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Friday, 2 August 2013


DCP, diagnosis and DSM

I would agree with Richard Pemberton that the Division of Clinical Psychology (DCP) Position Statement on Classification is a more balanced document than reported in the media (Letters, July 2013). I would also agree that there are inherent problems with existing systems of psychiatric classification. Given that, by definition, psychiatric diagnoses are used in the absence of identifiable physiological abnormalities, deciding what is an ‘illness’ and what is a normal reaction inevitably involves the use of arbitrary cut-off points, thereby laying the system open to the kind of criticisms made by the DCP (along with many others).
However, there are some aspects of the position statement that I would question.
Firstly, it lumps together a variety of very different conditions, such as schizophrenia, ADHD and conduct disorders. While many do claim a biological basis for schizophrenia (pace Mary Boyle and others), few would make the same claim for, for example, conduct disorders. Pemberton says that we do not conceptualise ‘other’ responses to life events such as bereavement as diseases, but this begs the question, assuming that it has been clearly demonstrated that all conditions given a psychiatric label are nothing more than reactions to life events. In the case of schizophrenia (or the phenomena associated with this diagnosis), despite Boyle’s thorough examination of the issue, it is actually very hard to make a convincing case for it being entirely due to adverse experience. Childhood abuse has been linked to a wide variety of conditions in addition to schizophrenia, including depression, eating disorders, personality disorders and substance abuse; if biological predisposition plays no part in any of these, there would need to be specific types of adverse experiences that are unique to each condition, otherwise it is impossible to explain why some people develop one condition and some another. As far as I know, no evidence has ever been produced to support this.
Secondly, the paper confuses the stigma arising from a psychiatric diagnosis with that which arises from the condition itself. It is a sad fact of life that people perceived as different have always tended to be rejected by society, and the ‘insane’ were stigmatised long before Bleuler and Kraepelin gave their condition a medical label. However, the implication in the DCP paper is that, were it not for psychiatric diagnoses, the stigma would not exist.
It is still possible that some kind of neurophysiological abnormalities may be found to be the cause of at least some psychiatric conditions; the fact that these have not yet been discovered should not be so surprising given the huge complexity of the human brain. Chris Frith, for example, presents a plausible model of this kind to explain the phenomena associated with schizophrenia, generating testable hypotheses, some of which have been supported by research (Frith, 1992).
I believe the DCP should continue to be open to such possibilities, while continuing to draw attention to the weaknesses in existing diagnostic systems. Steve Bamford
Frith, C.D. (1992). The cognitive neuropsychology of schizophrenia. Hove: Lawrence Erlbaum.

The DCP has recently made a well-considered attempt at communicating a position on diagnosis, formulation, and related clinical issues. It has generated further debate much of which is helpful and thought provoking. However, aspects of the debate appear stifled and unhelpful, especially concerning the legitimacy of diagnosis, the role of ‘biological’ factors, and the role and activities of non-psychologist colleagues.
As psychologists we rightly advocate psychological formulation as a prime means of understanding clinical information, identifying helpful interventions, and communicating with others. We have trained for this, we train others, and we are rightly concerned about the sufficiency of psychiatric diagnosis and the associated classification systems. But as a profession we risk being seen as unreasonably intolerant if we caricature how diagnosis is used and those who use it (usually psychiatric colleagues). A diagnosis can provide a shorthand for communicating a case-essence. It does not necessarily imply permanence, or the necessity for pharmacological or indeed any other clinical intervention (including psychological or psychosocial). Arguably it is used more pragmatically now than previously and can be valued by service-users. It can be a starting point for them.
We should also be cautious about unreasonably criticising the work of colleagues. I work on care pathways for people with neurological conditions or injuries (including some who have no ‘diagnosis’, neurological or psychiatric). Much first-line psychological care is provided by neurology colleagues or specialist nurses. Some is provided by GPs. Psychiatrists are occasionally involved. Sometimes people get to see a clinical psychologist/neuropsychologist, but few are available.
I am concerned that our rightful professional esteem for our own role sometimes appears unmatched by a respect for non-psychologist colleagues who attempt a different contribution to care of the ‘psychological’. In my experience, non-psychologist colleagues are not indiscriminate dispensers of pharmacology, nor are they blind to psychological processes and the influence of adverse life events or circumstances.
It is important to our professional credibility not to be seen to deny or unduly minimise the role of biology in some conditions, nor to overstate others’ emphasis of it. I know of few psychiatric colleagues who use contentious diagnoses (e.g. schizophrenia, bipolar disorder, personality disorder, conduct disorder) in a way that excludes the importance of the past and present experience of the client, either in understanding their current state or in its development over time. Equally, I thankfully know of no psychologists that still insist on a singular psychogenic or social-environmental cause for some conditions including autistic spectrum conditions, Tourette’s syndrome, or many other conditions that can involve neurocognitive or neurobehavioural disability. Adverse life events do not necessarily induce emotional, behavioural or cognitive difference (from what is normal for self or others – although of course they often do). Conversely, emotional, behavioural and cognitive difference does not necessarily imply a root-cause in adverse life event (or that ‘distress’ is necessarily present).
There are now a growing number of conditions thought to have a possible ‘biological’ contribution; some of the diagnoses referred to as ‘functional’ in the DCP position statement may in due course come to have revised understandings. Either way, psychologists have a promising role in contributing to the quality of life of people with these conditions and we risk unnecessary clinical and professional compromise (and marginalisation) if we are perceived as denying the possibility of ‘biology’ in these or as oversimplifying the complexities in understanding them (it is of course a simplification to even talk of biology without deconstructing what that means, be it genes, body, brain, or the many interactions between all of these and the environment).
We have a distinct and challenging role as psychologists. We should avoid it becoming further complicated by perceived premature or misplaced arguments. Otherwise we risk being seen as more conceptually flawed and clinically unhelpful than the targets of our discontent in the first place.
Patrick Vesey
Consultant Clinical Neuropsychologist
Department of Clinical Psychology and Neuropsychology
Neurosciences, Nottingham University Hospitals NHS Trust

The spate of comment and correspondence arising from the DCP Statement on Diagnosis, while important for many obvious reasons, fails in one very noteworthy way, that of contextualising diagnosis within health care, particularly the mental health sector. The issues are not just about diagnosis. As the Society’s guidance statement on the Electronic Health Record (BPS, 2011) makes clear, psychiatric diagnoses are used for many different purposes within mental health, including policy, research, and service evaluation, as well as the day-to-day clinical uses and the fact that the terminology is entrenched in the language of professionals, the media and the public. The critics of such diagnoses – and these include psychiatrists – apart from seemingly overgeneralising their criticisms to all diagnosis, nevertheless do a service in pointing out that the basis for using such diagnoses within clinical practice is flawed. There is abundant evidence that this is so, summarised for instance in my recent paper (Berger, 2013), prepared partly to provide a background and context for the DCP Statement. Hence, the challenge to psychologists and other critics is: ‘Can you do any better?’ As my paper notes, there are some options in development, but it is not clear that these will satisfy the diversity of functions served by psychiatric diagnosis, nor will they necessarily satisfy those service users who may want such a diagnosis.
The most significant feature of the context is the ongoing central drive towards the national implementation of what are now called the Integrated Digital Care Records (IDCRs). These rebranded Electronic Health Records are intended to serve within organisations and sectors (Healthcare Trusts and the NHS in England), as well as across sectors (health, social care and possibly even education – for instance in relation to children’s social services), and for the lifetime of the individual. The IDCRs, like their predecessors, will, in addition to core clinical content, also have to contain all the information required for the diverse purposes noted above. IDCRs (and paperless or paper-light systems that provide them), are a salient goal of government policy. Indeed, such systems are well established in many mental health services, and are becoming ubiquitous. In this context, if something is not in the electronic record, it effectively does not exist, with many serious ramifications. This being the case, there is a further question: ‘How might psychologists or other practitioners want their activities represented in IDCRs if these are not to be focused around psychiatric diagnosis?’
An approach to answering this question is developed in the second part of the Berger (2013) paper, accompanied by practical illustrations of what is entailed. In essence, it suggests that we need to develop psychology models and datasets that capture the perspectives of psychologists relevant to their activities, that are specifically intended for inclusion in IDCRs. This is a complex, demanding and ongoing challenge. For instance, such a model must incorporate the implications of epigenetic studies pointing to biological anchors linking early experiences to later-appearing psychological difficulties, and to the recent developments in extinction research (for further references, see Berger, 2103). Proper salience must also be given to social factors in the emergence and maintenance of individual difficulties. Although focused on clinical psychology in the first instance, the proposals also serve as a basis for the other practitioner disciplines wishing to have their contributions recognised within the domains of their activities.
It would be easy to dismiss the issues raised here, and in the broader debates underpinning the previous correspondence, as matters that are relevant only to some practitioners. That would be a serious error. For all, the advent of electronic records will have profound consequences – they will contain information about us, among other things our medical histories and our sometimes deep and sensitive personal concerns and difficulties. These records will influence how we are seen and what will happen when we want, or access, services in health, social care or education. The information they contain will also increasingly be used to determine which services merit funding. In all these core services and in other areas, there are crucial psychological perspectives and resources. There should thus be a space where psychological perspectives relevant to the purposes of such records can be identified and be used for the benefit of the subjects of these records. Michael Berger
Chair, BPS PPB Informatics Advisory Committee
Emeritus Professor of Clinical Psychology
Royal Holloway, University of London

Declaration of interest: The author is a member of the DCP Working Party that produced the Statement on Diagnosis. He does not benefit financially from sales of the Paper.

Berger, M. (2013). Classification, diagnosis and datasets: Towards an approach for clinical psychology services and electronic records. DCP Occasional Paper No. 8. Leicester: British Psychological Society.
British Psychological Society (2011). Guidelines on the use of electronic health records. Leicester: Author. (Available at tinyurl.com/elechealthrec)

As one of the few British psychologists to have contributed substantially to the DSM-5 and to be actively involved in the revision of the International Classification of Diseases (ICD-11), I thought it might be helpful to record my experience of this process.
Since the publication of DSM-III in 1980 the principle has been that disorders are to be described as clearly as possible on the basis of their symptoms and not linked to specific aetiologies in the absence of compelling evidence. Thus, although the new manual undoubtedly introduced an explicitly medical rather than psychosocial focus, there was no necessary implication that mental disturbances are a subset of physical diseases; rather, in the words of DSM-III, ‘Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome’. Although some clinicians and researchers do adhere to a predominantly biological model, the contribution of psychosocial factors, including cultural factors, is explicitly recognised by the editors of DSM-5 (Regier et al., 2009) and appears in many places within it. Moreover, DSM-5 introduced for the first time
a category of trauma- and stressor-related disorders to identify conditions where adversity is considered to be a significant cause as opposed to one risk factor among many. The ICD-11 proposals contain a similar section. Both manuals also now recognise the occurrence in a trauma context of symptoms such as auditory hallucinations that have traditionally been seen as exclusively psychotic in nature. In my experience of the DSM and ICD there were many robust, well-informed, and sophisticated discussions that attempted to reflect the available evidence as accurately and helpfully as possible, while bearing in mind the deficiencies in the knowledge base. 

In my own field, post-traumatic stress disorder, DSM-5 has chosen to increase the number of symptoms whereas ICD-11 proposes to greatly reduce the number (Maercker et al., 2013), an approach that is closer to my own views about the best way forward (Brewin et al., 2009). The ICD-11 approach is largely in the service of clinical utility, attempting to make the recognition and treatment of these disorders easier and simpler. In most countries psychiatric disorders are managed with minimal specialist mental health resources. In these contexts there is a clear need for a common and comprehensible diagnostic system to guide thinking, raise awareness, and educate clinicians and patients. Diagnosis itself need not entail the adoption of a narrow, non-psychological approach, or be necessarily disempowering, although obviously it has been and in some cases continues to be applied in an unthinking and potentially harmful way. This is surely more of a problem with some disorders than others, and can be addressed without doing away with diagnosis altogether.
We have been here before. DSM-I and DSM-II incorporated broad, aetiologically-defined entities that were continuous with normality, based on the idea that the total personality and life experiences of the person had to be understood to provide a context for symptoms (Mayes & Horwitz, 2005). But this approach was heavily criticised for being too subjective, unscientific, and overly ambitious in terms of its ability to explain and alleviate psychological disturbance, and these problems were instrumental in bringing about the introduction of diagnostic categories in DSM-III. By acknowledging their own limitations, diagnostic manuals can do much to emphasise the complexity of psychiatric disorders and about the need always to consider the interplay of biological and psychosocial factors. Perhaps they are like many of our institutions – occasionally baffling and frequently disappointing – but we should be wary of rejecting them without good evidence that there is a better alternative. Chris Brewin
Professor of Clinical Psychology
University College London

Brewin, C.R., Lanius, R.A., Novac, A. et al. (2009). Reformulating PTSD  for DSM-V. Journal of Traumatic Stress, 22, 366–373.
Maercker, A., Brewin, C.R., Bryant, R.A. et al. (2013). Proposals for mental disorders specifically associated with stress in the ICD-11. The Lancet. tinyurl.com/oulgb64
Mayes, A. & Horwitz, A.V. (2005). DSM-III and the revolution in the classification of mental illness. Journal of the History of the Behavioral Sciences, 41, 249–267.
Regier, D.A., Narrow, W.E., Kuhl, E.A. & Kupfer, D.J. (2009). The conceptual development of DSM-5. American Journal of Psychiatry, 166, 645–650.

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