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Accompanying a press briefing on the same subject, the SMC gathered comments from the mental health community on the proposed fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.
Tim Carey, Associate Professor at the Centre for Remote Health and Central Australian Mental Health Service, said:
“The DSM does not assist in understanding psychological distress nor in treating it effectively. It does not “carve nature at its joints” as it were. It is a collection of symptom patterns that have no underlying form or structure. It is akin to an anthology of the constellations in the night sky. While it does not assist in understanding or treating psychological distress, it has generated phenomenal revenues for the APA, expanded the market for pharmaceutical companies, assisted in promulgating and maintaining a disease and illness model of psychological suffering, and constrained the focus of research activity. Are these the activities a humane and scientific society should seek to promote?
“The authors of the DSM themselves acknowledge the inadequacy of the DSM diagnostic system.
“On page xxxi of the latest edition of the DSM it states: ‘there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder. There is also no assumption that all individuals described as having the same mental disorder are alike in all important ways’.
“So, according to the DSM authors, the boundaries demarcating ‘schizophrenia’ (for example) don’t separate ‘schizophrenia’ from ‘depression’ (or social phobia or intermittent explosive disorder or post-traumatic stress disorder or …) or (perhaps most importantly) the boundaries don’t separate ‘schizophrenia’ from ‘no schizophrenia’.
“One would have to ask: if the function of creating particular categories is not to separate these categories from each other or from their absence, what exactly are they for?”
David Pilgrim, Professor of Mental Health Policy, University of Central Lancashire, said:
“It’s hard to avoid the conclusion that DSM-5 will help the interests of the drug companies and the wrong-headed belief of some mental health professionals (mainly most psychiatrists, but sadly all too often others as well). Some patients and many relatives also gain some advantages from diagnosis some of the time because it reduces the reality of the complexity of their experiences and their responsibilities within those existential struggles.
“Madness and misery exist but they come in many shapes and sizes and so they need to be appreciated in their very particular biographical and social contexts. At the individual level this should mean replacing diagnoses with tailored formulations, and for research purposes we should be either looking at single symptoms or shared predicaments of those with mental health problems and their significant others. I worry that we risk treating the experience and conduct of people as if they are botanical specimens waiting to be identified and categorised in rigid boxes – in my opinion that would itself be a form of collective madness for all those complicit in the continuing pseudo-scientific exercise.”
Dr Felicity Callard, Senior Research Fellow, Service User Research Enterprise, Institute of Psychiatry, King’s College London, said:
“The ongoing chaos surrounding the development of DSM-5 has intensified rather than lessened fears that this project is ill-conceived and founded on a weak evidence base. People’s lives can be altered profoundly – and, we should bear in mind, sometimes ruinously – by being given a psychiatric diagnosis. In my opinion, that the architects of DSM-5 are pressing on with such a flawed framework undermines their claim that they wish to produce a DSM that is ‘useful to all health professionals, researchers and patients’.”
Nick Craddock, Professor of Psychiatry & Consultant Psychiatrist, Cardiff University and Director of Wales’ National Centre for Mental Health, said:
“On DSM5
“Scientific understanding has not advanced sufficiently since DSMIV to justify bringing out DSM5 at the present time.
“DSM5 is largely driven by expert opinion rather than solid scientific evidence. We urgently need more research and better understanding.
“This is arguably the worst possible time to be changing a major diagnostic classification – scientific understanding will improve enormously over the coming years, but has not yet advanced sufficiently to justify substantial changes.
“We must remember that DSM5 will have no direct effect on mental health services in the UK. Like most of the world, we use the International Classification of Diseases in our clinical work, not the American DSM system.
On the importance of diagnosis
“In all branches of medicine, including psychiatry, diagnosing the problem is a key step in guiding effective therapeutic intervention.
“Prompt and accurate diagnosis is a cornerstone of high quality health services and can be life-saving. However, good diagnosis also means distinguishing the normal from the abnormal and not medicalizing normal human behaviours.
“The issue of setting thresholds for diagnosis occur in all branches of medicine. Examples include the blood sugar level used to define diabetes or the blood pressure level used to define hypertension. The issues for psychiatry are no different.”
Peter Kinderman, Professor of Clinical Psychology and Head of Institute of Psychology, University of Liverpool, said:
“The proposed revisions to the DSM diagnostic system could only make a bad system worse. The diagnostic approach to psychological well-being was always hugely problematic – people’s problems need to be recognised and understood, and help needs to be offered, in ways that recognise the complexity of the situation, and place their difficulties in context. The traditional diagnostic approach has always struggled to reflect this. The existing diagnostic systems in this area are already notoriously invalid – they don’t reflect any ‘true’ or ‘real’ conditions.
“The proposed revision to DSM will make things worse. It will be less valid – less consistent with research findings. It will exacerbate the problems that result from trying to fit a medical, diagnostic, system to problems that just don’t fit nicely into those boxes. Perhaps most seriously, it will pathologise a wide range of problems which should never be thought of as mental illnesses. Many people who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labelled as ‘mentally ill’. This isn’t valid, isn’t true, isn’t humane. And it won’t help decide what help a person needs.
“It’s a huge missed opportunity.
“Instead of pressing forward with this scheme (which seems to be driven by the needs of publishers and commercial healthcare industries), the APA should stop, convene a genuine representative international expert panel, and produce a genuine, valid, humane and useful alternative.”
Dr Paul Keedwell, Honorary Consultant Psychiatrist and Clinical Lecturer in the Neurobiology of Mood Disorders, Cardiff University, said:
“Classifying mental disorders is always controversial because psychiatrists still don’t know what causes them and they lack lab tests to confirm any underlying disease processes. The best DSM can do is carefully distinguish the groups of symptoms (syndromes) which occur more commonly together than apart and have predictable effects on our functioning over time. Some diagnoses, like ‘Post-Traumatic Stress Disorder’ infer a theory of causation, while others, like schizophrenia, don’t. Only ongoing research will confirm their validity.
“New findings arising from genetics and brain imaging studies hint at biological mechanisms, and challenge the way we classify disorders: syndromes (like bipolar and unipolar depression) might merge, while others (like “the schizophrenias”) might diverge. However a few more decades will pass before we radically change our existing classifications.
“Where the proposed DSMV is particularly controversial is in its addition of more disorders, like “Apathy Syndrome” and “Disruptive Mood Dysregulation Disorder”, which suggest a worrying trend toward medicalising normal variation in behaviour.
“Every new diagnosis implies a new treatment, suiting vested interests in the health industry. Nothing should enter the final version of DSMV without sound research evidence of the need for professionals to intervene.
“Also, every mental health professional should remember that classification systems are a guide to diagnosis only: they do not necessarily map on to the complex needs of an individual in real practice, and they are definitely not a guide to treatment.”
Allen Frances, Emeritus Professor at Duke University and Chair of the DSM-4 Steering Committee, said:
“DSM 5 will radically and recklessly expand the boundaries of psychiatry by introducing many new diagnoses and lowering the thresholds for existing ones. As an unintended consequence, many millions of people will receive inaccurate diagnosis and inappropriate treatment. Costs include: the side effects and complications of unnecessary medication; the perverse misallocation of scarce mental health resources toward those who don’t really need them (and may actually be harmed) and away from those who do most desperately require help; stigma; a medicalization of normality, individual difference, and criminality; and a reduced sense of personal responsibility. The publication of DSM 5 should be delayed until it can be subjected to a rigorous and independent review, using the methods of evidence based medicine, and meant to ensure that it is both safe and scientifically sound. New diagnoses can be as dangerous as new drugs and require a much more careful and inclusive vetting than has been provided by the American Psychiatric Association. Future revisions of psychiatric diagnosis can no longer be left to the sole responsibility of just one professional organization.”
David Elkins, Professor Emeritus of Psychology, Pepperdine University, Los Angeles, and Chair of the Division 32 Task Force for DSM-5 Reform, said:
“My committee and I remain very concerned the DSM-5, as currently proposed, could result in the widespread misdiagnosis of hundreds of thousands of individuals whose behaviour is within the continuum of normal variation. If this occurs, it means these individuals will be labelled with a mental disorder for life and many will be treated with powerful psychiatric drugs that can have dangerous side effects.
“We are also alarmed that the DSM-5 Task Force seems unresponsive to the concerns of thousands of mental health professionals and dozens of mental health associations from around the world.
“My committee recently asked the DSM-5 Task Force to submit the controversial proposals for review by an outside, independent group of scientists and scholars. Our request was denied.
“My committee launched the Open Letter/Petition Website which has now gathered more than 11, 000 individual signatures and endorsements from more than 40 from mental health associations including 13 other Divisions of the American Psychological Association.”
Dr Kevin Morgan, Senior Lecturer, Department of Psychology, University of Westminster, said:
“The proposed revisions to the diagnosis of schizophrenia i.e. the elimination of subtypes and the use instead of symptom dimensions, is an example of how DSM5 may prove to be more clinically beneficial than the current version of the manual. I wait with great interest to see the final agreed set of changes.”
Til Wykes, Professor of Clinical Psychology and Rehabilitation, Institute of Psychiatry, Kings College London, said:
“The proposals in DSM 5 are likely to shrink the pool of normality to a puddle with more and more people being given a diagnosis of mental illness. This may be driven by a health care system that reimburses only if the individual being treated has a recognised diagnosis – one in the DS manual. Luckily in the UK we have the NHS which treats people on the basis of need, not if they fit a diagnostic system.
“It isn’t just a health care system that is subverted by the spreading of diagnostic labels into normality, research will also be changed. Most research studies that reach the widest readership get published in US journals which will expect these diagnostic labels to have been used.
“We shouldn’t use labels unless we are clear they have some benefit. Saying someone is at risk of a mental illness (in some categories of DSM5) puts a lot of pressure on the individual and their family. When we do not have a good enough prediction mechanism, this is too high a burden.”
Dr David Harper, Reader in Clinical Psychology, University of East London, said:
“The American Psychiatric Association’s revisions of the DSM have become as regular as updates for Microsoft Windows and about as much use. It has facilitated an increasing medicalisation of life (the number of disorders the DSM covers has increased exponentially from its first edition in 1952 to 357 in 2000) and is hugely costly (the text revision of DSM IV made $44m in revenue between 2000 and 2006). The problem is not simply the revisions proposed in DSM 5 but the idea that psychological distress matches its diagnostic categories – people’s experiences of distress cluster in an entirely different manner. This is why most people end up with more than one diagnosis, why the ‘not otherwise specified’ category is massively over-used and why ratings of agreement between psychiatrists continue to be poor. The DSM represents a massive failure of imagination: most clinicians and researchers know the system is flawed but try to convince themselves, despite the evidence, that it aids communication, research and treatment. It does not. The frustrating thing is that there are other viable alternatives – for example, a focus on homogenous experiences of distress would aid research, the use of case formulation would aid treatment. Unfortunately, the pharmaceutical industry can see little profit in either alternative and, instead, continue to swing their considerable weight behind the DSM.”
Richard Bentall, Chair of Clinical Psychology at the University of Bangor, said:
“I share the widespread concerns about the proposed revisions to the DSM diagnostic system. Like earlier editions, this version of the manual is not based on coherent research into the causes or nature of mental illness. For example, it treats ‘schizophrenia’ and ‘bipolar disorder’ as separate conditions despite evidence that this is, at best, an over-simplification. It also looks set to widen some of the diagnostic criteria, for example by removing the grief exclusion from major depression, and by expanding the range of psychotic disorders to include an ‘attenuated psychosis syndrome’ (my own research on this, in press, shows that only about 10% of people meeting the attenuated or prodromal psychosis criteria are likely to go on to develop a full-blown psychotic illness). As there is no obvious scientific added value compared to DSM-IV, and as there are some obvious risks associated with this expansion of diagnostic boundaries, one is bound to ask why there is a need for this revision, or who will benefit from it. It seems likely that the main beneficiaries will be mental health practitioners seeking to justify expanding practices, and pharmaceutical companies looking for new markets for their products.”
Dr Lucy Johnstone, Consultant Clinical Psychologist, Cwm Taf Health Board, Mid Glamorgan, South Wales, said:
“The DSM debate is all about how we understand mental distress. DSM and the proposed revisions are based on the assumption that mental distress is best understood as an illness, mainly caused by genetic or biochemical factors. It is important to realise that, with the exception of a few conditions such as dementia, there is no firm evidence to support this. On the contrary, the strongest evidence is about psychological and social factors such as trauma, loss, poverty and discrimination. In other words, even the more extreme forms of distress are ultimately a response to life problems. We need a paradigm shift in the way we understand mental health problems. DSM cannot be reformed – it is based on fundamentally wrong principles and should be abandoned.”
Dr Warren Mansell, Reader in Psychology & Clinical Psychologist, University of Manchester, said:
“Contemporary research across genetics, neuroscience, psychology and culture all point to the fact that the majority of psychiatric disorders share the same underlying processes and are treated by very similar interventions. Therefore in further emphasising different categories of mental health problems, DSM5 is heading in completely the opposite direction from the most pioneering research across the field of mental health.”
Simon Wessely, Professor of Epidemiological and Liaison Psychiatry at the Institute of Psychiatry, King’s College London, said:
“We need to be very careful before further broadening the boundaries of illness and disorder. Back in 1840 the Census of the United States included just one category for mental disorder. By 1917 the American Psychiatric Association recognised 59, rising to 128 in 1959, 227 in 1980, and 347 in the last revision. Do we really need all these labels? Probably not. And there is a real danger that shyness will become social phobia, bookish kids labelled as Asperger’s and so on.”
Professor Sue Bailey, President of the Royal College of Psychiatrists, said:
“We recognise the importance of accurate and prompt diagnosis in psychiatry. The classification system used in NHS hospitals and referred to by UK psychiatrists is the World Health Organisation’s International Classification of Disease (ICD). Therefore, the publication of DSM-V will not directly affect diagnosis of mental illness in our health service.”
The British Psychological Society has released a statement on the DSM-5 which can be found here: http://www.bps.org.uk/news/society-statement-dsm-5 The fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will be published in May 2013 by the American Psychiatric Association.