All right we're going to go ahead and get started. Welcome to the last seminar of the day or symposium of the day. I'm Dr. Hines. I'm the chair of this symposium and faculty at Walter Reed National Capital Consortium Residency. We're really excited to have Dr. Harrison here who's going to talk a little later about some of the ins and outs of it because she was very pivotal in really doing the work to do the TR update and so we'll pick her brain on that a little bit and we'll keep the sort of didactic part of this to about an hour so we have plenty of time for that. I'd also like to introduce a couple of our fantastic residents Dr. Candice Passarella and Dr. Alex Bell are both going to speak and with that I will turn it over to you. Good afternoon. So just go ahead and get started. So this is the standard disclosure. None of us have anything to disclose for this session and as Dr. Hines mentioned we're going to talk a lot today about the DSM-5 TR and a lot about the cultural, the ethno-racial, gender, and the social determinant changes that have been implemented but first to really gain a true appreciation of all of those changes that have been implemented we wanted to take a bit of a historical approach and think about where we started to really recognize the power of some of those changes and I'll caveat by saying I'm not a historian I just really like a lot of context to why I'm learning what I'm learning and so I think it gave me a better appreciation of everything that had been implemented in TR as I looked back and considered the past. So certainly we know that psychiatry didn't start after the DSM it really started before so we're gonna take a trip back to the 1800s. So this portrait here that you can see is an 18th century painting of one of the oldest mental health asylums in London which is called Bethlehem Royal Hospital and for those who are less familiar with that name you might recognize the name Bedlam. It was frequently described as very beautiful from the outside but as you took a step inside of the hospital you could often see very different conditions. It was not uncommon for it to be described as filthy from the inside and as we can see in the portrait in and of itself it was not infrequent to see individuals chained or shackled confined to certain areas of the hospital and two it was also common for outside individuals to be able to take a tour of the facility inside and see some of the treatments that were being implemented in psychiatry at the time and the patronage that was gathered from these visitors often went towards hospital maintenance. And certainly while we didn't have a structured manual of you know what encompassed mental health we certainly had our theories as to what caused these sort of illnesses. Madness or insanity was often attributed to sort of spiritual or religious causes. It's not uncommon to hear terms like demonic possession or feeling that God was punishing an individual afflicted with mental illness. Others who had a more biological basis of disease included physical ailments or injuries as a potential causal factor. Early medical practice implemented a concept of the imbalance of humors. For those who may be familiar with the book The Emperor of All Maladies by Siddhartha Mukherjee he talks about this imbalance of humors including bile, black bile, blood, and phlegm and while this was attributed to medical illnesses it wasn't uncommon to also encompass psychiatric illnesses within that concept. And then others still would attribute it to things such as fate or destiny. And even prior to our first diagnostic manual we had very renowned thinkers of the time including Freud and Jung who introduced the concept of conflict between the conscious and the unconscious mind both adapting that thought to their own theories including the psychoanalytic archetypal theory and how the discrepancies between these two states could often lead to conflicts and thus produce symptoms. While we recognize now that there's a fair amount of heterogeneity within manifestations of psychiatric illnesses it's become more recent of a concept to consider how culture, identity, background, and race can certainly play a role in how those manifestations might differ. It's really taken us a long time to bring this to light with especially within our diagnostic manual and as part of this discussion we want to really highlight some of these changes that have come. Thank you. Sorry if I'm speaking a little bit low. And certainly a prime example of how long it took us to recognize and implement these changes includes looking back at the language that had been used to denote mental illness. So the first three terms and really most of these terms have originated as a result of the American Statistical Association and censuses that were taken in the 1800s. There was a very stark frequency of the use of idiocy and insanity to denote mental illness and a lot of these terms have evolved from that larger term. The first three were often attributed to people of color primarily African-American individuals to describe insanity. Within the censuses mentioned it was a very frequent association of such individuals to be denoted as insane and the second and third term specifically had been utilized to defend the act of slavery as having positive benefit for individuals who have mental health diseases and they used them to argue that slavery was actually beneficial for individuals' mental health. The latter two in addition were often used to describe how enslaved individuals might try and run away or resist hard work as a manifestation of mental illness. Feeblemindedness was used to denote individuals who had deficiencies of the mind often relating to intellect and functioning and contrasted with other terms such as idiocy and imbecility is also utilized to justify forced sterilization in light of early eugenics movements. The next two were designated for women and or wives who acted in perceived opposition to their spouses or other males with the idea that either assertive or ambitious women were denoted as unnatural and thus sick and these terms would be utilized to justify institutionalization of women for extended periods of time and subject them to inhumane sort of treatments. Constitutional psychopathic inferiority was a term used to describe individuals not identifying as heterosexual and the concept of earnings and earning gin was a concept introduced by Karl Ulrich's to describe what he called the third sex where the earnings or the male spirit or the earning gins where the female spirit would be trapped in an individual's body and cause them to be interested in the same sex. And then lastly neurosis was a term that was commonly utilized as sort of a catch-all for mental illness similar to the term insanity and it in particular was utilized by Freud to describe mental illness that stemmed from the brain defending against psychological trauma. The term had replaced hysteria and then became a point of contention in later revisions of the DSM. So as we alluded to certainly we were hospitalizing and treating individuals even before we had a manual. In the United States the first mental asylum was established in Virginia in 1768. Historical conditions of the facilities were often described as less than ideal similar to that of Bedlam and from advocacy from individuals such as Dorothea Dix we had brought attention to mental illness as more akin to regular illness and not something incurable. Through her advocacy there were 32 new psychiatric hospitals that had been established with the goal of providing a better environment for those who had been hospitalized and through providing care from doctors and nurses who had appropriate training. Some of the early treatments to utilize an institution such as Bedlam and those in the United States had been what we might describe as barbaric. The first as we can see here trephining was first utilized in the Middle Ages in the Renaissance eras and it is literally sort of creating a hole within one skull. It was initially thought as a treatment for epilepsy and then progressed further into a psychiatric treatment. Conversion therapy which most of us are probably some degree familiar with was initialized, excuse me, initially utilized with hypnotic techniques and then claimed as successful in 1899 then evolved into more painful and aversive techniques with the goal to cure someone from their ailments. Diabetic comas or shock therapy was utilized to essentially put someone into a hypoglycemic state and thus have a seizure and then coma to ideally cure someone from their mental illness. And then most of us if not all of us are probably familiar with the term lobotomy so for the sake of our limited time here today I won't belabor that one too much. So I'm sure most of you are wondering okay well when when do we get to the actual DSM? So the last step that we'll take looking through our history is talking about two precursor texts to the DSM. The first is the AMA standard which was later referred to as simply the standard. It was including about 22 diagnoses and was provided by the APA in collaboration with the AMA for their otherwise general medical guide. It encompassed general medical conditions and then when the APA started working with the AMA they provided these diagnoses to include within the larger scope of health. And then the medical 203 was actually a shorthand version of the War Department technical bulletin section 203. It was actually created during World War II where the armed forces started utilizing psychiatrists in the process of selection, processing, assessing, and treating soldiers. They initially had used the standard when they were doing their assessments but then realized they were finding sort of pathologies that were unrecognizable at least on in terms of what the standard had at the time. So led by Brigadier General Menninger it was developed into an entirely new classification system to encompass these pathologies that had not been seen in the standard and then later adopted by all of the armed forces and then the Veterans Administration in 1947. So finally we get to the DSM-1 in 1952. The APA Committee on Nomenclature and Statistics had developed a version of the manual for standard use across the country rather than having to rely on some of the other precursor texts at the time including the medical 203 and the standard. Much of the structure and framework actually models what had been established in the medical 203 including some direct quoting of diagnoses as well as modeling the structure and framework. And the first iteration included about a hundred mental disorders within about a hundred and fifty pages of text. And so I wanted to give everyone a look of what the first edition of DSM looked like because I know I certainly haven't used it within my own practice and being able to compare one of the other I find particularly helpful and for those who are APA members you should all have access to this through the DSM legacy page within the APA website. So as we can see looking through the page here the classification system in the first iteration is far from what we're accustomed to now. So rather than including sections on pretext, additional figures and features, subsections, this is really more kind of broad conceptualizations of the categories that we're rather familiar with now and includes general descriptions as well as categorizing the disease states. They also pay homage to thinkers of the time including Emil Kraepelin as we see mentioning dementia praecox in the first line. And then we can see certain sub variants of the larger pathology that are discussed in no more than a sentence as you take a look at the hebephrenic type of the schizophrenic reaction. And for those who don't know what the term hebephrenic means it's basically a synonym to say disorganized. So naturally the production of the DSM was met with mixed reviews. A couple of the main criticisms of the DSM included regarding homosexuality as a sociopathic personality disturbance. While the view of same-sex relationships was kind of mixed prior to the implementation of DSM, they utilized a study by Irving Bieber discussing how these relations were denoted as an acquired pathological condition. And he in his article described a hidden fear of the opposite sex as a result of traumatic child-parent relations as a justification. Later studies including one by Evelyn Hooker examining happiness and social functioning of same-sex versus opposite-sex related males had demonstrated no significant differences between sexual orientation but homosexuality was still retained as a pathologic term within later versions of the DSM despite some of this amounting evidence. There was also a lot of growing criticism on the idea of mental health and illness as a whole. So individuals such as Thomas Saz had argued that mental illness afflictions were more a myth to disguise moral conflicts. Irving Goffman had described illnesses as a form of society labeling those who did not behave appropriately or otherwise non-conforming. And then behavioral psychologists as well had challenged sort of the reliance of psychiatrists on non-observable phenomena. So these criticisms later evolved into the anti-psychiatry movement of the 1960s which had been led by individuals including R.D. Lang, Thomas Saz, David Cooper, and Franco Basiglia. The movement at large had questioned kind of the legitimacy as well as the validity of psychiatric theory and practice including diagnostic practices, forms of treatment, which as we mentioned were kind of questionable at best. And anti-psychiatrists had criticized psychiatry as sort of arbitrary and humane citing some of the practices that had been utilized at the time as well as long-term involuntary hospitalization. Certainly these arguments had helped to propel reform within the field itself and motivated changes including deinstitutionalization, improvement in diagnostic standardization and categorization, and even motivated the production of standardized interviews. Around 1968 the APA had been assisting with the next revision of the ICD which at the time had been ICD-8 and decided at the same time to update their model with the DSM. During this revision they utilized a committee of about 35 individuals. They expanded the diagnosis to about 180 in just slightly fewer pages than the previous version. As we'll see when I pull up the next slide we'll notice a lot of similarities between the DSM-1 and the DSM-2. Some notable changes are recognizing the dropping of the term reaction in their classification, although they did continue to utilize the term neurosis. And it's worth noting that both the DSM-1 and the DSM-2 had reflected sort of psychoanalytic theory which was predominating at the time. So here we can see what was previously denoted as a schizophrenic reaction is now schizophrenia within DSM-2. We can see the descriptions in the DSM-2 are slightly longer here. For example, the subtype of hepaphrenic schizophrenia now has two sentences compared to one. However, it's still vastly different from what we consider the diagnostic and statistic manual at this point. And some of the other things that we can notice as we look through this image here is they start to begin describing differences between major categories of illness. For example, they start to discuss the difference between affective illnesses and paranoid states. So between the DSM-1 and the DSM-2, there was still a number of criticisms about how reliable this diagnostic tool was. Certainly this came further into question after the Rosenhan experiment in 1973. For those who are less familiar with this experiment, Rosenhan, along with eight other individuals, had poses mentally ill to be admitted to psychiatric institutions with the goal to try and ascertain if they'd be found out for feigning mental illness, as well as seeing how the course of their hospitalization would progress. While there are several limitations and criticisms of this study, it certainly brought to light the topic of involuntary commitment and treatment in hospital settings, as well as further criticism of the diagnostic process. There was also a lot more activism for gay rights along the 1970s. After the Stonewall uprising in 1969, the first annual Pride Parade took place in 1970. And in continuing to express dissatisfaction with the term homosexuality being retained as a pathology within the DSM, the Gay Liberation Front had also held a demonstration at the 1971 APA Convention. The continued designation of homosexuality as pathologic had become a source of tension for psychiatrists who also identified as gay. Bringing this to light was Dr. John Fryer, who, as we can see in the photo, had come to the APA Convention in 1972 under disguise, calling himself Dr. H. Anonymous, to discuss his experiences as a gay psychiatrist. And then following a position statement in the following year, in December 1973, in preparation for the seventh printing of the DSM-2, the APA had finally removed homosexuality as a category of disorder in 74, and then it was later replaced with sexual orientation disturbance. And then, as well, we've noticed between the first two iterations of the DSM, there's still no real specification of symptoms akin to what we would see in the current diagnostic manual. So the third iteration took a lot of note of the previous criticisms from iterations. In light of the concern of poor reliability, which had been further emphasized by the Rosenhan experiment, as well as lack of standard diagnostic practices, Robert Spitzer, who chaired the third iteration, had looked towards the Washington University School of Medicine, who at the time was led by John Feiner in publishing a study in 1972, which had laid out specific diagnostic criteria for 14 conditions, including depression, schizophrenia, and anxiety. These findings had later been denoted as the Feiner criteria, and Robert Spitzer had opted to reflect these changes within the third version of the DSM. He also utilized several chairs and advisory committees for each category within the manual. And then the final product included approximately 260 diagnoses among 500 pages. They also emphasized the use of a clinically significant syndrome or a psychological syndrome to address the arbitrary sort of criticism of labeling individuals. This meant that individuals had to be either significantly distressed by their illness or have sort of significant behavioral changes, similar to our current phraseology of a clinically significant distress or an impairment in a social, occupational, or other important areas of functioning that we're used to these days. In this third iteration, they also introduced the multiaxial system to give attention not only to the diagnosed psychiatric disorder, but to the environment in the areas of functioning that may have been previously overlooked within our diagnostic framework. They also included a side-by-side comparison of the updated language and an interrater reliability assessment through the National Institute of Mental Health. So this iteration we finally start to see something resembling our current diagnostic criteria. Note as well how this includes further descriptions of examples of criteria they're looking for in diagnosing anxiety rather than just stating motor tension or autonomic hyperactivity. They also include an expected timeline of symptoms and differentiate it from other disorders which resembles our current process. So compared to previous iterations this version of the diagnostic manual is met more warmly. Notable criticisms included controversy over dropping the term neurosis which almost became a point of contention between the American Psychiatric Association as well as the American Psychologic Association. For those who have read the book shrinks he describes this this endeavor between the two associations where the American Psychological Association wanted to continue utilizing the term neurosis and had argued that they would make their own version of the diagnostic manual to include neurosis if it had not been dropped from the APA, the American Psychiatric Association's updated version of the DSM. Ultimately this did not happen but it was still a point that almost had divided two very large groups of psychiatric and psychologic individuals all working towards the same goal to treat those who have mental illness. And then the other large criticism was that there was still inconsistent use of this manual across sites within the United States. The next iteration of the DSM came about in 1994 which was chaired by Alan Francis and had similarly used several committees and working groups for each diagnostic category. The final product was about 900 pages and included 400 disorders. This is also the first iteration to reflect on and highlight variations in how culture, gender, age can all present with differences and manifestations of disease as well as how some variations which might otherwise appear as pathologic are consistent with certain cultural practices. So they had created an appendix which included an outline for cultural formulation as well as some common culturally bound syndromes, examples of which you can see in the last bullet point. So for this version I wanted to emphasize the shift towards addressing more of this variation on culture, gender, and age. So this is the first page of the appendix discussing the cultural formulation and culture bound syndromes. So finally we come to the last iteration before our current model of DSM-5-TR which is the DSM-5. At about 950 pages the DSM-5 was produced in 2013 with some of the most notable changes from previous iterations including elimination of the access system introduced in DSM-3, reframing certain diagnoses such as reconceptualizing Asperger's syndrome to autism spectrum disorder, eliminating certain subtypes of schizophrenia, and reconceptualizing gender identity disorder to gender dysphoria. This edition also expanded further on the cultural highlights of DSM-4 by offering the cultural formulation interview, the first part of which you can see in the image to your right, in addition to a supplementary guide on conducting this interview separate from the DSM itself. While it's difficult to really encompass the full history and the background of the DSM and other relevant historical pieces within this limited time frame, some of the themes that we have found across successive iterations have included the utilization of large diverse task forces to delve into the specifics of diagnostic categories and related components. There's also been emphasis on utilizing objective data and measures, including the parameters and goals of working groups through successive iterations. There's also been increasing focus on culture and gender related variations within diagnoses itself, and within that scope the utilization of more inclusive language and development of tools to assess for such variations has become a point of focus for future iterations and certainly a goal of our current model. And that will bring us to the DSM-5-TR. So in reviewing the recent updates, we'll specifically be focusing on the cultural, racial, and social determinants for diagnosis, and with that I will hand it over to my colleague Candice. Thank you, Alexa. I'm Dr. and Lieutenant Candice Passarella. I'm a PGY-2 psychiatry resident at Walter Reed and a Howard University College of Medicine graduate, 2022. I see another one back there. So today I'll be discussing the second half of today's presentation, which focuses on the latest installment of the Diagnostic and Statistical Manual 5 text revision. So since the inception of the DSM-5-TR, a lot of attention has been focused on the more novel diagnoses, such as prolonged grief disorder, or on the new coding schema for suicidal behaviors and non-suicidal self-injury, for example. However, today we aim to invite more discussion about the landmark use of an ethno-racial equity and inclusion review group, whose mission was to develop the text into a more culturally and socially relevant manual. They also helped develop this manual into a text that offers mental health professionals even more of a framework for improving cultural competence and patient outcomes for a much wider variety of medically underserved patient populations. Now even though the review group worked tirelessly to develop these changes, it can be challenging to navigate through the manual and feel fully realize the extent of the changes. So that is why we are now going to recognize and understand the evidence behind why certain patient demographics do suffer poor outcomes in the field of psychiatry specifically. The review group was deliberate in outlining factors that have further exacerbated these prognostic differences, and these factors include under-representation in medical studies, miscommunication due to differing uses of language, and structural racism, which has been embedded into the fabric of not just our field, but into many aspects of our society at large. Additionally, the cross-cutting review committee on cultural issues was composed of 19 experts in cultural psychiatry, psychology, and anthropology. This committee was actually complemented by the ethno-racial equity and inclusion review group, and that group was composed of 10 mental health experts in disparity reduction practices, one of which was Dr. Hairston, who we have here on the panel today and will have the pleasure of including in today's panel discussion immediately after this presentation. Together they undertook what I am sure was a highly tedious and yet thoughtful line-by-line review of terminology and updated evidence-based diagnostic reasoning throughout the DSM. Notably, they also undertook these revisions alongside the sex and gender review group, which oversaw extensive revisions within the gender identity related sections. This group also ensured that variations in patient presentation by gender were adequately described throughout the manual. Some examples of these committee and working group interventions include referencing studies which attribute a higher prevalence of a disorder within specific patient communities, but while also scrutinizing the adequacy of sample sizes, of participant representation, and thus the overall validity in these previously referenced studies. They also ensured that social determinants of health were adequately addressed. More specifically, they aimed to ensure that factors such as racial bias and discrimination were also highlighted for the clinicians' consideration, and they aimed to make it known that these revisions were not intended to somehow comment on the overall approval of the manual itself, but rather to help improve our clinical reasoning by introducing more diversity into our clinical interpretation of these disorders. So on this slide we can see some examples of how the language of the text was adapted to be more accurate. When we are describing concepts that have traditionally been accepted when it comes to identifying patients by race versus ethnicity, it's important to note that these groups have been lumped together by cultural factors and not always by country of origin, for example. So this helps bring to light another underlying and important historical fact, which is that race was born as a social construct rather than a biological classification, which has further complicated these disorders by then also introducing the social determinants of health as a direct result of that. Another thing I'd like to note here is that when it comes to the term Latinx, it has been shown that the majority of those who actually self-identify as Latinx are U.S.-born, English-speaking, college-educated, and between the ages of 18 and 29. Now admittedly, I will be using the term throughout this presentation, even though I do not fit into that last age category whatsoever, but keep in mind that the most marginalized communities do not tend to use the term Latinx. Additionally, in Spanish-speaking parts of Latin America and in their respective social activist circles, the term Latine with an E is now being used. However, both Spain and Argentina put out a ban in July of 2022 on using either the terms Latinx or Latine, nor any other gender neutral variant. I mention all of this because it further makes the case as to why language is so powerful, how quickly it's still evolving, and also emphasizes the purpose behind this entire presentation, which delves into not only why the changes were made, but why they became necessary. The use of the word minority was also scrutinized given the changing demographics in the U.S. as a whole, and it was recognized that the term Caucasian is not only obsolete, but it is an erroneous characterization of patients who have white skin, and this has also served to further racialize our society in biased and unhelpful ways. Now something I would like to highlight on this particular slide is how the terms sex and gender were used to more accurately define and separate biological traits from gender identity. The sex and gender review group really worked to further neutralize the concept of gender identity with the adaptation of language that describes the experience of gender rather than further pathologizing it. This change was then applied to sections of text that describe gender-affirming medical procedures and gender assignments at birth. These changes now serve as a reminder that, to date, we still do not regularly perform chromosomal mapping nor the measurement of hormones, for example, when we are assigning gender at birth. So with those modifications and revisions in mind, we'll now proceed to the section-by-section review of some of the more noteworthy accomplishments of the review and working groups that were involved in the development of the DSM-5 TR. Beginning with section 1, cultural and social structural issues. We can see here the referencing of studies from 2015 through 2020, so more updated, in order to help emphasize the point that racism is a social determinant of health. This is because racism has a direct and quantifiable impact on not only medical conditions like hypertension, but also on suicidal behavior and even PTSD. In addition, those who endure racism are then also more predisposed to things like substance use and schizophrenia. My text just got way big. Mood disorders and even psychosis. Furthermore, discrimination and unequal access to care was then affiliated with other poor patient outcomes. One of these is misdiagnosing mood disorders as being a psychotic disorder, which is happening more among African-Americans, as was shown by three different studies all published in 2019, which you can see cited here. Other poor outcomes are the higher use of physical restraints among African-Americans and the less optimal treatment options being offered and delivered to them. So racism then becomes a great deal more than merely being a social issue or just an issue of psychological well-being or even just an issue of human development. Now moving on to section two, which is where the bulk of our diagnostic criteria are. If you are tracking a copy of DSM with you, we're just going to work our way through the major diagnostic categories in order, highlight some of the most interesting changes, and they've been formatted here by correlating each respective section of text from the DSM-5 with the updated text in the text revision wherever possible, and the changes are highlighted in red to make it easier for you to see. But really there's no need to read these slides. You can really just listen and get the material from that. So to begin, when exploring the neurodevelopmental disorders chapter, autism spectrum disorder was one diagnosis that was specifically updated within the prevalence section. The revision committees made mention of the fact that even after controlling for socioeconomic factors, the lower prevalence of this diagnosis among US black and Latinx children has been shown to potentially be explained by other misdiagnosed conditions in its place, one such diagnosis being conduct disorder, and that this diagnosis is reciprocally less often diagnosed in white children. Additionally, the committees made updates to the sex and gender related issues section for this diagnosis. When it comes to accurate diagnostic features of ASD for females, for example, we have come to now realize some of the reasons why the age at diagnosis is later in females versus males. According to a 2015 study, clinical samples revealed that females with ASD are being more likely to show in accompanying intellectual developmental disorder, and another study from 2011 suggested that girls without intellectual impairments or language delays may go unrecognized, and that this is due to subtler manifestations of social and communication difficulties than their male counterparts. Also in comparison with males, a 2015 study showed that females are more likely to share in their interests of others and then to modify their behavior by situation despite having similar social understanding difficulties as males. Females with ASD are also more likely to attempt to hide or mask autistic behaviors by copying the dress, voice, and manner of socially successful women. So here we can begin to build a picture in our minds of why girls and women are frequently underdiagnosed and why their prevalence is skewed by age at detection. Next, we have attention deficit hyperactivity disorder, and under the associated features section supporting this diagnosis, there's now an expanded description of some of the mood features of ADHD. This includes being quick to anger or frustration and being observed to be more emotionally overreactive. I point this out because these are features that emerge as ones that are more easily misinterpreted in socially oppressed ethnic or racialized groups. And when juxtaposed with the fact that foster children or inmates, for example, have a much higher prevalence of this diagnosis, we begin to see a fuller picture of why these same populations are frequently misdiagnosed with other things like oppositional defiant disorder or conduct disorder rather than being considered to potentially have ADHD. And when it comes to white children with a disorder, a 2020 study did find them to have a higher prevalence rate that was also linked to greater parental demand for this diagnosis in that demographic. So this then further skews the data in terms of who is actually being overdiagnosed versus who is still being underdiagnosed. Another thing I'd like to point out about ADHD, which I didn't outline here, is that the differential diagnoses listed under ADHD have been updated with the addition of post-traumatic stress disorder as one for consideration. And this was due to the fact that concentration difficulties are also associated with PTSD, especially in children under the age of six who were found in two different studies over the past 15 years to have often manifested PTSD with nonspecific symptoms such as restlessness, irritability, inattention, and poor concentration, all of which can mimic ADHD. Schizophrenia spectrum disorders had multiple updates within the sections on environmental, gender, and culture-related issues. So we have a couple slides dedicated to that diagnosis and features here. Here we can note that social deprivation and adversity have been shown to be associated with increased rates of this diagnosis in some patient populations, notably within refugee and migrant communities. And of note, ethnic discrimination has been found to be an independent contributor to stress responses and mental disorders in migrant women specifically. Also, the severity of adverse childhood experiences has been shown to directly correlate with the severity of both positive and negative symptoms in those diagnosed with schizophrenia. And multiple studies throughout the last decade that examined these groups with a higher prevalence of schizophrenia have also found higher rates of not only discrimination and stigmatization, but also of social isolation and poor access to what they phrase as normalizing explanations of abnormal beliefs or perceptual experiences. These observations have contributed to the reasons why living in areas with lower proportions of people from similar ethno-racial backgrounds has been associated with higher rates of schizophrenia. In terms of updates to the gender-related issues for this diagnosis, there has been an expansion in the explanation of the previously identified features of later age of onset, higher prevalence of affect-laden symptoms, and worsening psychotic symptoms later in life for females specifically. And all of these were mentioned in the DSM-5, but the text revision specifically now makes mention of lower estrogen levels during both menses and during menopause as being periods in which psychotic symptoms are observed to worsen in women, as well as the fact that this association is further strengthened by the observation of improvement in the symptoms during pregnancy when estrogen levels are higher. We can again see here that the DSM-5 TR has really strived to again call attention to the fact that African-Americans are more likely to be diagnosed with schizophrenia than they are with mood disorders with psychotic features, for example, and it lists eight different studies here that point to racism and discrimination as reasons that the quality of information leading to these diagnoses has been poor up until recently. So this group in particular has really suffered from worse diagnostic precision than other patient populations. Next, we have bipolar 1 disorder, which underwent some culture-related diagnostic issues updates. Interestingly, the text revision now notes that countries with reward-oriented cultural values, in which individual pursuit of reward is valued more heavily, these countries also have a higher prevalence of bipolar disorder than countries without this cultural distinction. The DSM-5 had also noted that the prevalence of bipolar 1 disorder is lower among African-American blacks specifically, and the TR then cites evidence that this is due to higher inaccuracy in the assessment of psychotic symptoms, which has led to inappropriate treatment approaches and thus suboptimal outcomes in this group. And in fact, three decades of research in the U.S. have shown that blacks are at higher risk of being diagnosed with schizophrenia than whites, even when they are actually presenting with symptoms of bipolar disorder. One clinical example of why this might be was specifically cited in the text revision, and that was the misinterpretation of cultural mistrust as instead being a feature of paranoia. In actuality, this mistrust is often born in quite accurate historical contexts, as my colleague just beautifully pointed out, of the persistent and well-documented mistreatment, misrepresentation, and misinterpretation of black Americans. When it comes to gender-related diagnostic issues for bipolar 1 disorder, we see yet again a similar phenomenon as was detailed for schizophrenia, in which DSM-5-TR specifically explains the reasons for differing presentation between men and women, again related to decreasing estrogen levels. Estrogen, again, is highly correlated with the worst course of this illness and now has been specified as the higher risk of mood episodes that exist in pregnant women with bipolar 1 disorder unless they have discontinued their medications for the pregnancy, in which case they do not share that elevated risk. And because the increase in mood episodes in the postpartum period when estrogen levels are again decreasing, the specifier with peripartum onset is now highlighted for mood episodes that begin during pregnancy or within four weeks of delivery. Finally, we can see detailed here that postpartum psychosis strongly resembles a manic or a mixed mood episode with psychotic symptoms, and this diagnosis is strongly associated with bipolar 1 disorder. When it comes to the DeFlorio and Jones 2010 study that has been cited here, the study actually stated that one study estimated women were over 23 times more likely to be admitted with an episode of bipolar disorder in the first postpartum month. The association between childbirth and the triggering of severe postpartum episodes in this disorder may rank as one of the strongest associations in all of psychiatry. That's what the study says. So I think this statement in and of itself justifies so much of the work that these cross-cutting committees and working groups performed in order to help highlight these diagnostic disparities. When it comes to bipolar 2 disorder, the TR makes mention of the common co-occurrence of both premenstrual syndrome and premenstrual dysphoric disorder with bipolar disorder in women, as was done previously in the DSM-5, as well as the higher severity of mood lability in these patients. But the TR now goes on to feature a discussion about the coexistence of both insomnia and hypersomnia as being over- represented in women with bipolar 2. Interestingly, this is also a common feature in major depressive disorder, but not to the same degree as it is seen in women with bipolar 2 disorder. The text then points out that atypical depressive symptoms, such as hypersomnia and hyperphagia, are also over-represented in bipolar 2, and that hypomanic symptoms that co-occur with depressive symptoms are over-represented in females with bipolar 2, especially those who are labeled as having mixed features. This sort of hypomania has been otherwise interpreted as being presenting symptoms of depression with either increased energy or irritability, when in fact they may actually be depressive symptoms co-occurring with a hypomanic episode or hypomanic symptoms with a depressive episode. Speaking of major depressive disorder, again here TR points out the stage between menarche and menopause as being behind the reasons that women experience double the rate of MDD than men, beginning during adolescence. They also experience more atypical symptoms, such as increased appetite or latent paralysis. So overall, now across three different disorders that cross the spectrum of both psychotic and mood disorders, TR has made an incredible case for understanding the effect of hormones, specifically estrogen, on how psychiatric illnesses present much differently in women. Next, as we come to the trauma and stressor-related disorders section, TR includes extensively updated diagnostic features for the diagnosis. More specifically, it expanded the definition and description of qualifying criterion A1 experiences. So this can now include things like acute myocardial infarction, debridement of severe burn wounds, emergency cardioversion, parents witnessing their child in an acute life-endangering incident, such as a diving accident, and also indirect exposure of professionals to grotesque effects of war, rape, genocide, or abusive violence inflicted on others. They include first responders, military personnel who collect human remains, and here on this slide, I've highlighted the updated definition of sexual trauma, which can be now alcohol or drug facilitated. It can look like being forced to watch pornography, visual and unwanted exposure to genitalia, and being victim to unwanted photography or videotaping, or the unwanted dissemination of those types of media. And bullying can now be a source of A1 trauma when there is a credible threat of violence. The battery is about to run out here, it just told me. So I apologize if it runs out. Additionally, DSM-5-TR lists things like drone operators, members of the news media covering traumatic events, and even psychotherapists who are exposed to details of their patients' traumatic experiences. Next is a section on gender dysphoria, of which we have about four slides worth of material dedicated to this section. So the first thing I'd like to point out is the introduction section for gender dysphoria. There has been a thoughtful word change to rename disorders of sex development to disorders or differences, and it also goes on to point out that traditionally, gender assignments have been based on phenotypic sex alone, as we discussed earlier. This leads to discussion about why terms like assigned sex and assigned gender can now be used to also reference reassignments made during early childhood, and as can the terms gender non-conforming, gender variant, and gender diverse. Then under the section on associated features, TR goes on to point out new evidence that autism spectrum traits have been observed to be overrepresented in all age groups with gender dysphoria specifically. The TR has three studies now cited that have also shown that those with ASD, Autism Spectrum Disorder, are more likely to exhibit gender diversity. And additionally, we can now see three studies cited here all within the last 10 years that have shown that the behavioral and emotional issues that prepubertal children with gender dysphoria face are directly correlated with the amount of non-acceptance they encounter socially on behalf of others. Both children and adolescents who do feel supported and accepted in their gender non-conformity may show less or even no psychological problems whatsoever. This is a really powerful statement as it shows how integral the core of public opinion can be towards the development of both self-esteem and self-regulatory behaviors of these age groups. Next year, we can see an entirely new section that was added under gender dysphoria in which the diagnosis is pointed out to have an association with suicidal thoughts or behavior. Transgender individuals have suicidality rates that range from 30 to 80 percent. And though some risk factors like depression, past maltreatment, or substance use do not seem that much different than the general population, they do have additional risk factors for suicidality including gender victimization. They also display suicidality at a younger age than others. Interestingly, both suicidal thoughts and suicide attempts have been shown to be higher before gender-affirming treatment as shown by two studies in 2016. And though some continue to suffer from anxiety or other affective symptoms afterwards, one study in 2020 did know an improvement in these symptoms after gender-affirming treatment. Yet the text is also purposeful in still pointing out that even children who were referred for gender identity concerns, they were still 8.6 times more likely to self-harm or attempt suicide than other groups, especially during adolescence. As the section on gender dysphoria continues, again it makes mention of the fact that hostile, discriminatory, non-supportive, and non-accepting environment, both among family and others, that is an integral part of why it's associated with negative self-concept, depression, and suicidality. Also named here are second order effects of school dropout, unemployment, economic marginalization, and reduced access to mental health services. Next, we have some updates to the substance-related and addictive disorders section, and more specifically within the prevalence and culture-related diagnostic issues for alcohol use disorder. In the previous version of DSM-5, we can see here that it made mention of a higher prevalence of alcohol use disorder among Native Americans and Alaska Natives, at about 12%. In the text revision, however, there was inclusion of community-based survey data of Native Americans from Southwestern and Northern Plains tribal nations, which showed a much wider prevalence range among those tribes. It also points out that there are over 570 American Indian and Alaska Native communities within the United States alone, creating diversity not only in those afflicted, but also in the rates of abstinence, which are also quite high in some of those same communities. And the text now points out that an increased risk of alcohol use disorder has been found in those who experienced dispossession, subjugation, and ongoing discrimination in this country, to add more of a context as to reasons why the disorder pervades these communities in particular. The final diagnostic section I would like to bring everyone's attention to is within the neurocognitive disorders, specifically Alzheimer's disease. When it comes to the development and course of the disease, the TR expands on the previously accepted 8th and 9th decades as the typical onset of symptoms. It points out, for example, that U.S. Latinx patients can develop symptoms up to four years earlier than whites, and that African-Americans tend to show much slower cognitive decline. Interestingly, these groups have also been shown to have longer survival periods than non-Latinx whites, and it lists updated risk factors for the development of Alzheimer's, which now includes things like lower educational status, social isolation, and also in addition to the medical afflictions, such as hypertension, obesity, or diabetes. Here we can see that while age is still the strongest risk factor by prevalence alone, the genetic susceptibility profile differs by ethno-racial group. The examples shown here are that the APOE4 gene association has not been consistently found among non-white patients, but that a mutation in the glycine 206 alanine presenilin 1 gene was found to be prevalent in Puerto Rican patients with the disease, and that this was also related to earlier age of onset. It also points out that there's a stronger association with ABCA7 protein transporter gene, and that was found among African-Americans with the disease. So this is another example of why participant representation in these studies does actually make a huge difference, as it can impact the stage at which the disease is diagnosed, the prognosis, and even the efficacy of any future treatment options that may be found. Lastly, there have been updates to the sex and gender related diagnostic issues associated with Alzheimer's disease as well, and I'm really excited about this one because I thought it was really interesting. The newly written section points out that though a higher incidence of Alzheimer's was found in European women, the incidence was similar between men and women in North America. And though previous studies determined that dementia progresses faster in women, a newer study from 2019 points out that women's higher performance on verbal memory tests means that the cutoff scores being used were actually making the diagnoses less accurate for this group. Specifically, the study states using sex-adjusted norms or cut scores led to a significant reduction in diagnostic error rate for women. And a particularly noteworthy finding was the almost five-fold higher likelihood of having an APOE4 allele in the false negative versus the true negative women. So this suggests that the cognitive reserve offered by the female advantage in verbal memory may be most salient for these APOE4 carriers. And the female APOE4 carriers are then most at risk of a missed diagnosis. So with that, this concludes our presentation section for this topic and that we will now transition to a panel discussion in which we'll open up the floor for questions and further discussion from the audience. Thank you. Thanks, that was great. I think I'll ask the first question. Primarily, Dr. Harrison, my question is how did you do it? These things tend to take years or even a decade or more to get through a process like you went through. And then if you just, anything that your subject matter expertise brings to the table that you'd like for us to know, I'd love to hear that as well. All right, thank you for the question. How did we do this? It was a lot. It was a lot of work and I would like to say that my co-chair was Dr. Roberto Luis Fernandez who took a huge lead in this and really going through all of the literature. When I was asked to do this, I didn't really want to do it, to be honest. But Altha Stewart, who was the first black president of the APA, said, Dr. Harris, we really need you to do this. And Helena Hansen said, can you just do it? It's not gonna, it's gonna take a little of your time. I was like, okay, maybe just a little of my time. What I thought was gonna be just a few weeks turned out to be several months and we had to go through line by line. Like, you know, the DSM is not light reading. We had to go through line by line and anything that we wanted to change, we had to have multiple resources, multiple sources to justify the change. Also, we had to go through legal, so the lawyers had to be there, too, in all of our meetings to make sure we weren't saying anything that was illegal. And we also had a team of, I think there were about 14 or so of us, who would go through this and we would say, well, this is the section we're gonna go through tonight, and then everyone would look at all of the data for this. And I think going into it, the research that I do and what I write about, because one of my mentors here, Dr. William Lawson, is about the over-diagnosis of schizophrenia in black men and the use of restraints and the use of higher doses of antipsychotics. So I think going into it, I was like, okay, I'm just gonna focus on the schizophrenia. I'm just gonna listen. I'm not gonna do too much about the other things. But then every line, we would notice, we would, someone would bring up, well, we can't bring up this or we can't miss this. This has to be included. So I think going in, my focus points were the over-diagnosis of schizophrenia in black males, also including racism as a source of trauma that had to be a part of it. And, but then even the first meeting we had, we had to talk about the language and the language changing. So when Dr. Passarella brought up that Latinx was in there, it was a whole controversy. It took like a whole meeting just talking about Latinx and whether or not Latinx is acceptable, who uses it, who doesn't use it, if we can continue this. So that was one of the controversies. Also, we were making statements when we were discussing an Indigenous population substance use. I thought it was important that if we are gonna say that there's a higher rate of alcohol use disorder in Indigenous and Native populations, you're gonna explain why. Because of the trauma and the historical trauma that they've gone through. So this DSM-5 iteration was really important, not just to state the facts, but to understand what was going on behind it. And it took hours and hours. Also, I was pregnant at the time, so it seemed extra long every second of the day. But I felt it was important work. So I was dedicated to the cause. I'm known for calling the APA out for knowing more things. So I am appreciative that they have done, not appreciative because they needed to do it, but I am recognizing, I will say, that they did this work. I wanted to also say, from Dr. Bell, went through all the history. It's important for us to know that this organization was, in psychiatry as a subspecialty of medicine, was based in racism. And that it perpetuated racism. As you saw, there was a 2021 apology letter from the APA because of the racism that they were complacent with, and that they allowed to be continued. So if you go and look in the APA Learning Resource Center, there's a talk that I did about drafts mania. Well, drafts mania to schizophrenia. I think it's gonna be up there until September. You can get CME credits for that. Just to understand a little bit more what Dr. Bell was saying, like how we got to here, how we got to where we are, and understanding that even Benjamin Rush, who's been a part of the APA's logo for all of this time, was perpetuating a term or diagnosis called negritude, and how people were mentally ill because of the color of their skin. So we have to understand where we came through in the historical context for that. Another one that we didn't bring up, that I wasn't even thinking about when we were working on this, was antisocial personality disorder. I think it's commonly assumed or discussed in residency training in medical school that, oh, black males are in the carceral system, so there must be a higher rate of antisocial personality disorders with black men. But actually, what the data shows, time and time again, is that it's actually white males who are more likely to have... And more likely to have and be diagnosed. I see some of you are like, we knew that. But are more likely to be diagnosed with antisocial personality disorder. So things like that came up. Also, I don't treat children unless they come into the emergency room. A shout out to all of you who are child psychiatrists. When we thought of... When we discussed all the child topics, and something that Alpha Stewart also says is, don't ask what's wrong with the child, but what happened to the child. And really moving away from the conduct disorder or oppositional defiant disorder, and the bad kid diagnoses, and understanding the missed trauma, the missed anxiety, the missed mood disorders in these children. So it was important to me, even though I was dragging during these meetings, it was very challenging for me to make sure that this is something that's going to be here forever, that it's going to last. And that when the next iteration, DSM six comes out, with Dr. Bell and Dr. Passeron, not me. When they are working on those things, that we have laid the framework, that this is how this document should be. This is supposed to be the quote unquote, no religious, but the quote unquote Bible for psychiatry and for mental health and behavioral health disorders, and it has to be on a different level. We have to level up here. So I think that was what was important here for me and my crew. It was important that... To understand, we didn't agree on everything. Sometimes I would say, why are we talking about this? This is not important. Or sometimes someone would say, we need to change this. And I would say, oh, I didn't even think about that. Like, yes, this language is important. It was important to really identify that we talk about racialized groups, because it was important that people understand that this was a social construct. And yes, now these groups are in place, but know that it wasn't based in biology. And that even though people are called minorities, there was a little disagreement about minoritized, or if we were gonna use that or not, that although black and brown people are the global majority, they're called minorities here in the US. So a lot of language, a lot of things had to be paid attention to, some things that I didn't even think of. So it was good that we had a whole team of 14 plus people to participate. So if you do read this, and when there is a DSM 6, just understand all the work that it took to get into it, just to make a change on one line. You saw she said, oh, these three lines, I'd have eight resources to go along with it. So it was a lot of work. And I just also want to say that I am now happy and appreciative of being in a place where one of my students can say, oh, I got the slides for you, Dr. Harrison. You just have to sit up there. I'm on a new level. So I'm appreciative of Dr. Passarella for putting those slides together to really show you all the work that we've done for this document. Can you put an hour number on, just thumbnail, how many hours you spent on that? Oh, man, it was three months and at least, like three hours a meeting, maybe two or three hours per meeting, or three months, and you're pregnant. Yes. A lot. I don't know how many hours is that. A lot of hours. A lot. Well, thanks for doing that work. Dr. Ruslan? Hey, thank you so much, y'all, for this work. It's made me reflect a lot on some of the more challenging patients that I've had in residency and kind of reflecting on how I might have failed them given my own misperceptions of a lot of the things that y'all have updated in the DSM-TR. So my question for you is, as we gain new knowledge about our own misconceptions on these patients, especially the low SES autism spectrum disorder patients and how they can be misperceived as conduct disorder or other psychiatric illness that's not neurodevelopmental, do you have any advice on how to best approach both this AUD diagnosis in patients in which collateral is limited and we have a lot of bias against the population implicitly and also how we can kind of move forward as trainees to kind of bridge this gap of the things that we're learning that are new that we just might not have any experience or training on kind of how to do the right thing for our patients. Thank you. Thank you for that question. My question. So I'll just, I'll start by saying, having forums like this, we're all doers in this room and I feel like sometimes it's important just to take a step back and recognize that simply sitting through and listening to these things does start to change some of our thought process and it does make us more aware of what's going on and it does make us more purposeful in the future. So we are doing by being listeners and being considerate of new ways of thinking of things. And another thing I've found helpful is to just always be curious. And Dr. Tyson at Children's National, she taught me so much in the short time I worked with her but there can be a lot of contention between different levels of training that practice psychiatry and if you always approach it as being curious and wanting to help others learn better, it just fosters a much more productive conversation, I think. Anything to add to that? I'll add to that, that this is not the time to be comfortable. We're beyond the time to be comfortable. So you need to ask questions. You need to ask questions of others, like of your colleagues, of your attendings in a respectful way. Like, well, why are we doing this? Or how do we get to this? Or what led to this? But not just asking questions of others, asking questions of yourself. Like, is this the treatment that this person should get? Is this the evidence-based next step, next best step in treatment? Is that what I'm doing? Is this the treatment that I would want someone to give my family member, someone I care about, significant other? Is that what is appropriate? Despite your misconceptions, despite the biases that you have, you also have to ask yourself this and check yourself. And that's for all of us. I know that I used to work in a certain area and there would be a certain patient population that always seemed to trigger me. And I would just say like, I don't even wanna deal with this. I know you're just gonna be like the same person that I've already seen. And I had to say and ask myself, like, why am I doing this? What led to these thoughts? Is this the treatment that this person should get? And just anecdotally, I will say that I used to work in Baltimore and I'm a consultation liaison psychiatrist if we didn't say that earlier. And I only see children if they come to the emergency room. And there was a child that came in, I did maybe two shifts a week or something at this time. And the child came in one shift and like a Thursday. And they said, oh, well, he jumped out of a car. His case manager was picking him up from school and he jumped out of a car. We don't know what's wrong with him. Can you like, I think we think he needs to go to a higher level school. Like we think he needs to go to a level five school. And I was like, well, why did he jump out of the car? And everyone's like, I don't know. He's like, he's a bad kid. Why did he jump out of the car? And then I asked him, why did you jump out of the car? Little eight year old, why did you jump out of the car? And he said, well, was I had a stick in school and they told me that I was gonna get in trouble. And then my case manager was going to, I was getting in trouble. So I thought that meant I was going to jail. And he said, I don't wanna go to jail, do you? I said, no, I don't wanna go to jail either. And he was like, well, that's why I jumped out the car because I thought my case manager was gonna take me to jail. And he had seen other people in his neighborhood and his community have interactions with the police and he was trying to avoid that. So when we're considering these diagnoses, asking questions is important. Asking questions of everyone is important and asking questions to further understand what's happening with your patients is important. That's what I would add. I want to thank Dr. Harrison and her team in terms of doing what I think is one of those monumental changes in the field and laying the foundation for going forward. Just want to note a few points. An excellent discussion in terms of history. The disturbing thing is a lot of what you said is not history. It's going on at the present time. We're still doing lobotomies. That's still an accepted treatment in parts of the U.S. and all of us, especially in terms of obsessive compulsive disorder. And we're still having folks admitted to psychiatric hospitals, as I call it, illegal way of getting a divorce. You don't like your wife, she's having a behavioral problem. So we have to put her in a hospital, perhaps for a long period of time with one of these disorders that you described. The other point that still continues to be a challenge is that the DSTR and ALBAs have to depend on the existing data. And unfortunately, there are large parts of the field that have not been studied as appropriately as it should. There's a major difference between what's being done in psychiatry. If you look at other fields, you look at what's going to internal medicine and surgery and others, which have much more of an international flavor than psychiatry does. And it's becoming important in terms of psychiatry because of immigration, shifting of populations and geography, that a lot of the focus that was done before in terms of white folks, as much of the data is based on, has become irrelevant. We still use the term African American. What does that mean? We found half of the folks that are referred to as, quotes, African American in the DC area are from Native Africans that, on the other hand, had not experienced the whole impact of slavery, so forth and so on, in terms of their history. Yes, Doctor. And in terms of the focus on developing a better system, a major problem is that how are you going to get people to use it? We're going to discuss that some tomorrow at my talk. But we're going to discuss all the ramifications of modifying DSM, we want to, if people in the criminal justice system, in terms of emergency rooms, in terms of everyday life, do not use this criterion or work on it systematically, and especially in terms of our mental health clinics, it's not going to happen. So I'd like the panelists to discuss how can we use this wonderful database in a way that's usable in terms of everyday clinical practice? Okay, that was a lot, Doctor Lawson. William Lawson, the legendary here. Okay, I just want to address a couple things that Doctor Lawson said. One is that, yes, we had to, when we made changes to the fourth TR, it can only be changes or adaptions to what's already there. So it can only be a modification, if that makes sense, or deleting or adding, but it couldn't, or adding to something that's already existing. So if you, a whole nother talk that I did this morning about considering whether or not witnessing trauma or vicarious trauma should be included in DSM, I guess, six, because we couldn't make those changes for the DSM-5 TR because you cannot add a whole different thing. It has to go through a different process that I encourage all of you to think about. It is important to understand that, yes, while we are saying we're making these changes and the psychiatrists will adapt and mitigate the differences in their assessments and their treatments, we do have to understand that we're not the only people who are involved in the mental health treatment of people in this country. So there are, there's the carceral system, there's the, not justice, injustice, there's the legal system, thank you. There's the legal system, there's the education system. Even within medicine, like emergency medicine, there's the, what is the diagnosis that emergency room doctors say that they use, an EMS for giving high doses of ketamine to patients? What's that diagnosis they say? That's not a real diagnosis. Thank you, agitated delirium, that they say that agitated delirium is a cause of death, that pathologists had to come through and say it's actually not a thing, like that it's, we don't know where you got that from. And then they thought that they got it from psychiatrists, but they didn't know where they got it from. So unless there are changes at a societal level, yes, this is not gonna have the same impact that we wish it would be. And I think what's gonna help is visibility and bringing more light to the issues. Again, not just the changes in the diagnosis, but the reasons behind the things. What are the higher upstream things, the structural issues that are in place that have led us to these changes? Do you think that, how do we not lose momentum when the DSM-6 comes around, that the right people will be at the table to make some of those definitive changes that you weren't able to do? I think it's gonna take advocates like these, oh, I'm a millennial, but a Jerry millennial or something like that. And the, what's after me? Generation Z? Z, Gen Z. The Z-ers, yes, okay. People like them and people like Dr. Bell and Dr. Passarella are gonna have to advocate. They're gonna have to say, because I'm retiring when I turn 40 and I'm close. So, you're gonna have to advocate. You're gonna, you do, everyone does so well advocating now, they're gonna have to continue that to continue to make these changes. You can't just say, okay, well, we accept that we got this. Oh, okay, racism is now a source of trauma. We're gonna just take that. You have to keep pushing for further changes. Sir? Yes, hi, I'm Roberto Luis Fernandez, the co-chair with the- I think everyone should give him a hand because that's the real man behind the- Thank you. That's the real reason I stood up to ask a question. No, you did a great job summarizing, all of you, summarizing the changes and the process. It was wonderful. One thing that I think we can use some of this time to reflect on is, since the DSM is an evolving process and you've already mentioned there, in the future, there'll be changes to the DSM, what is it that we haven't done yet regarding social determinants of health and their relationship to psychiatric diagnoses that could be a next step in the work that this committee engaged in and other committees engaged in too for DSM? And in particular, I'm thinking, for example, of the ways in which we could improve the assessment of social determinants in the DSM assessment side, because it has a section on assessments, and also, especially with the loss of Axis IV, which used to, in DSM-5, which used to link the V codes and other social determinant type characteristics with diagnoses. We no longer have that kind of a system in the DSM. What kind of assessment side and what kind of linkage between social determinant understanding and diagnosis could we better build into the DSM as it improves? I know you know this answer. And research. Well, so I will say, similar to what we did for the diagnosis for the indigenous or native people who with the alcohol use disorder, that further explanation should be a part. That further explanation should be there for, we didn't have that much time. We had a deadline. So that further explanation should be there also for the schizophrenia diagnosis, for the psychotic. They are more likely to be, they're more likely to be diagnosed with this because of this, because of what's happened in this society. When people who immigrate are more likely to have psychotic episodes when they get to this country because of this and explain this. So that's where we could take it to a different level. And then as far as the assessment aspect, Helena Hanson, Jonathan Metzl are great people who write about structural competency and doing a structural interview as well as Morgan Medlot. Like understanding, taking a structural history so you understand what structures are at play when you're interviewing your patients, when you're assessing them. Because if you're saying, oh, I'm doing this assessment and they have a history of non-compliance. All right. People love to write that. They have a history of non-compliance. They're not adhering to treatment. Why are they not? What's going on? What's at play on them? What's been on play, what's been playing on them for generations, their family and all the things that are going on. So actually doing a structural history is something that we could address in DSM 6, 7, 8, 1,000, whatever versions there are going to be. Actually including that, having tried to get Helena Hanson, Jonathan Metzl to collaborate on that. Like how we can improve this to expand. I think coming here to San Francisco, I'm in a group that will remain anonymous for now, like a social media group. And a lot of people in the group were saying, well, I don't want to go to San Francisco because of all the homelessness. Like there's so many homeless people. I don't want to go there. Homelessness and crimes. And I was like, what? I think it didn't even occur to me that I see patients who are experiencing homelessness every day. Like that's a daily part of my practice. So for a patient, for a psychiatrist to make statements like that, I was like, you don't have homeless patients? Is what I was just thinking. I couldn't even understand that concept. But if you do not have homeless patients, then let's have this DSM 678 to explain to you what it's like and how they got there. Because you all seem to be confused and you seem to be having a misunderstanding about homelessness and the connection between homelessness and lacking a stable housing. And what led to that redlining, we can talk about that, all of the things. And how that impacts mental health and people's ability to adhere to treatment. So when you're writing here, it's not adherent to treatment, what that language really means. Not to mention that crime data is demonstrably false, right? Right. That cities are not more violent than rural areas. We only have two minutes, so hopefully a quick question. Yes, hi, I'm Ensign Greenhalgh. I'm from Uniformed Services University. And I guess my question is, since there has been an evolution towards the identity mentions in the DSM towards de-stigmatizing it, I was wondering what the future of the term gender dysphoria is, and if there's any push to ultimately remove it from the DSM. To remove gender dysphoria? Yes, or just like identify, or diagnosing identity as inherently a mental health illness. So I think this is something we also try to highlight in that it's not that it's their stress or the level of stress or anxiety in dealing with this. Not that you questioning your identity as a mental health disorder. And I think that's what we tried to explain further. But then again, I have to explain this in a way of, it's not just what psychiatrists are saying, but I'm going to go back to what Dr. Lawson said, because if I am going to do a psychiatric evaluation and recommend that, yes, my patient is clear, good to go for gender affirming surgery, they're gonna ask for a diagnosis. And the diagnosis they're asking for and looking for is gender dysphoria. So I don't wanna completely eliminate that because although in psychiatry and behavioral health, we are ready to move forward, insurance companies and surgeons are not on the same page. So unless we are all on the same page, it's not the time, in my opinion, as a subject matter expert, it's not a time that we have that right now that we can delete this. But I think we can change the language to what we're talking about. It's the response, not the thought or the questioning that's the issue. Thank you for that question. I would also say as a transgender care team champion from 2014 to 2018, in the military, it's a big issue because you, as Dr. Hairston mentioned, we had to start with the diagnosis of gender dysphoria before we could offer any treatment to the soldiers. And so it has to be something there, particularly for rigid organizations like the military to sort of be able to put their ducks in a row. Not just like the military, also the medical system also has the same level of rigidity. Thank you, everybody. I know it's late. I hope you get to have some dinner. Thank you.

DSM-5-TR

cultural disparities

racial biases

psychiatric disorders

diagnostic accuracy

historical context

Dr. Hines

Dr. Harrison

Dr. Candice Passarella

Dr. Alex Bell

social determinants

mental health equity