It's easy to think that the Diagnostic and Statician's Manual (DSM) (published by the American Psychiatric Association (APA)) has become so refined, polished and researched, that when it comes to defining, diagnosing and treating mental illness, there is simply no other game in town.
But actually, as the DSM has evolved - and created hundreds more new 'disorders' with each iteration - the criticism of the DSM within the mental health community itself has actually reached gigantic proportions.
Below, I’m bringing open letters from:
1. The British Psychiatry Society (BPS) - complaining of the ‘continuous medicalisation of…natural and normal responses to [patients'] experiences.’
2. Thomas Insel, director of the National Institute of Mental Health (NIMH) in the US, who actually states that the NIMH can no longer support the diagnoses and diagnostic criteria being put forward in the DSM-5.
In that far-off time when transparency and honesty was more apparent in the hallowed halls of psychiatry, the APA itself, in the foreword to the Diagnostic and Statistical Manual of Mental Disorders (DSM) III in 1980, stated that the diagnostic system the manual contained was imprecise, and should never be used for forensic or insurance purposes.
Another leading voice in the field of psychiatry, Bessel Van Der Kolk, had this to say about the DSM 5:
“With DSM 5, psychiatry firmly regressed to early nineteenth century medical practice. Despite the fact that we know the origin of many of the problems it identifies, it’s ‘diagnoses’ describe surface phenomena that completely ignore the underlying causes.”
The main problem is that psychiatry, as defined by the DSM 5, has thrown all of its weight behind the canard that ‘chemical imbalances’ are causing mental illnesses, despite the fact that no scientific evidence proving this has ever been put forward, despite 30 years’ of research.
It remains an unproven theory of mental illness, and one that the pharmaceutical companies have been exploiting ruthlessly, because if you can pretend that a mental illness is caused by a ‘chemical imbalance’, then you can also pretend that you can manufacture a pill to ‘cure’ the problem.
The real issue causing mental illnesses is trauma, and particularly, the trauma children experiences when they are abused, neglected, ignored, or otherwise not cared for by their parents or other main caregivers.
But there are two big obstacles preventing this information about what's really causing mental illness from being widely accepted, and properly dealt with, namely:
MONEY - the APA is estimated to have made $100 million from sales of the DSM, which is currently retailing for a whopping $144 over on Amazon.
But that's just the tip of the iceberg: The disorders put forward in the DSM for the most part rely very heavily on the unproven notions of 'chemical imbalances' causing the issues, and drugs being the solution to the problem.
Psychiatrists are the only people in the mental health field who can prescribe psychotropic medications for patients, hence, if the 'drug-solution' model was abandoned, most people would have absolutely no reason to visit an expensive psychiatrist, and would probably prefer a cheaper (and probably much friendlier and more effective...) therapist.
PARENTS DON'T WANT TO ACCEPT HOW MUCH RESPONSIBILITY THEY REALLY HAVE FOR THEIR CHILDREN'S WELFARE AND HAPPINESS
It's much easier for all of us to pretend that hitting and yelling at our kids, or preferring Facebook and online pursuits to spending quality time with our children, really doesn't impact them as much as it does.
It's much easier for all of us to pretend that mental illnesses and depressed, unhappy children are caused by faulty genes or bad wiring in the brain, and nothing to do with how badly they're often treated by us, their parents, and the other people in their lives.
But while believing that lie is definitely MUCH easier for the grown-ups, it makes things so much harder for the kids themselves. Why? Because instead of taking the onus off them for why they're so messed up and acting out, it labels them as 'defective' people with broken brains, and lets the people who actually really caused the problem - normally the parents - completely off the hook.
And if that's not guaranteed to make a person crazy and depressed, then I don't know what is.
As always, there's more to say on this topic, but for now, here's the text of the two open letters criticising the DSM-5:
OPEN LETTER FROM BPS criticizing the DSM 5: (emphasis mine)
“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.
We therefore do welcome the proposal to include a profile of rating the severity of different symptoms over the preceding month. This is attractive, not only because it focuses on specific problems (see below), but because it introduces the concept of variability more fully into the system.
That said, we have more concerns than plaudits. 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. Diagnostic categories do not predict response to medication or other interventions whereas more specific formulations or symptom clusters might (Moncrieff, 2007).
Finally, disorders categorised as ‘not otherwise specified’ are huge (running at 30% of all personality disorder diagnoses for example). 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.
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.
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.
DSM-5 2011 British Psychological Society response, June 2011 Page 3 of 26: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. While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word) understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits.
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.
There is ample evidence from psychological therapies that case formulations (whether from a single theoretical perspective or more integrative) are entirely possible to communicate to staff or clients.
We therefore believe that alternatives to diagnostic frameworks exist, should be preferred, and should be developed with as much investment of resource and effort as has been expended on revising DSM-IV. The Society would be happy to help in such an exercise.”
By Thomas Insel on April 29, 2013
In a few weeks, the American Psychiatric Association will release its new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This volume will tweak several current diagnostic categories, from autism spectrum disorders to mood disorders. While many of these changes have been contentious, the final product involves mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published. Sometimes this research recommended new categories (e.g., mood dysregulation disorder) or that previous categories could be dropped (e.g., Asperger’s syndrome).1
The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has
been “reliability” – each edition has ensured that clinicians use the same terms in the same ways.
The weakness is its lack of validity.
Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.
Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. Through a series of workshops over the past 18 months, we have tried to define several major categories for a new nosology (see below). This approach began with several assumptions:
· A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
· Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
· Each level of analysis needs to be understood across a dimension of function,
· Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.
It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data.
In this sense, RDoC is a framework for collecting the data needed for a new nosology.
But it is critical to realize that we cannot succeed if we use DSM categories as the “gold standard.”2 The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories. Imagine deciding that EKGs were not useful because many patients with chest pain did not have EKG changes.
That is what we have been doing for decades when we reject a biomarker because it does not detect a DSM category. We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response.
That is why NIMH will be re-orienting its research away from DSM categories.
Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system. What does this mean for applicants? Clinical trials might study all patients in a mood clinic rather than those meeting strict major depressive disorder criteria.
Studies of biomarkers for “depression” might begin by looking across many disorders with anhedonia or emotional appraisal bias or psychomotor retardation to understand the circuitry underlying these symptoms. What does this mean for patients? We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system. The best reason to develop RDoC is to seek better outcomes.
RDoC, for now, is a research framework, not a clinical tool. This is a decade-long project that is just beginning. Many NIMH researchers, already stressed by budget cuts and tough competition for research funding, will not welcome this change. Some will see RDoC as an academic exercise divorced from clinical practice. But patients and families should welcome this change as a first step towards "precision medicine,” the movement that has transformed cancer diagnosis and treatment.
RDoC is nothing less than a plan to transform clinical practice by bringing a new generation of research to inform how we diagnose and treat mental disorders. As two eminent psychiatric geneticists recently concluded, “At the end of the 19th century, it was logical to use a simple diagnostic approach that offered reasonable prognostic validity. At the beginning of the 21st century, we must set our sights higher.