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Sunday, 12 May 2013
JOIN THE DEBATE - READ OBSERVER ARTICLE 12-05-13 :"Medicine's big new battleground: does mental illness really exist?" - SEE SOME CONTRIBUTORS AT OLD TRAFFORD ON JUNE 28th - Courtesy of the Guardian / Observer website
latest edition of DSM, the influential American dictionary of psychiatry, says
that shyness in children, depression after bereavement, even internet addiction
can be classified as mental disorders. It has provoked a professional backlash,
with some questioning the alleged role of vested interests in diagnosis
Division of Clinical Psychology is calling for the abandonment of psychiatric
diagnosis, even as the American Psychatric Association's DSM-5 seeks to codify
more illnesses. Photograph: Alina Solovyova-Vincent/Getty Images
has the distinctly uncatchy, abbreviated title DSM-5, and is known to no one
outside the world of mental health.
even before its publication a week on Wednesday, the fifth edition of the Diagnostic
and Statistical Manual, psychiatry's dictionary of disorders, has triggered
a bitter row that stretches across the Atlantic and has fuelled a profound
debate about how modern society should treat mental disturbance.
claim that the American Psychiatric Association's increasingly voluminous
manual will see millions of people unnecessarily categorised as having
psychiatric disorders. For example, shyness in children, temper tantrums and
depression following the death of a loved one could become medical problems,
treatable with drugs. So could internet addiction.
such claims have given ammunition to psychiatry's critics, who believe that
many of the conditions are simply inventions dreamed up for the benefit of
disturbing picture emerges of mutual vested interests, of a psychiatric
industry in cahoots with big pharma. As the writer, Jon Ronson, only half-joked
in a recent TED talk: "Is it possible that the psychiatric profession has
a strong desire to label things that are essential human behaviour as a
supporters retort that such suggestions are clumsy, misguided and unhelpful,
and complain that the much-hyped publication of the manual has become an excuse
to reheat tired arguments to attack their profession.
even psychiatry's defenders acknowledge that the manual has its problems. Allen
Frances, a professor of psychiatry and the chair of the DSM-4 committee, used
his blog to attack the production of the new manual as "secretive, closed
and sloppy", and claimed that it "includes new diagnoses and
reductions in thresholds for old ones that expand the already stretched
boundaries of psychiatry and threaten to turn diagnostic inflation into
in the mental health field have gone even further in their criticism. Thomas R
Insel, director of the National Institute of Mental Health, the American government's
leading agency on mental illness research and prevention, recently attacked the
now, in a significant new attack, the very nature of disorders identified by
psychiatry has been thrown into question. In an unprecedented move for a
professional body, the Division of Clinical Psychology (DCP), which represents
more than 10,000 practitioners and is part of the distinguished British
Psychological Society, will tomorrow publish a statement calling for the
abandonment of psychiatric diagnosis and the development of alternatives which
do not use the language of "illness" or "disorder".
statement claims: "Psychiatric diagnosis is often presented as an
objective statement of fact, but is, in essence, a clinical judgment based on observation
and interpretation of behaviour and self-report, and thus subject to variation
language may be arcane, but the implication is clear. According to the DCP,
"diagnoses such as schizophrenia, bipolar disorder, personality disorder,
attention deficit hyperactivity disorder, conduct disorders and so on" are
of "limited reliability and questionable validity".
is often described as the holy grail of psychiatry. Without it, psychiatry's
foundations crumble. For this reason Mary Boyle, emeritus professor at the
Univerity of East London, believes that the impact of the DCP's statement marks
a dramatic shift in the mental health debate.
statement isn't just an account of the many problems of psychiatric diagnosis
and the lack of evidence to support it," she said. "It's a call for a
completely different way of thinking about mental health problems, away from
the idea that they are illnesses with primarily biological causes."
say that such claims have been made many times before and ignore mountains of
peer-reviewed papers about the importance that biological factors play in
determining mental health, including significant work in the field of genetics.
It also, they say, misrepresents psychiatry's position by ignoring its emphasis
on the impact of the social environment on mental health.
psychiatrists concede that diagnosis of psychiatric disorder is not perfect.
But, as Harold S Koplewicz, a leading child and adolescent psychiatrist,
explained in an article for the Huffington Post, "those lists of
behaviours in the DSM, and other rating scales we use, are tools to help us
look at behaviour as objectively as possible, to find the patterns and
connections that can lead to better understanding and treatment".
experts also say that it is hard to see how the world of mental health could
function without diagnosis. "We know that, for many people affected by a
mental health problem, receiving a diagnosis enabled by diagnostic documents
like the DSM-5 can be extremely helpful," said Paul Farmer, chief
executive of the mental health charity Mind. "A diagnosis can provide
people with appropriate treatments, and could give the person access to other
support and services, including benefits."
even Farmer acknowledged that diagnosis is imperfect. "For example it
takes, on average, 10 years before a person with bipolar disorder gets a
correct diagnosis, which comes with a number of mental and physical health
implications, such as side-effects from the wrong medication," he said.
now the DCP has transformed the debate about diagnosis by claiming that it is
not only unscientific but unhelpful and unnecessary.
though it may sound, you do not need a diagnosis to treat people with mental
health problems," said Dr Lucy Johnstone, a consultant clinical
psychologist who helped to draw up the DCP's statement.
are not denying that these people are very distressed and in need of help.
However, there is no evidence that these experiences are best understood as illnesses
with biological causes. On the contrary, there is now overwhelming evidence
that people break down as a result of a complex mix of social and psychological
circumstances – bereavement and loss, poverty and discrimination, trauma and
Longden, who hears voices and was told she was a schizophrenic who would be
better off having cancer as "it would be easier to cure", explains
that her breakthrough came after a meeting with a psychiatrist who asked her to
tell him a bit about herself. In a paper for the academic journal, Psychosis,
Longden recalled: "I just looked at him and said 'I'm Eleanor, and I'm a
writes: "And in his quiet, Irish voice he said something very powerful, 'I
don't want to know what other people have told you about yourself, I want to
know about you.'
was the first time that I had been given the chance to see myself as a person
with a life story, not as a genetically determined schizophrenic with aberrant
brain chemicals and biological flaws and deficiencies that were beyond my power
who is pursuing a career in academia and is now a campaigner against diagnosis,
views this conversation as a crucial first step in the healing process that
took her off medication. "I am proud to be a voice-hearer," she
writes. "It is an incredibly special and unique experience."
is an inspirational story. But to focus on one person's experiences would be to
ignore the testimonies of others who believe that their mental distress has
biomedical roots. Indeed, many people report that they can see no clear reason
for their distress and firmly believe their life stories have little bearing on
their mental state.
the DCP believes the world of mental health treatment would benefit from a
"paradigm shift" so that it focused less on the biological aspects of
mental health and more on the personal and the social.
essence, instead of asking 'What is wrong with you?', we need to ask 'What has
happened to you?'," Johnstone said. "Once we know that, we can draw
on psychological evidence to show how life events and the sense that people
make of them have led to the current difficulties."
shift away from a biological focus would give succour to psychiatry's critics,
who question society's reliance on the use of drugs or interventions such as
electroconvulsive therapy to treat psychiatric breakdown.
of antidepressants increased nearly 30% in England between 2008 and 2011, the
latest available data.
recent article in the online edition of the British Medical Journal
suggested "that only one in seven people actually benefits" from
antidepressants and claimed that three-quarters of the experts who wrote the
definitions of mental illness had links to drug companies.
Sir Simon Wessely, chair of Psychological Medicine at King's College London
(KCL), argues that his profession has always emphasised the need to "look
at the whole person, and indeed beyond the person to their family, and to
society", and that claims psychiatry is being "taken over by the
biologists" are unfounded.
defence, which will be outlined at a major international conference on the
impact of DSM-5, to be held at KCL at the beginning of June, is often lost in a
it is noticeable just how vocal psychiatry's critics are becoming ahead of the
publication of DSM-5. In an attempt to pour oil on troubled waters, Professor
Sue Bailey, president of the Royal College of Psychiatrists, conceded that
"many of the criticisms that are levelled at DSM" were valid but
warned that the row was "distracting us from the real challenge, which is
providing high-quality mental health services and treatment to patients and
insisted the manual's publication "won't have any direct influence on the
diagnosis of mental illness in the NHS". But it will frame the wider
debate about how people see mental health. As Wessely acknowledged,
psychiatry's critics will seize on the manual's "daft" new categories
of mental disorder to bolster claims that the profession is "medicalising
is an irony here. Psychiatry lies wounded and much of the damage appears to be
self-inflicted. The emotional scars may take decades to heal.