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Monday 20 May 2013


20 May 2013

Under new psychiatric guidebook we might all be labelled mad:

Professor Emeritus of Psychiatry at Duke University 

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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.



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.


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.

The University of LiverpoolProvides funding as a Founding Partner of The Conversation.

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.

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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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