It not that often that I come across an article in the Guardian that leave me grinding my teeth in sheer frustration, save for those rare occasions on which the newspaper has given Nadine Dorries an undeserved platform. However, this truly dreadful piece of naked churnalism by the paper’s health editor, Sarah Boseley, on the controversy surrounding the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) did the trick for its lazy condensation of a complex and extremely important professional debate into a few crass soundbites.
Psychologists fear US manual will widen mental illness diagnosis
Mental disorders listed in publication that should not exists, warn UK experts
Sarah Boseley, Health Editor – Thursday 9 February 2012 22.31 GMT
Hundreds of thousands of people will be labelled mentally ill because of behaviour most people would consider normal, if a new edition of what has been termed the psychiatrists’ diagnostic bible goes ahead, experts are warning.
Oh FFS, its the ‘experts are warning’ gambit, which is generally a sign that we should approach the article with a degree of skepticism and, if you do nothing else, take the time run down and verify any factual claims it contains.
So, here we have seemingly unsourced d claim by ‘experts’ that ‘hundreds of thousands of people will be labelled mentally ill because of behaviour most people would consider normal’, a claim which appear to have originated in wire copy from Reuters aimed primarily at the US market, whiuch explains why the original reads…
Millions of healthy people – including shy or defiant children, grieving relatives and people with fetishes – may be wrongly labelled mentally ill by a new international diagnostic manual, specialists said on Thursday.
I suppose we might credit Boseley with having the sense to downgrade the size of this anecdotal headline claim to something that sounds a bit more plausible in relation to the size of the UK’s population although, as the original doesn’t specify exactly how many millions of people might be allegedly affected and the UK population is only a little under a fifth of that of the US, it would only take 5 million or so healthy Americans to be be affected for the UK figure to reasonable top the one million mark, assuming that any of the concerns are at all realistic to begin with.
The basis of this particular claim stems from strong criticisms of changes within DSM-V, which are seen with some considerable justification, as amounting to a lowering of diagnostic thresholds for some common and well-recognised disorders, including major depressive disorder, contributing to an increase in the medicalisation of what should otherwise be considered to normal response to complex and stressful life events.
These criticisms are real enough, but what’s lacking in them is anything which seeks to quantify the potential effects of these change in terms of a concrete figure for an increase in ‘false positives’, i.e. overdiagnosis. In short, it would appear that these important criticisms are being rewritten to fit an established media narrative, i.e. a standard ‘health scare’ story, rather than being presented for what they are, part of a ongoing debate which goes to very heart of modern psychatric practice.
Psychiatrists and psychologists in the UK are speaking out against the publishing of DSM-5, an updated version of the Diagnostic and Statistical Manual that categorises every type of mental disorder, including some that the psychologists say should not exist.
Actually, the words used by psychologists to describe some of the proposed additions to DSM-V include, according to Reuters, “silly” and “worry and dangerous”. However, neither the Reuters original or the Guardian’s remake quite captures the context behind the proposed additions to DSM, the drafting of which has been conducted via a semi-open process under which the American Psychiatric Association has accepted, for consideration, submissions from both within and from outside the psychiatric profession. In particular, the DSM-5 taskforce has received a number of submissions from mental health advocacy groups requesting the inclusion of a number of new conditions and disorders ranging from some which are fairly well established, such as Foetal Alcohol Syndrome, through to a number of rather speculative proposals for ‘conditions’ such as ‘Internet Addiction’, ‘Apathy Syndrome’ and ‘Parental Alienation’ for which there is currently little or no empirical basis in current research literature.
To put these submissions into context, one of the many functions that DSM serves is that of providing the US health insurance industry with a master list of psychiatric conditions for insurance cover can be provided and this, as one might well imagine, creates an incentive for advocacy groups to campaign for the inclusion of their particular condition in DSM-V in the hope that this will enable them to recover the costs of treatment from insurers.
What needs to stressed here is that, at this stage, these proposed additions to DSM-V are, for the most part, nothing more than proposals. There is no guarantee than any of them will make the final draft, least of all those that psychiatric professionals currently consider to be unsubstantiated and/or of questionable validity. What the APA has done with these proposals is issue a call for comments on whether the current evidence base does, or does not, provide support for their inclusion which has, itself, proved to be a source of some considerable controversy due to the manner in which DSM exerts an influence over the activities of the health insurance industry in the US, leading to accusations that the industry, itself, exerts too great an influence and that is it attempting to keep some of these proposed conditions ‘off the books’ in order to minimise its own liabilities.
So while it is true to say that some submissions have been criticised for proposing new conditions about which psychologists are extremely skeptical, it is wrong of Reuters, The Guardian and other media organisations that have churned this particular story to imply that these conditions will be included in DSM-V by way of failing to give an adequate account of the context under which these proposals have been put forward for consideration.
A petition condemning the new manual circulated by psychologists in the United States attracted 11,000 signatures. Its predecessor, DSM-4, is used in research worldwide, and has an influence, for example, in naming conditions that pharmaceutical companies devise drugs to treat.
There are actually several petitions flying around, including petitions organised by advocacy groups seeking to secure the inclusion of many of the newly proposed conditions about which psychologist have expressed severe reservations. However, the specific petition referenced here is to be found at dsm5-reform.com and on the ipetitions website in the form of an open letter to the DSM-V taskforce and the American Psychiatric Association, This petition has been drafted by the Society of Humanistic Psychology and draws, to a considerable extent, on criticisms levelled at DSM-V by the British Psychological Society in its own formal submission to the same taskforce.
The petition has the support of the BPS and an impressive array of other professional organisations and association of, admittedly, varying degrees of credibility and it is well worth reading through in full, even if it gets a little technical at some points. However, for our purposes, I’ll be using the BPS submission and its general comments on DSM-V and the review process to explain the issues that are really at stake here..
Before looking at the BPS’s comments, its essential that we understand a little about exactly what DSM is, how its developed since its first edition (1952) and why it has long been a source of debate, dispute and controversy.
DSM is, first and foremost, a taxonomic manual of psychiatric conditions and disorders, one that systematically classifies disorders by type based on groups of behavioural characteristics that are deemed to symptomatic of specific disorders. This is, in essence, the medical model of mental illness under which each disorder is associated with a list of ‘symptoms’ which provide psychiatrist with a standardised diagnostic model, i.e. you match the patient’s symptoms to the behavioural patterns set out in the manual and, eh voila, you have your diagnosis.
When it was first introduced, back in the early 1950s, DSM was without doubt a major step forward in psychiatric practice not least because, up until that point, patient diagnoses were commonly based on nothing much more than the whims and vicissitudes of individual psychiatrists. However, right from the outset, the medical model encapsulated by DSM was somewhat controversial and drew a considerable degree of criticism from, amongst others, Jacques Lacan, Erich Fromm and Hans Eysenck. Fromm’s 1955 book, ‘The Sane Society‘ proved to be particularly influential in shaping the attitudes of what would come to be known, by the late 1960’s, as the anti-psychiatry movement, as were the later works of Michel Foucault, Thomas Szasz and R D Laing, although Laing somewhat disassociated himself from the actual term ‘anti-psychiatry’ and Szasz, a classical liberal/libertarian, disavowed the anti-psychiatry movement entirely and, by 1969, was to be found working in collaboration with Scientology in the formation of the Citizens Commission on Human Rights.
The anti-psychiatry movement is often, and somewhat inaccurately, regarded as providing a left-wing critique of psychiatric practice and the medical model of mental health, largely due to the early influence of Fromm and later roles played by Foucault and by the South African psychiatrist and trained Marxist revolutionary, David Cooper, who coined the term ‘anti-psychiatry’ in 1967. In reality it can be more accurately described as a secular humanistic critique of psychiatry and, as such, has proved to be particularly influential amongst psychologists where the humanistic outlook championed by Carl Rogers, Abraham Maslow and others tends to predominate, particularly in clinical practice.
What you need to take from this brief lesson in the history of DSM is that there nothing especially new about the current debate surrounding the development of DSM-V. Rather, all that has actually happened is that the APA’s decision to develop a new edition has reignited an internal debate with the field that has been ongoing since the 1950’s at the heart of which lie some extremely fundamental differences of opinion and outlook as to the very nature of psychiatric medicine itself.
Before moving on to the content of the BPS submission to the APA is should, perhaps, declare my own interest here. As a former psychology student I was, while at university, a student member of the British Psychological Society and although clinical psychology was not my own chosen field of study, my personal outlook fall very much within the humanistic school, so its fair to say that I am favourably disposed towards many of the criticisms that the BPS have put forward even in recognising that DSM was, in its day, an extremely important innovation in the field of psychiatry.
So, moving on to the BPS’s commentary, we begin with…
The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.
We therefore do welcome the proposal to include a profile of rating the severity of different symptoms over the preceding month. This is attractive, not only because it focuses on specific problems (see below), but because it introduces the concept of variability more fully into the system. That said, we have more concerns than plaudits.
This hints at the central question that bedevils clinical psychiatry, and psychology, much as neuroscience is is plagued by the mind-body problem and moral philosophy by the is-ought problem.
What, exactly, is ‘normal’?
Or, more precisely, how do we define what is, and isn’t, normal human behaviour in the absence of any objective, independently verifiable standards of normality?
The only viable solution we have to this problem is that of using our own society as basic reference point. Normal is whatever it takes for someone to function reasonably successfully within the confines of that society without experience too much in the way of significant and debilitating psychological distress. Normality is, first and foremost, socially constructed and therefore subjective, malleable and prone to change. It doesn’t provide us with a fixed reference point against which we can reliably assess or define certain psychological states as being either objectively normal or abnormal over time, and in terms of DSM the classic example of the kind of shifting social cultural sands on which psychiatric professionals operate is, of course, homosexuality.
Homosexuality featured in both DSM-I and DSM-II as a specific disorder until the publication of the seventh edition of DSM-II in 1974, at which point it was replaced by new category of disorder with the name ‘sexual orientation disturbance (homosexuality) the background to which is set out in this fascinating position paper/proposal by Robert L Spitzer MD which dates to June 1973. The exact nature of this shift in approach is explained by Spitzer as follows:
This revision in the nomenclature provides the possibility of finding a homosexual to be free of psychiatric disorder, and provides a means to diagnose a mental disorder whose central feature is conflict about homosexual behavior. Therefore, this change should in no way interfere with or embarrass those dedicated psychiatrists and psychoanalysts who have devoted themselves to understanding and treating those homosexuals who have been unhappy with their lot. They, and others in our field, will continue to try to help homosexuals who suffer from what we can now refer to as Sexual orientation disturbance, helping the patient accept or live with his current sexual orientation, or if he desires, helping him to change it.
In other words, its a compromise position drafted at a time when social attitudes towards homosexuality were beginning to change (for the better) but not so much as to allow the APA to drop the idea that homosexuality might cause some people to experience significant psychological distress.
With the publication of DSM-III, sexual orientation disturbance had evolved, in terms of nomenclature, into ‘ego-dystonic homosexuality’ and by this point (1980) homosexuality had firmly ceased to be regarded as a disorder of any kind – the condition that DSM-III describes is that of an individual who experience severe psychological distress as a consequence of their being unable to reconcile the sexual orientation with their own self image. However, with the release of DSM-IIIR in 1987, even ego-dystonic homosexuality was deprecated such that , today, the last vestiges of homosexuality’s treatment as a psychiatric condition are to be found under the heading “sexual disorder not otherwise specified” where “persistent and marked distress about one’s sexual orientation” is listed as symptom.
Homosexuality, of course, has not altered one jot over the last 50 years nor, despite more than 40 years of research, are we really any closer to understanding what ’causes’ homosexuality largely, and this is my own personal view based on my own reading of this research, because we’ve been asking the wrong questions all along. In terms of individual psychology, what I take from the various partial and most unsuccessful theories for the aetiology of homosexuality is that same-sex attraction is no more significant than any other type of sexual attraction such that asking ‘why are some people gay?’ is really of no more significance, in the grand scheme of things, than asking why some people prefer brunettes over blondes or why some women find bald men attractive? The underlying mechanisms for sexual attraction are, I suspect, overwhelming likely to be the same regardless of who you’re attracted to – and that goes for lesbians as well, regardless of what some radical feminists might like to believe – and, as such, homosexuality has been afforded undue and unnecessary significance within psychiatry/psychology purely for social reasons, i.e. because of the longstanding and wholly irrational religious/moral prejudices it has faced over many centuries.
So, my answer to the question ‘why are some people gay?’ is simply ‘because they are.’ and while I think that the psychology of sexual attraction is a worthy and extremely interesting field of study, in itself, I really don’t see that there’s much value in picking out homosexuality as a specific issue within this field and treating it as it if were somehow different from other forms of sexual attraction.
Getting back to the point after that brief digression, homosexuality hasn’t changed at all in the last 50 years and today’s gay men and lesbians are, in fundamental terms, no different to their counterparts of half a century ago although, of course, they do have much more freedom to be open about their sexual orientation than was once the case, the point being that the only thing that has changed over this period is society itself and its these changes, and these changes alone, that account for the changes to DSM’s treatment of homosexuality and its downgrading from a full-blown psychiatric disorder to a potential symptom of a non-specific condition the validity of which is still subject of considerable contention and dispute due to determination of some religious groups and denominations to resist changes in the moral zeitgeist that wider society has accepted.
So, we have no fixed or objective standards or normality to work with here, only a clutch of subjective and mutable social norms and that necessarily raises questions about the both validity of those norms particular under conditions in which a variety of vested interests come into play and, indeed, play a pivotal role in the shaping of a manual – DSM – which provides psychiatrists and others with what amounts to detailed working model of normality. As already mentioned, several new disorders have been proposed for inclusion in DSM-V by mental health advocacy groups that, however well-intentioned they might be – have a clear pecuniary interest in seeing the condition they advocate for including in DSM-V as this paves the way for members of those group to obtain insurance cover for their treatment. Pharmaceutical companies also have a vested interest in the drafting and eventual contents of DSM-V as, of course, they provide and develop the drug treatments used for many existing conditions and this, inevitably, gives rise to accusations of ‘disease-mongering’ for profit which are not altogether without factual validity; just consider for a moment how quickly impotence, a relative common sexual problem in older men which can have both organic and psychological causes, mutated into the highly medicalised ‘male erectile dysfunction’ no soon a Pfizer obtained marketing clearance for Viagra.
The poster child for psychiatric disease mongering in the last 2-3 years has – perhaps – been a drug called flibanserin which was widely touted by the press, aided and abetted by its developer, Bohringer Inglehiem, as a putative ‘female viagra’, although it was not the first drug to be afforded that ‘accolade’, which had previously been applied to Intrinsa, a testosterone patch developed by Proctor & Gamble which is licensed for use in the UK as prescription-only treatment for ‘female sexual dysfunction’ – there we go again – in post-menopausal women. Less than a year later, development of flibanserin as a putative ‘treatment’ for hypoactive sexual desire disorder” was discontinued following a scathing review by the US Food and Drug Administration, covered here by Neuroskeptic, which found that, basically, it just didn’t deliver on its supposed aphrodisiac properties.
So, what exactly is this ‘hypoactive sexual desire disorder’ when its at home? Well, it a really enough condition, inasmuch as it can be found in DSM-IV, but as Neuroskeptic explains, the fancy medicalised language hides a much plainer truth…
But what was flibanserin supposed to treat in the first place? Something called “hypoactive sexual desire disorder” (HSDD). What is hypoactive sexual desi…oh, hang on. I think I can work it out. It’s a disorder where you have hypoactive sexual desire. The clue is in the name.
The truth of course is that it’s more than a clue: HSDD is nothing more than its name. And in fact, the “disorder” bit is entirely superfluous, and the “hypoactive” is needlessly technical. HSDD is simply a description for low sexual desire.
As such, it is wrong to say that it doesn’t exist – clearly some people do have low sexual desire, and some of them (though not all) would prefer to have more. But giving it a fancy name and calling it a disorder is entirely misleading: it gives the impression of depth (i.e. that this is some kind of medical illness) when in fact it is simply describing a surface phenomena, like saying “I’m bored” or “I’m tired”.
HSDD is a socially constructed ‘disorder’ and its status as a disorder is distinctly arguable. There is no objective benchmark in humans for how often they should want to have sex, although for women who are fertile a natural increase in core sexual receptiveness occurs at around the time of ovulation, as happens with all species that engage in sexual reproduction. That doesn’t mean, of course, that women are automatically ‘gagging for it’ when they’re at the most fertile. Far from, human sexual behaviour is extremely complex and the hormonal changes that accompany ovulation are only one of many factors that come into play as an influence on female sexual desire, such as the availability of suitable sexual partner, whether they pulling their weight around the home and whether or not you’ve had a bad day at work and much rather curl up in front of the TV and chill out – that’s obviously very much a non-exhaustive list.Of course, for post-menopausal women, even the hormonal bets that might have operated earlier in life are pretty much off, give or take the use and availability of hormone replacement therapy, so there really is no objective way of determining whether someone’s ‘sex drive’ is normal or not.
In practical terms, therefore, HSDD doesn’t even mean ‘low sexual desire’, all it really means is that someone doesn’t want sex as often as their current partner and its pissing their partner off enough to cause serious problems in their relationship. There are, of course, numerous reasons why someone could lose interest in sex, even within a seemingly committed relationship and not all of these are by any means irrational or consistent with disordered thinking or behaviour. At far end of spectrum encompassed by HSDD there are some people who profess to have no interest in sex at all and who are actively campaigning for recognition of their ‘condition’ – asexuality – as a sexual orientation on a par with heterosexualiy and homosexuality – so who is to say what is and isn’t normal.
HSDD is another condition that is essential a byproduct of changing social attitudes. It didn’t even exist, as a formally recognised condition, until it was introduced into DSM-III in 1980 as ‘Inhibited Sexual Desire Disorder’ – it acquired its current name with the publication of DSM-IIIR in 1987 – and to a considerable extent it reflects nothing more than changes in social attitudes to sex which occurred during the so-called ‘sexual revolution’ of the 1960’s and 70’s and, therefore, changes in the social constructs against which subjective assessments of the ‘normality’ were made.
The social and purely subjective basis of many of the ‘disorders’ described in DSM is addressed by BPS in its next statement which also serve to introduce another major issue in psychiatric practice, the lack of reliable, evidence-based, underpinnings for many of the conditions described in DSM.
The putative diagnoses presented in DSM-V are clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements, with little confirmatory physical ‘signs’ or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity.
Diagnostic categories do not predict response to medication or other interventions whereas more specific formulations or symptom clusters might (Moncrieff, 2007).
Finally, disorders categorised as ‘not otherwise specified’ are huge (running at 30% of all personality disorder diagnoses for example).
Many people would, I strongly suspect, be shocked, if not horrified were they to realise just how limited and weak the evidence base is for many common facets of psychiatric practice, from the classification of conditions in DSM, through diagnostic practices to the treatments themselves.
Most people are sufficiently familiar with the medical model of diagnosis that they have a fair understanding of how it works just from their experience of visiting their GP. You sit down, describe your symptoms to the doctor, your doctor has good look at you, prods and pokes you a bit and maybe does a couple of simple tests, i.e. blood pressure, etc. and then either tells you what they think is wrong with you or maybe refers to on for a few more tests if your problem is bit more complicated that the usual run of the mill stuff that occupies much of a GP’s working life.
Its an exercise in pattern recognition. Your doctor collates information about your condition in form of symptoms and other physical indications and uses the knowledge they’ve gained in six years of medical training and how many years they’ve had in practice to match that information against what they know about the symptoms and indications that are associated with specific illnesses – sometimes its the overall pattern of symptoms that lead them to conclude that you probably have X or Y, sometime it may just a particular symptom that makes for the diagnosis; the rash you get when you contract chickenpox is usually sufficient distinctive to seal the deal without much in the way of additional flummery beyond asking whether you might be aware of having come across someone with chickenpox fairly recently.
It’s a way of working that works pretty effectively for most common ailments but its not perfect by any means and it can be a bit hit miss when its comes to patients who present with something just a bit unusual unless something emerges in the consultation process to give the doctor a good reason think out of the usual box, e,g, that the patient has recently returned from a tropical holiday or such like.
Doctor’s don’t always hit the right diagnosis first time around, but this tend to happen either because the patient presents with symptoms that are ambiguous, i.e. commonly found in a number of different illnesses or, more rarely, because they present with symptoms that are somewhat atypical of the actual illness they’ve contracted. So even when the system fails and doctors fail to arrive at the correct diagnosis, its not because the system itself is at fault but because many illnesses don’t have a unique signature that can be readily identified by a doctor without either carrying out further invasive, and expensive, tests or by going through a process of elimination in which the doctor a treatment for the most likely cause of the illness before revisiting their diagnosis, a couple of weeks later, if the treatment proves to be unsuccessful.
Such is the medical model of diagnosis and, to most people, it would seem a reasonable assumption that the same model applied to psychiatry via DSM should work in much the same way and prove to similarly effective, i.e. you a series of defined conditions, each with their own pattern of symptoms, against which the behaviours of patients can be reliably matched and assessed in order to arrive at a consistent diagnosis.
So, what if I were to tell you that for schizophrenia, which is one of the more common and, in terms of public perceptions, better known, but not understood, major psychiatric disorders, it is entirely possible for two individual patients to receive this diagnosis under the diagnostic criteria set out in DSM-IV-TR – the current ‘live’ version of DSM – without either patient having a single listed symptom in common?
This is perfectly true. Two people could easily be diagnosed with schizophrenia despite the neither of them having any ‘symptoms’ in common at all – and I dare say that it wouldn’t require too exhaustive a search of the case files held by psychiatrists working for local mental health trusts to turn up examples of people who have been diagnosed with schizophrenia in precisely this way. This is part of what the BPS is driving at when it cites Moncrieff’s view that the current diagnostic categories in DSM-IV-TR ‘do not predict response to medication or other interventions whereas more specific formulations or symptom clusters might’. It’s not just a matter of psychiatric disorders being complex or difficult to diagnose accurate because different conditions have a number of symptoms in common. Moncrieff’s argument is that the system itself is severely flawed and that many of the current diagnostic categories do not accurate describe conditions for which there is, or may be, some solid empirical support.
Nowhere are these problems more evident than in relation to personality disorders and psychoses where, in addition to the 30% of current diagnoses logged under ‘other, not specified’, there are other substantial problems that DSM has yet to adequately address.
Personality disorder and psychoses are particularly troublesome as they are not adequately normed on the general population, where community surveys regularly report much higher prevalence and incidence than would be expected. This problem – as well as threatening the validity of the approach – has significant implications. If community samples show high levels of ‘prevalence’, social factors are minimised, and the continuum with normality is ignored. Then many of the people who describe normal forms of distress like feeling bereaved after three months, or traumatised by military conflict for more than a month, will meet diagnostic criteria.
In this context, we have significant concerns over consideration of inclusion of both “at-risk mental state” (prodrome) and “attenuated psychosis syndrome”. We recognise that the first proposal has now been dropped – and we welcome this. But the concept of “attenuated psychosis system” appears very worrying; it could be seen as an opportunity to stigmatize eccentric people, and to lower the threshold for achieving a diagnosis of psychosis.
I have to say that I fully share the BPS’s misgiving over the concepts of ‘attenuated psychosis syndrome/system’ not just because of the very real risk that this might stigmatise eccentricity but also because it seems uncomfortably close to the kind of attitudes exposed by one of the most famous and controversial experiments even conducted into the validity of psychiatric diagnoses, the Rosenhan experiment:
Rosenhan’s study was done in two parts. The first part involved the use of healthy associates or “pseudopatients” (three women and five men) who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different states in various locations in the United States. All were admitted and diagnosed with psychiatric disorders. After admission, the pseudopatients acted normally and told staff that they felt fine and had not experienced any more hallucinations. Hospital staff failed to detect a single pseudopatient, and instead believed that all of the pseudopatients exhibited symptoms of ongoing mental illness. Several were confined for months. All were forced to admit to having a mental illness and agree to take antipsychotic drugs as a condition of their release.
The second part involved an offended hospital challenging Rosenhan to send pseudopatients to its facility, whom its staff would then detect. Rosenhan agreed and in the following weeks out of 193 new patients the staff identified 41 as potential pseudopatients, with 19 of these receiving suspicion from at least 1 psychiatrist and 1 other staff member. In fact Rosenhan had sent no-one to the hospital.
Rosenhan’s original paper, ‘On Being Sane in Insane Places’ can be read in full at the delightfully-named ‘Bonkers Institute’ and its as sobering a read today as it was when I first encounter it more than 20 years ago. Of the many striking observations to emerge from Rosenhan’s study the one that really leaps off the page is that of his observations on the ‘stickiness of psychodiagnostic labels’:
A psychiatric label has a life and an influence of its own. Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be schizophrenic. When a sufficient amount of time has passed, during which the patient has done nothing bizarre, he is considered to be in remission and available for discharge. But the label endures beyond discharge, with the unconfirmed expectation that he will behave as a schizophrenic again. Such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy. Eventually, the patient himself accepts the diagnosis, with all of its surplus meanings and expectations, and behaves accordingly.
Between them, Rosenhan’s experimental pseudopatients, which included Rosenhan himself, were successful in gaining admission to 12 different psychiatric hospitals which ranged from underfunded rural public hospitals to urban university-run hospitals and one very expensive private hospital with all but one receiving a schizophrenia diagnosis – that researcher was disgnosed as having manic-depressive psychosis. On discharge, all 12 were given a diagnosis of schizophrenia ‘in remission’. They weren’t cured – although none of them were ill in the first place – and none of institutions that they successfully infiltrated recognised them for what they were, although many of the inmates weren’t so easily fooled, hence they were still officially deemed to be mentally ill albeit with their condition being in a state of remission.
Schizophrenia in remission. Attenated Psychosis Syndrome. That’s just way too close to the kind of attitudes that Rosenhan exposed for me to feel comfortable with such a proposal.
This is what the BPS were driving at in their open paragraph when they expressed concern that clients and the general public are negative affected by the labels generated by the increasing medicalisation of ‘normal’ responses to difficult life events and experiences. Its not just a matter of people being stigmatised by these labels and encountering social prejudice as a result, its the fact that labels themselves can prove to be counterproductive and inhibit the normal recovery process. Just as the label can become the person, so the person can become the label.
*Admission time – this is the reason why I really dislike the somewhat ubiquitous feminist practice of prefacing articles about rape and sexual assault with a ‘trigger warning’. Yes, I know these ‘warnings’ are given with the best of intentions but nevertheless it as well to remember that ‘the road to hell…’ and all that. Not only do these ‘warnings’ promote a somewhat stereotypical view of women who have been raped – rape is traumatising, yes, but not all rape victims go on to developed PTSD as a result of their experiences – but these ‘warnings’ are, themselves, a form of labelling and are, therefore, potentially unhelpful if not, for some people, possibly harmful. I’m not saying that you shouldn’t give your readers fair warning before tackling difficult subjects, just that there are less obtrusive ways of doing it that don’t play into potentially stigmatising stereotypes.
Hopefully, you’re still with me at this point, in which case you’ll be pleased to know they were entering the closing stretch…
Diagnostic systems such as these therefore fall short of the criteria for legitimate medical diagnoses. They certainly identify troubling or troubled people, but do not meet the criteria for categorisation demanded for a field of science or medicine (with a very few exceptions such as dementia.) We are also concerned that systems such as this are based on identifying problems as located within individuals. This misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our wellbeing and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives.
On this issue, the full petition raises an important point…
Advances in neuroscience, genetics, and psychophysiology have greatly enhanced our understanding of psychological distress. The neurobiological revolution has been incredibly useful in conceptualizing the conditions with which we work. Yet, even after “the decade of the brain,” not one biological marker (“biomarker”) can reliably substantiate a DSM diagnostic category. In addition, empirical studies of etiology are often inconclusive, at best pointing to a diathesis-stress model with multiple (and multifactorial) determinants and correlates. Despite this fact, proposed changes to certain DSM-5 disorder categories and to the general definition of mental disorder subtly accentuate biological theory. In the absence of compelling evidence, we are concerned that these reconceptualizations of mental disorder as primarily medical phenomena may have scientific, socioeconomic, and forensic consequences.
In other words, the best that research in genetics, neuroscience and psychophysiology has been able to add to our understanding of the causes of some conditions is the view that biological factors may possibly give rise to a particular susceptibility towards particular conditions in some individuals when subjected to significant levels of social and environmental stress, which really doesn’t tell us very much at all in diagnostic terms unless were dealing with conditions in which such succeptabilities are thought to be hereditary.
The Society recommends a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with ‘normal’ experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or ‘symptoms’ or ‘complaints’. Statistical analyses of problems from community samples show that they do not map onto past or current categories (Mirowsky, 1990, Mirowsky & Ross, 2003). We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety etc)? These would be more helpful too in terms of epidemiology.
While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word) understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person’s real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person’s problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives. There is ample evidence from psychological therapies that case formulations (whether from a single theoretical perspective or more integrative) are entirely possible to communicate to staff or clients.
Even allowing for all, much of which agree with, I’m still somewhat agnostic on the question of diagnostic labels. It not that we don’t need or have no use for a clear taxonomic system for the classification of psychiatric conditions and disorders, its more that system we have at present is seriously flawed and has been constructed from the top down in such a way that the evidence base that should support the system is often weak, confused and in places contradictory, and – sad to say – its also a system that’s prone to misuse not only colloquially but also with the professional environment. It’s a system that needs to be rebuilt and reformulated from, as the BPS rightly argues, the bottom up and one that desperately needs to be rigorous grounded in the best available evidence, not in top down theoretical assumptions and models which have been shown to be of dubious validity.
This would, of course, necessitate a significant investment of both time and resources – in short, an international effort – and such a venture would not be without its own risks. For all that there is a lot of good solid research and sound evidence-based practice to build on, there are still large tracts of psychiatric and counselling practice out there that are, at best, poorly evidenced and unscientific,and at worst, founded on not much more than quackery and pseudoscience and these fields possess their own highly vocal – and sometimes powerful – vested interests who would inevitably seek to protect their own ‘turf’ in such a process, just as its alleged that pharmaceutical companies, the US health insurance industry and some even powerful, and rather influential, psychiatric practices have acted to try to protect, and maybe even extend, their own highly lucrative turf during the drafting of DSM-V.
Anyway, getting back, at long last, to the Guardian – or should that be Reuters – it should now be entirely obvious that its treatment of the debate surrounding the development of DSM-V is, at best, extremely weak and, at worst, overly concerned with what are relatively trivial details in what is, otherwise, a very fundamental debate about the future direction and development of psychiatric medicine. The media coverage sees the real issues woefully short in favour of picking off a few bits of low-hanging fruit from the DSM-V process.
Among the anxieties to be labelled mental disorders if DSM-5 is published in May by the American Psychiatric Association are shyness in children and uncertainty over gender. Loneliness could attract a diagnosis of chronic depressive disorder, and so could unhappiness following bereavement. A serial rapist could be classified as mentally ill, given a diagnosis of paraphilic coercive disorder.
Unless something has changed in the last few days, DSM-V is not due for publication until May 2013, so the most we’re likely to see this May is a final draft for consultation.
Shyness in children is not going to become a disorder in its own right. It was, and still is, recgnised as a potential symptom of social anxiety disorder (social phobia) and, subject to appropriate diagnostic thresholds this is not the least bit unreasonable. Chronic shyness can be socially and emotionally debilitating and deserves to be taken seriously and, frankly, there are far too many adults in the the media and, in some cases, in psychiatric practice, who exhibit a marked tendancy towards addressing issues relating to the mental health of children in a wholly patronising manner, as if to suggest that this a trivial field – and this seriously pisses me off.
Uncertainty over gender falls within the revised definition of Gender Dysphoria, which replaces DSM-‘s Gender Identity Disorder, and would take us into an extremely complex and heavily political debate were I to choose to go there. There is still some considerable debate as to how best to deal with gender identity issues however the civilised view is that, much like the residual elements of homosexuality that fall within the ‘other/non specified’ category its an issue that needs to remain on the books, so to speak, in order to ensure that people who struggle to reconcile their inner sense of their own gender with the biological hand they’ve been dealt can be supported while they work through their feelings and stabilise their own sense of identity.
As for lonliness and unhappiness following bereavement, these are potential symptoms of chromic depressive disorder under DSM-V and, as such, the main bone of contention is that of diagnostic thresholds. Its entirely normal to experience grief, sadness and a sense of loss after a bereavement, whether that leads to chronic depression is ultimate a question of degree and persistence of symptoms – someone who gives it the full Queen Victoria probably is doing rather more than just grieving normal but, as ever, concrete judgements on what can and can’t be considered normal behaviour remain elusive.
Oh, and the proposal for paraphillic coercive disorder has apparently already been dropped by the DSM-5 Sexual Disorders Work Group for reasons which appear to have more to do with politics and the vicissitudes of the American legal system than anything remotely scientific. Although most people would consider serial rapists to be mentally ‘disturbed’ this cannot be formally acknowledged by psychiatrist in the United States for fear that it would result in rapist being incarcerated in mental institutions rather than SuperMax prision, which leaves one wondering whether a promise to bring Nurse Ratched out of retirement might help get it on the books.
That rape is a crime has no bearing on the question of whether or not a particular perpetrator is suffering from a psychiatric disorder or not, but that’s another big debate in itself and beyond the scope of this article.
Under the DSM-4, last revised 12 years ago, children who argue and refuse to obey parents can be classified as having oppositional defiant disorder.
Professor Nick Craddock, consultant psychiatrist in Cardiff and director of Wales’ National Centre for Mental Health, said: “Somebody who is bereaved might need help and even counselling, but they did not need a label saying they had a mental illness. I believe that a large proportion of psychiatrists in the UK and Europe are sceptical about DSM-5.”
Peter Kinderman, professor of clinical psychology and Head of Institute of Psychology at the University of Liverpool, said the revisions “could only make a bad system worse”. The diagnostic approach, a tick-box list of symptoms leading to a label, was always “hugely problematic”, he said. What is termed “oppositional defiant disorder” is dubious, he said: “Since my children say ‘no you are an idiot, dad’ repeatedly to me, by definition my children are ill.” He also disagreed with the label of paraphilic coercive disorder: “In my view, rape is a crime and should not necessarily be regarded as a disorder. It gives people an excuse for that behaviour,” he said.”
Picking on Oppositional Defiant Disorder from DSM-IV really is going after the low-hanging fruit not least as much of the derision heaped on this ‘disorder’ has tended to come from people who still think its reasonable to socialise children by beating them into submission. ODD, as specified in DSM-IV, may be somewhat dubious however it would, for once, be nice to see someone provide an intelligent and considered critique rather than a trite anecdote about his own occasionally mouthy kids.
Again, I have to ask whether it really is too much to ask that we take the mental health of children seriously, even if some of the current diagnostic categories seem to be built on dubious foundations?
Til Wykes, professor of clinical psychology at Kings College London, said: “The proposals in DSM-5 are likely to shrink the pool of normality to a puddle with more and more people being given a diagnosis of mental illness.”
Maybe, or maybe not. At this stage we don’t know how DSM-V will pan out, or even what will make the final published version. There seems to be a default assumption here that psychiatrist will simply follow the manual without exercising their own professional, which may well be true in some cases but nevertheless smacks of blaming the tools for the existence of bad workmen.
The American Psychiatric Association strongly defends DSM-5. In response to criticism from the British Psychological Association last year, Darrel Regier, vice-chair of the DSM-5 task force. wrote: “While we agree that human feelings and behaviors exist on a spectrum that contains some overlap of normal reactions to disease states, psychiatry also recognizes that there are real and discrete disorders of the brain that cause mental disorders and that can benefit from treatment.”
In view of the fact that a decade of intensive biomedical research has yet to successfully validate any of the DSM categories, the APA’s response seems just that bit too complacent. Oh, and BTW, its British Psychological Society, not Association – someone please wake the subs up, FFS – which only serves to emphasise the extent to which the Guardian has resorted to a fairly lazy piece of churnalism here.
In closing, if you’ve got this far, you’ll have hopefully realises that inspite of the fairly shoddy treatment given to this issue by the press, the issues this debate actually raises are of fundamental and far-reaching importance to the future of psychiatric medicine and practice.
The America Psychiatric Association has, over the years, served its members well as the custodian of DSM – DSM-III was particularly and well-received for its efforts to put psychiatry on a much firmer scientific footing in the wake of stringent criticisms engendered by the Rosenhan experiment, but things have moved on and the medical model of psychiatry encapsulated in DSM is showing its age.
For that reason, I fully support calls for both a independent external review of DSM-V and for its publication to be delayed until such a review is carried out.
I also support the British Psychological Society’s calls for a fundamental rethink of our current approach to the classification and diagnosis of psychiatric disorders, although I remain skeptical of the idea that we can do away the with higher level taxonomic classifications, i.e. by disorder or condition, in favour of a system built entirely on the low-level classifcation of symptoms. If nothing else, the evidence-based, ground-up diagnostic/epidemilogical system suggested by the BPS is likely to produce recognisable clusters of symptoms which are broadly indicative of specific psychopathologies and taxonomic names will inevitably be given to these clusters, if only as a time-saver. for all that psychodiagnostic labelling under the present taxonomic system has created problem, its not clear to me that the best way address those problems is to simply get rid of the labels altogether not least as I suspect that such a move would only open the door to an orgy of psot-modern, pseudoscientific riffing from the quack end of the profession with the risk that this would put us right back to where we started before the creation of DSM.
Its better that we stick to a systematic approach and work towards the development a much more accurate and properly grounded taxonomic classification system while, at the same time, putting a concerted effort into educating the public to see mental health is altogether more enlighted terms, particular as past experience suggests that taking away the labels doesn’t take away the prejudices, it just forces those prejudices to find new ways of expressing themselves.