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.
DSM-5 2011
British
Psychological Society response, June 2011
Page 3 of 26
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
British
Psychological Society response, June 2011
Page 4 of 26
Comments on
specific disorders
Code Title Comment
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.
DSM-5 2011
British
Psychological Society response, June 2011
Page 5 of 26
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
British
Psychological Society response, June 2011
Page 6 of 26
B 00 Schizophrenia
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.
The general
concerns about the scientific validity and utility of diagnoses articulated
above are
particularly relevant to the diagnosis of schizophrenia. We note in
particular, that
the invalidity of this diagnosis is such that it is entirely possible for two
individuals with
the diagnosis to share no characteristics or symptoms. We also note
the poor
prognostic and therapeutic validity of this group of diagnoses.
B01 Schizotypal
Personality 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.
The general concerns
about the scientific validity and utility of diagnoses articulated
above are
particularly relevant to the diagnosis of Schizotypal Personality Disorder –
as it suffers from
the problems associated with personality disorder more generally,
as well as
problems associated with psychosis.
DSM-5 2011
British
Psychological Society response, June 2011
Page 7 of 26
B02
Schizophreniform 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.
The general
concerns about the scientific validity and utility of diagnoses articulated
above are particularly
relevant to the diagnosis of Schizophreniform Disorder, which
appears to be a
reflection of vague concerns about a person’s mental health –
effectively one of
many ‘catch-all’ classifications.
B03 Brief
Psychotic 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.
The general
concerns about the scientific validity and utility of diagnoses articulated
above are
particularly relevant to the diagnosis of Brief Psychotic Disorder, given the
problems
associated with psychiatric labels, the particular consequences of a
psychotic label
and the known transience of many of these fleeting psychosis-like
experiences.
DSM-5 2011
British
Psychological Society response, June 2011
Page 8 of 26
B04 Delusional
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.
The general
concerns about the scientific validity and utility of diagnoses articulated
above apply
equally to the diagnosis of Delusional Disorder.
B05
Schizoaffective 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.
The general
concerns about the scientific validity and utility of diagnoses articulated
above apply
equally to the diagnosis of Schizoaffective Disorder.
DSM-5 2011
British
Psychological Society response, June 2011
Page 9 of 26
B06 Attenuated
Psychosis Syndrome 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
significant concerns over the inclusion of “attenuated psychosis syndrome”.
The concept of “attenuated
psychosis system” appears very worrying; it looks like an
opportunity to
stigmatize eccentric people, and to lower the threshold for achieving a
diagnosis of
psychosis (and hence increasing the number the people receiving
antipsychotic
medication and a range of other social ills).
B07-14
Substance-Induced Psychotic
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.
The general
concerns about the scientific validity and utility of diagnoses articulated
above are
particularly relevant to the diagnosis of Substance-Induced Psychotic
Disorder. People
take drugs; these drugs affect their mental state and can have
long-term
consequences. That appears somewhat different from a diagnosis of
conventional
medical illnesses.
DSM-5 2011
British
Psychological Society response, June 2011
Page 10 of 26
B15 Psychotic
Disorder Associated with a
Known General
Medical Condition
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.
These concerns
include the association between physical and psychological health –
where we believe
it is unnecessary and misleading to represent such associations as
‘psychiatric
illnesses’ – and ‘catch-all’ classifications such as ‘unspecified’ or ‘other’.
B16 Catatonic
Disorder Associated with a
Known General
Medical Condition
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.
These concerns
include the association between physical and psychological health –
where we believe
it is unnecessary and misleading to represent such associations as
‘psychiatric
illnesses’ – and ‘catch-all’ classifications such as ‘unspecified’ or ‘other’.
B17 Other
Specified Psychotic 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.
These concerns
include the association between physical and psychological health –
where we believe
it is unnecessary and misleading to represent such associations as
‘psychiatric
illnesses’ – and ‘catch-all’ classifications such as ‘unspecified’ or ‘other’.
B18 Unspecified
Psychotic 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.
These concerns
include the association between physical and psychological health –
where we believe
it is unnecessary and misleading to represent such associations as
‘psychiatric
illnesses’ – and ‘catch-all’ classifications such as ‘unspecified’ or ‘other’.
DSM-5 2011
British
Psychological Society response, June 2011
Page 11 of 26
B19 Unspecified
Catatonic 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.
These concerns
include the association between physical and psychological health –
where we believe
it is unnecessary and misleading to represent such associations as
‘psychiatric
illnesses’ – and ‘catch-all’ classifications such as ‘unspecified’ or ‘other’.
C00-06 Bipolar and
related disorders 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.
These general
concerns about the scientific validity and utility of diagnoses
articulated above
apply equally to the area of bipolar disorder and related disorders.
DSM-5 2011
British
Psychological Society response, June 2011
Page 12 of 26
D01-02
and
D04-09
Depressive Disorders
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.
These general
concerns about the scientific validity and utility of diagnoses
articulated above
apply equally to the area of depressive disorders. We note that, in
this context,
sadness and unhappiness which are deserving of help and intervention
– are not best
considered illnesses. We also note that, by regarding them as such,
there is a danger
of misunderstanding their nature and cause and applying
inappropriate
medical remedies.
DSM-5 2011
British
Psychological Society response, June 2011
Page 13 of 26
D00 Disruptive
Mood Dysregulation
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.
These general
concerns about the scientific validity and utility of diagnoses
articulated above
apply equally to the area of depressive disorders. We note that, in
this context,
sadness and unhappiness which are deserving of help and intervention
– are not best
considered illnesses. We also note that, by regarding them as such,
there is a danger
of misunderstanding their nature and cause and applying
inappropriate
medical remedies.
We have particular
concerns at the inclusion of this diagnosis, whose essential
characteristics: “...severe
recurrent temper outbursts in response to common
stressors....”
appear to reflect exactly those normative judgements referred to above.
DSM-5 2011
British
Psychological Society response, June 2011
Page 14 of 26
D03 Chronic
Depressive Disorder
(Dysthymia)
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.
These general
concerns about the scientific validity and utility of diagnoses
articulated above
apply equally to the area of depressive disorders. We note that, in
this context,
sadness and unhappiness which are deserving of help and intervention
– are not best
considered illnesses. We also note that, by regarding them as such,
there is a danger
of misunderstanding their nature and cause and applying
inappropriate
medical remedies.
We have particular
concerns at the inclusion of this diagnosis, whose essential
characteristics: “...depressed
mood for most of the day...” certainly reflects a state of
affairs that any
humane individual should attempt to address, but does not appear to
reflect any form
of medical illness.
DSM-5 2011
British
Psychological Society response, June 2011
Page 15 of 26
E00-14 Anxiety
Disorders 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.
The concerns noted
above also apply to anxiety disorders. We note that many
people have
experienced, and live in, circumstances that reasonably induce normal
and understandable
anxiety. We further note that many of the specific diagnoses –
particularly
social anxiety and generalised anxiety disorder – appear, again, to reflect
conditions that
are understandable, and deserving of help and intervention, but are
not best
considered illnesses. We also note that, again, by regarding them as such,
there is a danger
of misunderstanding their nature and cause and applying
inappropriate
medical remedies.
F 00-09
Obsessive-Compulsive and Related
Disorders
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.
Although
obsessive-compulsive problems appear to have more empirical validity
than some other
disorders, many of the concerns noted above also apply here –
particularly the
concerns over inappropriate medicalisation and potential overreliance
on medical
interventions.
DSM-5 2011
British
Psychological Society response, June 2011
Page 16 of 26
G00-08 Trauma- and
Stressor-Related
Disorders
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.
Again, we have
concerns in the area of trauma-related disorders. Obviously it is
right and proper
to recognise the effects of traumatic events on people, and to be
able to offer
appropriate help. In this context however, we fear that those benefits
might be made more
difficult if, instead of recognising the effects of traumatic events
on people, these
were considered to be ‘disorders’ or ‘illnesses’. As noted above,
there are more
appropriate conceptualisations.
H00-05
Dissociative Disorders 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.
These concerns
also apply to this area.
DSM-5 2011
British
Psychological Society response, June 2011
Page 17 of 26
J00 Complex Somatic
Symptom 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.
Many of these
concerns also apply to this area.
It is good to
see the assumptions implicit in ‘somatization’ terminology have been
removed, but we
retain concerns about the criteria used.
Concern about
medical seriousness arises from the universal experience of pain as
a warning signal
of something wrong, as in many acute pains. Until and unless an
adequate
explanation is given to the person with persistent pain, distinguishing it
from the ‘alarm
signal’ of acute pain, they continue to search for a medical
explanation as is
the case in acute pain. “Reassurance” that nothing shows on
investigation
often exacerbates the patient’s concerns that what they have is hard to
detect or
diagnose. The judgment of what is ‘disproportionate’ or ‘excessive’ is a
subjective, value-laden,
issue.
DSM-5 2011
British
Psychological Society response, June 2011
Page 18 of 26
J01 Simple Somatic
Symptom 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.
Many of these
concerns also apply to this area.
It is good to
see the assumptions implicit in ‘somatization’ terminology have been
removed, but we
retain concerns about the criteria used.
Concern about
medical seriousness arises from the universal experience of pain as
a warning signal
of something wrong, as in many acute pains. Until and unless an
adequate
explanation is given to the person with persistent pain, distinguishing it
from the ‘alarm
signal’ of acute pain, they continue to search for a medical
explanation as is
the case in acute pain. “Reassurance” that nothing shows on
investigation
often exacerbates the patient’s concerns that what they have is hard to
detect or
diagnose. The judgment of what is ‘disproportionate’ or ‘excessive’ is a
subjective,
value-laden, issue.
J02-06 Somatic
Symptom Disorders 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.
Many of these
concerns also apply to this area.
DSM-5 2011
British
Psychological Society response, June 2011
Page 19 of 26
K00-07 Feeding and
Eating Disorders 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.
These concerns
also apply to this area.
L00-01 Elimination
Disorders 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.
These concerns
also apply to this area.
DSM-5 2011
British
Psychological Society response, June 2011
Page 20 of 26
M00-20 Sleep-Wake
Disorders 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.
These concerns
also apply to this area.
N00-10 Sexual
Dysfunctions 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.
All the comments
made earlier apply also here.
Of particular
concern are the subjective and socially normative aspects of sexual
behaviour. It is a
matter of record that homosexuality used to be considered a
symptom of
illness. The Society would not be able to support considering sexual
differences as
symptoms of illness.
DSM-5 2011
British
Psychological Society response, June 2011
Page 21 of 26
P00-03 Gender
Dysphoria 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.
All the comments
made earlier apply also here.
Of particular
concern are the subjective and socially normative aspects of sexual
behaviour. We are
very concerned at the inclusion of children and adolescents in
this area. There
is controversy in this particular area – the concept of a ‘diagnosis’ of
a ‘psychiatric
disorder’ disputed.
Labelling people
who need help as ‘ill’ may make supportive and therapeutic
responses more
difficult.
DSM-5 2011
British
Psychological Society response, June 2011
Page 22 of 26
Q00-07 Disruptive,
Impulse Control and
Conduct Disorders
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.
All the comments
made earlier apply also here. Of particular concern are the
subjective and
socially normative aspects of conformist behaviour. We are very
concerned that ‘headstrong’
behaviour is considered to be pathognomic of an illness
(in Oppositional
Defiant Disorder). Many people – many governments – would like
children and
citizens to be less defiant and more compliant. However, it is not a
symptom of illness
to be defiant. It may be a social or psychological problem to be
addressed, but it
may, in some circumstances, be a characteristic to be praised.
An ‘unspecified’
disruptive or impulse control disorder, in this context, is even more
subjective,
value-laden, conceptually confused, and therefore worrying.
DSM-5 2011
British
Psychological Society response, June 2011
Page 23 of 26
R00-31 Substance
Use and Addictive
Disorders
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 note with
concern the concept of ‘Gambling Disorder’. Gambling is a problem,
and it is a social
phenomenon and issue that requires study and response.
However, we feel
it is conceptually wrong to regard this as an illness with symptoms.
We recognise that
here – as in other ‘disorders’ – no concept of organic pathology is
necessarily
implied (DSM-V is, we recognise, intended to be a useful list of
‘disorders’), but
we also are aware that inclusion in such a list has implications, and
we strongly feel
that an alternative non-medical conceptualisation is called for.
S00-35
Neurocognitive 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
British
Psychological Society response, June 2011
Page 24 of 26
Personality
disorders The Society has several concerns in this area.
While a hybrid
dimensional-categorical model for personality and personality
disorder
assessment and diagnosis may be welcome, little of that is visible.
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 are
particularly concerned that the system proposes to diagnose psychiatric
disorder on a
rating of “quite a bit” on personality trait domains.
DSM-5 2011
British
Psychological Society response, June 2011
Page 25 of 26
U00-09 Paraphilias
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.
All these comments
apply also here. Again, of particular concern are the subjective
and socially
normative aspects of sexual behaviour. It is a matter of record that
homosexuality used
to be considered a symptom of illness. The Society would not
be able to support
considering sexual differences as symptoms of illness.
We, finally, have
severe misgivings about the inclusion of “Paraphilic Coercive
Disorder” in the
appendix. Rape is a crime, not a disorder. Such behaviours can, of
course, be
understood, but we disagree that such a pattern of behaviour could be
considered a
disorder, and we would have grave concerns that such views may offer
a spurious and
unscientific defence to a rapist in a criminal trial.
DSM-5 2011
British
Psychological Society response, June 2011
Page 26 of 26
V01-06 Other
disorders 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.
Clearly it is good
for healthcare professionals and others to recognise self-harm.
However, we do not
believe that self-harm should be classified as a symptom of a
disorder. Rather
we would support recognising this behaviour, understanding it and
offering help.
Similarly, a “pattern
of falsification of physical or psychological signs or symptoms, or
of induction of
injury or disease” is a worrying and important phenomenon. But again
it should be
understood and responded to, not conceptualised as a symptom of an
illness.
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