Articles

Understanding the DSM-5: What every teacher needs to know


[MUSIC]>>JONES: We are delighted. Our next speaker
is Dr. Greg Neimeyer who works very close by, I think. You work very close by?>>NEIMEYER: Very close by.>>JONES: He is the current Associate Executive
Director and Director of the Office of Continuing Education in Psychology here at the APA. His
background. His BS is from. He has a BS from the University of Florida. His MA is from…>>NEIMEYER: Notre Dame.>>JONES: And his PhD is from the University
of Notre Dame as well. He will be speaking to you about something that he knows a great
deal about and something that we are all learning about and that is, changes in the DSM-5. Thank
you Dr. Neimeyer.>>NEIMEYER: Great. Thank you. Thank you very
much. [clapping]>>NEIMEYER: It’s delightful to be here.
The truth of the matter is I do work very close by. In truth, I never leave this building.
Between the 9th floor and the 5th floor, I just have a cot in the back. I’m thrilled
to come and have a chance to talk with you today about what I regard as one of the most
exciting things happening in the contemporary field of psychiatry and psychology, and it
has to do with a sea change in psychiatric nosology. And, I want to just be clear with
you that the sea change I’m referring to is a three-step process because we are now
undergoing the transition from the DSM-IV-TR (Diagnostic and Statistical Manual IV-Text
Revision) to the DSM-5. But don’t forget right on the heels of that will be a shift
from the current use of ICD 9 codes (International Classification of Diseases 9) to ICD 10 codes
which just got pushed back from October 1st of 2014 to October 1st of 2015. That’s the
second in a three stage process of a sea change in psychiatric nosology. The third is going
to be the approval of ICD 11 which was scheduled to occur next year and just got pushed back
by the World Health Organization to 2017. So all I’m telling you is what you know
if you are in the world of teaching and that is, things are always changing. Okay? So this
is not new to you. You learn to expect the unexpected. But I’m telling you we’re
not talking about an event. We’re talking about a process. So let me ask you by way
of a multiple choice question because there’s no better way to start than with an assessment. I want you to tell me “When it comes to
your level of familiarity with the DSM-5, multiple choice question, how many of you
would say that “I’m highly informed, I know most, if not all, of the significant
changes and I could easily teach this myself but I don’t want to”? How many is that
true for? [laughter]>>WORKSHOP PARTICIPANT: Your hand is up.>>NEIMEYER: My hand is down. I’m looking
for an assist from you. How about this? How many of you would say
“I’m moderately well informed. I’ve heard about most, if not all of the changes.
I probably know most of the big ones at least.” How many is that true for? Excellent. I will
get my assist. How many of you would say c. “I’m somewhat
well informed. I’ve heard bits and pieces here and there but I’m not actually sure
how many I can recall off hand. Excellent. There’s the golden… And, how many of you would say d. “I’m
genuinely clueless. If I have heard anything at all about the changes I honestly can’t
recall a single one of them at the moment.” [unclear remark from the audience] NEIMEYER: I love candor among colleagues. [laughter] NEIMEYER: Fabulous. Thank you. Well we will
not be able to circumnavigate the entire terrain but I have a consultation with Emily and others
and looking at some of the materials that are available to you… A couple quick disclaimers here. I am not
representing the American Psychological Association. I am not representing the American Psychiatric
Association. As you know the DSM is a wholly owned proprietary instrument. I was invited
to do the train the trainer institute at the American Psychiatric Association when they
launched last May in San Francisco. But they were clear with us then and I want to be clear
with you now it’s a proprietary system and it is not something that I have any commercial
interest in whatsoever so I’m not a mouthpiece of the American Psychiatric Association. I’m
not here representing them. At the same time, while it is true that I work for the Office
of Continuing Education in Psychology here at the American Psychological Association
and I did write the review for PsycCRITIQUES of the DSM-5 for the American Psychological
Association, I’m not here representing officially the American Psychological Association because
APA remains mute. It’s selective mutism, gang, in relation to the DSM-5. [laughter] NEIMEYER: They have remained neutral. They’re
neither for it nor against it and so I’m here today as a free agent in relation which
means I will tell you candidly what the objective changes are and be glad to share with you
my impression of the good, the bad, and the ugly, the implications and consequences associated
with those changes. Okay. So let’s talk about what we’re going to
talk about. I imagined we would do three things in our short time together today. Number 1, I want to say something about three
of the critical new orienting features of the DSM-5. Second, I want to spend most of our time,
almost all of it, looking at selected revisions, of areas that will be most centrally relevant
to you in a school-based context. And, then third, in the immortal words of Buzz Lightyear,
I want to say something about to infinity and beyond. Where is the DSM-5 headed, and
what does its future look like? Okay, so let’s say something about the first,
the three new orienting features of the DSM-5. And, here I want to call attention to the
fact that we have now eliminated the familiar traditional multi-axial system that has been
in place for a venerable 33 years since the introduction of DSM III in 1980. So, we’ll
talk about that. Number 2, I want to talk about the primacy
of neuroscience in the DSM-5. It is completely unlike previous DSMs. If there is a single
major conceptual, truth be told, epistemological shift in the DSM-5, it is the movement away
from its previous dedication to an atheoretical system, an equal opportunity nosological system
that owed no allegiance to any given theoretical orientation to an avowed dedication to biological
reductionism. So we’re going to look at that and what the implications and consequences
of that may be. And, then, third, something about the radical
reorganization that this new commitment permits in relation to the old familiar disorders.
Okay. And here, when we talk about that, I’m going to warn you, that we’re going to,
that so radical and so substantial is that reorientation that for those of you who are
familiar with DSM-IV-TR, DSM-IV, DSM-III-R, DSM-III on back, you may experience some trauma
because it is a dramatic shifting. It is almost as if they took all the individual disorders,
shook them up in a hat, tossed them down that stairs and then picked them up and ordered
the book in that way. [laughter] I don’t think that’s actually what they
did do but what it does mean is that you will see many new names to old disorders and it’s
more than just old wine in new bottles, and you’ll see many new disorders and you’ll
see many many many many familiar disorders in utterly unfamiliar places which is to say
that the DSM-5 represents a diagnostic diaspora of epic proportions, so much so that you can
regard the DSM-5 as engaging in a kind of witness relocation program in relation to
its various disorders. [laughter] So you’ll see these things take on new names
and they crop up in new diagnostic villages with altogether new identities. So I just
want to habituate you to that because when we talk about that we’re going to have to
do like an in-vivo desensitization exercise, right? Join arms, deep breath, count to three,
and then traipse through the field of, sort of, the panoply of psychopathology, talking
about where these critters now reside. Okay. So let’s talk about each of these things. Multiaxial designation is gone. It used to
be in DSM. Introduced in the DSM-III and continuing through the DSM-IV-TR, up until May of last
year that there was a multiaxial system and people were diagnosed according to the clinical
syndromes (axis 1), developmental conditions, general medical conditions, psychosocial problems,
and global adaptive functioning. The point was that the multiple axes provided a context
for understanding the various diagnoses, the psychiatric diagnoses. DSM-5 does away with
that. And I’ll tell you why they did away with it. They did away with it for two reasons.
One is a great big overarching umbrella reason. And the others are specific concerns about
the axes themselves. The umbrella reason was very simple. We want the DSM-5 to have the
look and feel of a medical nosological system. In medicine you don’t have multiple axes.
You’ve got one axis. Everything is on the same order. So if you want to do what the
DSM-5 desperately wants to do which is harmonize with the International Classification of Diseases,
the World Health Organization’s ICD, the simplest way it can do that is to eliminate
the multiaxial system because the ICD does not have a multiaxial system. Are you with
me? That is a major orienting feature of the DSM-5. And what they are doing is they are
advertising to us that in their attempts to harmonize with the ICD, they recognize that
they will forever be joined at the hip. They will become, the DSM will become the companion
reader of the ICD. Yeah, it’s a big change. Okay. But, there are specific concerns and reasons
attending to each of the axes that did them in as well. I’ll just say a word about them.
Axis 2 is developmental conditions. It invited us to look back not only at what a person
has in front of us but to look out at personality and back at developmental things. That’s
where the old mental retardation and all the personality disorders were. What they realized
is that Axis 2 is not fulfilling its function fully for a number of reasons. One of them
is not everybody believed in personality disorders. They would say Easter Bunny, Santa Claus,
personality disorders. Some people would say I believe in them but they are pejorative.
That is, we are diagnosing people not for what they have but for who they are. And,
then, third, and this is just one of those practice, where the rubber meets the road
issue, personality disorders by definition cannot be present prior to age 18 but they
have implications and indications prior to that age. Most people in a pre-Obamacare world
didn’t get their first insurance policies until they were in their early 20’s and
had their first job. That meant personality disorders in a private practice context were
often pended and not reimbursed. So when personality disorders were diagnosed they were almost
always diagnosed as a secondary to some other condition. Depression, with a dependent personality
disorder. I get reimbursed for and primary treatment is around depression. Ergo, Axis
2, elephant graveyard. Axis 3. I’ll tell you why they did away
with general medical conditions. And I mourn the loss of this. Somebody comes in to me
and they’ve got a panic disorder but they also have a cardiac history, okay. Or they
have a mitral valve prolapse or they have ulcerative colitis. I want to know those medical
disorders that accompany. Before you put somebody with an anxiety attack or with a previous
heart history into a stress inoculation procedure or a flooding experiment, wouldn’t you like
to know that they had a heart attack? I mean just like for general information. [laughter] So, we asked the vice-chair, Darryl Regier,
of the task force of the DSM 5. Darryl, why would you do away with something so incredibly
helpful as general medical conditions? And I’m going to tell you what he said. I’m
going to quote chapter and verse what he said in response to that question. But, before
I do I want to tell you by way of disclaimer, do not shoot the messenger. So we said, Darryl,
why would you do away with something so incredibly helpful as general medical conditions? And
his response was this. We did away with general medical conditions because
they are all general medical conditions. Everything.
ADHD, intermittent explosive disorder, appendicitis, diabetes, narcissistic personality disorder.
There is no difference between an exploding appendix and an exploding ego in the DSM-5. [Laughter]>>NEIMEYER: Do you see the biomedical orientation
already?>>PARTICIPANTS: Yes.>>NEIMEYER: Okay. Axis 4 Psychosocial problems.
This is the one where you tick a box and indicate whether someone was homeless or somebody didn’t
have access to health insurance or they were living in a domestic violence environment.
And, you know and I know, you have two people who come in to you, with the exact same diagnosis,
296.22, moderate depression. One of them is middle class, gainfully employed, and has
a home and a job; the other is homeless, uninsured, and jobless. Aren’t we dealing with kind
of different things? So we asked the chair of the DSM-5 task force, why would you do
away with something so incredibly helpful as psychosocial problems? I’m going to tell
you what he said. I’m going to quote it chapter and verse. But, before I do, I want
to say, by way of disclaimer, do not shoot the messenger. [laughter] So we said, David, why would you give up something
so incredibly helpful as psychosocial problems? And he said, in response to that question,
he said, these are hard words to speak. He said because, these are really hard words.
Yeah, I know. It’s hard to even listen to these words, much less speak them. He said,
that’s what social workers do.>>PARTICIPANTS: Gasp.>>NEIMEYER: Oh, I’m so gratified by your
response because that’s exactly what we did. And, when we picked our jaws up, he explained,
look, we’re not saying context isn’t important. We’re saying it’s not essential to diagnosis.
In other words, here’s his example. Somebody has a heart attack. They may come by that
heart attack by hereditary predisposition, by poor diet, by poor exercise, by being a
Type A personality, by having a workplace with a lot of stress. There are lots of things
that could cause the heart attack but they do not define it. A heart attack is a heart
attack regardless of how you come by it or what you do about it. Are you with me? So
this is the reason why in the new world order, context is epiphenomenal to diagnosis.>>PARTICIPANT: That works great for heart
attacks.>>NEIMEYER: Pardon?>>PARTICIPANT: That works great for heart
attacks granted but anxiety disorders?>>NEIMEYER: But don’t forget, anxiety disorders,
they’re all general medical conditions now. And so they’re saying, you can conceptualize
etiology however you want to, analytically, pharmacologically, endocrinologically, oppression-sensitively,
systemically, but it is what it is. That is, if it meets the criteria for the symptoms,
it’s an anxiety disorder. Please.>>PARTICIPANT: [unclear] Is the one plus
that mental health is no longer secondary in the eyes of the medical community? That
if it’s a primary medical condition, and you can actually get, and insurance companies
aren’t going to be saying, oh, well, that’s not our problem.>>NEIMEYER: Do you envision that that would
be a wonderful thing, and let me just ask you if you believe that will lead instantly
to mental health parity?>>PARTICIPANT: No.>>NEIMEYER: Yeah, I think we would like to
see that collateral advantage. But I think we’re going to still see an uphill battle,
is my guess. The last is global adaptive functioning and
that was where you would rate somebody on a scale of one to, zero to 100. Zero would
be somebody who was a mass of psychological putridity, you know like a human petri dish,
and 100 would be the uber, Maslovian, self-actualized person. The problem in part with that global
adaptive functioning is two-fold. Number 1 is people really never were as low as a zero
or high as 100. Most people that I’ve seen even in the back wards of VA hospitals were
sort of in that 40 or 50 range. And, on the upper end, how many people have the luxury
of having people walk through their doors who are 90s or who are 80s? The truth of the
matter is I can tell you just personal confession I do not think I have had two weeks in which
I myself have been an 80. Are you with me? So most of us live in that sort of 50 to 70-something
period. So, it really wasn’t a 100 point scale. In addition to that, there was a lot
of social desirability, no matter where you started somebody at with their GAF score,
they tended to get better week by week by week, no doubt a wink to psychotherapeutic
acumen but also to social desirability owing to third party reimbursers. So they did away
with it. Okay. So, number 2. The primacy of neuroscience.
The DSM now explicitly predicates the future validity claims of these disorders, that is
these things will become real disorders as a function of ongoing biological, neurological,
and broader neuroscientific advances. The notion is that psychiatric distress and psychological
disorders in the DSM-5 are results of underlying brain pathology. Now that may have been in
some ways implicit in earlier DSMs but they especially, they tried very much to keep previous
versions of DSM atheoretical. DSM-5 is no longer atheoretical. Many people regard the
DSM-5 as a throwback to the DSM-I and II, in one critical respect. DSM-III, III-R, IV,
and IV-TR remember were empirically driven documents. They were supposed to, all decisions
about revisions, inclusions or exclusions, were predicated on available scientific evidence.
They were supposed to be atheoretical, not driven by theory. DSM-I and II were driven
by psychoanalytic theory. They were ideological documents. Many people believe that DSM-5
is a return to ideology rather than empiricism. That is, the movement is toward what we would
broadly call biological reductionism, that psychological disorder is due to underlying
brain pathology. Okay. So there is a concern about, it’s not a return to the metaphysics
of an analytic camp, it’s not going back to psychoanalysis. But, it’s going back
to kind of a biological reductionism. Okay. And we will see clear examples of that. This
is why incidentally the importance of neuroscience is one of the major reasons why DSM-5 is DSM-5,
and not V. Have you noticed that? It’s DSM-5 and not V. They switched from Roman to Arabic
numerals. From Roman to Arabic. From V to 5. Why is it not DSM V? It’s DSM-5 instead.
Well, the notion is because just like your software program, Microsoft 2.0, will soon
become Microsoft 2.1. DSM-5 is going to become DSM-5.1. so that it can more rapidly incorporate
the advances of scientific change and knowledge gained especially in the area of neuroscience.
Okay. And don’t forget if you retain a Roman numeral, a DSM V point 1, is going to look
a lot like DSM-VI, or DSM IV, however that works. Okay. So, they had to go over to Arabic
numerals. Nobody knows how many. Nobody knows how often the micro-revisions will be but
it is now a neurobiological document. Okay. The third thing is the radical restructuring.
And in these two slides I’m just showing you the chapter headings in DSM-5. If you
were familiar with any of the other DSMs, you will immediately recognize some differences.
And, do you see anything that looks odd, looks different? Well, A, what do you see in A? Here’s two
things that really shocked me. Number 1 is the very first syllable of the very first
word in the very first chapter is neuro. That’s not by accident. That’s not by default.
That’s by design, gang. It’s telling you something about the orientation. Number 2, what was that first chapter before?
Disorders of infancy, childhood, and early adolescence. They’re gone. Where have all
the children gone? Where have all the children gone? [laughter] Maybe we’ve cured them all. No, those little
suckers are just as pathological as ever. [laughter] All we have done is put them into that witness
relocation program and migrated them elsewhere around various diagnostic territories. Okay.
What else do you notice? Anything else? Well, you can see the introduction of schizophrenia
spectrum and other psychotic disorders, that’s the first of the spectrum disorders. There’s
another one under neurodevelopmental that we’ll look at. That’s the autism spectrum
disorders. It’s the attempt to spectrum-ize, to dimensional-ize disorders. DSM is trying
to do that. [unclear] Anxiety disorders used to include the anxiety
disorders, the obsessive-compulsive and related, the trauma and stress-related. Now they’re
all separate categories. The same thing if you notice with bipolar and related disorders
versus depressive disorders. These used to be combined into a category called mood disorders.
Okay. Now, today is the last day you are ever going to be able to use the term mood disorders
professionally. From this point forward, mood disorders no longer exist outside of Woody
Allen movies. Are you with me? So if you say something is a mood disorder you are advertising
that you are a diagnostic troglodyte. Okay. Because mood disorders no longer exist. So
what I am telling you is the shocking fact is that a bipolar disorder is no longer a
mood disorder. Okay. And, because it’s no longer a mood disorder we’ll see how it
has shift – shifted conceptually. It’s no longer a mood disorder; it’s in its own
category.>>PARTICIPANT: [unclear]>>NEIMEYER: There are no mood disorders.
Gone, gone, gone. Ok, so let’s talk about some of these specific
disorders. These are the neurodevelopmental disorders: the new autism spectrum, the social
(pragmatic) communication disorder, specific learning disorder, ADHD, and what now is called
intellectual disability. It was the former – it was artist formerly known as Prince
– it is the uh, used to be mental retardation. It’s now intellectual disability disorder
in the DSM-5, and called in the, incidentally in the ICD, it’s known as intellectual developmental
disorder – a change there as well. Ok so, I thought the two that might be most
interesting to you is to say something about autism – the new autism spectrum disorder,
and maybe something about ADHD. Autism spectrum disorder: what they did in autism spectrum
disorder is they took the old, uh, what they called, um, PDNOS (pervasive developmental
disorder not otherwise specified), they glommed it together with Asperger’s, with Ret’s,
uh, and, um, and put them all together, the very uh, low prevalence childhood disintegrative
disorder, and put them all into a spectrum disorder. They’re all now part and parcel
of an autism spectrum disorder. The autism spectrum disorder – every single disorder
in that spectrum contains some amount of these two domains: deficits in social communication
and interaction, and restricted or repetitive behaviors, interests, or activities – what’s
known as the RBB’s. Ok, and so, that’s for a greater or lesser extent, uh, common
core areas across the various disorders in this autism spectrum disorder category. The rationale for this is basically people
were not good at doing differential diagnosis. It’s weeding out and discriminating between:
where does Asperger’s let off and autism begin, uh. Why, uh, you know, is, is childhood
disintegrative disorder really different, or is it just a different phenotypic expression
of a common underlying genotypic disorder uh, vis-a-vis autism. So they decided instead that they would just
put everything in the autism spectrum disorder and then allow specifiers to do the heavy
lifting. So if you wanted, for example, to characterize somebody who previously would
have been diagnosed as Asperger’s, if you wanted to preserve their characterization
diagnostically now, you’d go ahead and diagnose them as an Autism – as autism spectrum disorder,
but then you would say: comma, without intellectual impairment (in other words, they have potentially
normal or superior IQ), and without structural language impairment. That is Asperger’s,
ok. So they’re letting the specifiers do the heavy lifting. It means that all instances
of Asperger’s effectively immediately are in fact Autism diagnostically, which means
that that huge class of individuals would be eligible for educational and therapeutic
services that had previously been reserved for autism, which is a big difference. Now the flip side is, as you well know, if
you’ve worked with Asperger’s, people with Asperger’s, are one of the few diagnostic
categories in the DSM-5 that have a positive identification with their disorders. They
call themselves “Aspies”, ok. And they call us “neurotypicals”, and they’ll
say “I’m so – you’re a neurotypical. I’m so sorry. I’m so sorry. It must be,
it must be, it must be boring to be normal. I mean I know I have challenges as an Aspie,
but I have special talents and abilities, too.” Ok. So what’s happening now is that
that diagnostic label is really, for individuals with Asperger’s, an identity issue, and
it has now been, that rug has been pulled out from under them diagnostically. Now they’re
still, they still hold to that title, but it has been removed – the sort of warrant
has been removed from them diagnostically, ok. The, uh, the big change in ADHD, which is
not, these are not huge changes, they’re really three. One is, they raised the age
of onset; ADHD is a childhood-onset disorder. There is no adult-onset in ADHD. There never
has been, it has always been childhood. But sometimes it presents for the first time in
adulthood, and when it does, like at a college counseling center, people had to trace symptoms
of the disorder back to age 7 in DSM-III, III-R, IV, and IV-TR, ok. Now they’re saying:
‘let’s just make you trace it back to age 12.’ The rationale is pretty simple:
I walk in for the first time as an adult to my university counseling center. They say
‘Greg you’ve got all the signs and symptoms of ADHD, but we’ve gotta trace this back
to earlier childhood. Could you just describe for us your typical day in first grade?’
And I’m like ‘I know I went to first grade… uh, I’m pretty sure I completed it. Uh,
but I can’t recall much of it.’ On the other hand, if they say, ‘Tell us what you
were like in middle school’, ok. Now it’s more accessible, and I’ve got the disciplinary
record to prove it, so it’s more available to me. The notion is they think it will not
dramatically increase the prevalence rates, but it may enhance the validity of the diagnosis.>>PARTICIPANT: Can I ask you a question?>>NEIMEYER: Please.>>PARTICIPANT: In the old DSM, it would have
the prevalence rates for a lot of things so ->>NEIMEYER: Yup.>>PARTICIPANT: [unclear] how does that now
manifest if things have been [unclear]?>>NEIMEYER: Uh, this is a very good question,
um. The, um, in all cases when there are criteriological changes, they tried to look at the impact
in incidence and prevalence, and publish those preliminary things in that text revision within
the book. So the preliminary data suggest that we’re not gonna see a big increase
in prevalence, uh as a function of this, we may just get sort of greater diagnostic specificity,
uh, not have as many false positives brought into the, into the fold. Um, there are some
very clear instances of where it’s the opposite. In fact, about 95 percent of all the criteriological
changes in the DSM-5 are in the direction of creating greater leniency. The more lenient
the criteria, the more people you bring into the fold of mental illness; the more stringent,
the more you exclude. So about 95 percent of the changes are to make it more lenient.
This is why people like the task force chair of DSM-IV and IV-TR, Al Francis, and the task
force chair of DSM-III and III-R, Bob Spitzer, have had a, I think what’s fair to characterize
as a scorched earth campaign against the DSM-5, because they are very concerned about what
they call ‘mission creep’ – that is, the DSM’s veracious appetite for pathologizing
powerful and negative, but potentially normal human experience. One way you do that is you
lower the thresholds. Another time-honored way you do that is to, you know, to develop
new disorders. And then there are others. The DSM-5, for example, for the first time
since the DSM-III, brings new disorders in that did not come through the appendix as
a condition of further study. So they never enjoyed being in that crucible of science,
they were brought in uh, for valid political reasons, which is very uncommon. I have not
seen that in DSM – from 1980 forward, you would never see that. Uh, we see it for the
first time in DSM-5; another reason why people regard it as more ideological than empirical,
as the, as the system goes. The only other two changes with ADHD is that
the symptom threshold, um, is, uh, for adults, basically has been reduced from six symptoms
to five, just on the assumption that there’s kind of cortical maturity, and people learn
to cope, so the impulsivity that would have a grade school kid jumping out of his or her
ta – uh, chair, uh twenty years later, translates into something as much more muted. It’s
the person next to you whose leg is going like this, and so as you’re taking notes
– palsy notes – uh, you know, your table is experiencing a point three on the Richter
scale. That is ADHD impulsivity and interruption, but it’s twenty years later, when you’ve
learned to cope in socially appropriate ways. The other change is just like in many, many,
many other disorders in the DSM-5: all the subtypes: ADHD-predominantly impulsive, ADHD-predominantly
inattentive, ADHD-mixed type – those are all now just specifiers. There’s only one
ADHD, it’s called ADHD, and then you just put ‘comma, with inattention; with impulsivity’.>>PARTICIPANT: [unclear]>>NEIMEYER: Well, it is, it is ADD. Yeah,
it is ADH – it sh – it’s ADHD, but you could have something that was, uh, didn’t
have the hyperactivity piece in it. There’s no separate ADD. There is no –>>PARTICIPANT: [unclear] you say ADHD, but
specify that there is no hyperactivity?>>NEIMEYER: Correct. Yep, you just say, you
just say the- ADHD comma with, um, you know, with inattention – with predominant inattention,
period. Ok, I promised today something about bipolar
disorders and I will. These are the recognized bipolar disorders. I’ll tell you the big
change in bipolar: because it’s no longer a mood disorder, because there are no mood
disorders, it is now emphasizing not just mood variation – that is, the ups and downs
that go with this kind of undulating mood: expansive, hypo or hyper-manic activity up
here, and then depression down here – but they’re reconceptualizing at – it as in
addition to the mood variability, it’s a disorder of energy and activity. It’s a
disorder of energy and activity, rather than simply a mood disorder. And if you have seen
or if you have worked with people who are bipolar – particularly bipolar I – you
will recognize that what gets them into trouble is their behavior; it’s their level of activity
and their level of energy. Uh, I worked with a kid – not a kid, he
was in his mid-twenties – uh, I’ll tell you when it was, uh, it was back when the
first Spiderman movie was released. And this kid, uh, during his hypermanic phase of bipolar
I – he was a comic book and fantasy sort of, uh, guru. He loved it; aficionado of all
things – he loved Spiderman, and when he got into his bipolar manic phase, uh, he,
uh, would envision himself – he would get lost in the fantasy world basically and uh,
one night at about 2, 3 in the morning in a sleepytown of Gainesville, Florida, 25-mile
per hour speeding zones, stop li- stop signs at every brick lined, uh, you know, uh, block,
um, he was going sixty, sixty-five miles per hour ripping through them like a hot knife
through butter [makes sound]. Police finally had to barricade the road and apprehend him,
and when he got out, he thought he was Doc Op. Remember the arch villain of, of the first
Spiderman, was Doctor Octopus?; he had these great big mechanical arms. And so he got out
[makes sound] doing battle with the police officers, uh, and of course he was hypermanic,
so he was really strong, he was completely unchained. They called in backup, they did
subdue him. Now, the relevant point here is: my client’s problem was not that he was
too happy – are you with me? It was the activity and energy levels. It was the failure
to sort out fact from fantasy. That’s what the DSM-5 is now emphasizing with the bipolar
disorders, ok, in addition to the mood variation and undulation.>>PARTICIPANT: [unclear] clarify things for
some of my students…>>NEIMEYER: Yeah.>>PARTICIPANT: because when we talk about
depression …>>NEIMEYER: Yep.>>PARTICIPANT: uh, and they – we talk about
the depression part of bipolar, they’re saying, one of them would say: ‘Well, I
don’t feel sad, I just feel powerle – en, uh, energy-less>>NEIMEYER: Yep.>>PARTICIPANT: so [unclear].>>NEIMEYER: Yes, and don’t forget, that
this is a common misunderstanding about depression, you know, uh, the guy who wrote, um, From
Death Camps to Existentialism – it was republished as a book called Man’s Search for Meaning?
A guy named Viktor Frankl? He had a beautiful metaphor; he called depression, he said, you
know, think of a violin, he said ‘A violin can play these incredibly melodic, happy,
animated tunes, or it can play these sad, soulful whisple – wistful kind of tunes,
but depression is none of those. Depression is like undoing the strings; it’s flat,
it’s absent, it’s, it’s the absence of, the inability to access emotions, as if
the world is lived behind a plate-glassed mirror.’ So, um, so, you know, depression – many
people – docs, by which I mean MDs, miss about fifty percent of all depressions – I
worked for about twelve years in a medical residency training program – and they miss
about half of u- all unipolar depressions. A big reason for that is a huge reason for
unipolar depressions do not present with any sadness at all; they present with musculoskeletal
tension, lack of concentration, disturbance in eating and diet and weight – those are
the kinds of symptoms rather than emotional lability or sadness per say. Now, when we come to depressive disorders,
I just wanna say, uh, this is a radically reconfigured area – in part because bipolarity
has been taken out of it, but also because they’ve added in the single most contentious
disorder in the DSM-5 that is going to be centrally relevant to you in classroom contexts,
and that is the disruptive mood dysregulation disorder, so I wanna be sure we spend a few
minutes on this. I’ll give you what it is, I’ll give you the backdrop for it, and I’ll
tell you the challenges it is going to invite. Disruptive mood dysregulation disorder came
into the DSM without ever going through the conditions of further study. It never went
through the conditions of further study. It’s invent- it is invented and put it de novo
for validly political purposes and I will give you the quote from the DSM that gives
you the rationale so you can see what they’re thinking and why they’re thinking it. So let’s talk about what it is, first. Well,
it’s a te- it’s a basically, it’s an emotional dysregulation disorder where the
kid – typically a kid – has temper outbursts that involve yelling, raging – it’s significant
emotional discontrol and aggression; the sine qua non in some ways is physical aggression.
It can be provoked or unprovoked. If it’s provoked, it’s making mountains out of a
molehill. Kid steps in front of a kid in a cafeteria line. Ninety percent of the time,
a- that kid will either defer, call him a name, step back in front of the line. With
an, with an, uhy, disruptive mood dysregulation disorder kid, they’re gonna grab him by
the lapel, turn him around, punch him in the face, take him to the ground, and keep pounding
him, ok. Mountains out of molehills. If you’ve ever seen people engage in uh,
intermittent explosive disorder, like if you’ve ever seen road rage, we’re looking at a
chronic version of road rage more like in childhood, ok. So it’s the overreaction
to common stressors and it has to be chronic, it has to go on for at least a year with no
more than three months of being sort of symptom-free. We’ll talk about why it can’t be diagnosed
before age six or after age eighteen. The backstory for this is this, and you will be
very familiar with this, because no one is more familiar th- with this than teachers.
Back up to about 19- the early 1990s – if you were in the field, back in the seventies,
or eighties, or early nineties – you will recognize – when the – in the old days,
the bipolar disorder was known as what; anyone remember th-?>>PARTICIPANTS: [unclear] manic depression.>>NEIMEYER: Manic depressive psychosis. Now
let me ask you: how many pediatric versions of manic depressive psychosis did you see;
this would be zero, ok. It got changed in 1990, 1991. There was a guy named Joseph Biederman.
Joseph Biederman was studying ADHD and what he said is, he said ‘Look, I got 20 percent
of my ADHD kids who are doing two things that are really odd. Number one is they’re not
medication-responsive to the methamphetamines, the Cylert or Ritalin that are typical medications
for the treatment of ADHD, and number two is they’re physically violent’. Now, you
know this as well as I do: your ADHD kids will drive you nuts. They’ll get w– they’ll
get on your one good remaining nerve, and at the end of the day you may be pulling your
hair out, but by and large you are not frightened of them. Ok, are you with me? You’re not
mostly afraid they’re gonna hurt you; they’re mostly afraid – you’re mostly afraid they’re
going to drive you crazy, ok. So what Broughtman says – I mean what um, what Biederman says,
is he says ‘The reason why they’re not medication-responsive and they’re aggressive
– rather than non-aggressive like the other eighty percent of ADHD kids – is that they’re
not ADHD. What they are, what they are, is they’re childhood bipolar cases. They’re
bipolar children. Well, within the next ten years, we had a
fifteen-hundred percent increase in the diagnosis of bipolarity. Fast-forward to the early 2000s,
TIME magazine front page cover – all colorful, you know: Baby Bipolar. We’re bi – we’re
diagnosing people who are like three years old, two years old. You’re in the crib,
you’re playing in a little bit too animated a form with your mobile, and they got the
Seroquel right there in your – it’s like, ‘Take, take this honey, mommy needs to sleep
[makes glug sounds]. Oh look, he’s so calm and peaceful’. ‘Well that’s because
you g- administered him a neuroleptic and so he’ll be awake on Thursday. So, but the good thing is he’ll be really
quiet until then.’ Um, and so it was a problem. It became a problem, and psychiatry recognized
– we were over-diagnosing and overprescribing, ok. So here’s the rationale for the creation.
This is verbatim quote from the DSM-5. Here’s what they say, they say: ‘Disruptive mood
dysregulation disorder address the disturbing increase in pediatric bipolar diagnosis over
the last two decades, which is due in f- large part to the incorrect characterization of
non-episodic irritability – in other words chronic irritability – as a hallmark symptom
of manic. Disruptive mood dysregulation disorder provides a diagnosis with children – for
children with extreme behavioral dyscontrol but persistent, rather than episodic irritability
– and here’s the critical phrase – and reduces the likelihood of such children being
inappropriately prescribed antipsychotic medication’. Do you see the raison d’être for the creation
of this disorder? Because we want to get them out of harm’s way as a function of our prescription
practices. We are overprescribing, so we’re creating a new category that gets these kids
out of harm’s way, and put them into –>>PARTICIPANT: [unclear] we still have to
medicate that.>>NEIMEYER: Well, this is a good point, and
– that she sa, she said ‘We still have to medicate that,’ now – you don’t have
to but,>>PARTICIPANT: You will.>>NEIMEYER: You, you will, and if you are
in a depressive disorder category, as this now is, what is the first line of pharmacological
treatment?>>PARTICIPANT: [unclear]>>NEIMEYER: It would be an SSRI, wouldn’t
it? [Participant chatter]>>NEIMEYER: It would be a selective serotonin
reuptake inhibitor. How many of you know what an SSRI does to a unipolar depr- or to a bipolar
disorder? [Participant chatter]>>NEIMEYER: It trips a manic episode. So what
I’m asking you is, is this gonna get kids out of harm’s way, or is it gonna put them
into a different harm’s way?>>PARTICIPANT: I thought antidepressants for
kids was, was– we don’t do that [unclear].>>NEIMEYER: No, no, no, no, no, no, no, no,
no, we, we definitely do antidepressants for kids.>>PARTICIPANT: [unclear] all that [unclear;
someone speaking over participant] societal ideation [unclear].>>NEIMEYER: There was a real, there was a
concern about ten years ago, twelve years ago with the Prozac rage; there was a concern
about a particular SSRI as tripping in childhood and adolescence rage in a small percentage
– one percent, one half percent of the cases. Most of that has blown over, and most of that
has not extended to S – to other SSRIs, but it’s still a concern, I mean, you know,
people are cautious.>>PARTICIPANT: [unclear]>>NEIMEYER: Pardon?>>PARTICIPANT: [unclear] now we’re gonna
make them [unclear]>>NEIMEYER: Well, it’s, it’s, it is a
concern, all I’m saying is it’s, it’s an imperfect deal, um, at this point. It is
the case, that because it cannot be diagnosed prior to age six – and that’s so we don’t
misdiagnose the terrible two’s and three’s – and we can’t be diagnosing it after
age 18, unlike bipolar, it cannot be a lifetime diagnosis. Now, the question is, what happens
to these people after they age out, at age 18? And the simple answer is, just like the
beautiful Mark Twain quote when he was asked a difficult question, he said ‘I was gratified
to be able to answer promptly; I said I didn’t know’ – and that’s the case here. Nobody
knows what happens once these kids reach age eight, eighteen. [Participant chatter]>>NEIMEYER: I won’t say anything more about
major depression, uh because it’s –>>PARTICIPANT: [unclear] it’s still the
same –>>NEIMEYER: It’s largely the same, um, major
depression did not, uh, did not change. Dysthymia changed. Dysthymia was that minor chronic
form that was marked by irritability and frustration, um. Some people almost see it as like a personality
kind of disorder. The clearest instance I can give you that – of that was a, a great
– there was a great movie several years ago, uh, by the name of Steel Magnolias, and
in that movie there was, uh, there were two actresses. There was an actress, you may have
heard of her, her name was Shirley MacLaine, and this actress Shirley MacLaine played this
character Ouiser, and Ouiser was this curmudgeonly, crotchety sort of middle-aged, uh, old, eh,
relatively old sort of really irritable, always angry, always curmudgeonly, always uh, irritable,
and she was playing opposite a fresh-faced ingénue, an actress by the name of Julia
Roberts. I don’t know if you remember her. Julia Roberts’ character came to Ouiser
and she said, ‘You know, I think your problem is maybe you’re just depressed. Maybe that’s
your problem. You are just depressed. You ever think about that? You’re suffering
depression.’ And Ouiser said in response, ‘I am not depressed, I’ve just been in
a really bad mood for the last 40 years’. That’s dysthymia, ok. That’s a chronic
irritability. But because we moved dysthymia out of the mood disorders, because they no
longer exist, it’s now a depressive disorder. So if you actually look at the diagnostic
criteria, dysthymia has lost all of its irritability. It’s lost all the distinctive features;
it’s now a low-grade depression that lasts two or more years, because it got moved out
of a category that no longer exists. Ok, I’m gonna say almost nothing about anxiety
disorders, not because they aren’t important, but because so many things left anxiety disorders,
that if anxiety disorders were a TV show, it would be called ‘The Biggest Loser’,
because it lost all the OCDs, it lost all the trauma and stress-related disorders, and
what it got in compensation for its losses, is it picked up selective mutism and separation
anxiety disorder from the childhood disorders, because they had to be migrated somewhere.
The biggest thing – I think the biggest two things – in anxiety disorders; there
were a lot of suggested changes in generalized anxiety disorder, but ultimately all they
did was change the characterization of it to include a lot more wording about worry.
Worry in generalized anxiety disorder is all about apprehensive expectation; people are
always worried about the next thing, they’re worrying about worrying about worrying about
worrying about worrying about worrying, and now I’m worried about worrying about worrying
about worrying about worrying and worrying, and so it’s on and – it’s the runaway
locomotive of worry. So much so is this change in the description of generalized anxiety
disorder, that GAD – generalized anxiety disorder – was going to be changed to, instead
of G-A-D, generalized anxiety and worry disorder: GAWD, until somebody said – [Crowd laughter]>>NEIMEYER: no kidding, they looked at the
acronym and they said oh my God, look what they’ve done to GAD, and then it no longer
passed the giggle test, so they went back to GAD. No other big changes. Eh, there is one other
change, and that is, it used to be that you could have a agoraphobia with or without – you
could have panic disorder with or without- without agoraphobia – the world’s shrinking
– and now DSM-5 allows you to diagnose agoraphobia without panic disorder, which was never true
before. You could only have panic disorder that did or didn’t have agoraphobia, but
not a free-standing agoraphobia.>>PARTICIPANT: Dr. Neimeyer, um –>>NEIMEYER: Yes?>>PARTICIPANT: When it said selective mutism,
did somatoform disorders also go away then?>>NEIMEYER: Somatoform disorders completely
evaporated [participants speaking over], completely evaporated. Because look, here’s the deal:
somatoform disorders – think about this for a second – somatoform disorders are
conceptually incompatible with the DSM-5.>>PARTICIPANT(S): [unclear]>>NEIMEYER: Because, a somatoform disorder
by definition is an intra-psychic problem, an, an, anxiety an- an, analytically, that
gets converted into somatic form. So you go up to do your concert recital at Carnegie
Hall and suddenly you have a dual hand paralysis, which is neurologically impossible, because
nerve innervation is this direction and not this direction. You have converted into somatic
form an underlying psychological issue. That’s what, that’s the common tie that bound.
But you can’t have in, an, a psychological cause for a psychiatric disorder anymore,
you have to have an undergo- you have to have an on- a biological cause, so you cannot have
a somatoform disorder. It’s conceptually incongruous in DSM-5. So they imploded the
entire category, renamed it somatic symptom disorders, re-conceptualized it, and ex, exported
as many things as possible, including exporting this one: body dysmorphic disorder, out of
that somatoform disorder [participants talking], it’s in OCD. You know what BDD is? Remember BDD? BDD, body
dysmorphic disorder, is the person who has imagined, uh, they have, there’s a real
facial or cranial asymmetry – like one eyebrow is higher than the other – maybe not that
much higher. Or one nostril is more flared than the other. Or perhaps it’s an earlobe
irreg- are my earlobes attached or unattached?>>PARTICIPANT: Uh, attached.>>NEIMEYER: My earlobes are attached, I have
an attachment disorder, ok? And so I go to the mirror and I realize I have a bilateral
attachment disorder, and I regard this as hideous. And so when I meet people, it’s
like, ‘Hi, I’m Greg. Nice to meet you. So nice to meet you. So nice to meet you.’
And so I’m sheltering you, ok? And I’m checking always on the exposure of my hideous
earlobes, ok? Body dysmorphic disorder. They moved that because of the obsessive attention
to and checking regarding these, these physical asymmetries, they moved that over into this
category, and they added in a specifier. It’s called, uh, the muscle dysphoria. It’s not
a subtype, but it’s a specifier for BDD – muscle dysphoria. You know these people.
You have seen these people. Go into any gym in the United States, and you will see these
people. Muscle dysphoria is mostly men – I’ve seen one woman, lots of men – who feel like
they are not big enough, but- buff enough, cut enough. Now they are, like you see them,
and they’ll come ul- up to you and they’ll be like, they’ll be like the incarnation,
the human incarnation of a tr- of a transformer. [Makes sound] And they’ll say, ‘Dr. Neimeyer,
I’m not big enough-f-f-f. I’m not buff enough-f-f-f. I’m not cut enough-f-f-f.
But, you know, they’ve got this big neck, and they’ve got these biceps and triceps
and pecs and these washboard abs, but as they come towards you [makes sound], you look down,
and all of the sudden as you follow that Adonis upper body down, you see these two little
chicken legs down there like this, little chicken legs. They forgot the lower body machines,
are you with me? So it’s this notion that ‘I don’t feel
masculine enough, I don’t feel present enough, I don’t feel virile enough’, uh, and they
call it in, in the lay literature, it’s known as bigorexia, but in the professional
literature, it’s known as muscle dysphoria. I don’t feel good about how muscled I am. Ok, I’ll say something about substance,
and then uh, maybe we’ll stop at that. Uh, substance is completely re-conceptualized
in the DSM-5. It’s the most re-conceptualized of all the disorders. Uh, I’ll say a word
about personality disorders because it represents the opposite, uh, the least changed. Substance-related
– you can just take your box cutter and cut out the DSM-IV and toss those pages away
because it’s uh, a completely re-conceptualized category. It’s re-conceptualized in relation
to substance-use disorders and substance-induced disorders. You have – substance-induced
disorders are intoxication and withdrawal, and psychological disorders that are induced
by drug use. Drink enough alcohol, you can develop psychosis, or you can develop [unclear]
central nervous system depression – you can trip a depression, and so forth. Ok so let’s look at substance – gone is
the old distinction between substance dependence and substance use. DSM-5 does not recognize
addiction. It does not recognize substance addiction, ok? It does not recognize dependence.
It only recognizes use, and induced disorders. This is the criteria set for substance use
disorders, and basically what it is, is a combination of the criteria that were in the
old dependence and abuse category, they mixed them together and said ‘any two will do’.
If you have any two of these symptoms, you qualify for a substance use disorder. It’s
a pretty relaxed criteria set. I’ll give you an example. The first one is ‘using
larger amounts than intended’. Now think about how frequently that occurs. You don’t
even need to go to a college campus. You only need to have gone to my house during the Superbowl,
where I set aside two beers for the first quarter, and then I quickly realized that
Peyton was not going to do it. And so I went to the refrigerator at the end of the first
quarter, and by golly, the whole six-pack was gone. And by the time we got to the halftime,
I was going to the 7-11 again. So, using larger amounts than intended, ok, um, please.>>PARTICIPANTS: I’m just curious about the
rationale for removing addiction given that, that there is a biological explanation for
addiction.>>NEIMEYER: Um, the concern, the current concern
was clinically we were not good at determining the line that could be drawn – there, there
are sort of two things. One is the concern about what is the relationship between psychological
and physical features of dependence in addiction, and we’ve never been able to, that’s always
been thorny enough that we haven’t been able to sort it out well, uh. Relatedly, uh,
it was never clear, uh, it’s almost like the old uh, the, you know, it’s kind of
like the Native American of uh, sort of, uh, uh, of adage. You know, first the man takes
a drink, then the drink takes the drink, then the drink takes the man. And we never knew
where in there to start calling the person addicted, um. And of course we recognize is
huge inter-individual uh, variation in terms of addiction, susceptibility to addiction,
and recovery. So, they felt like diagnostically, we weren’t able to, to reliably do what
we were trying to hold our feet to the fire in relation to. Now it’s created very huge problems. In
the state of Florida, I just heard a couple months ago, there was a PRN, a Physician Recovery
Network, as there is in every state in the United States, uh. Their guidelines require
that for a physician to be [unclear] into the custody of this program, to retain his
or her license, they have to be adjudicated as addicted. Because the DSM-5 does not recognize
addiction, they cannot use the DSM-5. So they are required in that Physician Recovery Network
in the whole state of Florida, they’re required to keep using the DSM-IV. Ouch. S, that- somebody’s
going like, ‘oops’. So it’s a very contentious issue. The other thing that’s a contentious
issue is that, the- for the first time in the DSM-5, we have the introduction of a behavioral
addiction, and that is gambling. Gambling is recognized in this category, this category
is known as, this category is known as Substance-Related and Other Addictive Disorders. The other addictive
disorder is gambling. Addiction does not refer to any substance in the DSM-5. Addiction refers
to gambling. It is the first behavioral addiction, and in the conditions for further study, there
is a second one that has been introduced for consideration in the next iteration and that
one is called Internet Gaming. Two countries stood up and insisted on the
inclusion of Internet Gaming. Those two countries were – not the United States surprisingly
– they were Korea, and mainland China. Because both countries have come out with governmental
proclamations that between fifteen and seventeen percent of their adolescent populations are
internet addicted, and for that reason, they really needed and wanted to have that included. Now, given that both internet-based and on-site-based
gambling has already come into the addictive disorders section, the substance abuse – substance-related
and other addictive disorders, is there any doubt about where internet gaming is gonna
come? Kay. Which is to say, if I own a chemical dependency center right now, I am not in this
room, I am out at my banker’s and I am getting a construction loan for a whole new wing of
my treatment centers, and I’m gonna make sure it’s internet-wired. Uh, an, an, and
pretty soon it’s gonna equal, it’s gonna the other side, isn’t it? It’s gonna equal
the other side. Uh, let me give you an example, cause there are all kinds of problematic internet
use, aren’t there? It’s not just about internet gaming. Isn’t it fair to say there’s
cyberporn, there’s addiction to online uh, auction houses. Let me just give you one sample
of another problematic internet use, brought to us by Weird Al, and it is internet addiction. [Plays video]: “Yeah
A used … pink bathrobe A rare … mint snowglobe
A Smurf … TV tray I bought on eBay My house … is filled with this crap
Shows up in bubble wrap Most every day
What I bought on eBay Tell me why (I need another pet rock)
Tell me why (I got that Alf alarm clock) Tell me why (I bid on Shatner’s old toupee)
They had it on eBay I’ll buy … your knick-knack
Just check … my feedback “A++!” they all say
They love me on eBay Gonna buy (a slightly-damaged golf bag)
Gonna buy (some Beanie Babies, new with tag) (From some guy) I’ve never met in Norway
Found him on eBay I am the type who is liable to snipe you
With two seconds left to go, whoa Got Paypal or Visa, what ever’ll please ya
As long as I’ve got the dough I’ll buy … your tchotchkes
Sell me … your watch, please I’ll buy (I’ll buy, I’ll buy, I’ll buy …)
I’m highest bidder now (Junk keeps arriving in the mail)
(From that worldwide garage sale) (Dukes Of Hazard ashtray)
(Hey! A Dukes Of Hazard ashtray) Oh yeah … (I bought it on eBay) Wanna buy (a PacMan Fever lunchbox)
Wanna buy (a case of vintage tube socks) Wanna buy (a Kleenex used by Dr. Dre, Dr.
Dre) (Found it on eBay) Wanna buy (that Farrah Fawcet poster)
(Pez dispensers and a toaster) (Don’t know why … the kind of stuff you’d
throw away) (I’ll buy on eBay) What I bought on eBay-y-y-y-y-y-y-y-y-y” You’ve seen it, you’ve seen all kinds
of problematic internet use, ok. The last thing I’ll say is just that as
you know, the uh, the personality disorders work group – I know Emily, uh, asked me
to say something about – personality disorders in the DSM-5 remain unchanged, um. They uh,
th- there’s the ten disorders that have been there since, uh, the DSM-III remain.
They try to radically re-conceptualize and dimensionalize, take away the categorical
system, and simply create a system of dimensions along which personalities would be arrayed.
It did not work. They ultimately came forward with a hybrid model. It is half-dimensional,
and it is half-typological. But it takes about forty-five minutes to an hour to confer a
diagnosis using it, and ultimately, not the task force, but the task force recommendation
to the board of trustees was rejected to make the changes that were proposed by the workgroup
on personality disorders. The – on the rationale that extraordinary revisions require extraordinary
evidence. Something that is brand new cannot have extraordinary evidence. So they literally
said to them, ‘thank you very much for your seven years of pro bono work, but we are accepting
none of your revisions’. When I saw the task force on personality disorders, uh, last
May in San Francisco, I can tell you they were to a person unipolar depressed, uh it
was really – it was cr- they were crestfallen because don’t forget, this is the first
workgroup in the history of the DSM that had none of the recommendations suggested, uh,
accepted – so not only was it, were they crestfallen and demoralized, but there’s
also an aspect of humiliation that is publically – nothing we have done has had any uptake. As a concession to the decision to not move
forward with any of their recommendations, the task force of the DSM-5 put into the new
section, section three, it’s an unofficial section: emerging measures and models: the
entire brand new, alternate system for diagnosing personality disorders. It’s not officially
recognized or sanctioned, but it is there for you look at and read and to see, uh, in
exactly the form that it went forward to the board of trustees, but it was rejected. I
think it is probably fair to say that that is cold comfort for that task force, but it
is there and perhaps it will have some uptake in the future. I hope these comments are helpful for you
in relation to understanding some of the changes associated with the DSM-5. Yep. [Applause]

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