Monday, January 25, 2016

Critiques of the DSM-5: Interview with Jeffrey Lacasse, Ph.D.

[Episode 101] Today's episode of the Social Work Podcast is a critique of the  Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5.

The most basic critique of the DSM-5 is the same critique that has been levied against psychiatry for decades: that it does nothing more than medicalize or pathologize normal behavior. So is it ever ok to say that someone isn’t normal? Are there ever situations where giving a diagnosis is good? As it turns out, yes. And I’m not just talking about diagnosis as a means to finance treatment. Yes, third party reimbursement hinges on diagnosis. But I’m talking about something less institutional and more personal. There are people who like labels, who find comfort in being able to name or label what is wrong. The label draws a boundary around an experience. Labels can even draw up boundaries around a group of people. According to psychologist Gary Greenberg, “[the label] Asperger’s syndrome gave people whose primary symptom was isolation a way to belong and provided resources to those who were diagnosed” (Reese, 2013).

Download MP3 [37:19]

So, I know what you are wondering - is DSM diagnosis good or bad? Well, today’s episode won’t be the definitive answer to that question. But, it will give you cause to pause when you think about the role of DSM-5 in the professional life of social workers and the people we serve. My guest is social work faculty member from Florida State University, Jeffrey Lacasse, Ph.D. Dr. Lacasse has published several critiques of the changes in DSM-5. In today's episode, Dr. Lacasse critiques the definition of mental illness, the empirical support for and reliability of most diagnoses, the politics associated with the DSM and the implications for social workers who represent the single largest group of professionals who provide DSM diagnoses.

Download MP3 [37:19]


  • Ph.D., 2008, Florida State University; Social Work
  • M.S.W., 2000, Florida State University; Clinical Social Work
  • B.A, 1997, St. Leo College; Liberal Arts and Psychology
Research Interests
  • Mental Health, Psychiatric Medications



Jonathan Singer: Today's episode of the Social Work Podcast is a critique of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5

"The two years leading up to the publication of the DSM-5 (American Psychiatric Association, 2013) in May, 2013 have been described as a “war… that has shaken psychiatry to its core” (Greenberg, 2013, p. 3). The chair of the DSM-IV task force, Allen Frances, publicly denounced the process used by the DSM-5 task force and cautioned that the changes in DSM-5 would “turn our current diagnostic inflation into hyperinflation by converting millions of ‘normal’ people into ‘mental patients’” (Frances, 2013, p. 3). The value of the DSM-5 as a “bible” for mental health practitioners was further questioned in 2013 when Thomas Insel, then the director of the US National Institute of Mental Health (NIMH) published a blog post in which he said, “[Mental health research] cannot succeed if we use DSM categories as the gold standard. ...That is why NIMH will be reorienting its research away from DSM categories” (Insel, 2013). By the time the DSM-5 was published in May 2013, it seemed quite possible that the addition of 15 new diagnoses, removal of the multi-axial system, and the reorganization of the text itself, would lead to a disaster of epic proportions" (Alvior, Drake, Kim, Lee & Singer, 2014, p. 2).  

So, have the dire predictions come true, or, were these predictions, to quote Shakespeare, “… full of sound and fury, signifying nothing” (Shakespeare, 2002, p. 179)?" Well, I’m recording this in January 2016 and it is still a little early to tell. The DSM-5 didn’t go into effect for most social workers until 2015. What we do know is that the critiques of DSM-5 haven’t let up. 

The most basic critique of the DSM-5 is the same critique that has been levied against psychiatry for decades: that it does nothing more than medicalize or pathologize normal behavior. Let’s play a game. I’ll describe something and you tell me if it is normal or not normal (because that’s basically what a DSM diagnosis is supposed to represent): Having a conversation with God. The desire to escape slavery.  Falling in love. Debilitating sadness over the death of a loved one. Forgetfulness in old age. Believing that you are invincible. If you answered “normal” to all of those, then you’d be right. But if you answered not normal to all of those, then you’d also be right. And if you answered “normal” to some and not others then you’d still be right. 

So, how can this be? In a nutshell, “normal” is a social construction. One of the vocal critics of the moral and scientific foundations of psychiatry, Thomas Szasz who was, himself, a psychiatrist, wrote about the social construction of schizophrenia in this way: "If you talk to God, you are praying; If God talks to you, you have schizophrenia. If the dead talk to you, you are a spiritualist; If you talk to the dead, you are a schizophrenic" (Szasz, 1973, p. 85).  That was in 1973. Today if I hear someone talking out loud but I can’t see who they are talking to, I’m much more likely to assume there’s a Bluetooth headset in their ear as I am to assume schizophrenia.

So, what about that question of escaping slavery? Again, it is an issue of social construction. In 1850, Samuel Cartwright, a doctor and slave owner invented a diagnosis called "drapetomania" which basically said that enslaved Africans who tried to escape were suffering from a mental disease (Reese, 2013). See - it wasn’t the conditions of slavery that would make someone want to run away – it was a diseased mind. If you accept this premise, then the corollary would have to hold true – that not trying to escape was proof of good mental health. Fast forward 120 years and we find that same-sex romantic or sexual attraction is a psychiatric illness. And then in 1973, the DSM committee voted to eliminate “homosexuality” from the DSM. That’s right. Committee vote and survey says, Homosexuality is no longer a psychiatric illness. Millions of people, not crazy. The best report about this historic decision is an episode of This American Life, called 81 Words. Look it up. It is amazing. 

Fast forward another 40 years to 2013 and Allen Frances, a psychiatrist and the chair of the DSM-IV committee that I mentioned earlier is warning people that DSM-5 will medicalize normal behavior. Is this starting to sound familiar? He even wrote about it in a 2014 editorial in Research on Social Work Practice. “DSM-5 exacerbates the medicalization of normal behavior by relabeling as mental disorder the sadness of grief, the temper tantrums of children, the normal forgetfulness of old age, the everyday distractibility of adult life, the worries of the medically ill, and the temptations of binge eating” (Frances & Jones, 2014, p. 12). Now, if you’re still in the mood for games you can try and name the diagnoses Dr. Frances is referring to.  

So is it ever ok to say that someone isn’t normal? Are there ever situations where giving a diagnosis is good? As it turns out, yes. And I’m not just talking about diagnosis as a means to finance treatment. Yes, third party reimbursement hinges on diagnosis. But I’m talking about something less institutional and more personal. There are people who like labels, who find comfort in being able to name or label what is wrong. The label draws a boundary around an experience. One of the most effective psychotherapies for the treatment of depression, Interpersonal Psychotherapy, which I talked about in episode 10 – uses labeling as a key intervention.  In IPT the therapist gives people the “sick role.” It goes something like this (imagine I’m the therapist and you’re the client. You meet criteria for major depressive disorder. I might say something like this: “The reason why you’ve been having difficulty is because you have an illness called depression. It is a treatable illness, but like all illnesses, it makes it difficult to do some things.” In the case of IPT, the sick role draws a boundary around the experience of depression and says “it is reasonable to do this and not reasonable to that, until your depressive symptoms decrease.” 

Labels can even draw up boundaries around a group of people. When you put up boundaries, you separate. When separation systematically oppresses people we call that boundary segregation. But, when labels group people together, it can also create community. Psychologist Gary Greenberg has suggested that one of the best examples of the power of a diagnosis to build community is the diagnosis of Asperger’s Syndrome (which was established in DSM-IV and subsumed under Autistic Spectrum Disorder in DSM-5). According to Greenberg, “Asperger’s syndrome gave people whose primary symptom was isolation a way to belong and provided resources to those who were diagnosed” (Reese, 2013). 

So, I know what you are wondering - is DSM diagnosis good or bad? Well, today’s episode won’t be the definitive answer to that question. But, it will give you cause to pause when you think about the role of DSM-5 in the professional life of social workers and the people we serve. My guest is social work faculty member from Florida State University, Jeffrey Lacasse, Ph.D. Dr. Lacasse is an expert in psychiatric medications and has published several critiques of the changes in DSM-5. In today's episode, Dr. Lacasse critiques the definition of mental illness, the empirical support for and reliability of DSM-5 diagnoses, the politics associated with the creation and publishing of the DSM, and what it means for social workers to be the single largest group of professionals who diagnose people with psychiatric disorders based on the DSM.

One quick note about the interview: I spoke with Jeff in January 2016 at the 20th annual Society for Social Work and Research conference in Washington DC. We did the interview in his hotel room and at one point you can hear music and children in the background. It’s not really distracting, but since we’re talking about mental disorders, I thought it was only fair to let you know that you’re not hearing things. 

And now, without further ado, on to episode 101 of the Social Work Podcast: Critiques of the DSM-5: Interview with Jeffrey Lacasse, Ph.D.

(Includes some grammatical and punctuation errors - if you would like to edit and clean it up, I'll give you a shout out on the next episode of the podcast).

11:0 Jonathan Singer: Jeff, thanks so much for being here on the podcast and talking with us about DSM 5.

Jeffrey Lacasse: Thanks for having me Jonathan!  

 11:1 Jonathan Singer: So one of the things that the DSM 5 was advertised as being was a significant improvement over the highly criticized DSM-IV. But you don’t really see it as an improvement do you?

11:14 Jeffrey Lacasse: I do not see it as an improvement and I think that is what the data would show. I think one thing that we have to remember especially as social workers is that the DSM 5 is a product of a private guild that makes a profit by selling it. And it’s essentially a very interesting thing if you think about it, that a private guild gets to decide who is mentally ill and who is not in our society. And as social workers and at a social justice stand point that is an awful, interesting, kind of American sort of thing for us to think about given the relationships between drug companies and psychiatrists especially the ones who are influential in something like the DSM 5. To be fair I think that there is plenty of academic psychiatrists out there that would say that the DSM 5 is not an improvement. And I am amazed many moved with their feet saying that they do not want to be involved with the DSM 5.

 12:5 Jonathan Singer: They said that they wanted to do the RDOCs.

12:6 Jeffrey Lacasse: And yeah they wanted to do the RDOCs criteria and I mean that’s a really complicated separate issue but obviously the DSM 5 is going to be in clinical practice. That’s why social workers need to be familiar with it for reimbursement purposes, etc. But as far as DSM 5 being an expression of proofs, science, I do not think that it true. And I think that is remarkable actually if you think about it because DSM-IV is 1994, DSM-IV-TR is 2000 and then 15 years later it be reasonable to say okay so we have improved this system right? We got a little better; actually some of the numbers for DSM 5 are worse than the tests for DSM-III in 1980.

12:50 Jonathan Singer: What do you mean by that? What numbers?

12:51Jeffrey Lacasse: Just to give you one example the capa value, the test value, the test for reliability for diagnosis, the variable to measure accuracy. Which is somewhat primitive but it has utility. So that means if a client goes to see two different clinicians around the same time period what percentage of the time do they agree that the client has depression.

13:12 Jonathan Singer: So if they went to see me and they went to see you.

13:15 Jeffrey Lacasse: Exactly and so if you know theirs 100% agreement that’s great, but that does not exist in medicine. There is always diagnostic ambiguity but I was stunned at the level of inaccuracy of the DSM 5. That is why I am at this conference with you and presenting a paper on this issue, its 28% for major depression, its 20% for generalized anxiety disorder, and the interesting thing was the American Psychiatric Association, their work group, they were trying to spin these results in the scientific journals. And you know as researchers were use to the average consumer of research results just think these are scientists, this is going to be objective research. They spun these as an improvement as very positive results, we got good results the DSM is pretty reliable, 20% and 28% I mean I am just going to cut to the chase those are dismal results and those are two of the most common disorders diagnosed. And let me be more specific if 100 clients who had previously been diagnosed with generalized anxiety disorder under DSM-IVTR or very prominent symptoms of it. You and I got trained specifically on how to share diagnostic patterns then we used instruments that are contained in the DSM 5 which are often used in the community. And if we did this study in a place that has a lot of people who have generalized anxiety disorder, the prevalence is quite high and then the number at the end of the study is 20% this leads to question and this is just reliability by the way this is not validity which is a whole separate discussion the DSM 5. The whole idea that the modern DSM system the reason why you have checklists is to make diagnosis reliable and validity we can’t really get to but reliable we can get to we cant get to reliability. Reliable status is supposed to be the point. 20-28%, schizophrenia was 46%, alcohol use disorder was 40%, but I have to say its realistic to expect numbers in the 90s and maybe in the 80s, you know autism was 69% for example and that’s something because of the eye contact and how young it happens its probably easier to diagnose. ADHD was fairly high, but some of these very commonly diagnosed mental disorders in this bell jar of an experiment where they trying very hard had numbers of like 20%. And of course the American Psychiatric Association defined what a good value was for this and they said unacceptable is 20% or lower implying that anything above 20% was okay and they are always acceptable if not good or excellent. And it was interesting because people may not be aware but to the primary critic to the DSM 5 were boxed in and wrote a letter in certainly you're going to get caps values that were as good as we got in 1980. I mean it was really interesting and Frances comes saying you are trying to redefine accuracy and you look similarity to the rest of medicine.

16:21 Jonathan Singer: Allen Frances, head of the DSM-IV, had his own tests.

16:24 Jeffrey Lacasse: Who has made a public apology for the DSM-IV and DSM-IV-TR came out of retirement to fight against the rhetoric around the DSM 5. So I think its an important issue and comes around to informed consent and some of the things you could argue from a stand point. There’s a way as far as what clinicians would gather something like this, there is a way to talk to a client about a diagnosis and there is pragmatic issues about reimbursement and all that stuff. But the clients know that I have been, imagine someone just got out of a divorce or bad relationship and has some other kind of loss and there diagnosis after three months of chronic symptoms with depression, with a clinician you have to make judgment calls, bereavement stuff and then the DSM there is a note to clinicians. But that client that is being diagnosed know look if you saw someone else on average 20% of the time those two people would agree that you are indeed depressed. Now the people, its really important to say it doesn’t mean we identify people who are distressed or disturbed or lots of symptoms that are in the DSM checklist but for social workers and social work academics like us. The dilemma that, its an unpleasant dilemma to raise is we have pushed all in this that this idea that this evidence based informed practice, that treatment guides, our work, are recognized around these clusters and diagnosis and in this recent tutorial I said hold on a second if a diagnosis isn’t reliable how do you even proceed beyond that. And I think it’s frustrating for people cause I don’t have a good answer to that question at all. But that’s a really important question and very convenient to skip that question I think but I don’t think anyone has a good answer to that question yet.

18:9 Jonathan Singer: That’s such a great point because for years, and as for as long as I went to school in the mid 90s for MSW and for years the mantra has been that treatment follows assessment and diagnosis. And your right if I am saying that’s major depressive disorder and I am not saying you could get a second opinion and they could totally disagree. Like there is no then the person is not providing informed consent to this and further more my treatment plan may very well be wrong because I diagnosed it does not necessarily mean I am right.

18:42 Jeffrey Lacasse: Well luckily a lot of what we do is non-specific. And luckily a lot of common factor stuff would say maybe it doesn’t matter whether you have generalized anxiety disorder quote unquote or its depression with anxious features and with the therapeutic relationship a lot of that stuff will work out the diagnosis. I study psychiatric medication as my primary thing and that’s a little different and I think and there is some non-specific stuff about the way drugs works to obviously. But its called an anti depressant because its used for depression but its also used for anxiety disorder and they are pretty effective and they are not as effective for that as they are for depression or even more so. Do they agree that they are effective at all? As a field, we have to start rethinking this a little bit. It actually opens up avenues of research and new ways of looking at things and also were not psychiatrists I mean we have a 100 year history of working very closely with psychiatrists but were theoretically more holistic and more committed social justice, the macro, the micro, the effects of things like oppression, related to depression that we don’t think is biological and I think when you diagnose using the manual written by psychiatrists. I understand it has to be done in practice. What I like to see is an agency, a state, and an area that experiments with diagnosing without the manual. I teach psychopathology and I would be curious to know your opinion about this. In all the text books it says that diagnosis are essential for good clinical communication so that which mean we can communicate with each other. For example John has major depression, of a severe nature, I do not understand I don’t mean to be viscous here but I don’t understand that is more helpful than me telling you ‘Hey Jonathan, John got divorced, he is chronically sad, suicidal, its going on for twelve weeks, and he is not doing well at all, he needs some help’, that took an extra five seconds to say that. I don’t understand, I literally don’t understand, I get the reimbursement issue, I get the medication issues, but in terms of clinical communication if you and I are working in an agency together, I think the latter description is much more descriptive and I did it at a 8th grade level of education you know but it sounds less medical. There is a lot of so that’s something that I think we all should think about. All the textbooks say that it’s essential for clinical communication and I don’t know that it is.

21:16 Jonathan Singer: what happens is that when I am saying, ‘o yes John has major depressive disorder, historically becomes more problematic’ when I am like, ‘o yea John has borderline personality disorder right?’ I am not talking yes, so there is some real issues with emotion regulation there is issues with self harm, he’s got this, there is some trauma background, all that stuff is really important clinical information. I am like right borderline, and your sitting there like yea I don’t want to work with this guy and I think that is a great example of how a diagnosis is terrible clinical communication.  

21:50 Jeffrey Lacasse: I would agree, and we kind of talked out both sides of our mouth out of necessity and we teach students in depth psycho socials and that is really good clinical communication. But the diagnosis is supposed to be like summary, statement, then borderline issues anxiety that is a fairly sexist diagnosis then rather than saying he was sexually traumatized as a child, acting out behaviors, we guessed it was borderline. What is interesting is that there was a study done where they looked at how many different types of borderline you can build using the checklist in the DSM 5 and you create hundreds of clients some of whom look nothing like each other and we still call them all borderline because that is the disorder. So in that idea that can communicate something, you can build different looking depressive symptoms too.

22:35 Jonathan Singer: It’s really different to by age.

22:38 Jeffrey Lacasse: Absolutely, I think the other thing about the DSM that we might want to think about as far as the degree to which its scientific is it was like a medical textbook and it looks very authoritative and its from the American Psychiatric Association. Which is a lot have respect for that profession and so forth. So what happened is a bunch of people got around a table and decided this is a mental disorder and here are the and there are books written about this. Paula Caplan wrote a book about the, I don’t want to say the invention but the creation of premenstrual dysphonic disorder or PMDD. She resented and discussed because she was offended by the process because it was so subjective but when you get that book in the mail or when you get the online book on Amazon or whatever and you look at it. You forget like a bunch of people just decided this now they may have used research to do that and it depends on which disorder were talking about, how well validated or how reliable it is. But Paula makes the point she wrote an entire book about how humans and how troubling she found the process. Speaking of DSM 5, we end up with new disorders like binge eating disorder, like minor neuro cognitive disorder which some people say is medicalizing being in your 50s and early 60s you know. And in this drug that was proved by the FDA for phemo hypoactive sexual dysfunction which you know its easy to critique that disorder on the basis, its medicalizing what is a very relational issue so if these capa values could be reliable its really high for all these entities. It could be a debate there is just really poor and I don’t, its not like I don’t understand what American Psychiatric Association would say no these are good values. This was just a rigorous test because they are selling their book with science and there are competitors we could switch to ICD the International Classification of Diseases. It’s on the web for free but I think people forget that they are buying this product that they marketed and you have to wonder if there will be a DSM 6. I mean I could remember the furor on the Huffington Post. I mean people in the supermarket are more familiar with the debates around the DSM 5, bereavement issues, you know ADHD being over diagnosed, this kind of stuff. So I don’t know if there will be a DSM 6. Its the most common question I get at the end of my psychopathology class do you think there will be a DSM 6. I mean I have no idea but from a PR stand point it might be better to not have a DSM 6 it really might.

25:7 Jonathan Singer: Yea or I could imagine them doing a DSM like I am not saying were going to completely rehaul again were just going to some updates.

25:18 Jeffrey Lacasse: Yea and just to give a little, this is a little bit in reverse order but the DSM 5 took so long to come out because they were incredibly optimistic in the year 2000 or 2001. When the white paper on DSM 5 comes out and they said look DSM 5 is going to integrate neuroscience and categorical diagnosis. And it was interesting because I was sitting in my PhD program and that time and I studying the limits of what we know about the brain, how complicated the brain is, what we know and about lesions underlying mental disorder. I was puzzled at the time, because I couldn’t imagine in ten years that we would be able to do that, but they were incredibly optimistic and none of that materialized. New science materialized that allowed them to map disorders on to the brain. You do wonder at what point do you say this is not endeavor, this could bare fruit to a clinician, and research studies are different. I mean provide data that be useful to other scientists, but as far as for the clinician, I mean a lot of times students are under the impression at any time, some of these disorders that we could discover the cause. And what is interesting is that happened between DSM-IV and 5 with one specific disorder that pretty rare called Rett's disorder which is sub type, which was classified under autism I believe. They found that a genomic problem that causes this Rett's disorder. The etiology of this disorder is discussed in the chapters right for each disorder; they removed it from the book. They said no DSM 5 is a book of behavioral disorders, mental disorders, that means we don’t know the cause of them. Alzheimer’s is always in their, dementia is always in their as these weird ones kind of in between but my students were flabbergasted. When I will say “wait a second that got taken out of the book cause we figured you what caused it so now its a known mental disease not a confusing mental disorder that takes on all kinds of clinical judgment to sort out” so that’s fascinating example of what the DSM 5 actually is.

27:15.6 Jonathan Singer: That is amazing, I didn’t know that I didn’t know that they took out Rett’s because they figured out what caused it, that’s bizarre.

27:23.7 Jeffrey Lacasse: What’s interesting is that I think that, the fascinating thing about being a clinician or researcher regarding mental disorder is that its very mysterious, its very confusing, it takes great clinical skills, and its a detective story to some degree. I mean you worked with people, you know what I am talking about. Often it gets presented to the public as very simple. “We know what depression is, depression is a is an imbalance in your brain.” That’s just by the way the DSM does not say that but so the DSM should be a book of things that are poorly understood, difficult to assess for, and maybe will always poor reliability due to how hard the studies are to do. And that these people clinical presentation change, people lives change, and the drugs they are taking change, so we could reach a place I think where we say this is going to be kind of a I don’t want to say a disaster but its always going to be a very troubling from a scientific standpoint sort of book. So what’s the purpose of this book: its financial, its for reimbursement, it’s for bureaucratic coding, cool. But you see its held up as a piece of shining science so that’s really difficult to support. And I think Allen Francis coming out of the woodwork – whose as conventional a psychiatric guy as you will find. I mean he was involved with the TMAP project which was a Texas medication algorithm project, which was a very well-critiqued conventional kind of project. Chair of psychiatry at Duke I believe. For him to come out of  came out of retirement to rail against this, I think was an important sort of thing. So other people think these social workers saying “they sure critique the DSM a lot those wacky hippy social workers…” It’s more like if you listen to the psychiatrists closely they beat upon the DSM 5 pretty bad to, but who’s using it mostly? Well we outnumber psychiatrists, its got to be close to 10 to 1 in terms of mental health clinicians in the United States. But I, if you go to the back of the DSM 5 and try to find, not those who participated in the field trials but the scientific advisors that printed the disorders and that sort of thing look for social workers. There are a few but there is not very many. So interesting that we do awful a lot of the work and as far as our representation, our voice, in the acts of creation with the manual not really there and that of course is assuming our voice would be different than their voice but I don’t know if that is true.

29:49 Jonathan Singer: So that is great critiques of the reliability, of the disorder, the internal fighting in psychiatry, the role of social workers in sort of perpetrating diagnosis as this thing we should do because we are the ones who are primarily, I mean if we look just in terms of numbers were doing it, are there other critiques that social workers should be aware of.

30:15 Jeffrey Lacasse: Well yeah, definitely there are and some of them are a little more conceptual in nature. But there important and there pretty social worky so to speak I mean one of them would be that the definition of mental disorder has changed yet again for DSM 5 its pretty inadequate scientifically. First of all its interesting that over the years the definition of something like mental disorder has changed which shows you how fuzzy this is and how it hard it is to pin down. Allen Francis said in an article in Wired that journal Greenburgers and stuff on DSM 5 he said cant define it you just cant define it so your starting with people who are engaged in this saying that you cant define where is that boundary between normality and disorder so that’s a that’s a problem. The other thing would be this is a thought experiment could you talk about mental disorder without assuming these are medical problems you could talk about behavior, you could talk about social, sociological or deviance kind of approach there are a lot of different ways you could look at these problems but its sort of in the book these are medical sometimes they use the word disease, sometimes they use syndrome and sometimes they use the word mental disorder they use those terms sort of interchangeably those are actually very different things if were going to be technical about it. I just use mental disorder refer to something in the DSM but even that concept I just said is a confusing concept DSM-IV had some really interesting limitations noted in the book there was a whole section called the limitations of categorical diagnosis that was removed for DSM 5 so there was something important for clinicians to know its just my opinion but I think its important. The DSM 5 was a much more political document than the DSM-IV to me, because I teach this class, because I am, I might be the only person who sat down and read DSM 5 cover to cover to see what was new that’s a bizarre thing to do I understand that but I did that and as I did that I noticed some changes that I thought were kind of disturbing first of all they deleted that section on the limitations of categorical diagnosis. DSM-IVTR mentioned that the brain changes seen as schizophrenia may be related to anti psychotic medication that’s gone now it just has a statement about I believe it says that it just to refers to the fact that there is brain changes that kind of suggest its due to the schizophrenia so there is a debate in the literature about that but the DSM-IV said it might be the drugs, DSM 5 says it hey the brain shrink over time, heavily medicated population, I don’t think it nailed every single one of them there’s also stuff about you know some effects of meds like akathisia where it looks to me more like a book written by people who diagnosis and primarily medicate and its political and almost promotional about how they present things and DSM-IV certainly had components of things like that and people who knew its literature deeply read it would said there was some politics here, spin here and there, but I think DSM 5 is worse objectively on these issues see this puts the idea that this is supposed to be a valuable resource for clinicians because my students are usually very upset about this by the way I show them on power points this is what the DSM-IV said and here is what the DSM 5 said do you think this is a better cause they removed that information or removed that limitation. And my students are like wow why was that taken out? Again it is also possible no one reads this information besides the billing codes and it doesn’t matter so I want to be realistic about it but I do think that’s an issue.

33:50 Jonathan Singer: So given all of these critiques which I think are really important for social workers to keep in mind and you know what you said earlier about social workers doing psycho social assessments in DSM-IV those really mapped onto the axis 4 the environmental stressors and those sorts of things and social workers have to use the DSM 5 in certain situations and since they do and since axis 4 is gone how should social workers be using this responsibly.

34:24 Jeffrey Lacasse: Yes that’s a great question Jonathan so to answer that, first of all the removal of axis four we should be more offended by that I think we are. Barbra Probst wrote an excellent piece of Research on Social Work Practice which I guest edited about the demise of axis 4. That was often called the social workers axis and as far as we can tell it just kind of disappeared with out the them asking an entire profession about that so your right, when I worked at a psychiatric hospice I spent a lot of time writing things like homelessness on Axis 4. And that might be a way that full five axis DSM-IV diagnosis might have provided some good clinical communication to that you get a good idea of the clients presenting problems pretty fast, you get a GAF score, that kind of thing. So GAS/GAF is gone. Axis 4 is gone. We have Z codes now instead of the previous V codes. And the Z codes list almost every conceivable social worker problem you could think of. So one suggestions, and I teach my student to do this to note the Z codes to give a more complete picture of the client. You know if someone has a diagnosis of major depression that we have been discussing and that’s the only thing on their chart and they have been depressive. You know I think we sort of pathologize it etcetera etcetera. And there is a list of ten Z codes that list just what they are facing in their life. That I think can paint a different picture so I think that can be important. As far as what we do in macro level its a very simple suggestion and I don’t know how you would implement it easily, and probably impossible, but if you could reimburse for z codes I like to see how many people would given the choice: I can diagnose you with this disorder, or I could just list these life problems your having which would you prefer? That’s an interesting though experiment at least. And Paula Kaplan one of her edited books - I think it was rural health clinical - they stopped using the diagnosis as an act of rebellion. And what they said was that nothing happened as far as you know, the impact of it as far as they could tell it didn’t change their practice very much. But those z codes - I think students I hope they get taught in DSM class cause I certainly teach them and you know those have some utility. And in actual practice when people take the time to fill those out.  I hope so.  I don’t know.

36:38 Jonathan Singer: Well Jeff thank you so much for talking about DSM 5 critiques, things that social workers should be thinking about, this new document.

36:46 Jeffrey Lacasse: thank you for having me Jonathan I really appreciate it.


References and Resources

APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2016, January 25). #101 - Critiques of the DSM-5: Interview with Jeffrey Lacasse, Ph.D. [Audio Podcast]. Social Work Podcast. Retrieved from

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