broad, where ICD 11 decided that they wanted to have two. Some of the other proposals, some I’ve heard some other proposals, but a lot of these proposals that have been floating around, haven’t really reached the stage of enough empirical research, really, to be able to be seriously considered for the DSM, they’re potentially good ideas, but none of them have been offered as actual proposals, with proposed evidence to be able to be evaluated, but any of those somebody, and if you’re any people listening, want to make such a proposal, you go to the way which you could do that. There’s a website, which is easy, http://www.DSM5.org, if you go to that website, that’s the DSM website. On the front page, you’ll see there’s a it tells you how you can make a proposal and what you need to do to fill out the application.
Katie Vernoy 21:44
It seems like what you’re describing is a process to really allow a feedback loop to the steering committee. And you also described the the DSM as being because it’s electronic, being a little bit more dynamic in being able to pick these things up.You know, what is the likelihood that one of these diagnoses assuming they’ve got the empirical research attached with my ended up in the next DSM like like is that?
Dr. Michael First 22:10
Well, to say that there is no next DSM for the time being, it could go in if somebody were to write a proposal today, for Complex PTSD and arguing that the current PTSD isn’t covering a very important group of patients that there’s a these are the kinds of things you would kind of argument you could make for something like that would include things like the fact that I that diagnosis does exist is hurting people because people are not recognizing it. More so the reason it’s hurting them, the treatment for complex PTSD would be different than regular PTSD. That’s another part of the compelling case. Another part of the argument is that you need to show that it’s somehow distinct from regular PTSD and distinct from other conditions, like adjustment disorder, or, or, you know, this new Prolonged Grief Disorder. So those are the kinds of things you would need to do to make a convincing case, and then you would submit it. And if it goes through the whole process, and was approved, it would now go into the DSM. The hardcopy version, of course, you know, it’s not if you buy it, it’s not in your version you bought, but the electronic version, it will go into there. So we’re in a funny transition now where you have the hardcopy version and the electronic version living side by side. And therefore, if you buy the hardcopy version, you’re not, you know, it’s it’s easy to see the ongoing changes, but APA considers what’s approved and in the electronic version to be the official DSM. And the hardcopy, like, the one that’s going on sale now is a snapshot of where the electronic version looks like, you know, it looks like now. So everything that’s in electronic version is now in hardcopy version. But as things happen, if somebody were to get complex PTSD in there, and it gets in there before the next hardcopy version comes out, then you’ll have the situation where it’s only on the electronic version, and not in the hardcopy version, but it’s it’s on the electronic version, you could use it, you know, it doesn’t have to be in the hardcopy version to be legitimate diagnosis to make when one of your clients
Katie Vernoy 24:03
That’s decided then, I’m not buying a new copy, then I’m just gonna get the electronic version.
Curt Widhalm 24:11
So when you’re looking at the research that’s submitted, what kind of thresholds are you looking at here? It sounds like part of this is not only the criteria that’s maybe showing up in people’s offices, but also some of the ways that things are being treated as some of the factors that you look at in how things are included, how things are rolled out, you’re kind of kept under some of the existing diagnostics that are there, but what are you really looking for in the research that people are proposing?
Dr. Michael First 24:43
Well, this does not that no one thing I mean, I personally, I’m a clinical utility persons so to me, the most compelling thing is making a case that is going to help people and not hurt them. I mean that person, but that’s not sufficient. I mean, you can make a proposal that that’s the case but if because there’s two things. One is this, say this is a good category to put in there. And then it’s how to define it. That’s a big problem and lots of concepts are out there. But what would be the criteria set, for example, for Complex PTSD that actually is a distinct group, and wouldn’t by accident, include people who don’t have complex PTSD? So it’s a technical thing is the case for complex PTSD is, like, let’s look at what happened with Prolonged Grief Disorder. There’s a perfect, so that’s already happened. How did that get in there? Well, patients were out there that people were noticing that didn’t fit in any of the DSM categories. And they clearly were suffering. So they had some kind of mental disorder. They didn’t have as I people say, Oh, well, they have Major Depression. That’s not Major Depression, you can have Major Depression, and Prolonged Grief Disorder. But they’re not the same at all. Hardly any overlap. So there’s a big home system that allows people to come into your office and not have any place for them. So that’s the first piece of it, then another compelling thing about comp, Prolonged Grief Disorder is is that psychotherapy that has specifically been developed, it’s a variation when a CBT for treating Prolonged Grief Disorder that’s been successful. So that’s another compelling reason not only are you calling it something, but you have something to offer your clients by saying, Well, this is the recommended treatment. So that’s the kind of argument you know, the DSM, it’s very the spin, especially since DSM-4 detector, in fact it was a paper that came out before DSM-4 came out called holding the line on diagnostic proliferation, it was very easy, used to be very easy, it sounds like a good idea, we go into the DSM, a couple of problems is that once a category gets into the DSM, it’s very, very, very hard to get it out. There’s been very few diagnoses which have been deleted, because always some constituency says you will ruin my practice if you get rid of this diagnosis. So that’s why knowing that it’s easy to get in easier to get in than to get pulled out, you really want to make sure that things that are in the DSM won’t need to be pulled out because you’ve too hastily added. I think there’s been kind of a much more conservative view about putting categories in the DSM nowadays than there were back in 20, 30 years ago.
Katie Vernoy 27:13
We also got some some questions and we’ve had some conversations actually recently about diagnostic criteria that potentially needs to be adapted to fit a more diverse population or an understanding of the diversity in our population. I’m just curious, how culture, other demographic differences, all that all the things, how those things have been addressed in the the text revision, but also kind of the the concept around how you’re making sure that the criteria, the descriptions all of the pieces really align with a very diverse population that we that we live in?
Dr. Michael First 27:50
That’s a great question. In fact, there’s been major efforts, since DSM-4, there was a special committee starting with DSM-4 for culture, culture related issues, how disorders present differently in different cultures. Now, the criteria sets are hypothetically supposed to be vanilla, that apply across all cultures, the way you deal with cultural variations in the text is one section called Culture Related Features. If you look at the content of that text, it’s very specific than in this population and may look like this. So it’s trying to show how that variability is taken into account. But it’s an opportunity to let me tell you about a very important thing that we did with the TR that was basically, it’s very interesting was they taking your during the development, During the development of TR, George Floyd happen, and our entire consciousness about systemic racism became sort of raised. Then the question was, are there things in the DSM that are reflective of this kind of systemic racism? So we actually created a committee that went through the entire DSM, looking for, um, not necessarily races as the most extreme case, but things that were not quite nuanced enough, like very often, you know, like, the big one of the big problems, of course, it’s like what is race anyway? But that is because you’re, you’re an African American, are you really different than other people? If you are different, like very often in the DSM, the prevalence section will say this, if we break it down by ethnic group will say of depression in blacks is this and in Latinos Is this the question is why is it different? Is it because of biological reasons among these groups is out twice as if it is a different life experiences? It’s lots of huge amount of data that the the disadvantage social settings for some of these groups, is the reason why they’re different, not something essential about being Black or Latino. So that was one of the things when they went through the whole book, they’re looking to avoid giving a message that something about the race itself is what’s causing it to happen. So the way they dealt with it, is that they have a statement that says it’s this in blacks and it’s not and an extra sentence that says, this difference is likely due to differential exposure to racism or things like that. So it was a very, very thoughtful way of trying to make it clear and de emphasize it also get rid of stigmatizing statements, that to the whole, the whole book went through that thing, and that was really triggered by the awareness that was that was not originally part of the original plan of the TR it was the fact that that happened during the process. A new committee was been doing the process. I’m glad that we had enough time was early enough in the process, that we’re able to get it in the DSM-5, I was a little dubious. But we they worked really, really hard that committee to be able to go through the all areas of the text revision to make sure it it worked for across culture, and also not not taking the certain minorities, stigmatized,
Katie Vernoy 30:54
Were any of the diagnoses assessed in that way and determining whether those diagnoses were appropriate across all the different demographic considerations. So one that comes to mind specifically, we recently had a discussion on Trans mental health and Gender Dysphoria is one that that kind of is a requirement to be able to kind of move forward with some of the things for transition. And it was interesting, the conversation was like, Well, I’m not dysphoric it’s it’s socially, you know, kind of everyone around me is dysphoric about my gender, I’m not and I have to kind of go through this process of saying that I’m dysphoric in order to get the letter that I need for the hormones or whatever, were there, or are there plans to look at kind of the impact of diagnoses or how diagnoses are put together and the impact on folks that are in in typically marginalized populations?
Dr. Michael First 31:44
Well, culturally, I think Trans is a special case, I could get to that whole issue of should trans even be in the DSM. I mean, lots of people in the Trans community don’t consider it a mental disorder. So let’s get general, we do consider that like Conduct Disorder is a good example, about a lot of the items and Conduct Disorder in minority populations living in high crime area, it’s normal, it’s like adaptive to do some of the items in the Conduct Disorder criteria sets. And we don’t want to give people who are trying to adapt to their typical environment a diagnosis simply because in a different population, it advantage suburban population, it would be evidence of pathology, so you get into text for Conduct Disorder has things in there and the criteria sets get adjusted to drop items that might be overly influenced by culture and not apply to other cultures. And now Trans is a different story. So…
Katie Vernoy 32:38
Dr. Michael First 32:38
Let me get into that. So the name is also changed DSM-5, it’s now called Gender Dysphoria. It used to be Gender Identity Disorder, that’s what it was, is up to DSM-5, so they actually changed it from Gender Identity Disorder to Gender Dysphoria to make it less stigmatizing it was felt that saying, there was something wrong with your identity, there’s a disorder and your identity was much more stigmatizing than saying that you’re upset or it’s creating a dysphoria. The fact that the term used in the ICD for this condition is Gender Incongruence, which is very well descriptive term, it’s the sense that your assigned gender and your experience gender are incongruent. So the recent the problem, is it. So the individual they say, Well, I’m not dysphoric. I agree, you could say that they shouldn’t get any mental disorder. But there’s a big problem. How do you get qualified for treatment? Unfortunately, we live in a country, there’s lots of things that are very harmful, like, you know, marital strife, child abuse, you can’t get paid if you put a code for marital relationship problem on your billing form and submit it, nobody’s gonna cover it because the insurance companies and the government have made a decision, unwise in my perspective, that’s not my call, to not inlcude, not cover things that are not really ensuring the way they look at us insurance is for medical conditions. That’s the basic concept, we’re not going to, for example, if you want to get plastic surgery to make yourself look better, and make you feel better, their government says we’re not going to cover that because that’s sort of a cosmetic thing, even though it makes you feel better. You’re not treating a disorder, to have a nose job, for example. There’s a whole bunch of things that the government doesn’t want to cover, unfortunately, basically, in the ICD, everything is outside of the disorder section, you won’t get covered for. Now Gender Dysphoria is in the mental disorder of section, actually, therefore, you could qualify for treatment. If they were to remove it from the DSM entirely, then you would never be able to, insurance companies would not, not to say the insurance companies are happy about covering it, but they would really have a weapon to say well, if it’s on the DSM, we have no obligation to cover so what what happened in the ICD 11 which I saw just came out they had the same problem, but they had a different solution. The ICD 11 is all of medicine not just mental disorders. So they had the option of moving Gender Incongruence out of the mental disorder section and moving it somewhere else so that it could still get paid for. And where did they move it, they created a new chapter called Conditions of Sexual Health or something like that. And therefore they were able to put it there. And now it’s a condition that could get paid for. The United States, which is still using ICD 11. United States still using ICD 10. So there’s no place in ICD 10 to move it. So that’s why we’re kind of frozen in the situation of it continuing to be in the DSM in that spot, for very utilitarian reasons. I mean, I’ll give you another example, somebody who actually heard this case, person had sexual reassignment surgery, and broke took it off as a tax deduction under the health thing. They were challenged by the IRS, they said, Oh, no sex reassignment surgery is a cosmetic procedure, you can’t take a deduction for that’s their attitude.
Katie Vernoy 35:59
Dr. Michael First 36:01
It’s very tricky, because again, they don’t want to cover things. So it’s a balance, yes, it’s stigmatizing. But on balance, is it better to deal with the stigma, by virtue of the placement in the DSM, or not have the services covered anymore, we’re kind of stuck, there’s some talk about moving maybe to a different spot in the DSM to try to help with that. But the code, still, the code, and the code is still mental disorder code. So until the ICD code actually changes, it’s going to, it’s gonna be a mental disorder, we don’t have any control over that. That’s the government.
Katie Vernoy 36:35
Sounds really complex.
Curt Widhalm 36:37
So if I can kind of synthesize down some of the important points that I’m hearing here is, in this process, you’ve taken some of the criticisms from the field of the DSM and made it more inclusive. As far as feedback opportunities for professionals. It’s not, you know, committees hidden away in dark rooms, you know, twirling their mustaches, or running their fingers and just, you know, being the arbiters of mental health diagnostics. But one of the major things that I want to emphasize that you’ve brought up here a couple of times, is that there’s a lot of parts of the DSM that are not just the diagnostic lists, that people should read from time to time. And I think that outside of maybe some of the psychopathology classes that grad students have to go through, we sometimes forget that and that a lot of the information that we do break up in our conversations that the text parts, this is the major emphasis of the text revision here is go and read these parts. And it probably answers a lot of the questions and criticisms that we have from the field. And now, more so than ever, it’s had an opportunity for a lot more people to at least make suggestions and that feedback has been looked at.
Dr. Michael First 37:51
I can’t agree with you more they criteria pretty bare bones. So yeah, on their own, they lots of could discuss argue about what what generally means that’s what the text is there for. The text allows you to explain what they are, how do you assess it? As I said, the text is like 99% of the words in the DSM and the criteria, maybe 1% or less. So the text is extremely important. That’s why we did the text revision. The difference to the from the last one is we did just leave it to the text, we also have the criteria. But you’re absolutely right. Many of these things we dealt with, like this whole thing about systemic racism, if you look at the criteria set, there’s nothing in the criteria in the TR, that would indicate that we did anything having to do with our sense sensitivity to race. That’s all in the text.
Katie Vernoy 38:35
So to that point, I wanted to check in on a couple of things, because it seems like there’s an opportunity for anyone anywhere who’s able to do some research make the case they can submit to the committee. But I’m curious about who’s at the table who’s who’s on the steering committee? And are you including folks that is there a diverse population of folks, there are other people with lived experience that are giving feedback, like how are you making sure that there’s enough folks at the table to make sure that you continue this process of assessing how you’re not managing just not even just culture, but also the lived experience of being autistic or, or other areas of neurodiversity? That there are folks who have psychotic symptoms that are weighing in on some of these things? And what the presentations, those things? I mean, it just it seems like there’s, there’s such a huge opportunity to have a lot of perspectives. How are you navigating that internally with a steering committee?
Dr. Michael First 39:33
Well, the steering committee is very small, then it goes to a committee are experts, there are women on the steering committee, and there are people who are African American, but it’s still Well, obviously, just because there’s one African American and a couple of women, it doesn’t mean all perspectives are covered. We realize you’re not simply a bunch of white guys making the decisions here. Got it tomorrow to the to where but you’re making it where do we get those other perspectives? Well, the way we try to deal with that is before when something gets like, lets this go to Prolonged Grief Disorder is a good example. That category was controversial because there are a number of people who felt that you’re calling people who are having normal grief, you’re calling them having a disorder. And there’s a lot of pushback against that category. So what we did is when before somebody gets into the final DSM and approved, it gets posted on the DSM-5 website for 45 days, it’s open for comment and we get lots of comments. And that’s really the opportunity for people with lived experience to say, you know, you, you clearly didn’t take into account this aspect that I live with this, if you didn’t get it to committee would read all of that. If they make a good case, then they could change it. Absolutely. So that’s the way I mean, being on this tiny group of people who make the decisions. Unfortunately, the limit to how diverse we can make this, there’s not that many people, but there are many layers. I mean, even within the American Psychiatric Association, it’s got to be approved by this thing called the APA Assembly, which is sort of like Congress, so to speak, with lots of diversity built into that. And then so the so many different levels of approval, that’s where some of the diversity comes in. It could it could be make it more, maybe, but that’s what we’re able to do.
Katie Vernoy 41:15
Well it seems like there’s also an opportunity to reach out to diagnostic communities when when a new diagnosis is being presented to make sure that you’re getting some of that feedback, it seems like there’s there’s mechanisms in place, my hope is that there’s also efforts to connect with folks with lived experience or those elements so that people can really be ready to take on that 45 day period.
Dr. Michael First 41:37
Right? That’s actually quite how do we, We do our best to publicize it. Yeah, but you’re right, it’d be great. In fact, we’ve done that before, I think that this particular case, with Prolonged Grief, I think there are organizations, you know, patient groups, we could go to them and say, you know, like, we made a change in the psychotic section, or clearly, individuals have lots of experience. NAMI and, those kinds of groups. So there have not been any changes, you know, recently that would affect that. But that would be obviously something we would want to do is to go perfect sure that they’re aware that the change is there and give them an opportunity to give their feedback.
Curt Widhalm 42:14
Where can people find out more about you and your work?
Dr. Michael First 42:17
I have a website at Columbia, at Columbia, every faculty member gets a website, I happen to have a Wikipedia page. So you could look at that. My email, I don’t keep my email addresses secret. That’s one thing. I mean, it was very interested in me working with this, if I have to contact an expert to get their email address could be incredibly difficult. You take them in and you type an email. It’s nowhere you have to. I don’t know why people are so afraid to have their email address public. But I mine has been public. It’s been public the entire time I’ve been in the field. And I’m happy for people to let me know what they think.
Curt Widhalm 42:54
And we’ll drop Dr. First’s email in our show notes. You can check that out over at mtsgpodcast.com. And we’ll include links to a couple of other episodes where we’ve had some relevant guests in the past talking about things like Prolonged Grief Disorder and some of the other things that we’ve done and follow us on our social media. Until next time, I’m Curt Widhalm with Katie Vernoy, and Dr. Michael First.
Katie Vernoy 43:21
Thanks again to our sponsor SuperBill.
Curt Widhalm 43:23
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Katie Vernoy 44:06
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