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|In 'The Psychologist' -August 2011
Society’s critical response to DSM-5
Work on the latest, fifth version of psychiatry’s diagnostic code (DSM-5: see www.dsm5.org), due for publication by the American Psychiatric Association in 2013, has already suffered from resignations and accusations of vested interest. Now the British Psychological Society has had its say by publishing a highly critical response to the planned revisions (access the full document at tinyurl.com/67wygp7).
The Society says it 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’. The statement was made public in June, signed off by Dr Carole Allan, chair of the Professional Practice Board, and prepared by Professor Peter Kinderman, chair of the Division of Clinical Psychology.
The statement criticises the DSM-5 for being based on social norms and subjective judgement, and for locating problems within individuals, rather than recognising the role of social causes, such as poverty. The Society also has concerns with specific conditions found in DSM-5, including the proposed new conditions of ‘attenuated psychosis syndrome’ (the presence of psychotic-like symptoms without a full disconnect from reality) and ‘disruptive mood dysregulation disorder’ (excessive temper tantrums). The former ‘is very worrying’ the Society statement says, ‘it could be seen as an opportunity to stigmatise eccentric people, and to lower the threshold for achieving a diagnosis of psychosis’.
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The only aspect of the DSM-5 welcomed by the Society is the plan to rate symptom severity over the preceding month, because to do so focuses on specific problems and ‘introduces the concept of variability into the system’.
The Society concludes by calling for a revision to the way mental distress is thought about, including recognition that mental disorder is on a spectrum with normal experience, and recognition of the role played by social factors. ‘Rather than applying preordained diagnostic categories to clinical populations,’ the Society says, ‘we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or “symptoms” or “complaints”’. The statement ends with the Society offering to help in any exercise to develop an alternative approach to the DSM.
The Vice-Chair of the DSM-5 task force, Dr Darrel Regier is robust in his defence of the DSM (see www.bps.org.uk/dsm5news). In an e-mail to The Psychologist he says that he and his colleagues agree that there is an overlap between normal responses and disease states, but that ‘psychiatry also recognises that there are real and discrete disorders of the brain that cause mental disorders and that can benefit from treatment’.
Regier says that experts working on DSM-5 have attempted to approach this issue by adding more dimensional approaches to describing psychological symptoms and opportunities to assess both disorder severity and associated disability levels. ‘The problem’, he says, ‘is that the psychologists quoted here think we shouldn’t consider any mental disorder, including individuals whose psychosis renders them mentally incompetent, to have a brain-based illness. The group also wishes to emphasize the relational context of mental disorders and wants to exclude the possibility of mental disorders being independently present in the person – the way that cancer or heart disease may be affected by social and psychological realities but nevertheless exist within individuals as discrete states. What seems to be missing is an appreciation of mental disorders as the result of gene–environmental interactions that would trigger abnormal neuronal function in the brain. Why the brain should be exempt from pathology when every other organ system is subject to malfunction is left unaddressed.’
Regier further explains that DSM-5 will recognise that boundaries between conditions like schizophrenia and bipolar disorder are not clear cut and better thought of as ‘central tendencies’, which can be modified by high-level psychological domains, such as anxiety or addictions. ‘However, the complexity of psychiatric disorders in no way abrogates the psychiatrist’s obligation to provide treatments, including talk therapies and medications, that succeed in ameliorating symptoms and reducing suffering,’ he says.
In conclusion Regier reminds us that psychiatric disorders have existed since the beginning of recorded history, but that tremendous progress has been made in recent decades in our ability to treat them. ‘The DSM strives to be a living document that will continue to draw upon research and clinical experience as we endeavour to relieve the suffering of the millions of people worldwide who suffer the devastating effects of mental illness,’ he says.
Looking ahead, Professor Kinderman notes that many psychologists continue to work in healthcare contexts that use diagnoses, including helping people with physical and neurological problems where he considers diagnosis to be valid. ‘So we have to strike a balance and offer pragmatic advice,’ he says. ‘We base our advice on evidence, and will continue to develop our position in the light of research. We are currently developing practical guidelines for psychologists in their day-to-day work. We will also continue to make a constructive contribution to the debate by promoting a positive way forwards in developing alternative paradigms rooted in psychological models.’ Christian Jarrett
- For background on the development of DSM-5, see April 2010 News and August 2009 Forum.
The response was coordinated by the Society’s Consultation Response Team.
To get involved with future responses, see www.bps.org.uk/consult. For other recent activity, see p.608.
The British Psychological Society Condemns DSM 5
The British Psychological Society (BPS) is a highly esteemed organization representing 50,000 members. Recently, it released an open letter to the American Psychiatric Association offering a harshly critical view of DSM 5. Most of the BPS criticisms are right on target, accurately pointing out the dangerous excesses of DSM 5. But some are so overly broad that the cogent points get lost in the shuffle, allowing the DSM 5 leadership to be archly dismissive of the entire letter. This is unfortunate because the BPS warning deserves serious consideration as we approach the endgame of DSM 5 decision making.
The BPS is at its best when exposing those DSM 5 proposals that medicalize normal variability. It vigorously and convincingly opposes the DSM 5 tendency to turn the expectable reactions to life's difficulties (eg grief)into psychiatric illness. The letter rightly expresses particular concern about suggestions to include in DSM 5 the risk syndromes (eg psychosis risk) or the attenuated, milder forms of existing psychiatric disorders (eg mixed anxiety depression, mild neurocognitive, binge eating) .
This portion of the BPS critique is crisply telling and completely true and goes to the heart of what is most wrong and most dangerous in DSM 5. Medicalizing normal experience stigmatizes and cheapens the human condition and promotes overtreatment with unnecessary and potentially harmful drugs. But the BPS critique goes too far and wide in denying the value of all psychiatric diagnosis.
The most striking example is its seemingly blanket disdain applied equally for both schizophrenia and for 'psychotic risk syndrome' (lately in a name changing game aka 'attenuated psychotic symptoms'). The letter implies that these are more or less equally flawed and undeserving constructs. Most decidedly they are not. The BPS willingness to throw the valuable baby of schizophrenia out with the problematic bathwater of 'psychosis risk' reduces the force of its otherwise persuasive argument against the risky bathwater.
Schizophrenia is admittedly a flawed construct with limited descriptive and explanatory power. It is a wildly heterogeneous with dozens of different presentations and probably hundreds of different causes (none of them known). This diverse group of schizophrenias contains within it a wide range of possible onsets, courses, severities, and treatment responses. There is no available biological test available for its diagnosis and none is on the horizon.
All that said, schizophrenia remains a valuable diagnosis that economically captures a great deal of information and serves as a useful (if imperfect) guide to clinical care and research. The literature on schizophrenia accumulated over the past century is extensive and suggests at least the outlines of what we don't yet know. The BPS criticizes schizophrenia as a construct, but offers no viable alternative.
In contrast, 'psychosis risk' is a relatively newcomer whose properties remain quite unknown. We don't know how best to define it, can't diagnose it accurately, don't know how to treat it, don't know if treating it has any lasting value, and don't know the extent of its harmful unintended consequences if it were to be made official.
Most telling of all is the widespread opposition to including psychosis risk syndrome as an official diagnosis in DSM 5 even among those who have devoted their careers to researching it. The tipping point was reached recently when two of the most prominent promoters of psychosis risk (Patrick McGorry and Alison Yung) withdrew their support for its inclusion in DSM 5 and asserted publicly that it will not be included in Australia's ambitious new mental health program that is targeted at treating early presentations of schizophrenia.
It is now only the DSM 5 diehards who are still hanging fast to the "psychosis risk" bandwagon- but unfortunately it is they who hold the final casting vote. The BPS is doing a great service in entering this fray and adding its strong voice to the diverse chorus trying to prevent this travesty. But BPS dilutes its valuable message when it simultaneously attempts a takedown of the venerable concept of schizophrenia (especially when there really is no currently available diagnostic alternative).
Psychiatric diagnosis is admittedly imperfect, but also absolutely necessary; extremely easy to criticize, but so far impossible to replace. It gives comfort to the misguided DSM 5 workers (and protection for their worst ideas) if outside critiques can be dismissed by them as "antipsychiatry" broadsides. DSM 5 deserves and badly needs searching and sustained outside criticism, but this will be most effective if targeted to its numerous, egregious, and specific defects, not to the whole enterprise of psychiatric diagnosis.