20
May 2013
Under new psychiatric guidebook we might all be labelled mad:
Professor Emeritus of Psychiatry at Duke University
SEE ALLEN FRANCES IN THE U.K. ON 28th JUNE:
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SEE ALLEN FRANCES IN THE U.K. ON 28th JUNE:
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Disclosure
Statement
Allen Frances has two published books critical of DSM-5: Saving Normal and Essentials of Psychiatric Diagnosis
“We
are all mad here” explains the Cat to Alice when she wonders about the strangeness
of Wonderland. Well, life is starting to follow art. If people make the mistake
of following DSM-5, the new diagnostic manual in psychiatry that was published on
Saturday, pretty soon all of us may be labelled mad.
When I worked on the taskforce for DSM-4, we were very concerned about taming diagnostic inflation – but we only partly succeeded. Then four years ago, I became aware of the excessive enthusiasm around all the new diagnoses being proposed for DSM-5, including many that were untested. I hate to rain on anyone’s parade, but I knew this would be disastrous for the millions of people who were likely to be mislabelled, stigmatised and given excessive treatment.
In
the US, the “sick” are distinguished from the “well” by the diagnostic and
statistical manuals developed by the American Psychiatric Association.
The
problem is that definitions of mental disorders are already written too loosely
and are applied much too carelessly by clinicians, especially by the GPs who do
most of the prescribing of psychiatric drugs.
And
things are about to get much worse. Under DSM-5 diagnostic inflation looks set
to become hyperinflation and will lead to an even greater glut of unnecessary
medication. I would qualify for a bunch of the new labels myself – and you might
too.
The
grief I felt when my wife died would now be called “major depressive disorder”;
forgetfulness in older age “mild neurocognitive disorder”; my gluttony now
“binge eating disorder”; and my hyperactivity “attention deficit disorder”. As
for my twin grandsons' temper tantrums, this could be misunderstood as
“disruptive mood dysregulation disorder”. And if you have cancer and your
doctor thinks you are too worried about it, there’s “somatic symptom disorder.”
It goes on, but you get the idea.
About
half of
Americans already qualify for a mental disorder at some point in their
lives and the rates keep skyrocketing, especially among kids. In the past 20
years, the prevalence of autism has increased, childhood bipolar has multiplied 40-fold and attention deficit disorder has tripled.
One
consolation: the kids are not suddenly getting much sicker – human nature is
pretty stable. But the way we label symptoms follows fickle fashions, changing
quickly and arbitrarily. And freely giving out inaccurate diagnoses can lead to
grave harms – medication that isn’t needed, stigma, lower self confidence and
reduced self expectation.
There
are also downstream effects. Many parents were panicked about the alarming rise
in rates of autism and fell for the disproven belief that it was caused by vaccination.
Trying to avoid a false epidemic of autism caused by nothing more than changed
labelling meant they stopped vaccinating their kids and exposed them to the
very real measles outbreak that recently occurred.
And
medication use is out of control – 20% of Americans regularly use a psychotropic
drug; 10% of teenage boys are taking a stimulant for ADHD; 25% of
our active duty troops report abuse of a prescribed med; and the US has more
deaths from
prescription drug overdoses than from street drugs.
In
the UK you are protected against the worst effects of diagnostic and drug
exuberance. Doctors use ICD-10, the classifications compiled by the World
Health Organisation, not DSM-5; they follow prudent guidelines from Nice, which
sets the standards for health treatment in the UK; the British-based Cochrane
group emphasises evidence-based medicine; GPs do less
prescribing; and drug companies exert much less power and cannot advertise
directly to consumers as they do in the US.
But
the measles outbreak and ADHD rates prove the UK is not out of the woods. Bad
ideas from America sometimes have much more influence than they deserve.
My
advice is to be an informed consumer. Never accept a diagnosis or a medication
after a cursory evaluation. A psychiatric diagnosis can be a turning point in
your life – as important as choosing a spouse or a house. Done well, it can
lead to life-improving treatment; done poorly it can lead to an inaccurate
label and a harmful treatment.
People
who have mild and transient symptoms don’t need a diagnosis or treatment. The
likelihood is they are visiting the doctor on one of their worst days and will
get better on their own. Medication is essential for severe psychiatric
problems but does more harm than good for the worries and disappointments of
everyday life. Better to trust time, resilience, support and stress reduction.
Disclosure Statement
Darryl
P. Watson has provided paid consultancy and received speaker's fees from a
number of Pharmaceutical comapanies criticised for supporting the development
and extension of illness categories. He has received research and educational
funding from several pharmaceutical companies. He is affiliated with the Royal
Australian and New Zealand College of Psychiatrists but is not the official
spokesperson for this organisation.
This weekend saw the release of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5). The manual has been attracting controversy throughout its revision process, but critical voices reached fever pitch in the weeks leading up to its release.
Indeed,
in the fortnight before its release, DSM-5 was panned by the director of the US
National Institute of Mental Health (NIMH) as well as the British Psychological
Society’s (BPS) division of clinical psychology. Interestingly, the criticisms
were at odds with each other.
The
NIMH wants psychiatry to focus on the biological bases of mental illness while
the BPS opts for psychosocial therapy. It seems that the DSM would have been
damned whichever way it opted to go.
NIHM
director Dr Thomas R Insel accused the manual of lacking scientific rigour, announcing
that he intended to:
reshape
the direction of psychiatric research to focus on biology, genetics and
neuroscience so that scientists can define disorders by their causes, rather
than their symptoms.
Criticism
from the BPS was not directed straight at DSM-5 but was “provocatively timed”, according to the Guardian, and questioned the benefits of
the manual. Here the BPS' spokesperson said:
it
was unhelpful to see mental health issues as illnesses with biological causes.
But
what are clinicians like me to think when confronted by criticism from such
respectable sources? We need a set of labels, updated routinely, as a shorthand
for talking with colleagues. Patients and families expect a diagnosis. We need
to justify funding for medication and hospital care. Even funders of talking
therapies and social supports expect a label.
The
truth is that making a diagnosis in health care is complex, and it is even more
complex in psychiatry. Say someone reports a painful arm after a fall. This may
indicate a broken bone. The clinical examination that follows is usually
helpful in finding tenderness and sometimes deformity. And technology, in the
form of X-ray, is commonly used to make a definitive diagnosis.
Now,
imagine the difficulty of diagnosis where the bulk of the information is from a
patient’s own report of symptoms that are not necessarily observable by the
clinician. There’s no definitive X-ray or blood test to point you in the right
direction.
Welcome
to the world of clinical psychiatry where:
the boundaries between many disorder “categories” are more
fluid over the life course than was previously understood, and many symptoms
assigned to a single disorder may occur, at varying levels of severity, in many
other disorders.
Psychiatrists
regularly treat people who experience marked distress and loss of function
caused by diseases or syndromes that have continued to evade definitive
biological definition.
The
early DSM editions were American modifications of the World Health Organization’s
International
Classification of Diseases (ICD) to give a “pure” mental disorders chapter.
DSM-I and DSM-II were clumsy by today’s standards and
labelled the world as it was without much help from research.
But
the American Psychiatric Association (APA) followed ground-breaking work into
the categorisation of psychiatric conditions of the 1970s with
the third edition of the DSM in 1980. DSM-III made a “best guess” at an
archipelago of diagnosis, where each island or illness was confirmed as
discrete with borders separated by clear water. A revision to iron out
inconsistencies followed in the form of DSM-III-R and DSM-IV was published in
1994.
By
2002, the APA was convinced that two decades of “modern” DSM
categories had not generated valid, clearly separated diagnoses. Research, it
seemed, had “not confirmed the wisdom of the current structure.” The
islands tended to stick together and overlapped repeatedly. The map was a mess
for researchers and clinicians alike.
In
the latest edition of the manual, conditions will be clustered in chapters with
dimensional measures encouraged over discrete diagnostic categories. If you
can’t separate each island, drag them together and describe different bits as
mountains or lagoons. This represents the triumph for supporters of a “spectrum
of illness”.
The
leaders of the process that changed the diagnostic concepts (driven by more
than two decades of peer-reviewed scientific research) might have expected some
public applause. Instead, even before the launch of the DSM-5, negative public
comments criticised their work.
But
the narrow debate that has ensued presumes mental illness has either a
biological or psychosocial basis, which does no justice to our current
scientific knowledge. Surely, in 2013, we can accept that all human memory,
behaviour and emotion is connected to the chemistry of our brain.
But
then many clinical psychologists spend all their time working with people who
clearly have a biological basis to their problem, such as head injury or brain
disease. Should we presume that the social circumstances or psychological
make-up of these people never mix with their altered brain anatomy?
All
of us are clearly a complex mixture of nature and nurture. Clinicians of all
types, including psychologists, need to stay focused on the person in their
office and use their judgement when making a diagnosis.
The
previous edition of the DSM included a reminder to use diagnostic criteria as
guidelines rather than a cookbook. Regardless of other changes, we can hope
that this reminder is retained in the latest version lest any of us stray into
using multiple unnecessary labels that distract from the distress of the person
sitting in front of us.
http://theconversation.com/despite-the-critics-psychiatrists-need-guidelines-like-the-dsm-5-14221
http://theconversation.com/despite-the-critics-psychiatrists-need-guidelines-like-the-dsm-5-14221
http://theconversation.com/despite-the-critics-psychiatrists-need-guidelines-like-the-dsm-5-14221
Disclosure Statement
Simon Wessely is a member of the ICD-11 Stress Disorders working party
The
Conversation is founded by the following universities:
Aberdeen, Birmingham, Bristol, Cardiff, City, Glasgow Caledonian, Liverpool,
Open, Salford, Sheffield, Surrey, UCL and Warwick.
DSM-5 has been described as the bible of psychiatry but the assumption that professionals use it for their own gain is far fetched. PA
DSM-5,
the latest version of the Diagnostic and Statistical Manual of the American
Psychiatric Association, was published in the US at the weekend.
Given
that not even its most passionate supporters would call it a good read, it had
already attracted unusual levels of attention. There has already been an
avalanche of serious comment pieces, magazine articles, blogs and the occasional sensationalist Daily Mail headline.
Why
is it proving so controversial? The DSM is nothing more than a list of
psychiatric disorders, accompanied by descriptions and explicit criteria for
their diagnosis. It’s also not new – it’s the fifth such revision – although
given the propensity of the association to trot out revisions on a regular
basis, there have been at least eight since 1952.
The
DSM is important in the US – unless your disorder is in the manual you won’t be
treated. Or more accurately, you can be treated but your therapist won’t be
reimbursed by your insurance company, which amounts to the same thing.
But
the manual also important because it tells us something about the state of
psychiatry.
Mission creep?
Early
versions of the DSM did not attract much attention or controversy. Much of
American psychiatry was dominated by psychoanalysis, which doesn’t give central
importance to diagnostic categories as every patient is considered a unique
individual. It was not until DSM III came along in 1980 that people really
started to take notice – and to complain.
The
first problem was the increasing number of diagnoses. In 1917, the APA
recognised 59 psychiatric disorders. When DSM-I was published in 1952 it had
128. By 1987 there were 253. DSM-IV has 347.
We
are promised that DSM-5 (now designated by digits rather than Roman numerals to
make revisions easier) will reduce the total for the first time. I’m not
holding my breath.
Given
that the real number of mental disorders, whatever that may be, is unlikely to
be increasing at a similar exponential rate, it’s not surprising that the cry
has gone up that this
represents psychiatric mission creep – a dastardly plot by the profession
to extend its influence into more and more aspects of our daily lives and
thoughts.
Indeed,
there is evidence for a medicalisation of the normal, the eccentric and the
odd. It seems increasingly difficult to find shy children anymore – instead
it’s now a social phobia. Who these days is called bookish or eccentric, as
opposed to someone suffering from Asperger’s?
When
you bring big pharmaceutical companies into the picture – who have occasionally
been caught colluding in the creation or expansion of psychiatric disorders in
order to create new markets for their drugs – it’s not surprising that the new
DSM is being greeted with a storm of criticism.
The difficulty of classification
But
the reality is a little different. Psychiatric classification is difficult
because we are restricted to largely symptomatic descriptions of disorders, as
opposed to leukaemias or endocrine disorders, for example, which are based on
very detailed knowledge of the actual pathological processes that underlie
clinical symptoms.
Psychiatry
is not at that stage yet, and as Gary Greenbergpointed out recently in the New Yorker, things have not
changed much since the superintendent of a Massachusetts asylum wrote in 1886:
“in the present state of our knowledge no classification of insanity can be
erected on a pathological basis.”
We
are on the brink of new discoveries that will transform our understanding of
major mental disorders such as schizophrenia and bipolar and a recent Lancet paper reported62129-1/abstract “”) common
genetic markers linking five major disorders. But until that point it’s not
surprising that when it comes to classification, a hundred flowers still bloom.
One
common assumption is that it is the psychiatrists that are seeking to extend
the boundaries. But you can argue that teachers also have an incentive to
promote the growth of psychiatric labels – children with ADHD or Asperger’s are
likely to make you eligible for more classroom assistants than difficult or
unruly children. Some parents will prefer to put their child’s problematic
behaviours down to genes or disordered development than inconsistent or absent
parenting.
When
Allen Frances, one of the architects of DSM-IV but now the leading critic of
DSM-5, started to repudiate his own contribution to expanded diagnostic
boundaries in autism, he was greeted with open hostility from many parents of children who had been diagnosed with
one of its looser definitions.
The
raging arguments over DSM have been more muted in the UK. Unlike the US, it
isn’t necessary to be a perfect fit with a DSM category to be treated. A GP may
decide to treat unhappiness as a case of depression, but it won’t involve
consulting the APA’s latest bible.
Many
mental health professionals will also be shaking their heads at the outrage
that DSM-5 has generated, in particular the claim that it’s all an underhanded
plot by the professionals.
For
psychiatrists, the biggest threat is the opposite. Far from extending our
empire, most of us are faced with the biggest reductions in funding and
services we can remember.
In
a recession, mental health services suffer first and foremost compared to acute
care.
For
most psychiatrists the current reality is trying desperately to protect
services to ensure that those whose mental disorders are indisputable – in any
classification system – do not lose out. The idea that we are looking for new
markets seems far fetched.
A two-day conference into DSM takes place at the Institute of
Psychiatry from June 4th-5th.
 |
Disclosure Statement
Peter
Kinderman does not work for, consult to, own shares in or receive funding from
any company or organisation that would benefit from this article, and has no
relevant affiliations.
Provides
funding as a Founding Partner of The Conversation.liverpool.ac.uk/
Explainer: what is the DSM?
Psychiatric
diagnosis relies on identifying a patient’s signs and symptoms rather than
clinical tests. PA/Ben Birchall
Traditional
psychiatry uses the approaches of medicine to try to understand mental health
problems and guide treatment. This means relying on diagnosis – identifying
what are believed to be mental illnesses from their signs and symptoms, in the
same way that doctors in other branches of medicine diagnose physical health
problems.
There
are two widely used systems in psychiatry: the World Health Organization’s
International Standard Classification of Diseases, Injuries and Causes of Death
– or ICD
– and the American Psychiatric Association’s Diagnostic and Statistical Manual
– or DSM.
The latest edition of the DSM was published this weekend.
Both
ICD and DSM were first published immediately after the World War II and have
been revised extensively over the years. But there hasn’t been a new edition of
DSM since DSM-IV was published in 1994 – almost 20 years ago.
ICD
is technically the international standard classification system and forms the
basis for NHS procedures in the UK. But the American DSM is also extremely
influential and is widely used in research and academic fields and for
planners, for example keeping hospital records. That’s why the publication of
its fifth edition is important.
The nature of psychiatric
diagnosis
The
diagnosis of mental health problems is extraordinarily complex – and
controversial. The basic aim of diagnostic manuals is to explain the underlying
nature and structure of mental health problems. They attempt to describe
patterns observed in nature, for example how a patient behaves, without (the
authors claim) making assumptions about why.
However,
the complexity of mental health problems can lead to difficult decisions. It
also means the manuals themselves are also complex: what criteria are included;
the rules about which disorders are included and which aren’t; and the
relationships between different families in the manuals, for example between
obsessive compulsive disorder and impulse control disorder. This also leads to
significant differences in opinion.
Families of illnesses
The
manuals are designed to group similar types of diagnoses together. For instance,
diagnoses that are all concerned with anxiety of various kinds are listed
together. And they are generally seen as separate from problems such as
learning disabilities.
Including
problems such as children’s learning disabilities, relationship and personality
difficulties, emotional problems and problems of later life such as dementia,
can be problematic. DSM-5 has come under critcism for changes in some of these
areas. One example discussed widely is that idea that it might be possible to
receive a diagnosis of “major depressive episode” when one is still grieving
for the death of a loved-one. Bereavement was specifically excluded from
previous versions.
The
ICD and DSM are different, and to an extent are rival systems, but there is
huge overlap. This allows researchers and clinicians to translate diagnoses
from one system to another – a bit like cross-referencing between two
dictionaries.
DSM
uses what is called a “multi-axial” scheme to classify diagnoses. Psychiatrists
use multiple axes to diagnose and treat patients. Primary diagnoses form a
first tier called Axis I and includes depression and schizophrenia. So-called
developmental and personality disorders lie in Axis II and includes autism.
Related issues such as the degree of disruption caused to a person’s life are
assessed on remaining axes. In practice, Axes I and II diagnoses tend to be
used in a similar way.
Psychiatric
diagnosis echoes and resembles conventional medical diagnosis, but there are no
useful biological markers or tests for illnesses like you might get if you were
treating someone with diabetes – which makes many people sceptical of
biological explanations per se.
Diagnosis
of a person’s problems is inevitably based on their descriptions of their
feelings, thoughts and behaviour and on the observations of the person trying
to make the diagnosis.
It
also means that decisions about the criteria for each diagnosis – the structure
and content of DSM and ICD – are essentially made by committee. In the case of
DSM, a taskforce.
New approaches
Different
clinicians – and particularly psychiatrists and psychologists – differ as to
what particular problems should be included or what the criteria should be.
Some also question the reliability of psychiatric diagnoses, whether we should
think of problems as illnesses to be treated or that a broadening of
psychiatric diagnoses means a wider variety of personal problems could attract
a diagnosis. One widely discussed example is that it might now be possible to
receive a diagnosis of “major depressive episode” when one is grieving for the
death of a loved-one.
Others
fear the opposite: that diagnoses, and therefore psychiatric support, will be
taken away. This has particularly
been the case with changes to the definition of autism and the exclusion of
Asperger’s from DSM-5.
While
the publication of DSM-5 has catalysed criticism, it is also pushing new
approaches into the spotlight.
The
director of the US National Institute of Mental Health, the largest funder of
mental health research in the world, said this month that it was moving away from a DSM-style
approach to focus on biology, genetics and neuroscience, allowing disorders to
be defined by causes, not symptoms.
New
research will continue to develop our understanding of the causes and treatment
of mental illness. But public debate and controversy over the way we should
approach it won’t be very far away.
 |
The
DSM-5 doesn’t attempt to define what is “normal”; and having a DSM diagnosis is
not the same as being “insane”. Image from shutterstock.com
The
fifth edition of the Diagnostic
and Statistical Manual of Mental of Mental Disorders (DSM-5) is due to hit
psychiatrists' and psychologists' shelves next month. Produced by the American
Psychiatric Association (APA), the DSM provides a standardised system of
diagnosing mental disorders.
From
its first edition in 1952, and with each new edition about every 15 to 20
years, the DSM has always had its critics. But as the arrival of DSM-5
approaches, their clamour is becoming louder.
As
a member of the DSM-5’s
Neurocognitive Disorders Work Group, I’m familiar with some of the
procedures involved in bringing the manual into shape. So let’s look at four
key criticisms about the DSM-5 – and whether they’re warranted.
1. It’s impossible to classify
mental disorders
The
primary purpose of the DSM-5 is to enable physicians or other clinicians to
reliably diagnose patients who present with a mental disorder. The manual also
outlines treatment pathways for the diagnosis, and the likely outcome over
time.
Unlike
other disciplines of medicine, a mental disorder cannot be confirmed by a
pathologist peering down a microscope or a biochemist measuring molecules in
the blood. Aside from a few exceptions, there is no other way of truly knowing
whether a disease really exists.
Inevitably,
there will be differences of opinion about what constitutes a disorder, and
some of these will be major ones. But using the DSM, two clinicians working
remotely from each other should reach the same diagnosis for a particular
patient.
2. The DSM is just a money maker
Critics
have argued the DSM “enterprise” has been very lucrative for the APA, and that
book royalties are the primary motivator for producing yet another edition.
Considering
that about US$25
million has already been spent on the fifth revision process, as estimated
by the chair of the task force, it does not appear to be a great investment if
book royalties were the primary objective.
Neuroscientific
knowledge is exploding exponentially, so revisiting the classification of
mental disorders after two decades is certainly not premature.
3. Under the DSM-5, more people
will be diagnosed with a mental disorder
The
process of revising the DSM is extremely rigorous, and any proposal for a new
disorder or a major revision of existing criteria needs to come on the back of
strong scientific evidence.
There
are 13 DSM-5 working groups, broken down into categories such as mood
disorders, eating disorders, and substance-related disorder. Any new proposal
must be accepted by other members of the advisory group, all of whom are
experts in their field.
The
total number of disorders in DSM-5 is yet to be announced, but its chair David
Kupfer has
said the total number of disorders will not be more than in the DSM-IV:
297.
It’s
important to note that the illnesses clinicians encounter in the psychiatric
clinic is often a more severe form of a phenomenon that pervades society.
Psychiatrists must therefore identify if it is severe or deviant enough to
warrant attention.
The
DSM-5 is intended to help them make that decision. They often end up applying a
threshold at which a particular set of symptoms become a disorder or a
diagnosis. The threshold is guided by the level of distress or dysfunction that
the individual is suffering.
It
is therefore not a culturally influenced whim, but culture does influence the
decision. Differences in such thresholds lead to the controversies in the
diagnosis of attention-deficit
hyperactivity disorder (ADHD), for example, or when bereavement
becomes depression.
4. The DSM is trying to redefine
what’s normal
The
DSM-5, and any other classification of mental disorders, is not an attempt to
define what is normal. Being normal is not the same as “not having a DSM-5
diagnosis”, and having such a diagnosis is not the same as being “insane”, as
some have wrongly argued about the DSM.
Insanity
is in fact a legal term, and “mad” or “crazy” are stigmatising lay terms that
do not apply to the vast majority of people with a DSM-5 diagnosis, and should
not in fact be used for anybody.
Many
individuals, including physicians, find it difficult to accept that mental
illness, not unlike physical illness, is common and most of it is not madness
or insanity. The 2007
National Mental Health Survey showed that one in five Australians
experienced a mental disorder in the previous 12 months.
When
dealing with the imperfections of psychiatric neuroscience, it is clear that
the debate on the appropriateness or otherwise of the classification system
will continue as the mental health profession ponders what is worth treating
and society delineates what is worth helping.
The
DSM-5 must simply be regarded as psychiatry’s next faltering step. It’s not
above criticism, but is probably the best manual of mental disorders that we
are likely to have for some time.
A
truly uncontroversial DSM-6 will have to await major breakthroughs in our
understanding of psychiatric disorders. Let’s hope we don’t have to wait for
more than a generation.
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