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1. 00:01 today I'm going to discuss two future trends and I'm not sure which of them is
2. 00:08 more worrying First of all the future of the diagnostic and statistical manual
3. 00:14 seems to be uh at risk or in question And the second thing is there are
4. 00:21 various attempts at legislation to allow state authorities and other authorities
5. 00:27 including medical authorities to detain people based not only on their current
6. 00:33 mental health conditions but on some kind of prediction or prognosis This is
7. 00:40 beyond terrifying My name is Sambachin I'm the author of malignant self- loveve
8. 00:46 narcissism revisited I'm a professor of psychology so be careful In the future
9. 00:52 I'll be able to detain you and I won't even need the DSM Okay Shashim don't get
10. 00:58 alarmed Don't panic Let us delve right in and educate and enlighten ourselves
11. 01:08 So um there was a public um kind of press press conference um the American
12. 01:15 Psychiatry Association APA in the annual meeting They presented exploratory plans
13. 01:23 for a new um edition of the Diagnostic and Statistical Manual of Mental Disorders also known for short as the DSM Currently the DSM is in its fifth
14. 01:36 edition text revision The fifth edition was published in 2013 The text revision
15. 01:42 was published in 2022 The bizarre thing in the press
16. 01:49 conference or in the annual meeting was that the APA refused to commit themselves to publishing a full sixth version of the
17. 02:01 DSM the DSM6 They were asked by multiple participants and the press when is the
18. 02:08 new edition coming out and they wouldn't say and they wouldn't commit themselves to a new edition Instead they've
19. 02:16 established a DSM strategic committee The chair is Maria Okouendo MD PhD head
20. 02:26 of psychiatry at the Pearlman School of Medicine University of Pennsylvania
21. 02:33 Philadelphia And so this is beyond bizarre The strategic
22. 02:40 committee hasn't been established yet A chairman has been appointed And what does it mean
23. 02:46 strategic it means they're considering to scrap the whole
24. 02:52 enterprise Aquendo said that the goal of the committee the goal of the group is
25. 02:58 transparency and to solicit public feedback I'll let her talk for herself There are people who are DSM fans and some who kind of hate it So we have made
26. 03:10 it a point to talk to people and ask how we can fix it because we are all ears If
27. 03:17 there are things we can do better we definitely want to know she told Medscape Medical
28. 03:23 News At this stage there are four DSM subcommittees One committee deals with
29. 03:30 social determinants the other one quality of life and functioning biomarkers and structure Four there have
30. 03:39 been a variet there's been a variety of oral sessions held partly also
31. 03:45 throughout the meeting and each subcommittee chair presented preliminary plans Everyone was very careful to emphasize that this is an early early
32. 03:56 phase or early stage It's still in development Everything is open to revision etc etc Aquendo again she said
33. 04:05 why now we want to advance the efforts that was st started in the DSM5 revision
34. 04:11 process with the idea that it's time to move the psychiatry noology forward
35. 04:17 specifically we want to reflect evolving knowledge the goal is to make the manual a truly living document with updates
36. 04:24 occurring in step with scientific advances and yet she refused to confirm
37. 04:30 whether this was the groundwork work for what eventually would become the
38. 04:36 DSM6 And she did say that something is going to be published um in about four years from now but she wouldn't commit herself to a DSM6 Now this the manual the DSM has a
39. 04:50 long history as some of you may know by now The first edition was published in 1952 and it it was comprised of 100
40. 04:57 pages The current edition 70 years later is um 1,100 pages There was a second
41. 05:06 edition in ' 68 a third edition in 1980 a very celebrated edition and the fourth
42. 05:12 edition in 1994 And there were various text revisions in the middle And so what were the big changes in the
43. 05:24 DSM5 honestly they were mostly cosmetic Some classifications for several
44. 05:30 diagnosis diagnosis were revised Some diagnoses were put together Roman
45. 05:36 numerals were discontinuated discontinued and abbreviations introduced and so on so forth And the
46. 05:43 they they removed the multi-ac actual system axis one axis 2 etc multi-actual
47. 05:50 system first introduced in the DSM3 was taken out and initially the committee of the DSM5 they said that they're going to
48. 06:01 shift to dimensional assessments they're going to move away from bullet lists and
49. 06:08 criteria and they're going to move away from what is known as a categorical approach and they're going to describe
50. 06:14 mental illnesses and mental health disorders and mental health issues on a spectrum with a kind of dimension in a
51. 06:20 more literary form that captures the essence of these disorders including
52. 06:26 emphasis on trait domains on functioning on symptom severity and and so on so
53. 06:32 forth Chapter orders were rearranged grouping of of these orders rearranged
54. 06:38 etc etc But the truth is that it took a decade to develop the DSM5 years of
55. 06:44 planning field trials revisions public feedback multiple rounds of updates you name it A lot of
56. 06:51 bruhaha and I'm sorry but the DSM was still born DSM5 was still born because
57. 06:59 it copy pasted the bulk of the text of the DSM4 True it introduced the
58. 07:06 alternative models There's for example an alternative model for personality disorders not all of
59. 07:12 them for narcissistic personality disorder borderline antisocial and so So there there is an alternative model
60. 07:18 relegate relegated to page 882 81 by the way Uh but the diagnostic criteria the
61. 07:26 outdated diagnostic criteria of the DSM4 a 25 year old document were copy pasted
62. 07:35 verbatim and included in the DSM5 which is beyond shocking honestly In March 2024 the board of trustees of the APA approved the
63. 07:46 creation of the strategic committee that I mentioned with Aquendo as the chair and so on so forth And the task is to monitor new developments that could affect the structure definition and criteria of DSM disorders as if nothing
64. 08:01 has happened in the past 25 years Aquendo again says the rapidity of
65. 08:07 scientific developments in psychiatry has never been faster The idea is we
66. 08:13 want to integrate critical feedback on the DSM and work towards including classifications models measurements and
67. 08:19 advances in neuroscience Good luck with that Aquendo is saying all the right things but she
68. 08:26 is echoing sentiments which are at least 15 years old and nothing has been done
69. 08:32 owing to commercial pressures by insurance companies pharmaceutical industries and so on so forth Aquendo
70. 08:39 says that the FDA wants to harmonize with the international classification of diseases the 11th edition of the ICD The
71. 08:47 ICD is used by 80% of humanity and it is like light years more advanced and more updated than the DSM So synchronizing or harmonizing with the ICD would be an
72. 08:59 excellent starting point There's also a new emphasis on
73. 09:05 neuroscience The first DSM oral session introduced a subcom a kind of subcommittee focused on the importance
74. 09:13 of functioning and quality of life And it's actually a euphemism for neuroscience As noted in the abstract the goal is to evaluate how these two factors
75. 09:25 functioning and quality of life I'm quoting can provide valuable insight
76. 09:31 into the patients perspective on how their disease impacts their ability to carry out important activities as well
77. 09:38 as provide key indicators for treatment progress toward patient centered recovery goals The chair of this particular subcommittee is Karen Karen Drexler
78. 09:51 She's an MD associate professor department of psychiatry and behavioral sciences Emory University School of
79. 09:57 Medicine in Atlanta She told people in the meeting in the annual meeting that
80. 10:03 key aspects including the perspectives of indiv the individual family community
81. 10:09 and clinician over time should be included She said they're all valid
82. 10:15 The social determinant subcommittee the other one has another task and its task
83. 10:22 its assignment is to assess the impact on mental health from factors such as ethnoracial backgrounds sex and gender belief systems personality income an
84. 10:33 individual's living circumstances socioeconomic stratum exposures through the years to advantages and
85. 10:40 disadvantages maybe even incorporating the ACE model adverse childhood experiences more and both subcommittees are examining single or multiple instruments to determine which are most reliable in assessing these factors But the emphasis as you can see is on
86. 10:58 medicalizing psychology All the heads of the subcommittees are medical doctors
87. 11:04 They are technically or clin practically psychiatrists but they are not
88. 11:10 psychologists And so there's an attempt to medicalize uh psychology by actually
89. 11:18 converting it into a branch of neuroscience and by emphasizing
90. 11:24 medications I will leave it up to you to construct a conspiracy theory around this indisputable fact For example maybe the pharmaceutical companies are behind
91. 11:35 this Who knows i'm not saying Okay The biomarkers subcommittee
92. 11:43 um is supposed to as they say bridge the gap between psychiatry and neuroscience
93. 11:51 and to evaluate the benefits and potential risks of incorporating biological a biological approach into
94. 11:57 the diagnostic process The group is also exploring the use of wearable devices
95. 12:04 There is a general trend away from psychology as we have known it and into
96. 12:12 neuroscience biology neurobiology neurology Going back full circle to
97. 12:18 Ziggman Freud who was a neurologist actually So um now everyone is talking
98. 12:24 about heredity Everyone is mentioning genetics brain abnormalities genes
99. 12:30 um um medications uh and yet the level of knowledge in these fields is very
100. 12:39 very low These fields are pioneering fields and at this stage there's a lot we don't know about the brain and a lot we don't know about genetics and heredity and to
101. 12:52 try to convert psychology into these purile adolescent sciences some of them
102. 12:58 pseudociences is really a seriously bad move in my view very hubristic very
103. 13:05 arrogant and grandio so The
104. 13:11 DSM is in my view straying going the wrong way from coping with the patients as a whole as a
105. 13:22 totality including of course genetics and brain but also life experiences and
106. 13:29 personal history and ambience and so on away from this and with emphasis
107. 13:37 on neurobiology and brain and devices and medications and and so on so
108. 13:44 forth Uh there's a fourth subcommittee and it is tasked with determining strategies to integrate a dimensional
109. 13:52 approach into the DSM's foundation using a more organic and functional approach
110. 13:58 In other words what has happened is the original DSM committees in the fourth
111. 14:05 edition definitely in the fifth edition wanted to transition from categorical to dimensional approach They wanted to
112. 14:11 transition from bullet list of diagnostic criteria to a descriptive model that captures the essence of the
113. 14:19 disorder or the disease This was undermined sabotaged and
114. 14:25 obstructed virolently and vehemently by the insurance and pharmaceutical industries So now the new strategim is
115. 14:34 to say okay we're going to transition to the dimensional approach but based on medication and based on brain studies neuroscience In other words we're going
116. 14:45 to transition to the dimensional approach while catering first and foremost to the commercial interests of
117. 14:51 our sponsors That is not science I'm sorry to say that is seriously egregious
118. 14:57 behavior and that is not harmonizing with the ICD There's no trace of the ICD in this approach The ICD is published by
119. 15:04 the World Health Organization and is immune completely to commercial pressures It is a true blue document
120. 15:12 which adheres to the latest knowledge and information in the field The DSM is
121. 15:18 has been deteriorating time and again starting with the text revision of the fourth edition the fifth edition and the text revision of the fifth edition and now this monstrosity of the DSM6
122. 15:32 The committee chairman um um
123. 15:38 dstur is again an MD a medical doctor PhD Mlean hospital of Harvard and
124. 15:45 Harvard Medical School He said that in the in the annual meeting that the current current manual has faced criticism for being overly specific and too vague particularly in cases
125. 15:57 involving unspecified diagnosis He said only a minority of patients present with a classic disorder as described in the current DSM Most present with a mixture of problems to
126. 16:08 varying degrees along dimensions of mood anxiety psychosis and addiction That is all true So why not
127. 16:16 adopt the approach of the ICD which is basically um trade domains the
128. 16:23 combinations of traits behaviors and so on Why why not why not go the ICD's way
129. 16:30 which essentially says observe the patient characterize the patient using a
130. 16:36 series of Lego bricks and then come up with an diagnosis that is unique to the
131. 16:43 patient tailormade customized idiosyncratic why not go that way
132. 16:49 because then insurance companies will protest insurance companies like homogeneity and uniformity And the
133. 16:56 pharmaceutical companies would be very pissed off because in the vast majority of cases medications are not only not
134. 17:04 necessary but they're damaging as recent studies about anti-depressants and so on are finding out And the the campaign against psychedelics is an example of
135. 17:17 the undue influence of of the pharmaceutical industries on the profession Enor introduced a preliminary and evolving concept involving four boxes
136. 17:28 that clinicians would fill out that would potentially include contextual factors biological factors diagnosis and
137. 17:35 transdiagnostic features Emphasized that the current content is only illustrative and not a formal proposal So it's just to
138. 17:46 illustrate the way the group is thinking about a workable framework The next step is to gather data and feedback from the
139. 17:53 field on what this structure should include And then step two would focus on proposing specific content After the
140. 18:00 presentations people asked him people asked whether there have been detailed considerations of how future updates to the new manual may be handle might be handled including frequency and use of
141. 18:12 techdriven platforms a Wikipedia style approach maybe And there was the chair of the session Nitin Gokai also medical doctor chief of research and deputy
142. 18:23 director of the APA and he said no decisions have been made yet said there
143. 18:29 is such a thing as too many updates but at the same time as the science advances we don't want to wait to address that so we need to that sweet spot in the balance no
144. 18:41 kidding okay what about suicide and suicidal ideiation and suicidal conditions Should they be separated completely from standalone diagnosis
145. 18:52 there was a session that explored the possible inclusion of four suicide related conditions as distinct diagnosis
146. 18:59 in the next edition of the DSM All of this has been proposed previously multiple times By the way it's
147. 19:06 regurgitation big time And these include suicidal behavior disorder suicidal
148. 19:13 behavior within the past 24 months non-suicidal self-injury disorder which may precede suicidal behavior suicide crisis syndrome a mental state of enttrapment and ruminative flooding with
149. 19:26 or without suicidal ideiation End quote an acute suicidal effective disturbance
150. 19:32 a conscious suicidal intent that escalates rapidly In the DSM in the
151. 19:38 current version of the DSM the text revision of addition 5 suicidality is included only as a symptom of other
152. 19:45 conditions such as depression borderline personality disorder and so on And so here's what the presenter presenters noted I'm quoting "Nevertheless a recent
153. 19:56 report estimated that 19.6 6% of individuals who attempted suicide did so
154. 20:02 despite not meeting criteria for any existing psychiatric disorders And they added that new
155. 20:09 suicide specific diagnosis would help identify at risk individuals who would otherwise be deemed healthy by current suicide risk screenings
156. 20:20 So there's this debate and regardless of whether these are included in the next DSM edition if there is one or not uh Edward Selby professor of psychology
157. 20:34 at Rad Radg said this in in the presentation Establishing suicide risk
158. 20:40 assessment and intervention intervention competency across disciplines will be essential
159. 20:47 over the next several years Michael Myers medical doctor chaired the scientific program committee in and he's a noted expert actually on suicide prevention He said that he is all for
160. 20:59 the inclusion of suicide related conditions He said this has been in the works for at least 10 years more
161. 21:06 actually 20 that there is something outside of our conceptualization in DSM
162. 21:12 and ICD that warrants it as a standalone Aquendo agreed but she noted that the
163. 21:19 DSM is also used for its coding the insurance companies looming Yeah So as
164. 21:25 much as a group may want a new diagnosis to be included it's important to understand the potential downstream
165. 21:31 effects inclusion could cause she said In other words how are we going to get paid in therapies psychologist
166. 21:38 psychiatrist especially psychiatrists how are we going to get paid if there are new diagnosis without an appropriate
167. 21:44 code to claim the insurance money it's all about money it seems And so starting
168. 21:50 a brand new DSM manual from scratch isn't realistic she noted She said "We
169. 21:56 need to be pragmatic We cannot just start over." I have no idea why by the way We cannot just start over because
170. 22:02 that has implications for people who are getting treatment today and whether their insurance is going to cover
171. 22:09 it These type of practical considerations are essential Do you believe this woman do
172. 22:16 you believe what you have just heard we cannot update the manual We cannot get it up to speed We cannot reflect the
173. 22:22 current knowledge We are bound to stay behind 20 or two or three decades We are
174. 22:29 bound to falsify things pretend that they don't exist and a million other issues All of this because we need to
175. 22:35 claim insurance money So there were nine prominent medical and social care organizations that have jointly condemned condemned
176. 22:46 the proposed amendments to mental health legislation So one of the main issues in newly proposed mental health legislation is
177. 22:59 detention There's a proposal serious of proposal actually in multiple locations multip multiple jurisdictions and so on
178. 23:06 including on the federal level a proposal to extend police powers of detention to medical
179. 23:13 practitioners in England and Wales This is almost be it it's on the verge of
180. 23:19 becoming law The amendments uh in England and Wales were tabled uh
181. 23:26 during the passage of the mental health bill They passed through parliament and
182. 23:32 they these amendments would empower authorized individuals including medical professionals to detain someone
183. 23:39 undergoing a mental health crisis At this stage only the police only the
184. 23:45 police have these powers of detention under the mental health act of 1983 So in England and Wales your psychiatrist
185. 23:53 could detain you your psychiatrist and your psychologist and your therapist and your social worker will acquire police
186. 24:02 powers Similar proposals are in a variety of countries United States
187. 24:08 Australia Israel other places included This is a shocking reversal which
188. 24:14 affords provides your caregivers with the power to arrest you basically indefinitely because this is not the
189. 24:25 kind of arrest under the criminal code and so on where there's habius corpus and you should see a judge and so this
190. 24:32 is an indefinite detention The nine groups including the Royal College of Psychiatrists the Royal
191. 24:38 College of Nursing the Association of Ambulance Chief Executives they warned of the risk of significant harm with
192. 24:44 dangerous consequences if these proposals were were to become law They issued a joint statement and they
193. 24:51 focused on proposed changes to the Mental Health Act Sections 135 and 136
194. 24:58 cover detention of people in crisis in public or private settings These amendments introduced in the House of Lords would authorize doctors
195. 25:11 nurses all mental health practitioners and professionals to arrest you Powers of detention Police officers would only need to attend to investigate a crime or if there was an immediate if there were an immediate risk to life Otherwise the
196. 25:28 detention is perfectly legal according to these amendments would be perfectly legal and you would find yourself in a
197. 25:35 cell with no exit date or exit strategy The signatorries of this joint
198. 25:43 statement protest statement said that police role is vital The organizations
199. 25:49 warned that removing police involvement in mental health incidents could be unsafe According to the statement and
200. 25:55 I'm quoting instances of detentions under the mental health act where there is no risk are almost non-existent They
201. 26:03 noted that the mere presence of unformed officers can ensure that an otherwise risky situation remains contained and
202. 26:10 safe They also noted that police are essential in carrying out many tasks that medical practitioners cannot
203. 26:16 perform For example to check whether it is safe to enter a home
204. 26:22 Yes the new powers will allow doctors psychiatrists psychologist therapists social workers to simply barge into your
205. 26:29 home and arrest you with no warrant This is mindboggling what's
206. 26:35 happened So this new bill is part of the government's manifesto and the
207. 26:41 commitment to modernize mental health legislation to give patients patients
208. 26:47 greater choice autonomy and enhanced rights and support I'm quoting this is Orwellian speech This is newspeak You
209. 26:54 know the manifesto says that they're going to give um patients I'm quoting
210. 27:00 greater choice autonomy and enhanced rights and support And at the same time they're
211. 27:06 allowing people just people who are not police officers to arrest you if you're
212. 27:12 their patient That's so much for your rights And and and so on They said the
213. 27:19 government manifesto says we need to ensure dignity and respect throughout the
214. 27:25 treatment So these are shocking and very worrying
215. 27:31 developments and uh they also create an ambiencece of hypervigilance and
216. 27:37 suspiciousness and paranoid ideation They risk they risk this kind of these kind of powers risk the therapeutic
217. 27:45 relationship If you know that your psychiatrist can arrest you or your psychologist or therapist can arrest you at any minute you would be reluctant to share with them certain things many things actually and then what's the
218. 27:57 point of therapy at all transferring police power to health care professionals is very damaging to the
219. 28:04 therapeutic alliance and and the whole relationship the whole process It would
220. 28:10 discourage people people from seeking help So Dr Lead Smith president of Royal
221. 28:16 College of Psychiatrist um echoed these concerns She said "It is
222. 28:23 well known that at times people experiencing mental health crisis cannot be safely reached and cared for without
223. 28:30 the assistance of the police So delegating police power without proper consultation or planning sets a
224. 28:36 dangerous precedent and is likely to increase risk to patients and compromise the safety of others
225. 28:43 So this is where we are at The DSM openly the committee of the DSM
226. 28:51 openly admit that they are under the thumb of insurance companies and pharmaceutical industry and that they
227. 28:58 are falsifying they are falsifying the DSM to conform to the needs of these
228. 29:05 industries rather than to reflect the current knowledge in the field
229. 29:11 And in multiple jurisdictions mental health practitioners clinicians and
230. 29:17 professionals would become police officers with powers far exceeding the police in the courts because they can could detain you indefinitely based solely on their own
231. 29:28 assessment There's no requirement even of a committee of mental health practitioners let's say minimum three No
232. 29:36 any single therapist or whatever can do this What about rogue therapists rogue
233. 29:43 psychiatrists criminal-minded and antisocial psychologists who would then blackmail patients if you don't give me £1,000 or £100,000 I'm going to detain
234. 29:55 you indefinitely What's going on i have no idea what's going on The whole field is
235. 30:02 is haywire berserk Phew From pseudocience to
236. 30:09 dystopia