Challenging Over-prescription of psychoactive drugs by Professionals in Education for Young People : THE BRITISH PSYCHOLOGICAL SOCIETY - still has major methodological and ethical concerns over DSM5 due to its poor statistical validity and inter-rater reliablity along with the dubious 'catch all' / over-inclusive categories which will be likely to hugely increase the chance of 'false positive' diagnoses for a range of these 'loose cluster' criteria in their response : "DSM-5: The future of psychiatric diagnosis (2012 - final consultation)" - PLUS previous BPS submission (2011) and statements from the BPS on this crucial issue.

Wednesday 20 June 2012

THE BRITISH PSYCHOLOGICAL SOCIETY - still has major methodological and ethical concerns over DSM5 due to its poor statistical validity and inter-rater reliablity along with the dubious 'catch all' / over-inclusive categories which will be likely to hugely increase the chance of 'false positive' diagnoses for a range of these 'loose cluster' criteria in their response : "DSM-5: The future of psychiatric diagnosis (2012 - final consultation)" - PLUS previous BPS submission (2011) and statements from the BPS on this crucial issue.

British Psychological Society still has concerns over DSM-V.

http://www.bps.org.uk/news/british-psychological-still-has-concerns-over-dsm-v

CLICK LINK FOR ACCESS TO BPS SITE and the full DSM5 Consultation Response.

+ SIGN PETITION: http://www.gopetition.com/petitions/write-the-wrongs-in-dsm-5-n-i-c-e-must-issue-guidanc.html

The British Psychological Society has responded to the final consultation on the DSM-V diagnostic framework. You can read our full response on this website.

Dr David Murphy, Chair of the Society’s Professional Practice Board, says:

    The Society applauds the American Psychiatric Association for engaging in this level of public consultation, and we welcome some of the changes from the previous iteration, such as the deferment of the decision to include the category of ‘attenuated psychosis syndrome’ and to recommend further research.

    However we continue to have serious concerns about many aspects of the framework. In our response we have argued that the categorical framework of DSM-V is flawed in that it fails to take account of the evidence for the dimensional spectrum of psychiatric symptoms such as low mood, hearing voices, unusual beliefs etc in the general population.

    We have also highlighted significant concerns about lowering of diagnositic thresholds and the validity ‘catch all’ diagnostic categoroies that exist within DSM-V such as ‘ADHD not elsewhere classified’, which we are concerned have poor inter rater reliability.

    We are concerned that both of these aspects lead to the risk of overdiagnosis and thereby potentially unnecessary and potentially harmful treatment with medication.

About this Response :

This response was prepared for the British Psychological Society by Dr Catherine Dooley,CPsychol, AFBPsS, committee member of the Division of Clinical Psychology (DCP), Chair of
the DCP’s Professional Standards Unit, and member of the Division of Neuropsychology andthe Faculty for Psychology Specialists Working With Older People,

With contributions from:

Isabel Clarke, CPsychol, member of the DCP, Chair of the Faculty of Psychosis and Complex Mental Health (FPCMH), and member of the Transpersonal Section;

Dr David Harper,CPsychol, AFBPsS, member of the DCP and the FPCMH;

Lucy Johnstone, CPsychol, AFBPsS,past committee member of the DCP, and member of the FPCMH;

Professor Peter Kinderman,CPsychol, AFBPsS, past Chair of the DCP;

David Traxson, CPsychol, committee member and
commenting on behalf of the Division of Educational and Child Psychology;

and David Trickey, CPsychol, member of the DCP and the Faculty for Children and Young People.

We hope you find our comments useful.

THE RESPONSE JUNE 2012 :

The British Psychological Society (BPS) thanks the American Psychiatric Association for the opportunity to respond to this consultation.

General comments

The BPS welcomes recognition that DSM 5 needs further consultation, but does not consider that the updated proposals fully address the serious reservations raised in our response to the 2011 consultation (BPS, 2011).

The validity of the basic categories is assumed, rather than evidenced from research into distress across both psychiatric and ‘normal’ populations which might challenge the appropriateness of the paradigm. In this circular process, both the original suggestions and subsequent modifications are based more on committee decision and public responses than on patterns arising out of the identification of underlying mental phenomena.

In the absence of such signs, judgments about pathology are inevitably grounded in subjective and cultural norms. This is particularly obvious in the case of ‘Personality Disorders’, (criterion ‘D’ for ‘Personality Disorder’: “The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment”), but also applies across the spectrum of functional diagnoses.

The BPS continues to believe that, by not taking account of the evidence for the dimensional spectrum of psychiatric symptoms such as low mood, hearing voices, unusual beliefs and so on across the general population, retention of a categorical model is a methodological flaw, particularly but not exclusively for ‘functional’ rather than ‘organic’ disorders.

We also are concerned that the revised proposals have failed to take account of the growing body of evidence implicating relationship and social factors as the primary risks for mental distress across the range of psychiatric presentations, including 'psychosis'. A recent editorial in the British Journal of Psychiatry (Read and Bentall, 2012) summarised this research and called for a paradigm shift in our understanding of mental distress. We recommend a return to basic science without preconceptions.

We consider that, as it stands, the revised DSM-5 would lead to an ongoing risk of pathologising individuals while obscuring well-established social and relationship causal factors. A considerable body of evidence from service users/survivors testifies to the damaging consequences of this approach (eg Geekie et al, 2012.)

Finally, as outlined in our 2011 response (BPS, 2011), we are particularly concerned about “catch-all” categories which have a particularly weak conceptual basis, as demonstrated by the fact that one third of people diagnosed with a personality disorder fall under the heading ‘Not otherwise specified’ (Traxson, 2010). This includes all catch-all terms such as "atypical ….." and "sub-clinical, normal variation ….." which wev feel will greatly increase the risk of 'false positive diagnoses particularly for children. 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. A more scientific approach, less likely to lead to the over-diagnosing of conditions such as ADHD and bipolar disorder in children, would be to research the extent of such experiences within the wider population without making a prior assumption of pathology.

For all the reasons stated above, the BPS, having reviewed the currently proposed revisions of the new diagnostic criteria in DSM 5, continues to have major concerns. These have, if anything, been increased by the very poor reliabilities achieved in many of the recent field trials (Huffington Post, 2012), especially given the limited time available to attempt to achieve more satisfactory outcomes. Since validity depends, at the very least, on acceptable levels of reliability, the unavoidable conclusion is that many of the most frequently-used categories will be unable to fulfil their purported purposes, i.e. identification

of appropriate treatments, signposting to support, providing a basis for research, etc.

Additionally, given that the potentially harmful effects of psychiatric medication are well-documented, the BPS is concerned that the risks of over-diagnosis outlined earlier may result in the inappropriate use of potentially significant adverse consequences.

References:

PS (2011) http://apps.bps.org.uk/_publicationfiles/consultation-responses/DSM-5%202011%20-%20BPS%20response.pdf

Accessed May 2012

Geekie, J., Randal, P., Lampshire, D., & Read, J. (eds) (2012). Experiencing psychosis: personal and professional perspectives. London, New York: ISPS for Routledge.

Huffington Post (2012)

http://www.huffingtonpost.com/allen-frances/dsm-5-reliability-tests_b_1490857.html

Accessed June 2012

Jiron, C., Chiodo, A., & Sherrill, R. (1995). Is ADHD being overdiagnosed? Paper presented at the National Academy of Neuropsychology, San Francisco, CA.

Lane C. (2009) Shyness – How Normal Behaviour Became a Sickness. New Haven, USA: Yale University Press

Read J. & Bentall R. P. (2012) Negative childhood experiences and mental health: theoretical, clinical and primary prevention implications. British Journal of Psychiatry, 200: 89-91.

Traxson,D (2010) The Medicalisation of Normal Healthy Childhood.- BPS-DECP Debate Magazine – Sept 2010.

Comments on specific disorders

Code Title Comment on Proposed Revision Comment on Severity

A 06

Attention Deficit/Hyperactivity Disorder

Although not a revision, we are concerned that the use

within the descriptor of “……for at least 6 months to a

degree that is inconsistent with developmental level…..”

could be part of the explanation for the finding that youngfor-

age-group children are more likely to be diagnosed

and medicated for ADHD (Morrow et al, 2012). Indeed,

Elder (2010) also reinforces the point that younger

children in an age cohort show more immature behaviour

and should not be stigmatised as a result.

In fact, the differential diagnosis rates for the existing

condition between the U.S. and the U.K. of 8% to 1.5%

are in themselves evidence of the potential risk for overdiagnosis

based on cultural or geographical variables.

Further evidence raising doubts about the validity of the

diagnostic criteria was described by Jiron et al (1995) in a

study of children who were diagnosed with ADHD and

subsequently referred to a specialist clinic due to their

poor response to standard interventions. They found that

75% of the sample experienced a wide range of

alternative causes of their symptoms, including postconcussion,

depression, learning disability and adjustment

problems as the primary cause of their behavioural

functioning.

References:

Elder, T. (2010) The Importance of Relative Standards in

ADHD Diagnosis: Evidence based on exact birth dates.

Journal of Health Economics, 29, (5), p641-656

Jiron, C., Chiodo, A., & Sherrill, R. (1995). Is ADHD being

overdiagnosed? Paper presented at the National

Academy of Neuropsychology, San Francisco, CA.

Morrow, R. L., Garland, E. J., Wright, J. M., Maclure, M.,

Taylor, S., Dormuth, C. R. (2012). Influence of relative

age on diagnosis and treatment of attentiondeficit/

hyperactivity disorder in children.

http://cmajopen.com/content/184/7/755.full.pdf+html

Accessed June 2012.

A 07

Attention

Deficit/Hyperactivity

Disorder (ADHD) Not

Elsewhere Classified

Regarding the wording “….may be coded in cases in

which the individuals are below threshold for ADHD or for

whom there is insufficient opportunity to verify all criteria.

However, ADHD-related symptoms should be associated

with impairment, and they are not better explained by any

other mental disorder.”

We are concerned that this wording is so vague as to be

impossible to operationalise in a consistent way raising

the potential for an unscientifically based ‘false positive’

diagnosis to be made.

Usually if a person is below the threshold for something

then logically they do not have the condition so it is

unclear why this is not the case here.

Schizophrenia Spectrum and Other Psychotic

Disorders Attenuated Psychosis Syndrome (proposed for section III of the DSM-5)

The BPS welcomes the continued debate and deferment

of decision on the inclusion of this category, and the

recommendation for future research.

In considering the risk of transition to full disorder, studies

that compare individuals with equivalent symptoms but

who have found or been presented with different

contextualisations for their anomalous experiences have

not been considered.

Research (e.g. Brett et al 2009, Heriot-Maitland 2011)

indicates a powerful role for contextualisation in

determining whether such experiences become

problematic and associated with significant impairment of

functioning or not.

Considered alongside studies on the stigmatizing effect of

psychotic diagnosis, we believe that caution in including

this lower level of diagnosis is indicated because of the

iatrogenic harm attendant on medical conceptualisation of

disorienting anomalous experiences, which can be

distressing, but might otherwise be viewed more benignly,

and managed with social support.

References:

Brett, C.M.C., Johns, L., Peters, E., & McGuire, P. (2009)

The role of metacognitive beliefs in determining the

impact of anomalous experiences: A comparison of helpseeking

and non-help-seeking groups of people experiencing psychotic-like anomalies. Psychological Medicine. 39, 939-950.

Heriot-Maitland, C., Knight, M. and Peters, E. (2011). A qualitative comparison of psychotic-like phenomena in clinical and non-clinical populations. British Journal of Clinical Psychology. doi: 10.1111/j.2044-

8260.2011.02011.x

B 08 Schizophrenia Regarding the rationale for introduction of

dimensionality.

The BPS welcomes this development.

In justifying dimensionality for hallucinations and delusions, reference is made to the impact of new ways of thinking about these symptoms introduced by CBT. Elsewhere the overlap between diagnoses is

noted.

The insights of CBT, particularly recent developments

employing mindfulness to impact on the way in which

the individual relates to their symptoms, with

beneficial results (Chadwick et al, 2005; Chadwick et

al, 2009) could lead to giving greater weight to factors

such as social functioning, distress and employability,

as opposed to symptoms, in diagnosing the disorder

and the severity. Such a change of emphasis would

accord with the Recovery initiative (Shepherd et al,

2008).

References:

Chadwick, P.D.J., Newman-Taylor, K. & Abba, N.

(2005). Mindfulness groups for people with distressing

psychosis. Behavioral & Cognitive Psychotherapy,

33(3), 351-360.

Chadwick P, Hughes S, Russell D, Russell I, &

Dagnan D.(2009) Mindfulness groups for distressing

voices and paranoia: a replication and randomized

feasibility trial. Behavioral Cognitive Psychotherapy.

37(4):403-12.

Shepherd, G., Boardman, J. & Slade, M. (2008)

Making Recovery a Reality.

http://www.centreformentalhealth.org.uk/publications/

making_recovery_a_reality.aspx?ID=578

Accessed June 2012.

G03 Posttraumatic Stress Disorder

Overall the revision is a very welcome clarification of the

criteria. Specifically, the addition of cognitive elements in

section D, and the decrease in avoidance symptoms in

section C are especially valuable and clinically useful

changes.

Subtype: PTSD in preschool children:

Including a subtype for preschool children is an extremely

important and helpful step in classifying (and decreasing)

reactions to traumatic events in young children, and is a

very welcome addition to the criteria.

In the preschool children subtype, the avoidance

symptoms are split into two separate groups (C1&2), both

of which refer to external stimuli. We suggest this

separation is unnecessary, particularly as only one

symptom is required from either of the two groups, and it

would be more straightforward to merge the two.

With regard to the criteria defining the event in the

preschool children subtype “A.2. witnessing, in person,

the event(s) as they occurred to others, especially primary

caregivers”. We suggest that that the phrase “especially

primary caregivers” could potentially confuse the

diagnosis, as exposure either does or does not fulfil the

criteria.

Subtype: PTSD in preschool children:

The severity scale is obviously aimed directly at the

person who has been traumatised, whereas with the

preschool subtype, diagnosis and classification will be

made based more on the report of the carers. It would

be very helpful to make a note to this effect in the

severity text.

S03 Mild Neurocognitive

Disorder

The BPS is concerned that the proposed new

diagnostic category “Mild Neurocognitive Disorder” might

be diagnosed in elderly people whose memory decline

simply reflects normal ageing. We welcome the use of an

objective psychometric criterion within this particular

DSM-5 diagnosis but has concerns about potential for

misdiagnosis of normal ageing given that the evidence is

that less than 40% of people diagnosed progress to

dementia (Mitchell & Shiri-Feshki, 2009)

We would further highlight the importance of valid

psychological interpretation of test results since the

proposed psychometric threshold encompasses one in

eight of the normal population. There is a particular

danger that cognitive functioning of people from ethnic

minorities is under-represented on psychometric tests.

Reference:

Mitchell, A. J. & Shiri-Feshki, M. (2009) Rate of

progression of mild cognitive impairment to dementia –

meta analysis of 41 robust inception cohort studies.

http://www.ncbi.nlm.nih.gov/pubmed/19236314#

Accessed June 2012.

Q00 Oppositional Defiant Disorder

The BPS remains concerned that the criteria lack

statistical rigor and will exacerbate ‘false positive’

diagnoses in future practice. The descriptors do not

adequately or rigorously define a coherent pattern of

behaviours. There is very little use of the conventional

behavioural descriptors of frequency, intensity, duration

and occurrence.

Q 04 Disruptive Behaviour Disorder Not Elsewhere

Classified

Regarding the descriptor “This category is for individuals

who exhibit symptoms of Conduct Disorder, Oppositional

Defiant Disorder, or both disorders but the number of

symptoms does not meet the diagnostic threshold for

either diagnosis and there is evidence of clinically

significant impairment associated with the symptoms.”

Although there is only a minor wording change from DSM

IV, this is another example of a ‘catch all’ category which

will broaden the rates of diagnosis of such conditions.

As mentioned previously, we are concerned that these

could cause stigma, iatrogenic harm and result in

significant side effects due to the unnecessary medication

prescribed as a result of false positive diagnoses.

End

British Psychological Society issues statement in response to DSM-5 encouraging members to sign Coalition for DSM-5 Reform petition
December 13, 2011

The Society has today (13 December 2011) released a statement expressing concerns regarding the proposed revisions of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, which is one the main internationally-used classification systems for diagnosis of people with mental health problems in clinical settings and for research trials.

The Society for Humanistic Psychology (Division 32) of the American Psychological Association (APA) has recently published an open letter to the DSM-5 taskforce raising a number of concerns about the draft revisions proposed for DSM-5 and citing a number of issues raised previously by the BPS.

In its statement today, the Society shares the concerns expressed in the open letter from the Society of Humanistic Psychology (Division 32) of the APA and encourages members of the Society to read the letter themselves and consider signing the petition.

David Murphy, Chair of the Society’s Professional Practice Board said:

“The Society recognises that a range of views exist amongst psychologists, and other mental health professionals, regarding the validity and usefulness of diagnostic frameworks in general and the Diagnostic and Statistical Manual of the American Psychiatric Association, in particular.

“However, there is a widespread consensus amongst our members that some of the changes proposed for the new framework could lead to potentially stigmatizing medical labels being inappropriately applied to normal experiences and also to the unnecessary use of potentially harmful interventions.

“We therefore urge the DSM 5 taskforce to consider seriously all the issues that have been raised and we would echo the American Psychological Association’s call for the taskforce to adhere to an open transparent process based on the best available science and in the best interest of the public”.

You can read the Society statement in full online.

Open PDF on the BPS site here: BPS Statement on DSM-5 12.12.11

Or open PDF here, on Dx Revision Watch: BPS statement on DSM-5 12-12-2011

Text version

    British Psychological Society statement on the open letter to the DSM-5 Taskforce

    The British Psychological Society recognizes that a range of views exist amongst psychologists, and other mental health professionals, regarding the validity and usefulness of diagnostic frameworks in mental health in general, and the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association in particular.

    The Society for Humanistic Psychology (Division 32) of the American Psychological Association (APA) has recently published an open letter to the DSM-5 taskforce raising a number of concerns about the draft revisions proposed for DSM-5 which has, to date, been endorsed by 12 other APA Divisions.

    A major concern raised in the letter is that the proposed revisions include lowering diagnostic thresholds across a range of disorders. It is feared that this could lead to medical explanations being applied to normal experiences, and also to the unnecessary use of potentially harmful interventions.

    Particular concern is expressed about the inclusion of a new diagnostic category “Attenuated Psychosis Syndrome”. This proposes to include individuals who are experiencing hallucinations, delusions or disorganized speech “in an attenuated form with intact reality testing” but who do not meet current criteria for a psychotic disorder. The Society shares the concerns expressed in the open letter about the potentially harmful consequences of lowering diagnostic thresholds in general and the questionable validity of this proposed diagnosis in particular.

    Another concern raised is about the impact of proposed revisions on vulnerable groups such as children and the elderly. The letter highlights that the proposed new diagnostic category “Mild Neurocognitive Disorder” might be diagnosed in elderly people whose memory decline simply reflects normal ageing. The Society welcomes the use of an objective psychometric criterion within this particular DSM-5 diagnosis but shares concerns expressed in the letter about potential for misdiagnosis of normal ageing. We would further highlight the importance of valid psychological interpretation of test results since the proposed psychometric threshold encompasses 1 in 8 of the normal population. There is a particular danger that cognitive functioning of people from ethnic minorities is under-represented on psychometric tests. The Society also shares concerns about the potential for children and adolescents to be misdiagnosed with Disruptive Mood Deregulation Disorder.

    We also concur that there is a lack of a solid basis in clinical research literature for this disorder and are also concerned about the risk of harm from inappropriate treatment with neuroleptic medication.

    The proposals for the revision of the personality disorders section in DSM-5 are described in the open letter as “perplexing”, “complex” and “idiosyncratic”. The Society has welcomed the move to a dimensional-categorical model for personality disorder. However, we have said that this has not been as visible as expected in the draft revisions.

    Moreover, we share concerns expressed in the open letter about the inconsistency of the proposed changes and their limited empirical basis.

    Finally, the open letter also draws attention to proposals to revise the basic “Definition of a Mental Disorder” and, in particular, a statement proposed by Stein et al that it “reflects an underlying psychobiological dysfunction”. The Society shares concerns about any unsubstantiated shift in emphasis towards biological factors and in particular the entirely unjustified assertion that all mental disorders represent some form of biological dysfunction. We are, however, reassured by the response from the APA task force (4 November 2011) which states that there is no intent “to diminish the importance of environmental and cultural exposure factors” and hope that this will be reflected in the final version.

    In conclusion, the British Psychological Society endorses the concerns expressed in the open letter from the Society of Humanistic Psychology (Division 32) of the APA and encourage members to view the letter themselves and consider signing the petition (http://www.ipetitions.com/petition/dsm5/ ). We also urge the DSM 5 taskforce to consider seriously the issues raised therein. These have been now been endorsed by a broad range of experts in mental health, including members of the British Psychological Society and two chairs of previous DSM revision taskforces.

    We are, however, encouraged that the DSM taskforce has already responded positively to the open letter and that in their letter (4 November 2011) they emphasized that the manual is “still more than a year away from publication and is continually being refined and reworked”. They commented that “Final decisions about proposed revisions will be made on the basis of field trial data as well on a full consideration of other issues such as those raised by the signatories of the petition.”

    In a statement issued on 2 December 2011 the American Psychological Association (APA) called upon the DSM-5 Task Force to “adhere to an open, transparent process based on the best available science and in the best interest of the public”. The British Psychological Society would certainly echo this call.

    The final draft of the DSM-5 criteria is due for publication in early 2012 followed by a third, two month, period of public feedback. The Society encourages those members who have relevant expertise to contribute to the on-going process of refinement and improvement of the DSM-5. As a Society we are, as is our counterpart the APA, committed to promoting and disseminating psychological knowledge and, as such, we are keen to ensure that the final version of DSM-5, and other internationally used diagnostic frameworks such as ICD-11, are based on the best available psychological science and will continue to monitor the DSM-5 revision process and contribute further as appropriate.

PREVIOUS BPS STATEMENT CALLING FOR REVIEW FEB 2011:

The British Psychological Society lends it support to the call for a national review of the use of medication to treat children’s behavioural issues including temporary sleep problems, mild social anxiety and shyness.

Peter Kinderman, Chair of the Division of Clinical Psychology said: “We welcome the announcement from the government pledging an extra £400 million for the provision of psychological therapies – including the promise of better support for parents and children with behavioural problems. However, we are concerned that the overall cuts to the public sector will place all of mental health care – including care for children - at risk.
“We know BPS members are involved in excellent work with Child and Mental Health Service teams, but child mental health is an area that is grossly under resourced, resulting in too few children and young people being able to get timely access to the appropriate therapy. Within the BPS we are already working closely with our psychiatry colleagues to ensure better mental health across the board. If there is evidence of inappropriate use of drugs or medication then we’re sure that our psychiatry colleagues would be equally concerned.

“Clearly, it is important to understand children’s behavioural and psychological problems fully, and to invest in proper, expert, therapeutic approaches. We would be very concerned if children were being prescribed medication as a quick fix rather than accessing the full assessments and psychological therapies which take may longer and cost more, but ultimately are likely to be better value in the long run.”

Figures released by the Department of Health show that in 2009 the number of prescriptions issued to 16-18 years olds to treat ADHD had risen by 51% in just two years.

Peter concluded: “Clearly, many children unfortunately have behavioural and emotional problems which of course demand appropriate care. Many psychologists are very concerned at the use of psychiatric and medical diagnoses in cases such as this – not only because of doubts about the validity of many of the diagnostic approaches, but also because of the possible adverse effects of the medication. Children for whom the diagnosis of ADHD is being considered should receive full multidisciplinary assessments, the option of receiving psychological and behavioural therapies, and their parents or carers should be offered parent-training and education programmes. Drugs should be considered as an option but this should be part of an overall therapy programme. In the case of problems such as temporary sleep problems, mild social anxiety and shyness, I fail to see how medicalising these problems and contemplating the use of drugs is justified. These may indeed be problems, but they are problems that clearly deserve a more psychological response”.

The call for a national review is also supported by the Society’s Division of Educational and Child Psychology.
PR: 1848 8 February 2011

http://www.youtube.com/user/Humanagement2011

For more information on these issues.

DSM-5 2011

British Psychological Society response, June 2011

Page 1 of 26

Response to the American Psychiatric Association:

DSM-5 Development

The British Psychological Society thanks the American Psychiatric Association (APA) for the opportunity to respond to the DSM-5 Development.

The British Psychological Society (“the Society”), incorporated by Royal Charter, is the learned and professional body for psychologists in the United Kingdom. The Society is a registered charity with a total membership of almost 50,000.

Under its Royal Charter, the objective of the Society is "to promote the advancement and diffusion of the knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of members by setting up a high standard of professional education and

knowledge".

The Society is committed to providing and disseminating evidence-based expertise and advice, engaging with policy and decision makers, and promoting the highest standards in learning and teaching, professional practice and research. The Society is an examining body granting

certificates and diplomas in specialist areas of professional applied psychology.

We are content for our response, as well as our name and address, to be made public. We are also content for the APA to contact us in the future in relation to this response. Please direct all queries to:-

Consultation Response Team, The British Psychological Society,

48 Princess Road East, Leicester, LE1 7DR.

Email: consult@bps.org.uk Tel: (0116) 252 9508

This response was prepared on behalf of the Society by Professor Peter Kinderman, CPsychol, AFBPsS, Chair of the Division of Clinical Psychology (DCP), with contributions from Susan van Scoyoc, CPsychol, CSci, AFBPsS, committee member of the DCP and member of the Division of Heath Psychology (DHP); Dr David Harper, CPsychol, AFBPsS, Professor David Pilgrim CPsychol, AFBPsS, and Professor Richard Bentall, FBPsS, all members of the DCP; Lucy Johnstone, CPsychol, AFBPsS, committee member of the DCP; Dr Amanda C de C Williams, CPsychol, member of both the DCP and the DHP, and Professor Pamela James, CPsychol, AFBPsS, committee member of the Division of Counselling Psychology.
We would like to thank

Berry Neil for informing aspects of this response. We hope you find our comments useful. Dr C A Allan, CPsychol, CSci, AFBPsS Chair, Professional Practice Board DSM-5 2011

British Psychological Society response, June 2011

Page 2 of 26

General comments

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.

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).

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 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.

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.

We therefore believe that alternatives to diagnostic frameworks exist, should be preferred, and should be developed with as much

investment of resource and effort as has been expended on revising DSM-IV. The Society would be happy to help in such an exercise.

References

Mirowsky, John. 1990. "Subjective Boundaries and Combinations in Psychiatric Diagnosis." Journal of Mind and Behavior 11(3): 407-

24.

Mirowsky, John, and Catherine E. Ross. 2003. Social Causes of Psychological Distress, 2nd Edition. New Brunswick, N.J.: Aldine

Transaction

Moncrieff J (1995) Lithium revisited. “A re-examination of the placebo-controlled trials”. The British Journal of Psychiatry. 167: 569-573

Moncrieff, J (2003) “Clozapine v. conventional antipsychotic drugs for treatment-resistant schizophrenia: a re-examination”. The British

Journal of Psychiatry. 183: 161-166

Moncrieff, J (2007) The Myth of the Chemical Cure: a critique of psychiatric drug treatment. (1 vols). Palgrave MacMillan: Basingstoke,

Hampshire

Moncrieff J, & Kirsch I (2005) “Efficacy of antidepressants in adults”. BMJ 331 : 155 doi: 10.1136

Moncrieff, J & Timimi, S (2010) “Is ADHD a valid diagnosis in adults? No”. BMJ 2010; 340:c547 doi: 10.1136/bmj.c547

DSM-5 2011

Comments on specific disorders

Code

A 00-01

A 02-08

A 09

Intellectual Developmental Disorders

Communication Disorders

Autism Spectrum Disorder

We have no specific comments on these disorders, other than to say that, in our opinion, the use of diagnostic labels has greater validity, both on theoretical and empirical grounds in these areas.

A 10 Attention Deficit/Hyperactivity

Disorder

As stated in our general comments, we are 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 believe that classifying these problems as ‘illnesses’ misses the relational context of problems and the undeniable social causation of many such problems.

For psychologists, our well-being 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.

We have particular concerns about the inclusion of Attention Deficit/Hyperactivity Disorder in this categorisation. Many of the concerns about the scientific validity and utility of diagnoses per se (articulated above) apply to ADHD. We are very concerned at the increasing use of this diagnosis and of the increasing use of

medication for children, and would be very concerned to see these increase further.

A 11 Other Specified Attention

Deficit/Hyperactivity Disorder

As stated in our general comments, we are 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 believe that classifying these problems as ‘illnesses’ misses the relational

context of problems and the undeniable social causation of many such problems.

For psychologists, our well-being 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.

We have particular concerns about the inclusion of Attention Deficit/Hyperactivity

Disorder in this categorisation. Many of the concerns about the scientific validity and

utility of diagnoses per se (articulated above) apply to ADHD. We are very

concerned at the increasing use of this diagnosis and of the increasing use of

medication for children, and would be very concerned to see these increase further.

In addition, we have serious concerns about the widespread use of the ‘other’ or ‘not

otherwise specified’ categories, which, in this context, appear to exacerbate all the

problems of labelling with invalid diagnostic labels.

A 12-15

A 16-22

Learning Disorders (Learning

Disorder, Dyslexia, Dyscalculia,

Disorder of Written Expression), Motor

Disorders

We have no specific comments on these disorders, other than to say that, in our

opinion, the use of diagnostic labels has greater validity, both on theoretical and

empirical grounds in these areas.

DSM-5 2011

B 00 Schizophrenia As stated in our general comments, we are concerned that clients and the general