DSM5 - DIAGNOSTIC SYSTEMS : No More Psychiatric Labels - PROFESSOR SAMI TIMIMI

Campaigning to improve mental health among children and young people - Professor Sami Timimi : www.youngminds.org.uk

DIAGNOSTIC SYSTEMS
No More Psychiatric Labels
Child psychiatrist Sami Timimi is calling for the abolition of formal psychiatric diagnostic
systems because he says they have failed to advance our understanding or treatment
of mental disorder. He outlines below his reasons for reaching this conclusion
Unlike the rest of medicine, psychiatric
diagnoses have failed to connect their
diagnoses with any causes. There are no
physical tests that can provide evidence
for a diagnosis. Diagnoses in psychiatry
are descriptions of sets of behaviours that
often go together. By itself a psychiatric
diagnosis cannot tell you about the
cause, meaning or best treatment. Even
the descriptions of behaviours have large
crossovers between them. For example,
‘distractibility’ can be found in diagnoses
such as ADHD, anxiety, depression, and
autism, as can aggression, difficulties
with making peer relationships, and
agitation. This problem is predictable
when the basis for the categories is only
symptoms (behaviours) and not signs
(measurable physical differences). If, as
now seems likely, our diagnoses do not
reflect real differences in our biology,
then there is always a potential to do
harm if we use them as if they tell us
something about the cause. For example,
if we believe that when a doctor makes a
diagnosis of ADHD they have discovered
some real life-long abnormality in
that child’s brain, we may accidentally
lower everyone, including that child’s,
expectation of what they can achieve.
Using psychiatric diagnosis does not
aid treatment decisions
A positive outcome for treatment of
psychiatric disorders is most strongly
related to factors outside of treatment
(such as social circumstances) and in
treatment the strongest association is
with developing a good therapeutic
relationship with the clinician. Matching
the diagnosis with a specific treatment
(whether a specific drug or specific
psychotherapy) has an insignificant effect.
Long-term prognosis for mental
health problems has got worse
Unlike the rest of medicine, no overall
improvement in mental health outcomes
has been achieved in developed countries
over the past half century. Some studies
indicate the opposite; that compared to a
few decades ago there are more patients
who have developed chronic conditions
such as chronic schizophrenia than in
the past. This is particularly so for young
people, more of whom are being labelled
as having a long-term disability because
of a mental condition than ever before,
with rates of psychiatric medication being
prescribed to children rising year-on-year
without any accompanying evidence that
their long-term outcomes are improving.
Use of psychiatric diagnosis
increases stigma
Surveys of public attitudes toward mental
illness have found an increase in Western
countries in the number of people who
believe that mental illnesses are like
other illnesses and caused by biological
abnormalities such as a “chemical
imbalance” in the brain. However, the
“illness like any other illness” model
is overwhelmingly associated with
stigmatising attitudes such as a belief
that patients are unpredictable and
dangerous, increasing the likelihood of
wanting to avoid interacting with them.
It imposes Western beliefs about
mental distress on other cultures
Countries around the world are
being encouraged to adopt Western
beliefs and to recognise diagnoses like
ADHD, depression and schizophrenia.
However, outcomes, particularly for
more severe mental conditions, have
been consistently better in developing
countries than developed ones. Several
international studies have also concluded
that the greater the inequality (in
economic and social resources) in any
society, the poorer the mental health.
In the process of encouraging the
adoption of Western psychiatric models,
we not only imply that those cultures
that are slow to take up these ideas are
‘backward’, but we may also undermine
effective local practices and distract
attention from factors that do make
a difference to mental health such as
economic ones.
Alternative evidence-based models
for organising effective mental
health care are available
We already know about many factors
associated with greater likelihood of
developing mental distress such as
trauma (particularly early childhood
trauma), adversity, socio-economic
inequality, lifestyle and family
functioning. In addition, rating levels of
impairment and distress would provide a
more accurate and less stigmatising way
of categorising mental health problems
than using psychiatric labels.
The message from research into
outcomes from treatment of mental
health problems is that using diagnostic
categories to choose treatment models
makes little difference, but concentrating
on developing meaningful relationships
with service users does. Service users,
including young people, need to be
active collaborators in their recovery.
Furthermore, the biggest impact on
outcomes comes from factors outside
treatment such as the social circumstances
and levels of support. Evidence-based
services need to learn how to work with
the lived reality people experience, not
just the space between the ears.
A more mature understanding of
mental distress that is not based on
wishful thinking or prejudice will
recognise that mental health concerns
us all. Campaigns like ‘One in Four’ will
then become redundant. Mental health is
a part of all our lives – the more important
campaign is ‘One in One’ with psychiatric
labels no longer used. !
For more see www.criticalpsychiatry.net
Sami Timimi is consultant child
and adolescent psychiatrist and
director of medical education
at Lincolnshire Partnership
Foundation NHS Trust