good evening and welcome to doctors on call I'm Mary Morehouse psychotherapist at Insight Counseling duth where I specialize in working with anxiety for teens young adults and parents I'm your host for our program tonight on the dsm5 Comes Alive the sex the success of this program is very dependent on you the viewer so please call in your questions or send them in our email at ask pbsn north.org our panelists this evening include Dr Nathan Chan a psychiatrist at Aspirus St Luke's Behavior Health Clinic in duth Mike claya lgsw at Insight Counseling duth and Dr David plude psychologist at Arrowhead Psychological Clinic in duth volunteers are standing by to answer your calls and now on to tonight's program the DSM 5 Comes Alive all right thank you uh gentlemen uh so much for coming uh on this show so the dsm5 comes alive so just so everyone knows what the dsm5 is it's kind of our the the the Bible for psychology it's the diagnostic and statistical manual the fifth edition and so this is the manual of all psychological disorders that we have to that that we treat and so that we have to that that that are available to us and so that is what I mean by the dsm5 comes Al and so it is kind of this broad kind of a question and there's so much out there on social media of um you know oh I have anxiety oh I'm just I'm so depressed I'm so OCD and so all these psychological terms are being thrown around which is great that we're talking about mental health more but I thought this would be a great opportunity to use you know a group of experts um to to try and um answer some of those questions so first of all I'm going to have you go along and just answer um just tell me a little bit about what your specialty is um Dr Chan yeah so I'm um uh General adult psychiatrist um at as Spyro St Luke's uh it's mostly 18 and up every now and then maybe a late teen uh and we kind of treat any disorder that will come into the clinic needing help whether it's mood disorders anxiety disorders ADHD substance use disorders um we don't we don't necessarily pick and choose and try to um uh you know confine ourselves to one one dis sworder of we treat whatever whatever comes in the building okay great wonderful thank you Mike tell us a little bit about where you work in your practice what you specialize in so I'm a psychotherapist at Insight Counseling and work with um anxiety depression PTSD couples um just kind of the general mental health conditions that people face and I would want to say one thing at the beginning at the outset here is I think that pretty soon we're going to get rid of the idea of these are disorders um already we say instead of you know PTSD post-traumatic stress disorder sometimes we'll just say post-traumatic stress because people there there's a stigma that goes with saying I have a disorder and I just really want to throw that out there that if you have anxiety you have anx xiety and you shouldn't really think of it as a disorder yeah and I yeah thank you very much I like that and or even I'm I am uh having these thoughts that happen to that happen to be anxious right now so even to even depersonalize them even more y all right uh Dr plug tell us a little bit about your practice and where you work yeah um I'm up at Arrowhead Psychological Clinic I've been doing counseling and and therapy and some assessment there for the past 30 years or so do a lot of couples's work a lot of family work uh started off in the career working with younger ones cuz I was such a young guy and as my hair's gotten grayer uh older populations are coming in and and families and and whatnot um do some sports psych and and uh wide variety of things yeah great Wonder wonderful we have a great a great panel here so let's um dive in so um depression and mood disorders Dr Chan if I could just start with you so um statistics range but about 7 to 10% of the you um of us adults annually are are um uh can be could be diagnosed with some sort of depression or mood disorder which is major depressive disorder um bipolar disorder and Seasonal effective disorder which if you could speak right is we live in a up here yeah up here is not so uncommon no not so uncommon so can you tell me a little bit about um how you know some of the I know this is obviously very general but you know some of the the ways that you uh would treat depression really what what do you see in your clinic with major depressive disorders sure I think it's certainly one of the the most common things that kind of presents um especially within a specialty clinic um other things like anxiety disorders often come up and and and mood disorders often come up in the primary care setting um but I think when things get severe enough and symptoms are are difficult enough to manage which which depression often is um we see it in the in a Psychiatry clinic and um our tools and our medications in particular I think are are imperfect I think um we're developing new treatments and we have a an expanding toolbox of of options um but a lot of patients are are have been through you know a gamut of of treatments that have worked partially maybe have had a lot of side effects maybe they've had difficulty you know achieving the uh remission um so our job I feel like as a specialist is to navigate what has worked what has not worked uh and try to you know tailor a regimen to a patient as a as a as an individual rather than as a a diagnosis and kind of come up with something that that may be a new Avenue of treatment or may be something that um uh it's just a different approach of what they've tried before um and we're in an era now of of I think Psychiatry psychopharmacology therapy as well as a whole where it's kind of exciting to be part of because we are developing new new treatments that are working um and they're having either less side effects or or becoming more um available um I would I would consider something like transcranial magnetic stimulation in that um category I would consider something like esketamine treatments whether it's a nasal spray or ketamine infusions as as treatments that are now more and more common um and specifically for depression specifically for depression there may be some utility in these in these um treatments in other illnesses right now just the way that payments and insurance uh uh are handled um those are the depression seems to be the most common thing that is um that is covered and available and and evidence-wise is responding best to the the methodologies we have in these treatments right now okay and actually I'm G to follow um up with you with a question and I may have to have you sure um pronounce that word okay yeah say we got is this from a caller we have is the treatment of propanel used often there you go thank you very much I think that's a I think it's a fantastic medication um I would say that the the most common use for that is something like social anxiety or or like um almost like um it's like stage fright if someone has has to give a speech has to be on stage has to plan a recital um has to be at a business meeting and they and they're noticing a lot of physiologic symptoms they're you know heart racing they can't get on stage they can't get the words out that's a medication that's been proven to kind of reduce that okay um uh kind of almost fight ORF flight response um there are some situations where it works to and lower anxiety in other situations as well the main benefit of that medication I think is that it does tend to work for that that option and it's also very safe I would consider there's there's a few few things we need to be worried about with the uh cardiac um system but outside of that it's it's one of the uh options that is is very very safe to use overall okay great thank you very much um Mike if we if you could talk about uh anxiety disorders about 19% of the US adults annually would be diagnosed with some sort of again I know we're going to use the word disorder because that's uh that's the current talk but I like where I like where we're headed for for taking off the disorder so generalized anxiety panic social anxiety and specific phobias um so again just kind of a general uh kind of what you see in the what you see in the clinic um and then like how how it presents in some of the tools kind of that that you would use yeah so I I think you know depression and anxiety are kind of the common colds of the mental health world yeah and um you know I mean in its most basic terms you depression is often focused back towards the past and anxiety is often said to be focused towards the future um a lot of people with anxiety it's all about it's worry um it's going through all the Whata ifs might happen um it's going with worst case scenarios and so forth there um and so really you know anxiety again activates that fight ORF flight um response system and and it gets them very um shaky um heart rate goes up and and it's really gets hard to think your way through your anxiety um the more you think about it the more anxious you can become and so forth there so so yeah I work with a lot of clients with anxiety and doing that and the self-fulfilling prophecy the more I say going down the rabbit holes and then the the and then's the emotion mind that you just and then this could happen and this could happen and then this and then and then off off the races we go so just trying to be able to stop that yeah and a lot of it I mean they call it the default mode Network which is you know when we're not really doing something like task Focus like making dinner or something then the default mode Network takes over and really starts to say how are we doing today how are you doing today um and then if you have a little bit of anxiety it's like well how am I doing today well I start to kick this anxiety Loop going um and it's it gets hard to get out of yeah yeah all right Dave if you could talk a little bit about um ADHD and its prevalence and so ADHD again a Autism Spectrum which I know is it but it's just also another neurodevelopmental um kind of disorder um so tell us a little bit about you know ADHD how it presents in the clinic how how you do you do testing for it and and things like that yeah ADHD is a little bit of a different animal than the depression and anxiety uh you know with depression anxiety I'd be thinking all right counseling meds exercise all wonderful interventions that can be really helpful idhd is a little bit different it's it really involves slowing the prefrontal cortex and um uh kind of slowed uh executive functions planning impulse control judgment those types of things are are the biggies there and so one of the best courses of treatment that I've seen over the past 30 years is the use of stimulant medications for correcting that um but the counseling element is really helpful too in terms of helping with parents helping with behavioral modification programs you know rewards systems that type of stuff structure organization and whatnot uh a couple other big things add is probably we did I did some research up at UMD we did free neuros pycho vals for all the student population up there like an ADHD screening at the end of the study 70% of the students that came in for the uh the study actually had some type of anxiety disorder so they're very easily confused and the only real way to flush it out from what I've seen is a little bit more of a comprehensive neuros a Val where you're actually assessing attention uh the rating scales aren't quite as accurate because if you feel you have ADHD or your parents do then they're going to say does is Johnny hyper yes right can he right and so they're they're so face valid that if you believe in it it can be misdiagnosed so they're both very real um but often times really confused and and fundamentally almost opposing conditions in terms of treatments with anxiety you're going to try to help people slow down a little bit uh with ADHD you're actually trying to stimulate the prefrontal cortex yeah at what point would um a parent or a or a a an adult to say you know what I think I think my symptoms of of of attention um deficit um are maybe rise to the to the level I might have to get tested what is that kind of litmus test for you like what is that yeah maybe you should get aesome question really for everything we've chatted about here already I remember when I was an abnormal psych and this is where we study all the diagnosis and the professor says now be careful because you're going to diagnose yourself with about 300 of these things okay but the real distinguishing factor that that I like to look for and it oftentimes spells it out in our our manual as well it's is is it interfering with relationships is it interfering with school is it interfering with work okay is it causing clinically significant difficulties in those areas and I think it fits with just about everything here more than one area in life right and so usually so if I see it so with parents I know sometimes my child may have it um at home but they are little angels at school or they you know that vice versa is it kind of that two like for kind of that yeah cuz that could be kind of a parenting type parent child dynamic or or if it's just at school it could be a teacher and child Dynamic yeah so I think if it's generalized through these different areas that's like okay let's get this checked out then it's a good idea to get checked out and then to call and get asked for a an assessment for ADHD or something yeah I mean they could get in with with a variety of counselors where they could walk through symptomology and try to determine is it is this a good one to send off for psych testing or is it clearly enough an anxiety based attention related issue or depression you guys noticed in your uh practices that there's been an increase in patients you've seen on social media or Tik Tok or something that oh you know based on Tik Tok this this 5sec clip I I probably have ADHD because I bumped into a door once yeah yeah for sure and and I mean there's even Trends diagnostically too I think '90s was the decade of ADHD and now we're kind of into the autism Trend it seems like which has become a lot more popular y a lot more popular or more recognized or more understood yeah and you know if if you're if you see these signs in your toddler there you know the early signs of autism was spinning well every toddler spins and so you know it's you you can't look at these 5 Seconds which again kind of goes back to what I was talking at at the beginning and so again there's so much talk about mental health and social media is not a bad but getting your mental health information um exclusively from social media that isn't a an established um psychiatrist psychotherapist or psychologist there's a lot of opinions out there right a lot of opinions right and so that's what so the dsm5 right these are this these are the facts right and so that's what I was kind of hoping to get you tonight yeah I would you say twoo since we brought up autism I mean it is such a spectrum condition and I think people often think of autism in Rainman you know and that it has to be that whereas um people can have autism and be very highly functioning you can't even tell that they that they have autism and so I think it's it's really important to I mean that and that's part of all the mental health conditions that we're working with is they're so varied um it's very hard to put something in a box and say okay here it is um here's all the boundaries around it um and then it's going to go from this person to that person to that person it's going to be unique everywhere yeah which is a which is a challenge right and so what I was speaking to earlier about yeah I have anxiety I have these thoughts that happen to be anxious sometimes I have these thoughts that are some some depressive I have impulse control sometimes ah these things come and go but it's not not to identify so closely sometimes with some of these mental health um things that we're talking about tonight and so I don't think no matter what your diagnosis is you are not your disorder no matter and there nowhere in any dsm5 you are not that you are the person what you spoke to like this how can I treat this person yes this may you know see a lot of anxiety and my eighth person that day that I am talking to with anxiety it is as unique as as they are right it's as unique as their fingerprints and so I think that some of these generalized things that are out there aren't as unique and I think there's actually a way to look at the DSM numbers and and make a case for that because just as an example if we look at something like major depressive disorder um the criteria you need to meet five out of seven criteria have a couple you know two two plus weeks but m mathematically there's about I think it's 227 different permutations of symptoms that can that can result in a diagnosis of major depression and you know as a clinician that that lines up because no no patient with depression is exactly the same as another patient and your approach to treatment is going to be different too um and kind of like what what Dave was saying about um you know symptoms overlapping in a lot of these things again if we look at the numbers there's there's about 250 I think 58 diagnoses in the DSM do you do you know how many symptoms there are there's there's 102 so that's to say that there's a lot of overlap and if you if you pick you know a handful of symptoms that that many people live with on a daily basis statistically you're likely to qualify for some of those things because we only have a handful of ways of describing these things even if they're just different disease processes yeah I think yeah which is a really good point with the DSM is what we're looking at are symptoms and so we're not finding the cause of the symptoms so you can't do a blood test to find depression or an fmri so we're just looking at symptomatology and then making guesses best guesses as to what's behind that and then trying to figure out the cause if we can MH yeah Y which actually leads me to our next question from a viewer talk a little bit and this I'm G to go for Dr Chan talk a little bit about why some anti-depressants work better than others depending on the person's genetics and I have again as a as a therapist I have I have had um P clients come in with their blood um results genetic gen testing and trying to figure out which comes which is heavier there anxiety or depression so those are always like which which should I treat is it the anxiety the depress which one do you think is so those are always but can you talk a little bit about this kind of this new at least in the last couple years this you know these blood tests for genetic markers for medication absolutely I think it's a very common question um we have a lot of patients who inquire about that even at the outside even if they've never tried meds U I think I think it's it's difficult to assess because I think our understanding both of our medications but also even of our the disease process of our brain is is so Advanced that it's it's tough to understand and and pick amongst our you know dozens of firstline Agents what's the right medication for for a given patient our genetic testing um I think is is okay at telling us how our medications are metabolized through our body but because we don't even have a complete understanding of the mechanism by which patients improve on these on these medications it's hard to pick even if we know the metabolism how a patient may respond uh to a medication whether or not it's it's in a green category or red category in genetic testing um the best I think genetic testing that has worked in in my practice is what has worked in the family there seems to be something related to the biology of our of our our DNA such that if ESAT talopram has worked in in a parent or or a child then it's that's a likely uh responder um for a patient um but ultimately it's just that we we don't have a a great understanding of exactly how these meds are working at you know whatever the micro level may be that we can say Yep this is the perfect Med for you we're going to give you a blood test we're going to give you this and and you're going to be great yeah not there not there yet one day maybe one day maybe but interesting um so I I'm Mike I'm gonna ask you this one about what are some of the benefits of pursuing a diagnosis of ADHD or Autism as an adult and are you ever too old for help the second question is no yeah exactly never too old that's a great question because I have worked with many people who find getting a diagnosis is completely liberating and freeing um you know if you get diagnosed with autism as an adult it can explain so much and you realize wow it wasn't me you know I'm autistic yeah and this is and that's why I have trouble with in social situations or that's why I need my space to be consistent and not have any change so yeah yeah so never too old never too old to get and never too never never too old to get help yeah um um Dave how how uh how do you treat ADHD um differently in children and adults what would be like some of the mechanisms that you would do yeah you know again going back to what we talked about earlier I think I think the stimulant medicine intervention is probably by far and the best the most effective intervention for ADHD the counseling component to it I think is very similar um uh also for for both populations it's going to be structure organization um if there's a hyperactivity component there's going to be outlets for energy um often times there's there's there's needed outlets for a creativity kind of element too uh in terms of just how folks are wired uh but it's not too different it's just that the parents are probably going to have to be managing the implementation of different structures different reminder systems um and whatnot for their child and helping them until they're capable of doing it more on their own whereas the parent can fire up the smartphone and get reminders going all over the place and get notes all over the place and and so uh I think it's really just structuring the behavioral modification organization structure in the counseling realm yeah and then you know for um a parent who has a child with ADHD who doesn't really understand it to get to get education and to kind of help because I think especially if as a smaller child gets gets diagnosed to try and understand that and that can give parents fits because there might be one parent that didn't grow up with ADHD but the other did and so the non-adhd parent is looking at their child going oh my gosh what is going on saying that's me right don't worry about it you know we'll just bring his glasses to school for him because he's going to forget them once a week you know um and and just kind of be a little bit more able to roll with it and yeah yeah yeah one's more one's more laidback and one's like I recognize this as a I could never yeah I I never been diagnosed but I forgot a lot of books at home a lot of books at home and so I think that's the kind of the nuance and so I think that that is kind of like you can have some of these elements and I you know I say this in clinic I'm like I have elements of ADHD I I wouldn't be diagnosed but you can have elements of that elements of personality disorders right and that's something we didn't touch on tonight but maybe you know next season we can do one on personality disorders of on how you know you can ele have elements of Nar they're so narcissistic or they're so OCD and things like that and so I think to kind of have that Nuance of you know we can have some of these characteristics and we have you know but we don't have to self-identify as them and so I think that that's kind of an important um I agree yeah yeah important all right all right um I want to thank our panelists Dr Nathan Chan Mike Clau and Dr David PL doctors on call is on Hiatus until the fall if you missed a program go to pbsn north.org for a complete list of shows from this season thank you for watching and for joining us all season long for doctors on call good night for