Six Critical Suggestions for DSM-6 with Dr. Awais Aftab

[00:00:00] Welcome back to Psychiatry Bootcamp. This is part two of an Awais Aftab double feature, and this episode's gonna draw heavily on Dr. Aftab's recent essay six Suggestions for DSM six, which is linked in the episode notes. Dr. Aftab, since before our first conversation, I have described you to friends and colleagues as the person who I think should be chair of the DSM six steering committee.

I'm not exaggerating, so I'm especially honored to be having this conversation with you. Couple of like intro questions before we get into your six suggestions. Why does the DSM change. Oh, okay. All right. that, that's a big question. I know, I'm sorry. Yeah. One simple reason simply is that our clinical and scientific understanding changes over, over time.

So, DSM has been around since the early 1950s. If you look at the span of 70 years, the thinking in the field about how to talk [00:01:00] about mental disorders and what disorders to formally recognize and what do we know about them in terms of their epidemiological features and clinical features, et cetera, all of that has evolved considerably and expanded in different ways.

So, some of it is just practical necessity that we have to do a kind of periodic update of clinical thinking and express a statement of the consensus of what, how the clinical community is thinking about these things. So that I think, you know, ha has accounted for the revisions. I think there has been.

Some more. I think skepticism hesitance about revising DSM in the 21st century because at the end of the 20th century when DSM five was being developed, there was this hope that the next classification manual that we have that would be neuroscientifically based and ecologically driven. So a lot of people when it came to DSM five were hoping for a paradigm shift.

And by the time DSM five came out, it was clear that was not gonna [00:02:00] happen. Science had just hadn't advanced enough. So the more neuroscientifically oriented psychiatrists, some of them were off the view, well, you know, wide or wise if, you know, if we don't have the neuroscientific answers yet. So, so I think right now, I think given the state of the field, you know, I think there's a pro camp and an and a against camp about whether it makes sense to revise or not.

But I think for much of the 20th century it was just a, you know, response to evolving understanding. Now that I think about it, just about every textbook needs to be periodically updated. So maybe that was an overly simple question. And also I'll comment that one thing you said, which is that the neuroscience has not evolved to the point that we are able to make this sort of a strictly neuroscientific document and make classifications based on biological processes.

I would argue that we're never going to, and my audiences can feel free to throw tomatoes at me, and I hope that maybe in a hundred years I'll sound really stupid, but I highly doubt it. I think that humans and human behavior and human motivations and the patterns of behavior that we display over time are just more complex than [00:03:00] neuroscience.

And maybe that sounds silly to some, but I'm happy to die on that hill. well, I, agree with you. I think we can get to a point where we'll probably have a, classification that is decently informed by neuroscience, but, I, don't think we'll have a mainstream classification of psychiatry, which is, which primarily revolves around kind of neuroscientific mechanisms.

Second of three intro questions. Just brief overview if you don't mind. How does the DSM change? So, DSM is, is owned by the American Psychiatric Association. So it's a process that's very much driven by the, a PA, and they decide how they wanna do it. And there has not been a uniform process for the five DSMs so far.

all of them have, you know, the exact stages and process involved have been slightly different for all of them in general terms. what happens is that the first, a PA has to authorize that they're, yes, they're going to create a new version of the D sm. And one, once they authorize that, a task [00:04:00] force is com is created.

Which includes, usually includes very, senior and distinguished individuals. So that's why I'm, flattered that you think I should be on it, but I'm too early career for, and, I, you know, that would be a surprising thing that if it happens. But anyway, so there's a, task force of distinguished and, senior clinicians and, you know, other researchers who have some kind of a.

Vision for what that manual is gonna be. That, you know, implicitly APA is also on board with, you know, they, they, feel like yes, you know, like whatever vision this task force has, we, endorse it. And then that task for creates a number of different work groups. And, you know, oftentimes those work groups are organized around, around diagnostic lines.

Where there, let's say there's a work group or mood disorders and one for, you know, anxiety disorders, you know, the exact will change from. So work groups will, conduct extensive literature reviews and review scientific evidence and clinical evidence. and they'll make proposals for what needs to change or [00:05:00] what kind of, you know, new categories need to be considered.

And then those proposals are hammered out and there's a lot of, you know, negotiation and discussion. In the DSM five, they also added other layers of scrutiny where proposals from work group had also had to be reviewed by, a scientific review council. And, they also had a council that looked at issues of clinical implementation and clinical utility.

And so they also you know, had to give them their, you know, okay vote or, you know, give, offer their assessment. And then it comes to kind of a PA at large and, you know, and, the a PS decide whether to approve or reject those changes that, that have been proposed by the task force.

Once the work groups, have finalized their proposals and they've been endorsed, you know, by them, they, are open for public comment. So, so a PA usually posts them, and there's a time period in which anyone, any concerned person in the public can comment on, those changes. I think that speaks [00:06:00] to what an important document the DSM has become, not just in the practice of clinical psychiatry, but for a lot of different things, forensic issues, insurance, billing, et cetera.

Not to mention self understanding. Diving into your six suggestions for DSM six, I wanna start by picking on one of your assertions, so I'm gonna quote you to yourself. I'm sorry to do this. You're right. Obviously, for a lot of people, including many philosophers and psychiatrists calling something, a mental dysfunction is a much stronger claim that says something about failure of a natural design or neurophysiological, alterations, et cetera.

For them, it's not just, oh, you're suffering in a way that is socio culturally atypical, and we have clinical interventions that can potentially help you. So you're saying that for the way we use the word disorder, it carries with these implications of specific neuropsychiatric pathways that are aberrant rather than the way that we might optimally understand the word disorder, which is [00:07:00] that you are suffering in a way that is socially, culturally atypical and we have clinical interventions that could potentially help you.

So my question really, do you really think there are people with professional clinical training who interpret the word disorder to imply that there are necessarily neurophysiological alterations present? The issue comes down to, I think, people's understanding of how the disorder concept should be appropriately understood.

The folks who understand disorder concept in these more strict terms, thinking in terms of either failure of evolutionary design or thinking of it as being atypical in a biostatistical sense from, species level functioning, or, you know, thinking in terms of brain circuit dysfunction, et cetera, they recognize that yes, you know, like DSM currently u using these categories in a, symptom-based manner that, you know, the, explicit criteria do not refer to either failure of natural design or, you know, neurobiologic, abnormally, et cetera.

But the thing is that, you know, they think that is the [00:08:00] right way to understand the concept of the disorder. So they think that either the DSM is simply mistaken in, in how it is using that term, or they think that there's actually a hypothesis. Hiding behind it that people behind the DSM are actually hypothesizing that yes, there are these neurobiological alterations that we'll find.

We haven't found them yet, but you know, they think that the hypothesis is there. And you know, maybe it's a false hypothesis or maybe it's a, maybe it's a true hypothesis, but that's a kinda, you know, guiding idea behind it. A lot of, I think, you know, there, it is, there are many philosophers who take that kind of view.

There are many psychiatrists who take that view too. And, I think this kind of thinking about disorder is particularly appealing and attractive to people who work in evolutionary psychiatry, because from an evolutionary perspective, there's a clear distinction between symptoms that are caused by intact mechanisms that are doing what they were naturally selected to do.

Versus [00:09:00] mechanisms that are experiencing some kind of breakdown of the function that they were designed to do. So, you know, think of in, you know, in, in terms of anxiety is an evolved function. We evolve to experience anxiety because it's a signal of threat and danger. So we are predisposed, evolutionary speaking, to have a certain degree of apprehension and generalized worry.

We are pre predisposed to have, you know, certain experiences like panic attacks, you know, because, 'cause they serve an evolutionary function. And people who were not anxious in this kind of manner, they did not survive in the course of evolution 'cause they did not take the right kind of precautions that that they needed.

So for a person experiencing anxiety. From an evolutionary standpoint, some of them are basically experiencing exaggerated version of an evolutionary design response. And some of them are experiencing a threat system that is malfunctioning in some way that has weirded off the course of what it was evolutionary designed to do.

You know, you can divide the [00:10:00] group into, those kind of people. That similar thing with low mood, is also an evolved kinda mechanism, similar to like a cough and fever and, pain. And so some people are experiencing low mood because that's an appropriate response to their situation versus for other people's you know, they're, in low, mood is abnormal in an evolutionary kind of kind of sense.

So you can see how, you know, the evolutionary psychiatry folks would be attractive to, you know, thinking about that. But that is not the, way in which DSM uses that term. And if you think of the general public and you think of, well, how does, you know, how do people think of the word disorder?

They tend to think of it in those strong. Terms of abnormality that something has gone wrong in some kind of neuroscientific mechanism sense that something in the brain is not gonna doing what it is supposed to do. And I think a lot of people, even a lot of psychiatrists don't realize that the DSM definition or DSM way of thinking about disorder is [00:11:00] basically in terms of social culturally atypical rather than some other kind of reference.

I'm interested by that because my understanding was that DSM defined a disorder mostly by dysfunction. It does. So there, there are two elements to the definition of a mental disorder. The first element is dysfunction, which kind of refers to the idea that something has gone wrong in some sense. So you need one, a dysfunction in biological, psychological, or developmental processes associated with mental functioning.

The second component is. Distress and impairment that either the person experiencing, you know, serious, significant depress by or their day-to-day life is very affected. Their day-to-day functioning is affected. The challenge here is that I think when a lot of people think about dysfunction, they're thinking of functional impairment.

They're thinking of, oh, kind of DSM is talking about impairment disability. It's talking about the negative impact on life. But that is not what the [00:12:00] term dysfunction means in the context of the me mental disorder definition. And that's also not how philosophers use that term. if you look at kind of philosophical work in, in, in kind of definition of, you know, disorder, dysfunction is not understood as being functional.

Impairment dysfunction is understood in terms of either mechanism failure understood in terms of some kind of abnormality. So think of it this way, think of the criteria for generalized anxiety. So you know, you have excessive worry that is persisting and that, you know, it has a certain number of symptoms, three out of six symptoms for six months, and.

That kinda excessive worry causes, you know, or is accompanied by significant distress or functional impairment. So there are two elements. One is the excessive and persistent anxiety part, and the second is the distress and impairment part. And so when DSN talks about dysfunction. It is the excessive and persistent anxiety that is the dysfunction.

And how do we know that anxiety is excessive and [00:13:00] persistent? It's just our common sensical, intuitive folk psychological standard. You know, the person feels it's excessive, the clinician agrees it's excessive with reference something. So when DSM defines disorder as being a dysfunction, that is also distressing and, impairing the intended meaning of dysfunction is something along the lines of an abnormality of some sort.

It does not mean functional impairment. And, I think this is the point which I think confuses a lot of people because they think dysfunction and they immediately think, oh, it's negative effect on day-to-day living. But, that's not the, that, that's not the intended meaning, that's the more full psychological understanding.

Yes. I think, I think folks psychological understanding is kind of mixed. I think a lot of clinicians focus on distress and impairment as the kind of driving consideration. They, you know, I think they, they recognize problems as being problems based on whether the person is distressed and, impaired.

But historically speaking, that is an [00:14:00] unusual way to talk about disorder. I think when, a lot of people think of disorder, a lot of, I think, lay people, they're, thinking in terms of abnormality that. They're not just thinking, you know, so if someone says, you know, Hey, I have a, you know, I have an anxiety disorder.

It's not just, you know, Hey, I'm, you know, I'm anxious and I'm, it's negatively affecting my life. But rather they think that their brain is different in some manner that causes them this kind of anxiety. You know, it's, the kind of know, that's why, you know, the chemical imbalance idea was, you know, so appealing and intuitive to a lot.

So not just that, oh, it's not just the fact that. You are depressed and your low mood is negatively affecting your life, but rather, hey, there's something different. There's something abnormal going on in this situation, right? So, so how to talk about that idea of abnormality is the tricky part, you know, and, the DSM has just kind of chosen to talk about it in this, you know, commonsensical folk psychological way.

So the more scientifically inclined or naturalistically [00:15:00] inclined people think that maybe that's okay as a starting point. But really I think we have better ways of talking about abnormality. And again, we can talk about either, you know, breakdown of evolutionary mechanism, we can talk about bios, statistical deviation from species, typical functioning.

We can talk about quantitative deviations in brain circuit change, et cetera, et cetera. So they say, you know, hey, if we wanna talk about abnormalities, then let's do it in a rigorous manner, rather than just using this kind of, you know, folk psychologically commonsensical language. Got it. So suggestion number one, clarify the DSM concept of quote, mental disorder follow up.

Mechanistically speaking, how, what do you want the d sm to do? Just give a definition in the intro to the DSM. Include it as a criterion to every diagnosis, et cetera. I, think the main thing would just be being very clear about what that means in the introduction. Now, DSM to its credit, it does offer. A [00:16:00] definition of mental disorder, and it can defines it as a syndrome that is a result of dysfunction in biological, psychological, developmental processes and is usually associated with, you know, distress and impairment as not entirely due to conflict between individual society.

The problem is that it doesn't define the term dysfunction further, and that's where the meat of the philosophical in scientific difference come in. That's where a lot of philosophical and scientific debate is. So, so someone just reading the DSM would not know what does DSM mean by that? Now, if you look at the criteria.

And you, can get a good sense of it. You realize that. Okay. you know, what dysfunction means in the DSM context is this kind of just, you know, this general sense that anxiety is excessive or something is out of proportion or something. It's persisting beyond what we would expect.

Right? So, and, this is also kind of like in some of the authors and people who have been behind the DSM, so for example, Kenneth Kenter, he confirmed, he, when I interviewed him as part of my [00:17:00] conversations in critical psychiatry series, he confirmed that the idea of dysfunction in DSM is commonsensical in the same way as we referring.

So insiders know. A lot of people don't know. And, and what happens is that I think when anytime a new diagnosis is, you know, added to the manual, it generates this kind of controversy. I guess the most recent example would be pro prolonged grief disorder. When prolonged grief disorder was added in, in, in TSM five a couple of years ago.

And so people are like, oh, so prolonging so, you know, psychiatry has now declared grief to be a disease or kind of like a medical problem. So the backlash is not around the fact that yes, there are people who have persistent grief and that negatively affects their life. I mean, I, think, I don't think anyone would deny that.

No one would deny that. Yes, there are people who are, who suffer for prolonged periods and that negative affects them. But rather, I think people who challenge the inclusion of that diagnosis, they think that there's a stronger hypothesis being made. [00:18:00] Something stronger is being said about grief. And they don't like that hypothesis.

They don't like that we are talking about grief in those terms. And so. I don't think the people, the, you know, the general public appreciates what the DSM meaning of dysfunction is, the very least DSM can do. Is that at least make it very clear as to what they're talking about. I reluctantly want to stay with this first suggestion for one more question because I think it's so important, and I think you probably made your first suggestion for a reason.

What are the consequences for the field if we don't get this straightened out? I think the consequences is just gonna, you know, continued muddled discussion around medicalization and then psychiatry would kind of re remain trapped in these futile debates of, you know, whether we are medicalizing suffering unnecessarily and whether we are, you know, conceptualizing psychological and men you mental health problems as diseases or as neurobiological abnormality.

So I think it would continue to generate [00:19:00] this tension where a lot of people would continue to think that, you know, psychiatry makes these, neurobiological, reductionistic and assumptions about mental suffering. And then they would react and against those assumptions, you know, and so I, I think a lot of this debate is unnecessary and I think it could be resolved if we were simply clear about the concepts we are using.

Yeah. And I think. If we clarify this concept and we clarify that when we say someone has a mental disorder as defined by the A DSM, they don't necessarily have a discreet pathological process that's associated with that disorder. We expand the role that psychiatrists can play in helping people to make meaning of their lives.

We maybe expand the role of psychotherapy because we're not just assuming that everything needs to be targeted in a very neurobiological way. I think. I'll just speak from personal experience. You know, when I've made major changes in my life that have led to significant changes in, let's call it quality of [00:20:00] life, it's usually driven by psychiatric symptoms and in some cases, maybe even a full blown major depressive episode.

And so I think by clarifying this, it allows people to understand that just because they can find themselves in the DSM, it doesn't necessarily mean that the only intervention is biomedical in nature. And that things like psychotherapy can be really important for helping them make sense of things. It's not that they have this monkey on their back that they need to get off of their back by taking some pills.

Yes. And I think the other thing is that I think, you know, the, dysfunction idea, I think in ways, a sense of brokenness. I think it, it can, ways that, you know something. In the mind or in the brain is not doing what it is supposed to. It is broken in some way. It is malfunctioning in some way.

And again, there's, a grain of truth to that. But we have also seen that many psychiatric symptoms do have some kind of adaptive significance to have some kind of a signaling role to play. Their, content can be analyzed. And so I think it's, also important to, to clarify and move away from these [00:21:00] assumptions of brokenness that dysfunction in inadvertently conveys.

Moving on to suggestion number two. Suggestion number two is indicate the degree of empirical validation for all diagnoses. So intro to this, Dr. Aftab, how is the DSM like a house of mirrors? I, was thinking, trying to think of analogies to use in, this regard. And again, I settled on house of I like mirror.

I like, that's why I'm asking. I love it. But it's all in, in a, it's in a worse way. I mean, think usually what happens in a house of mirror is that I think it, it distorts and exaggerates into, you know, things, into proportions that they're not, you know, usually exaggerated once. So I think what is happening in the case of DSM is that it's like an inverse house of bear where it's equalizing everything.

It's you know, taking someone big and someone small and it's just making them the same size. and the reason I think is that is just. You know, it presents all diagnosis on an equal footing. You know, you open the manual and it's just like, you know, hey, here are these formal diagnosis. It doesn't give, say anything further about whether there's a hierarchy of diagnosis or [00:22:00] some diagnosis.

Are, you know, more empirically supportive than others? You just have these diagnosis and so intermittent explosive disorder is all the same footing as schizophrenia, even though they're, you know, continents apart in terms of how much evidence them, what kind.

Silence around the empirical status of categories also hurts the profession because it gives a dis distorted idea to, you know, many clinicians as to public about, you know, the, standing of these diagnosis and whether, you know, some of them are more kind of well, well supported than others. It also obscures the degree of uncertainty and controversy around certain diagnosis.

You know, and whether some diagnosis are simply a loose way of referring to some, you know, isolated symptom or whether they're, part of a, you know, bigger problem. So I feel that's an issue as well. And I think it also becomes permanent in the context of comorbidity too, when people have a number of different [00:23:00] diagnosis and, you know, when patients don't necessarily know which diagnosis is more paramount or is more well supported than others.

For, I think for reasons of, I think scientific integrity and also kind of clinical, you know, integrity and, facilitating more transparent discussions around this. I think one easy way of simply seeing, finding, some way of communicating, you know, the degree of empirical support behind different diagnostic kind of frameworks, diagnostic constructs, and, that way the constructs that are relatively weaker.

We can all be open about their weak status as a field, and maybe they're not scientifically validated, but they have utility in other ways. They're needed due to some clinical reality where we need a descriptor of this, et cetera. So you're kind of, you're kind of suggesting that the DSM may be designed a system for indicating to what degree this diagnosis is empirically validated.

Maybe some sort of a composite score system of letters, maybe an index, et cetera. Yeah, I mean, I think I, I didn't intentionally commit myself to any [00:24:00] particular way in which we could, you know, do that. Yeah. And, this actually kinda, I think, you know, this relates to a bigger issue, the issue of kind of, you know, validator convergence.

So the way we talk about validity of different diagnosis is in terms of these different lines of evidence that, that were originally proposed by psychiatrist Robbins and Ze in 1960, 1970s. And then they were kind of clarified by, the psychiatrist Kenneth Kendler. And Kenneth Kendler was also the one who used the terms validator.

So these refer to things like family history and genetic associations and pattern of clinical symptoms, you know, associations with other disorders, so patterns of comorbidity, neuropsychological associations, treatment response, longitudinal course of illness. So we kind of, we, have these different lines of evidence to think about.

You know, do different conditions differentiate on them? And by and large, I think, you know, most psychiatric disorders show differences on, on, on them. There's a lot of overlap, but on average they'll show differences. [00:25:00] So, for example, the prognosis of schizophrenia and bipolar disorder, both of them are very broad and overlapping, but on average, bipolar disorder has a favorable course of illness compared to schizophrenia.

On average, we can think of, you know, if you look at cognitive functioning on average, schizophrenia patients have worse cognitive functioning compared to, you know, major depression patients, et cetera. Now, because of that overlap. It has limited predictive value. You can't use someone's IQ or you can't use course of illness to infer back what their diagnosis is because it's not, you know, reliable enough in terms of making that prediction.

But because there are average differences associated with that, it points out that, alright, you know, there, there's something going on. These diagnosis are kind of pinging or indexing slightly different configurations of problems. The, challenge is that these different lines of inquiry, things like family history and brain associations and coil, they don't all align very well.

They don't all align, you [00:26:00] know, neatly or even sufficiently robustly. So they all get a little bit misaligned and they present in kind of, you know, they, point in different directions and there is no optimal way. To resolve that misalignment. You know, there would be, if there was a central etiology, you know, if there was a central cause like Huntington's disease or measles or you know, something like that, then it, everything would all kind of fit together.

But in the absence of a central cause. It depends on you, which validators you wanna prioritize. You know, do you wanna prioritize genetics? Do you wanna prioritize course of illness? Do you wanna prioritize treatment, response, et cetera. And there's actually a really wonderful paper by Ken Kendler and Miriam Solomon talking about this problem of convergence validators.

And they actually show that there is no adequate resolution that, you know, from a philosophical I scientific standpoint, there is no optimal resolution to this issue of how to compete in know validators that don't align very well. So, so we're stuck with that. So, you know, so I think any kind of composite that we [00:27:00] create would run into that issue of convergence into that issue of how do we wait different lines of evidence that are not, you know, on paper equal, maybe an index can do a good enough job, but even if we don't have an index or a composite store, I think finding some other way of weighing the strength of evidence, you know, I think I, think would be useful and, would be, you know, I, would strongly encourage the field to consider that.

I can't wait to listen through this episode again so that I can catch everything you just said. But I did read the Kendler and Solomon paper, which shed a lot of light for me, and I have to have at least one of them on the podcast at some point. And I think I would say that's why I'm not confident that we are going to come to a unifying scientific explanation for mental disorder and why we are never going to get to what we used to imagine.

The DSM might sometimes sometime be. We are gonna take a quick break. When we come back, we'll do suggestions three through six.

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Welcome back Dr. Aftab. Your third suggestion, I think, is sneakily also the most subversive. You think that the threshold for each diagnosis, so for example, five out of nine SIG ME caps, four out of seven, dig fast for a manic episode. You think that this threshold should come with an explanation as to why this number.

Now my longitudinal understanding is that this threshold is in reality quite arbitrary. I know there's a great story. Maybe it's apocryphal. I don't think it is about the creation of DSM three. And the chair, Robert Spitzer says that he would get experts in a room and have them argue about what the threshold should be, what the number of symptoms should be, and the duration required for each illness.

And he would check in with them around noon and they would be angry and they would be arguing, and then he would feed them sandwiches. And he basically said that the conversation never went past 1:30 PM because. As we all know, people [00:31:00] tend to agree when they are not so hungry and crabby, which I just, I love that story because I think it speaks to the arbitrary nature of the cutoffs that we sometimes refer to as a part of an infallible bible, which is just like astronomically silly to me and a major driving force for why I do everything that I do.

So. Don't you think that the a PA would just have to write vibes or perhaps expert consensus for all the thresholds? What am I missing? It may be the case that we may, you know, we have to write vibes for a lot of diagnosis, but I think in some cases we do have more data or we have kind of some lines of evidence pointing towards a certain threshold.

The challenge is that right now. We just have no formal recognition of why the threshold is what it, is, which means that even in situations where we do have some legitimate line of reasoning behind it, that remains unknown and, no one quite knows what that threshold is supposed to do. So, for example, I think, you know, when prolonged grief disorder was included in, the DSM, [00:32:00] its threshold was supported by a number of statistical analysis about the sensitivity and specificity of the diagnostic criteria.

And so they, conducted, analysis of you know, how many criteria items do you, do, you need to get a sufficiently good balance of sensitivity and ity. And so, so the threshold that they. That they selected for prolonged grief was in some ways, you know, informed by the scientific and clinical research that was available to them.

Now, that has not been the case for all diagnosis, especially in the ones that have been historically present in, in the manual. And their original inclusion might have been based on much more clinical impression. You know, you were mentioning about some of the stories, you know, with Robert Spitzer.

One relevant to the diagnostic T or depression is when Daniel Carlette interviewed Robert Spitzer, for, his book. And he asked him about, you know, why five out of nine criteria for, depression. and Spitzer said that it just seemed about [00:33:00] right, that four seemed too low and six seemed too high, and five just seemed about right.

Now, Spitzer was also being a little bit flippant. they had some data as well that they could analyze, but there was still a lot of judgment call involved. And, what the threshold is, going to be, My overall frustration, my bigger frustration with this issue is that I think because we, when we don't specify what the threshold is doing, we, also fail to optimize it in, a manner that is needed.

Take an analogy with hypertension. Blood pressure is also a dimension, it's a, you know, it's a spectrum. Everyone has a systolic blood pressure, anti stoic blood pressure. There are no natural discontinuities in blood pressure distribution. If you plot the blood pressure distribution of the population, you'll get a continuous curve.

and to some degree, the values that we pick, you know, on the blood pressure continuum are semi arbitrary. If you pick historically, for example, one 40 by [00:34:00] 90, it has changed now in some situations. But let's go with 41, 40 by 90. You know, one 40 is not magically different than 1 39 or 1 41, but as a rough guided kind of works, but.

The one 40 was selected for very good reasons. You know, and this has to do with the practical nature of the categories. What we are trying to do with essential hypertension is that we're not trying to identify people with quote unquote, abnormal wanes and artery or abnormal venous circulation. Rather, we are trying to identify a blood pressure, kind of blood pressure values that predispose people to higher risk of cardiovascular disease in the future.

So, so we wanna reduce the risk of stroke, we wanna reduce the risk of heart attack. So we have a clear goal, you know, we wanna reduce future incidents of cardiovascular disease. We can then look at the data. Optimize the threshold based on that data. Right? So we know clearly what we are doing. We can also [00:35:00] kind of optimize the threshold based on at what point do the benefits of the treatment outweigh their harm.

So, so if you look at the hypertension guidelines, they refer these judgments, they refer that, we looked at this and we, we decided, you know, we, you know, people felt that, you know, at this threshold, you know, the benefits of treating with a hypertensive medication or through some other intervention can outweigh the risks that are there.

And kind of, you know, and if you keep the blood pressure below this future risk is lower, so you know what you're doing. Do we know what five out of nine depression is doing? I don't know. I don't think a lot of other people know. Right? And so if we don't know. We can't optimize it. And, once we realize we don't have to accept some random guess as a threshold, we can actually optimize these thresholds to achieve the things we wanna do, then a whole new space of clinical and scientific inquiry opens up.

You know, you can ask what kind of diagnostic threshold makes sense, where, you know, most [00:36:00] people would experience, let's say, benefit from an depression medication. you know, what's the threshold at which the response to, you know, significantly separates from placebo or where benefits begin to outweigh potential risk of the treatment.

What is the threshold at which a person is more responsive to psychotherapy? What is the threshold where we seem to be able to differentiate people with a certain psychological profile or certain pattern of comorbidity from others? Right? So we can ask all of these questions, but we can't ask them if we first don't even know what the threshold is about.

In some other cases, the threshold can be somewhat kind of pseudo specific. So take generalized anxiety disorder, for example. So you know right now the time threshold for generalized anxiety disorder is six months. That kinda anxiety has to persist for six months or more to qualify as generalized anxiety.

And the reason behind that is that the authors of the DSM wanted generalized anxiety to refer to. Persistent cases of anxiety that are [00:37:00] not situation limited or transient or self resolving. So they did not want GAD to capture cases in which people are anxious because they're going through a divorce or they're going, they're just going through a stressful situation.

And they felt that if a person has been anxious for six months persistently, the odds are that they have something more chronic going on. And this is not just situational. So in that case, instead of coming up with this pseudo precise number of six months, you can just say anxiety that has been persisting for several months and it's gonna, you know, persist beyond, you know, situational stressors, things like that.

And ICD, in fact, ICD used more vague language for G-A-D-I-C-D said, kinda anxiety that persists beyond a couple of months rather than specifying a six month period. So you can, ask all these sorts of interesting questions and you can also. Instead of making just a blunt decision that we're gonna make it six months for everyone.

You can also empower clinicians to make that judgment. you can [00:38:00] have clinicians decide, you know, when an anxiety is explained by situational circumstances and when is it explained by something more persistent, like, you know, elevated neuroticism or other kind of thing. I have so many follow up on that.

I think one thing it's making me think of is how artificial intelligence is gonna be involved in this process. Yeah. Because we're talking about like huge data sets and trends and really interesting specific questions that you'll be able to get from it. And then also, if we are going to empower clinicians to use the DSM more as a guidebook and a set of tools to choose from rather than a Bible and a prescriptive guide.

Are we also then making the DSM more subjective? 'cause we're relying on all these different clinicians, subjective judgments? I think the list goes on. Any final thoughts on number three? Yeah, I, think one thing I'll say is that I think clinicians already are kind of, you know, they're, not really taking DSM thresholds very strictly because, 'cause they, don't see the [00:39:00] value.

they don't see why we have to respect those exact thresholds. So what is happening in practice is that clinicians are using distress and impairment as so it, it doesn't matter how many symptoms of anxiety you have or how long you've had them, if you are significantly distressed and impaired by them, that's good enough for, a psychiatric clinician.

Right. Same thing with depression. So, so in, in practice, distress and impairment have become the defacto, you know, threshold kind of markers and, people that generally disregard the, whatever exact symptom count or the time threshold that, that DSM recommends. It's so hard to try to put words in your mouth, but are you sort of saying you want the DSM to catch up then to what's actually happening in clinical practice?

In one way, yes. I think the reason clinicians are disregarding DSM thresholds is because they don't know what the, threshold is doing or what is optimizing. And I think, and if DSM made it clear, you know, they can actually ma make a case for why those thresholds should be, you know, taken more seriously than, they [00:40:00] currently are.

I think it opens up, also opens up a plurality of threshold. You know, we don't have to have one single threshold. We can have different thresholds depending on the context or, you know, depending on what we are trying to do. Wow. Yeah, absolutely. and it speaks to how the DSM is used for research, for clinical practice, for insurance billing, for deciding if someone is not guilty by a reason of insanity.

And these are all very different societal roles and maybe would require, different criteria for each diagnosis. Okay. Suggestion four is acknowledge gaps in the descriptive schema. So I love this one. It's amazing to me how many patients I see in clinical practice that clearly meet criteria for however we want to define a mental disorder.

You know, they're experiencing that dysfunction. Maybe we could even say that whatever is happening in their life, or I would even go so far as to say in their neurochemistry is clearly and obviously atypical, but they don't actually clearly fall into any specific [00:41:00] DSM category. So I end up with a lot of unspecified diagnoses.

Practically speaking, what is the problem with an unspecified diagnosis? I think the biggest problem is that it basically creates a lower class of diagnosis. It, kind of gives the impression that, hey, there, there's this group of real legitimate, you know, true diagnosis that deserve to be taken seriously and that, you know, we do research on and that everyone talks about.

And then there's this second class of citizens that just kind of, you know, they're just wishy-washy and maybe waste baskets and there's no research funding dedicated to them. They're, just like, you know, there's, no formal discussion of them. So. I think there's this kind of in, there's this intellectual incentive to disregard them.

There's also not a quite a sense of, well, from a patient perspective to them, you know, if someone says you have bipolar disorder, they kind of know what to make sense of it. But if someone tells them you have unspecified mood disorder, what does that mean? How do you kind of [00:42:00] build up some kind of a coparent narrative around having an unspecified mood disorder diagnosis?

Right. Or unspecified anxiety. So I think it creates all these kind of problems. And it also, I think, means that if large portions of our patients are meeting unspecified criteria, it means that those patients are not represented in kind of research being conducted. You know, they're not, represented in search for treatments.

You know, we are basically operating in ignorance about. Optimal treatments, you know, what kind of adjunctive medications would work? If a medication works for a specified category, would it work for unspecified? You know, oftentimes we, extrapolate, but it's all inference. You know, we, not know. So I think it creates this situation where no one is incentivized to study it very well.

No one is incentivized to take it very seriously. The incent, the people are discouraged from diagnosing it, and it creates pressure to diagnose those [00:43:00] people as having a specified diagnosis. See it all the time. Yeah. So a lot of people, for example, who get diagnosed with major depression in primary care settings don't actually meet the DSM criteria for major depression.

But, you know, from a primary care perspective, it doesn't make sense to give someone unspecified, you know, depression if the person is suffering kind of enough. So the specified categories get bloated in a way that kinda becomes problematic and invite skepticism. So think, for example of what's happening with A DHD.

We don't have a general category for diagnosing focused difficulties and inattention difficulties. That is not linked to neuro neurodevelopmental onset, you know? So in order to give someone, in order to give someone a DH ADHD diagnosis, we have to say, you know, you've had this problem your whole life. It started when you were a child, and you know it, it comes with all of these neurodevelopmental ations.

I can't just, you know, you know, there is no [00:44:00] a general, you know, cognitive or, you know, disorder, a general inattention disorder, you know, category that I can use. So, but the reality is that we have a lot of adult patients who have genuine difficulties with focused concentration, motivation, you know, reward, et cetera.

And they're struggling to function and they need some kind of help. They often respond very favorably to clinical treatment, but in order to get them treatment, we have to pretend collectively that they all have a DHD, right? So that's another, I think a example of how having gaps in form schema.

Puts kind of, you know, unnecessary pressure on existing categories. And it, those categories then become bloated, and then people can become cynical and skeptical about them. You know, they can start saying, oh, everyone is getting diagnosed with a DH, adhd. So maybe it's a, maybe it's not a legitimate diagnosis, maybe it's not a solid, versus if we had a more, you know, accurate, let's say [00:45:00] dimensional way of categorizing people with their attentional difficulties, you know, then we don't have to pretend that everyone has a neurodevelopmental onset and we, can still treat the people we wanna treat.

Sorry, what'd you say? I got a notification from TikTok. No, I just, I mean, it's absolutely right. It's common sense that we're living in a world where we're, it's ding, ding, ding, vibrate. Like the world is exploding somewhere else, but right now I need to do, it's, what a sophisticated way to understand something that all of us, I'm gonna say psychiatric clinicians and everyone else in the world is experiencing all the time.

Thank you for that refreshing take. I totally agree. So what should the DSM do about this? Well, I think the first thing, I think this relates to appreciation of dimensionality and, the cutoff point that we were talking. What is the value of saying that? Hey, you know, people above this threshold have some kind of specified [00:46:00] diagnosis, and people below this threshold don't deserve a proper name.

You know, if things genuinely exist on a dimension and on a spectrum, and there are people below that threshold who are genuinely suffering, then why? Why do we wanna play this game? Why do we wanna, you know, insist on some kind of, you know, we weird threshold? Why not just say that, you know, hey, there's this spectrum of these issues.

And anyone who experiences, you know, a distress and impairment along that threshold is, you know, deserving of treatment or birth while you know, of recognition, right? So I think the first is this. I think this lack of alignment between, you know. what do we want the di threshold to do?

And what do we want? What kind of recognition do we want in the clinic? So I think it, it rein invites that, that kind of like question. The second thing is that I think it, it, you know, I think we should be more clear about recognizing that there are gaps in our formal schemas and [00:47:00] we need to have a discussion collectively about what to do about those gaps.

You know, when I, was in, in psychiatric training at that time, I was very much influenced by the work of Alan Francis and some of the other people who were talking about overdiagnosis. And I, still, I think, you know, I think I, I'm still influenced by that and I think they, they made a lot of good point.

But over time, you know, over the course of 10, 12 years, I have actually come to take the view that DSM and ICD are actually conservative manuals that, you know, they haven't broadened diagnosis enough, you know, and, the reason I say that. It's because, you know, we have a lot of patients in the clinic that just don't have a specified diagnosis.

So clearly the domain of treatable and recognizable clinical problems is a much bigger domain than the domain of specified problems. Right. And, again, kinda retreading that point that just, that does lead to overdiagnosis. [00:48:00] Off the specified categories because we're just not paying attention to the rest of the, rest of the people.

So, so we need a kind of, you know, one of the basic things we should expect from descriptive classification is that it should not have holes in it. Then, you know, a descriptive schema should be able to describe any potential kind of clinical problem that, that comes right. So, you know, if we wanna have a descriptive classification, then why are we doing a half-ass job at it?

Why do we have a descriptive system that cannot even describe large chunks of people we see in the clinic? Why not adopt a more dimensional approach where we actually can describe exactly what we're seeing and not just lump people into categories that don't mean anything? Yes. Yeah. And I think, and I think this is a bigger problem in the context of psychotherapy, you know, 'cause I think, you know, psychotherapists see all kinds of mental health problems and, many of them are not gonna fall into specified categories, but they're, [00:49:00] still forced because of the way healthcare system is designed to use one of those kind of specified categories.

You know, so they have to call it something, you know, maybe adjustment disorder or, you know, mood disorder or whatever. You know, they have to give it some kind of a, you know, name. And again, it, generates its own, you know, weird and odd incentives in, in, in, the context that, you know, That the full range of mental health problems has to be filtered through this small set of categories that cannot do justice to it. Yeah. I think maybe this is where Alan Francis' pragmatism kind of shines through in this. You're not saying we should be diagnosing more people that could be considered normal and necessarily putting them on medications.

You're suggesting that we overhaul the whole system and have a more sophisticated understanding of the dimensional landscape so that people who maybe are more toward that normal range might get interventions that are more appropriate for them, like psychotherapy, and so that when we are deciding that we need to place a label on a patient, we actually have labels that work instead of, again, using what you, I think [00:50:00] described as a wastebasket diagnosis.

Yes. Yeah. Okay.

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so this next one is loaded, so we're gonna take a deep breath together. We're gonna talk about the hierarchical taxonomy of psychopathology. what is the high top is kind of the acronym for it. What is high top and why do you think that it should be included in DSMs Appendix? Yeah, so, so high top is an, alternative classification of mental health problems, or, you know, psychopathology as [00:52:00] the term goes.

It's developed by a consortium of, of quantitatively minded psychologists and psychiatrist who are interested in symptomatic classification symptom-based classifications, but they wanna go about it in an empirically rigorous manner. So, kind of what has happened in DSM is that DSM relies on clinical patterns that have been recognized by clinicians over the course of history of the field.

So, you know, clinicians recognize that, hey, there's this group of people that have psychotic symptoms deteriorating course, and we'll call it schizophrenia. And, you know, there's this group of people with mania and depression and there's this group of people who seem kind of generally anxious, you know, we'll call them generalizing anxiety.

And there's this group of people who have, you know, depression and that has worked. That does a decent enough job, you know, it, it works well enough that you can actually, you know, match people with the, you know, roughly, you know, proper treatments. You know, they, showed average differences in validators, but if you look at.

[00:53:00] The symptom distributions from a statistical perspective, the separations between those conditions disappear. So from a, from when you look at actual real world patients and, you see kind of, you know, like what symptom patterns, you know, major depression does not emerge as a distinct statistical cluster from generalized anxiety.

Rather it's a mishmash of symptom that does not distinguish. Right. Similarly, kind of schizophrenia does not emerge as a distinct condition, you know, among psychotic disorders. But rather what we see is that we see a psychosis spectrum, you know, and that has, and different people along those spectrum have different varying levels of cognitive functioning, vary levels of, you know, negative symptoms, you know, tho those kind of things.

So people who have been interested in what, is called structural evidence or quantitative evidence or statistical evidence have been unhappy with the, categorical schema of the DSM. Initially there was hope that [00:54:00] maybe DSM five would take this seriously, but when it, when DSM five came out and you know, those scientists realized that this was not happening, they were like, you know, enough is enough.

We're taking matters into our own hands. So, so a grassroots consortium was created and the first high top. Classification was formally presented in, in, in 2017. And so it, it relies on statistical patterns of comorbidity and it generates, kind of latent factors that explain proportion of shared variants among these symptoms.

So what you get is that you get a hierarchy of symptoms at different levels of generality. So think of like, think of it as an, as a pyramid if you want, or like an, inverted tree. So at the bottom you have symptoms and traits. And if you statistically analyze them, there are some factors that emerge.

So, for example, depression symptoms and generalized anxiety symptoms, as I mentioned, they don't, separate, rather they form a [00:55:00] cluster that we call the distress factor and. Problems like different kinds of phobias and social anxiety. And some of the other ones they cluster into a fear sub factor and we get a factor of kind of sexual problems.

And then those sub-factors congregate into higher order factors, which explain a larger portion of that variant. So you get spectra, so you get internalizing spectrum. Which covers a very wide range of kind of mood problems and kind of anxiety, related problems, kind of. So there's a somatoform spectrum.

There's an externalizing spectrum that covers things like, you know, impulsive behaviors and A DHD related issues and substance use kind of related issues. There's a psychosis spectrum or a thought disorder spectrum that, that emerges. So you get these, six spectrum and any particular patient will have a certain value along those spectrum.

So any psychiatric patient, they will have a [00:56:00] certain value on the internalizing spectrum, a certain value on externalizing spectrum, a certain value on thought disorder, spectrum, et cetera. And then at the highest level, all of these spec have a common statistical factor that is known as the general factor of psychopathology.

So there in a statistical sense, there's a latent factor that explains common shared variation. Among all mental disorders, and that represents the increased likelihood that if you have one categorical diagnosis, you're gonna have a different categorical mental health diagnosis too. So add and in a statistical sense, there's something shared by different mental health problems in a similar way.

As, you know, if you think of intelligence, there are different types of intelligence and different aspects of intelligence. But in a statistical sense, these different types of intelligence share something in common. It's the G factor of intelligence or the IQ score, right? So, it's the shared, kind of variance of different [00:57:00] aspects of intelligence that is captured by the G factor.

So in a similar sense in when it comes to mental health problems. There is something that all of these mental health problems share, statistically speaking, and that's the P factor or the general psychology factor. And these dimensions are very well supported by a statistical analysis of large data sets.

You know, they, are replicable and they associate with a variety of traditional validators. So these spectra differentiate on kinda genetics. they differentiate on course of illness treatment response. So SSRIs are more effective across the internalizing spectrum, for example. So they capture some of these larger associations with, the two much better than the DSM ca categories.

And so the idea is that instead of assigning people these categorical labels. Every psychiatric patient gets a dimensional profile along those dimensions. So everyone has a certain internalizing score, externalizing score, a thought disorder score, you know, SMARTFORM [00:58:00] score, et cetera. And this is similar to the kind of dimensional model of personality disorders that was developed, before that.

And that is in the appendix of the D sm. So if, you remember, there's the alternative model of personality disorders and that describes personality disorders along five dimensions. There's neuroticism, extraversion, detachment, you know, psychotic, et cetera. So instead of saying that this person has narcissistic personality, or this person has borderline personality, you can take that clinical presentation and you can say, this person is high on neuroticism and high on antagonism and high on detachment, right?

'cause in reality, personality problems are not arranged into packets. They are arranged along dimensions. And you know, we can describe those problems along those dimensions so we can create a dimensional profile of personality problems. And that dimensional model of personality problems is empirically well supported, has a lot of research behind it.

And that is why it was included in the appendix of the DSM as in, you know, hey, there's this alternative way of thinking about [00:59:00] personality. And later on it became the dominant model for ICD 11. So ICD 11 adopted the dimensional model of personality disorders. And I think research has, I think, you know, accumulated to a point where we can say with confidence that.

We are doing something right with this dimensional approach that, you know, this is statistically robust. It, captures a lot of, you know, validator association that we want. And it, bypasses the categorical thinking and forces us to think about the rich dimensionality of every, you know, every patient.

And it does not have the same kind of threshold problem as the kind of traditional DSM because, you know, again, along any dimension we can pick the. Threshold that we want. Right now, we are using population level norms. So you can, you know, using T scores so you know, how many standard deviations are you, are you away from a population level norm for internalizing symptoms or externalizing, but you can easily switch to, you know, disability based thresholds or impairment based threshold or treatment based threshold, et cetera.

So [01:00:00] that's why I, you know, I recommended that hightops should be in the appendix because I think it would be a clear recognition that we have multiple different ways of thinking about classification and they offer different advantages. You know, I think the, traditional GSM categories have the clinical advantage that they're familiar to clinicians and, you know, there's a long history of clinicians working within that.

But we now, we have, you know, a robust statistical evidence that a different way of thinking about diagnosis is possible. And I think DSM should recognize that. I don't feel any need to go over that. I think you explained that pretty concisely. It came together at the end and I felt like I had a handle on that.

Just with an eye on time. What is your sixth and final recommendation? So I think the sixth one was generally kind of along the lines of, increased transparency and public accountability. and in two ways. One is that, you know, DSM is, by and large pay vaults, you know, like, you know, people, can just go on the, you know, a PA website [01:01:00] and read the exact criteria.

The second thing is that people who work on the a PA task force, majority of them ha, tend to have some degree of association with the industry. Pharmaceutical, majority of them. Wow. Majority of them, yeah. 60 to 70%. Wow. You know, on, on the whole, and you know, the, a PA has an internal mechanism where the task Corps members have to report those associated, you know, relationships to the A PA and a PA then analyzes them and determines whether they pose an obstacle or not.

But that data is not publicly released. So there, there is no public accountability in that sense, and I think given the importance that DSM plays in, you know, healthcare bureaucracy and the system and public perception of these problems, I think the least we can do is that. Make the DSM accessible to the public in the same way as ICD is accessible.

Any, anyone can go on the WHO website and look at what the ic d criteria are, you know, and that signals that, Hey, wait, we take this seriously. And in the [01:02:00] same way, although I think, you know, there are critics out there who think that the pharma, you know, influences how DSM, you know, decides and, you know, minutia of criteria.

I don't think that is true. I don't think that pharma influences driving, you know, the decisions that get made, but the mere fact that, you know, a PA is not transparent about that. It allows people to speculate and, I think in environment where trust and medical authority is already deteriorating, I think, you know, the more public accountability we can have and transparency, the better it is for the legitimacy of the manual and the profession.

Dr. Aftab. Thank you for that summary. I couldn't agree more. I think it's a pretty simple recommendation, but a very important recommendation to increase access and transparency. I totally agree. Especially considering where we are as a culture. Do you have any final thoughts for our psychiatry boot camp audience?

I would just encourage, again, thinking about the, hidden assumptions behind diagnosis and classification and kinda asking, what it is that we are doing [01:03:00] when we use words like disorder and dysfunction when we, use certain diagnostic thresholds, when we use specific criteria. So paying attention to conceptual assumptions, paying attention to patient narratives and how diagnosis, influence patient perceptions.

and then opening oneself up to the plurality of ways in which we can talk about mental health problems and approach issues of classification. If you want more of this, we will link Dr. Aftab's work in the episode notes, and you can go back to season one, episode one where we launched Psychiatry Bootcamp with the Weis off top.

Thanks for joining me at Weis. Wonderful to see you again, and best wishes for the future. And maybe you'll be the chair of DSN seven. Thank you, mark.

Thanks for listening to this episode of Psychiatry Real Camp. I hope you enjoyed the show and like me, I hope you enjoyed listening to this episode several more times so that you can soak up all of the wisdom that Dr. Aftab just shared with us. If you are enjoying the show, I'd love to know what you think.

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