It has the distinctly uncatchy, abbreviated title DSM-5, and is known to no one outside the world of
mental health.
But, even before its publication a week on Wednesday, the fifth edition of the
Diagnostic and Statistical Manual,
psychiatry's dictionary of disorders, has triggered a bitter row that
stretches across the Atlantic and has fuelled a profound debate about
how modern society should treat mental disturbance.
Critics claim
that the
American Psychiatric Association's increasingly voluminous
manual will see millions of people unnecessarily categorised as having
psychiatric disorders. For example, shyness in children, temper tantrums
and depression following the death of a loved one could become medical
problems, treatable with
drugs. So could internet addiction.
Inevitably
such claims have given ammunition to psychiatry's critics, who believe
that many of the conditions are simply inventions dreamed up for the
benefit of pharmaceutical giants.
A disturbing picture emerges of
mutual vested interests, of a psychiatric industry in cahoots with big
pharma. As the writer, Jon Ronson, only half-joked in a recent
TED talk:
"Is it possible that the psychiatric profession has a strong desire to
label things that are essential human behaviour as a disorder?"
Psychiatry's
supporters retort that such suggestions are clumsy, misguided and
unhelpful, and complain that the much-hyped publication of the manual
has become an excuse to reheat tired arguments to attack their
profession.
But even psychiatry's defenders acknowledge that the
manual has its problems.
Allen Frances, a professor of psychiatry and
the chair of the
DSM-4 committee, used his blog to attack the production
of the new manual as "secretive, closed and sloppy", and claimed that
it "includes new diagnoses and reductions in thresholds for old ones
that expand the already stretched boundaries of psychiatry and threaten
to turn diagnostic inflation into hyperinflation".
Others in the
mental health field have gone even further in their criticism. Thomas R
Insel, director of the
National Institute of Mental Health, the American
government's leading agency on mental illness research and prevention,
recently attacked the manual's "validity".
And now, in a
significant new attack, the very nature of disorders identified by
psychiatry has been thrown into question. In an unprecedented move for a
professional body, the Division of Clinical
Psychology
(DCP), which represents more than 10,000 practitioners and is part of
the distinguished
British Psychological Society, will tomorrow publish a
statement calling for the abandonment of psychiatric diagnosis and the
development of alternatives which do not use the language of "illness"
or "disorder".
The statement claims: "
Psychiatric diagnosis is
often presented as an objective statement of fact, but is, in essence, a
clinical judgment based on observation and interpretation of behaviour
and self-report, and thus subject to variation and bias."
The
language may be arcane, but the implication is clear. According to the
DCP, "diagnoses such as schizophrenia, bipolar disorder, personality
disorder,
attention deficit hyperactivity disorder, conduct disorders
and so on" are of "limited reliability and questionable validity".
Diagnosis
is often described as the holy grail of psychiatry. Without it,
psychiatry's foundations crumble. For this reason Mary Boyle, emeritus
professor at the Univerity of East London, believes that the impact of
the DCP's statement marks a dramatic shift in the mental health debate.
"The
statement isn't just an account of the many problems of psychiatric
diagnosis and the lack of evidence to support it," she said. "It's a
call for a completely different way of thinking about mental health
problems, away from the idea that they are illnesses with primarily
biological causes."
Psychiatrists say that such claims have been
made many times before and ignore mountains of peer-reviewed papers
about the importance that biological factors play in determining mental
health, including significant work in the field of genetics. It also,
they say, misrepresents psychiatry's position by ignoring its emphasis
on the impact of the social environment on mental health.
Most
psychiatrists concede that diagnosis of psychiatric disorder is not
perfect. But, as Harold S Koplewicz, a leading child and adolescent
psychiatrist, explained in an article for the
Huffington Post,
"those lists of behaviours in the DSM, and other rating scales we use,
are tools to help us look at behaviour as objectively as possible, to
find the patterns and connections that can lead to better understanding
and treatment".
Independent experts also say that it is hard to
see how the world of mental health could function without diagnosis. "We
know that, for many people affected by a mental health problem,
receiving a diagnosis enabled by diagnostic documents like the DSM-5 can
be extremely helpful," said Paul Farmer, chief executive of the mental
health charity Mind. "A diagnosis can provide people with appropriate
treatments, and could give the person access to other support and
services, including benefits."
But even Farmer acknowledged that
diagnosis is imperfect. "For example it takes, on average, 10 years
before a person with bipolar disorder gets a correct diagnosis, which
comes with a number of mental and physical health implications, such as
side-effects from the wrong medication," he said.
But now the DCP
has transformed the debate about diagnosis by claiming that it is not
only unscientific but unhelpful and unnecessary.
"Strange though
it may sound, you do not need a diagnosis to treat people with mental
health problems," said Dr Lucy Johnstone, a consultant clinical
psychologist who helped to draw up the DCP's statement.
"We are
not denying that these people are very distressed and in need of help.
However, there is no evidence that these experiences are best understood
as illnesses with biological causes. On the contrary, there is now
overwhelming evidence that people break down as a result of a complex
mix of social and psychological circumstances – bereavement and loss,
poverty and discrimination, trauma and abuse."
Eleanor Longden,
who hears voices and was told she was a schizophrenic who would be
better off having cancer as "it would be easier to cure", explains that
her breakthrough came after a meeting with a psychiatrist who asked her
to tell him a bit about herself. In a paper for the academic journal,
Psychosis, Longden recalled: "I just looked at him and said 'I'm Eleanor, and I'm a schizophrenic'."
Longden
writes: "And in his quiet, Irish voice he said something very powerful,
'I don't want to know what other people have told you about yourself, I
want to know about you.'
"It was the first time that I had been
given the chance to see myself as a person with a life story, not as a
genetically determined schizophrenic with aberrant brain chemicals and
biological flaws and deficiencies that were beyond my power to heal."
Longden,
who is pursuing a career in academia and is now a campaigner against
diagnosis, views this conversation as a crucial first step in the
healing process that took her off medication. "I am proud to be a
voice-hearer," she writes. "It is an incredibly special and unique
experience."
Hers is an inspirational story. But to focus on one
person's experiences would be to ignore the testimonies of others who
believe that their mental distress has biomedical roots. Indeed, many
people report that they can see no clear reason for their distress and
firmly believe their life stories have little bearing on their mental
state.
Nevertheless the DCP believes the world of mental health
treatment would benefit from a "paradigm shift" so that it focused less
on the biological aspects of mental health and more on the personal and
the social.
"In essence, instead of asking 'What is wrong with
you?', we need to ask 'What has happened to you?'," Johnstone said.
"Once we know that, we can draw on psychological evidence to show how
life events and the sense that people make of them have led to the
current difficulties."
A shift away from a biological focus would
give succour to psychiatry's critics, who question society's reliance on
the use of drugs or interventions such as electroconvulsive therapy to
treat psychiatric breakdown.
Prescriptions of antidepressants increased nearly 30% in England between 2008 and 2011, the latest available data.
A recent article in the online edition of the
British Medical Journal
suggested "that only one in seven people actually benefits" from
antidepressants and claimed that three-quarters of the experts who wrote
the definitions of mental illness had links to drug companies.
Professor Sir Simon Wessely, chair of Psychological
Medicine
at King's College London (KCL), argues that his profession has always
emphasised the need to "look at the whole person, and indeed beyond the
person to their family, and to society", and that claims psychiatry is
being "taken over by the biologists" are unfounded.
This defence,
which will be outlined at a major international conference on the impact
of DSM-5, to be held at KCL at the beginning of June, is often lost in a
shrill debate.
Indeed, it is noticeable just how vocal
psychiatry's critics are becoming ahead of the publication of DSM-5. In
an attempt to pour oil on troubled waters, Professor Sue Bailey,
president of the Royal College of Psychiatrists, conceded that "many of
the criticisms that are levelled at DSM" were valid but warned that the
row was "distracting us from the real challenge, which is providing
high-quality mental health services and treatment to patients and
carers".
Bailey insisted the manual's publication "won't have any
direct influence on the diagnosis of mental illness in the NHS". But it
will frame the wider debate about how people see mental health. As
Wessely acknowledged, psychiatry's critics will seize on the manual's
"daft" new categories of mental disorder to bolster claims that the
profession is "medicalising normality".
There is an irony here.
Psychiatry lies wounded and much of the damage appears to be
self-inflicted. The emotional scars may take decades to heal.
■ Disruptive mood dysregulation disorder, or DMDD, for those diagnosed with abnormally severe and frequent temper tantrums.
■ Binge-eating disorder. For those who eat to excess 12 times in three months.
■ Hoarding disorder, defined as "persistent difficulty discarding or parting with possessions, regardless of actual value".
■
Oppositional defiant disorder, described by one critic as a condition
afflicting children who say "no" to their parents more than a certain
number of times.
The
term "gender identity disorder", for children and adults who strongly
believe they were born the wrong gender, is being replaced with "gender
dysphoria" to remove the stigma attached to the word "disorder". Experts
liken the switch to the removal of homosexuality as a disorder in the
1973 edition.
Hypersexuality
and internet addiction will both be included in a section that suggests
they could become disorders following further research.
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