The British Psychological Society* has posted a response to the American Psychiatric Association’s (APA) invitation to comment on the Development of the DSM-5 (the latest revision of the Diagnostic and Statistical Manual of Mental Disorders): http://apps.bps.org.uk/_publicationfiles/consultation-responses/DSM-5%202011%20-%20BPS%20response.pdf

There are two big points here:

The BPS is effectively trashing the whole idea of a multiple medical categorisation of mental illness problems.

What the BPS say brilliantly backs up what I said in this Tuesday’s ‘Ways of Being Mad’ lecture – and no, I hadn’t read their response before doing the lecture.

The BPS group that reviewed the DSM-5 proposals did include Richard Bentall, who I highlighted in the lecture as throwing doubt on the whole Kraepelian schizophrenia/bipolar model, so perhaps it’s not surprising that they were doubtful about the DSM’s systematic classification, but they go further than that.

Their central statement (repeated over and over in their analysis of specific categories):

We believe that classifying these problems as ‘illnesses’ misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our well-being and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives.(emphasis added)

I’ve ended up quoting the BPs document very extensively, because they do make a lot of (what I think are) good points.

First of all, they’re speaking up for a more psychological and less medical approach:

The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.

They point out, that although the overall model is medical, the criteria that are used aren’t medical/biological ones:

The putative diagnoses presented in DSM-V are clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements, with little confirmatory physical ‘signs’ or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity.

This echoes Szasz’s (admittedly simplistic and over-the-top) distinction between ‘bad brains’ (illness) and ‘bad behaviours’ (expressions of problems in living). I think you can see Szasz’ (‘there is no such thing as mental illness’) and Laing’s (‘schizophrenia is a way of trying to coping with unbearable social relationships’) criticisms as extreme and over-the-top extensions of the BPS position, and not quite as weird and irrational as they appear at first.

The BPS response is politely phrased, but the underlying message seems to be to be ‘this is a load of rubbish, and is based on a mistaken, and over-inclusive, idea of mental illness’. The model the APA is using fits well with the ’Neo-Kraepelinian Manifesto’ that I showed you in the lecture.

The BPS ends up by saying:

Diagnostic systems such as these therefore fall short of the criteria for legitimate medical diagnoses. They certainly identify troubling or troubled people, but do not meet the criteria for categorisation demanded for a field of science or medicine (with a very few exceptions such as dementia.) We are also concerned that systems such as this are based on identifying problems as located within individuals. This misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our wellbeing and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives. The Society recommends a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with ‘normal’ experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or ‘symptoms’ or ‘complaints’. Statistical analyses of problems from community samples show that they do not map onto past or current categories (Mirowsky, 1990, Mirowsky & Ross, 2003). We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety etc)? These would be more helpful too in terms of epidemiology.

I think it’s unlikely that the BPS views will affect the new version of the DSM much. As I said in the lecture, psychiatric care is an industry and, particularly in the US, the insurance industry is a large and powerful part of the system, and such industries need to be able to apply industrial standards, which is what the DSM does.

Read on if you want a bit more detail about the BPS response (and how it fits with the lecture):

They point out the overall lack of specificity of the apparently very specific diagnostic approach used in the DSM:

Finally, disorders categorised as ‘not otherwise specified’ are huge (running at 30% of all personality disorder diagnoses for example).

They make Bentall’s point that the basic categorisation system doesn’t hold up well:

Since – for example – two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person’s real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person’s problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives.

They point out that ‘showing some symptoms’ isn’t really an indication of mental illness, but needs to be taken in context:

Personality disorder and psychoses are particularly troublesome as they are not adequately normed on the general population, where community surveys regularly report much higher prevalence and incidence than would be expected. This problem – as well as threatening the validity of the approach – has significant implications. If community samples show high levels of ‘prevalence’, social factors are minimised, and the continuum with normality is ignored. Then many of the people who describe normal forms of distress like feeling bereaved after three months, or traumatised by military conflict for more than a month, will meet diagnostic criteria.

This fits with the (brief) discussion in the lecture of statements like “1 in 4 British adults experience at least one diagnosable mental health problem in any one year, and one in six experiences this at any given time.” Perhaps all this means is that lots of people feel depressed/anxious/confused/persecuted from time to time, and there’s often a good reason for that, and these are not necessarily ‘symptoms of mental illness’ in themselves, even though people who do have serious mental problems may show the same responses.

They’re also dubious about the vagueness and ‘borderline-ness’ of some categories:

In this context, we have significant concerns over consideration of inclusion of both “at-risk mental state” (prodrome) and “attenuated psychosis syndrome”. We recognise that the first proposal has now been dropped – and we welcome this. But the concept of “attenuated psychosis system” appears very worrying; it could be seen as an opportunity to stigmatize eccentric people, and to lower the threshold for achieving a diagnosis of psychosis.

This parallels the point I made in the lecture about Blueler’s (1911) worryingly general category of ‘latent schizophrenia:

“There is also a latent schizophrenia, and I am convinced that it is the most frequent form, although admittedly these people hardly ever come for treatment. It is not necessary to give a detailed description of the various manifestations of latent schizophrenia …irritable, odd , moody, withdrawn or exaggeratingly punctual people arouse, among other things, the suspicion of being schizophrenic.” Blueler, 1911, quoted by Bentall in Understanding Madness

“irritable, odd , moody, withdrawn or exaggeratingly punctual”? Yes, that’s me.

They’re particularly concerned about ADHD diagnoses and medication with children:

We have particular concerns about the inclusion of Attention Deficit/Hyperactivity Disorder in this categorisation. Many of the concerns about the scientific validity and utility of diagnoses per se (articulated above) apply to ADHD. We are very concerned at the increasing use of this diagnosis and of the increasing use of medication for children, and would be very concerned to see these increase further.

*I have often rubbished the BPS in the past, and compared it unfavourably with the American Psychological Association, which I think is more socially aware and constructively self-critical than the BPS (one of the reasons I recommend so many articles from American Psychologist), but maybe I should apologise: I think this is well done.