DSM 5 ………………….
Lloyd L. Lyter, Ph.D., LSW
Professor
Marywood University, Scranton, PA
Sharon C. Lyter, Ph.D., LCSW
Professor
Kutztown University
Brandywine
November 5, 2013
David Kupfer, MD
Chair of DSM-5 Task Force
Thomas Detre Professor and Chair
Department of Psychiatry
Professor of Neuroscience
Department of Psychiatry
Thomas Detre Hall of the Western Psychiatric Institute and Clinic University of Pittsburgh
3811 O'Hara Street
Pittsburgh, PA 15213
Dear Dr. Kupfer:
We urge you to consider the role of Social Work professionals in the provision of mental health
services in the United States and in the development of the upcoming Diagnostic and Statistical
Manual of Mental Disorders, DSM-V.
As stated by the National Association of Social Workers (NASW) Executive Director Elizabeth J.
Clark, the DSM is widely used by social workers. Social workers are one of the largest providers of
mental health services in the United States.
We ask you to consider the voices of social work providers, represented here by the signatures of
attendees at the annual conference of the New Jersey chapter of the National Association of Social
Workers. Please consider our request for an active role in the development of the DSM-5.
Sincerely,
Who are the providers? Which is the largest provider
discipline? …
social workers
psychiatrists
psychologists
???
The Primacy of Social Work
Social workers provide most of the country’s mental health
services. Of mental health professionals …
45% -- social work
5% -- psychiatry
17% -- psychology
24% -- counseling
9% -- marriage and family therapy
Both social work and psychology have grown in number of trained
mental health professionals in recent years, while psychiatry has
remained stable.
(Substance Abuse and Mental Health Services Administration, 2012).
Where did you learn about DSM – classroom,
practicum?
How did you learn about the DSM - from social
workers? from psychologists? psychiatrists?
Quality of learning?
How should students be prepared regarding DSM?
….
What are the strengths and limitations of DSM? ….
Authority to diagnose …. Licensure of educators…
Knowledge regarding DSM-5 …
DSM Views: What do you know about NIMH?
As an indicator of their involvement and interest in the
development of DSM-5, participants were asked if they were
aware of current efforts by NIMH (National Institutes of
Mental Health) with regard to classification systems and, if
so, to indicate their understanding. A quarter (26%) of the
respondents affirmed that they were aware, but only 4
statements were accurate (i.e., focus on brain research,
biomarker identification, NIMH has developed strategic
planning around creating new ways to classify and diagnose
mental disorders, revising to include neuroscience advances).
Most mistakenly believed that NIMH and the APA the same
organization.
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DSM Views: What do you know about NIMH?
NIMH director Thomas Insel noted in The Director’s Blog on the NIMH
website (2010) that The Diagnostic and Statistical Manual of Mental
Disorders has validity problems and, furthermore, that “The Research
Domain Criteria (RDoC) is an initiative that will develop neurosciencebased criteria for classifying mental disorders” (para. 4).
In 2013, Insel, stated:
“That is why NIMH will be re-orienting its research away from DSM
categories. Going forward, we will be supporting research projects that
look across current categories – or sub-divide current categories – to begin
to develop a better system. What does this mean for applicants? Clinical
trials might study all patients in a mood clinic rather than those meeting
strict major depressive disorder criteria. What does this mean for patients?
We are committed to new and better treatments, but we feel this will only
happen by developing a more precise diagnostic system. The best reason
to develop RDoC is to seek better outcomes.”
By Thomas Insel on April 29, 2013 Transforming diagnosis. http://www.nimh.nih.gov/about/director/2013/transformingdiagnosis.shtml
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Impact of personal experiences with mental illness …
Summary of Educator Views
Overall, the study participants, social work educators, were licensed clinical
professionals, live in states where social work has authority to diagnose, and favored a
state level license for all social work educators and a clinical license for those who
teach direct practice. They voiced support of all professions named-social work,
psychology, and psychiatry-to diagnose. They favored retaining the DSM as it is but
preferred that the Social Work profession have a role in developing and updating DSM.
They favored incorporation of the strengths perspective and do not believe that DSM is
sensitive to person-in-environment and family-in-environment perspectives. However,
they agreed that even with its strengths and limitations, students are capable of
understanding those nuances of DSM. They noted regard for DSM as an essential tool
and a good fit for Social Work practice.
They favored altering thresholds such that fewer people would be eligible for a DSM
diagnosis of Attention Deficit Hyperactivity Disorder and for Autism. In addition, they
would like to retain the grief exclusion under major depressive disorder.
They expressed the belief that mental health content should include some DSM content
at both BSW and MSW levels and noted, in fact, that this is true at their own schools;
most favored giving a basic understanding at the BSW level and teaching to formulate
a diagnosis at the MSW and doctoral levels.
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Despite the fact that Social Work was not represented on the
DSM Task Force (as it had been in the past), there are signs
of ……….. good news.
Contributing psychosocial and environmental factors
(previous Axis IV), client person-in-environment, and
family-in-environment are now represented in part by:
Z-codes and Cultural Formulation Interview
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ICD-10 Z-Codes
Contributing psychosocial and environmental factors or other reasons
for visits are now represented through an expanded selected set of ICD9-CM V-codes and, from the forthcoming ICD-10-CM, Z-codes.
These provide ways for clinicians to indicate other conditions or
problems that may be a focus of clinical attention or otherwise affect
the diagnosis, course, prognosis, or treatment of a mental disorder.
These conditions may be coded along with the patient’s mental and
other medical disorders if they are a focus of the current visit or help to
explain the need for a treatment or test.
Z-codes include family upbringing, child and adult maltreatment and
neglect, and educational, occupational, and housing problems.
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ICD-10 Z-Codes
Z63.4 High expressed emotion level within family.
Z63.0 Relationship distress with spouse or intimate partner.
T74.31XA Spouse or partner abuse, psychological,
confirmed.
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ICD-10 Z-Codes
Z62.29 Upbringing away from parents.
Z62.898 Child affected by parental relationship distress.
Z63.5 Disruption of family by separation or divorce.
Z64.1 Problems related to multiparity.
Z64.0 Problems related to unwanted pregnancy.
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ICD-10 Z-Codes
Z60.2 Problem related to living alone.
Z59.3 Problem related to living in a residential institution.
Z59.2 Discord with neighbor, lodger, or landlord.
Z59.0 Homelessness.
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ICD-10 Z-Codes
Z59.5 Extreme poverty.
Z59.1 Inadequate housing.
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ICD-10 Z-Codes
Z59.4 Lack of adequate food or safe drinking water.
Z60.5 Target of (perceived) adverse discrimination or
persecution.
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ICD-10 Z-Codes
Z64.4 Discord with social service provider, including
probation officer, case manager, or social services worker.
Z75.4 Unavailability or inaccessibility of other helping
agencies.
Z75.3 Unavailability or inaccessibility of health care
facilities.
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ICD-10 Z-Codes
Z56.82 Problem related to current military deployment
status.
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ICD-10 Z-Codes
Z65.4 Victim of crime.
Z65.4 Victim of terrorism or torture.
Z65.0 Conviction in civil or criminal proceedings without
imprisonment.
Z65.1 Imprisonment or other incarceration.
Z65.2 Problems related to release from prison.
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“Telescoping” and Cross-Cutting Symptom Measure
(13 domains for adult)
1. depression
2.
anger
3.
mania
4.
anxiety
5.
somatic symptoms
6.
suicidal ideation
7.
psychosis
8.
sleep problems
9.
memory
10. repetitive thoughts and behaviors
11. dissociation
12. personality functioning
13. substance abuse
26
“Telescoping” and Cross-Cutting Symptom Measure
(12 domains for children 6-17)
1. somatic symptoms
2. sleep problems
3. inattention
4. depression
5. anger
6. irritability
7. mania
8. anxiety
9. psychosis
10. repetitive thoughts or behaviors
11. substance use
12. suicidal ideation/ suicidal attempts
27
Despite the fact that Social Work was not represented on the
DSM Task Force (as it had been in the past), there are signs
of ……….. good news.
Cultural Formulation Interview
The word “strength” does not appear, but related terms are:
resources, social supports, and resilience.
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Cultural Formulation Interview
Cultural Formulation Interview, DSM-5, pp. 749-759
(interviewer and informant versions with 12 modules).
(collaborate with WHO for ICD 11)
Should precede the standard diagnostic interview.
Designed to be used with EVERYONE!
Gender and Cross-Cultural Issues DSM-5 Study Group
Neil K. Aggarwal, MD, MBA (Columbia NIMH fellow)
Sofie Baarnhielm, MD, PhD (Sweden)
29
Cultural Formulation Interview
Cultural Definition of the Problem
What do you
think are the
Stressors and Supports
causes?
Role of Cultural Identity
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Cultural Perceptions of Cause … Stressors … Supports
Stresses… money
… family
How would you describe
your problem?
resources, social
supports, and resilience
spiritual reason
kinds of support that help … support
from friends, family…
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Role of Cultural Identity
communities you belong
to …. languages you
speak…
homelessness
as culture
race … ethnic background …
gender … sexual orientation …
faith … religion
migration-related problems
discrimination due to … ?
conflict across generations?
We all have multiple
identities!
32
Self-Coping
treatment, help, advice, healing ….
most useful … least helpful
doctors, helpers, healers
folk healing, spiritual counseling,
alternative healing, support groups
33
Barriers
money, work, family
stigma, shaming,
discrimination
lack of services that understand your
background
what got in
the way?
34
Preferences
What do you think would be
most useful?
social network views
What have family, friends
suggested?
35
Clinician-Patient Relationship
Concerns about client-patient
relationship?
Racial/ethnic differences,
language barriers that may
be viewed as barriers…
Communication …
36
“Telescoping” of CFI function provided by 12
supplementary modules to use in subsequent sessions.
1. Explanatory Model
2. Level of Functioning
3. Social Network
4. Psychosocial Stressors
5. Spirituality, Religion, and Moral Traditions
6. Cultural Identity
7. Coping and Help-Seeking
8. Patient–Clinician Relationship
9. School-Age Children and Adolescents
10. Older Adults
11. Immigrants and Refugees
12. Caregivers
37
Social work did not hold a key decision-making role in the
publication of DSM-5, yet there appears to be a presence of social
work themes that exceeds that of earlier editions.
Within DSM-5, attention to strengths are not now incorporated
within the diagnostic categories themselves, but do appear in the
form of the enhanced Z Codes, the Cultural Formulation Interview
(in section III – emerging measures and models), and the efforts to
incorporate global themes and models, such as WHODAS (World
Health Organization’s Disability Assessment Schedule).
Social work values are reflected in the elegance of a bio-psychsocio-cultural perspective.
38
Social work’s primacy in mental
health may indeed be enhanced
given the need for a bio-psychsocio-cultural perspective.
39
NIMH/RODC, APA, NASW ……
competition and race for knowledge =
knowledge building
40
joint agreement, accord, balance
…
harmony within interdisciplinary
mental health care teams …
new level of cooperation,
collaboration, and partnership …
NASW CEO, Angelo McLain, NASW
News, October 2013
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