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The Psychologist News - Society's critical response to DSM-5
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July 13, 2011
  Society's critical response to DSM-5
Work on the latest, fifth version of psychiatry's diagnostic code (DSM-5: see www.dsm5.org), due for publication by the American Psychiatric Association in 2013, has already suffered from resignations and accusations of vested interest. Now the British Psychological Society has had its say by publishing a highly critical response to the planned revisions (access the full document at tinyurl.com/67wygp7).

The Society says it 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'. The statement was made public in June, signed off by Dr Carole Allan, chair of the Professional Practice Board, and prepared by Professor Peter Kinderman, chair of the Division of Clinical Psychology.

The statement criticises the DSM-5 for being based on social norms and subjective judgement, and for locating problems within individuals, rather than recognising the role of social causes, such as poverty. The Society also has concerns with specific conditions found in DSM-5, including the proposed new conditions of 'attenuated psychosis syndrome' (the presence of psychotic-like symptoms without a full disconnect from reality) and 'disruptive mood dysregulation disorder' (excessive temper tantrums). The former 'is very worrying' the Society statement says, 'it could be seen as an opportunity to stigmatise eccentric people, and to lower the threshold for achieving a diagnosis of psychosis'.

The only aspect of the DSM-5 welcomed by the Society is the plan to rate symptom severity over the preceding month, because to do so focuses on specific problems and 'introduces the concept of variability into the system'.

The Society concludes by calling for a revision to the way mental distress is thought about, including recognition that mental disorder is on a spectrum with normal experience, and recognition of the role played by social factors. 'Rather than applying preordained diagnostic categories to clinical populations,' the Society says, 'we believe that any classification system should begin from the bottom up - starting with specific experiences, problems or "symptoms" or "complaints"'. The statement ends with the Society offering to help in any exercise to develop an alternative approach to the DSM.

The Vice-Chair of the DSM-5 task force, Dr Darrel Regier is robust in his defence of the DSM (his full response can be found below). In an e-mail to The Psychologist he says that he and his colleagues agree that there is an overlap between normal responses and disease states, but that 'psychiatry also recognises that there are real and discrete disorders of the brain that cause mental disorders and that can benefit from treatment'.

Regier says that experts working on DSM-5 have attempted to approach this issue by adding more dimensional approaches to describing psychological symptoms and opportunities to assess both disorder severity and associated disability levels. 'The problem', he says, 'is that the psychologists quoted here think we shouldn't consider any mental disorder, including individuals whose psychosis renders them mentally incompetent, to have a brain-based illness. The group also wishes to emphasize the relational context of mental disorders and wants to exclude the possibility of mental disorders being independently present in the person - the way that cancer or heart disease may be affected by social and psychological realities but nevertheless exist within individuals as discrete states. What seems to be missing is an appreciation of mental disorders as the result of gene - environmental interactions that would trigger abnormal neuronal function in the brain. Why the brain should be exempt from pathology when every other organ system is subject to malfunction is left unaddressed.'

Regier further explains that DSM-5 will recognise that boundaries between conditions like schizophrenia and bipolar disorder are not clear cut and better thought of as 'central tendencies', which can be modified by high-level psychological domains, such as anxiety or addictions. 'However, the complexity of psychiatric disorders in no way abrogates the psychiatrist's obligation to provide treatments, including talk therapies and medications, that succeed in ameliorating symptoms and reducing suffering,' he says.

In conclusion Regier reminds us that psychiatric disorders have existed since the beginning of recorded history, but that tremendous progress has been made in recent decades in our ability to treat them. 'The DSM strives to be a living document that will continue to draw upon research and clinical experience as we endeavour to relieve the suffering of the millions of people worldwide who suffer the devastating effects of mental illness,' he says.

Looking ahead, Professor Kinderman notes that many psychologists continue to work in healthcare contexts that use diagnoses, including helping people with physical and neurological problems where he considers diagnosis to be valid. 'So we have to strike a balance and offer pragmatic advice,' he says. 'We base our advice on evidence, and will continue to develop our position in the light of research. We are currently developing practical guidelines for psychologists in their day-to-day work. We will also continue to make a constructive contribution to the debate by promoting a positive way forwards in developing alternative paradigms rooted in psychological models.'

- For background on the development of DSM-5, see April 2010 News and August 2009 Forum

-- Christian Jarrett

The Regier response in full:
Please note that one of the first authoritative references in the British Psychological Society's response to DSM-5 is from Joanna Moncrieff. Moncrieff is a well known member of the "Critical Psychiatry Network" in England that has largely adopted the Thomas Szasz approach to mental illnesses, which holds that mental disorders are simply normal human responses that are appropriate to certain social circumstances. The treatment approach is to be compassionate, not to "force" treatment on patients regardless of the risk of a psychotic patient to himself or others, and to let such individuals live in a homeless state if they "choose" to do so.(1) While we agree that human feelings and behaviors exist on a spectrum that contains some overlap of normal reactions to disease states, psychiatry also recognizes that there are real and discrete disorders of the brain that cause mental disorders and that can benefit from treatment.

The general critique on the part of the British Psychological Society is that the DSM-5 will continue to medicalize natural and normal responses to human experiences. One way we have approached this issue in the DSM-5 is the addition of more dimensional approaches to describing psychological symptoms and providing an opportunity to assess both the severity of disorders and associated disability levels. The problem is that the psychologists quoted here think we shouldn't consider any mental disorder, including individuals whose psychosis renders them mentally incompetent, to have a brain-based illness. The group also wishes to emphasize the relational context of mental disorders and wants to exclude the possibility of mental disorders being independently present in the person - the way that cancer or heart disease may be affected by social and psychological realities but nevertheless exist within individuals as discrete states. What seems to be missing is an appreciation of mental disorders as the result of gene-environmental interactions that would trigger abnormal neuronal function in the brain. Why the brain should be exempt from pathology when every other organ system is subject to malfunction is left unaddressed.

We are clearly indicating in the DSM-5 that we no longer consider the boundaries between mental disorders like schizophrenia and bipolar disorder to be rigid and pure categorical disorders. We are well aware that such disorders might better be thought of as "central tendencies" that are important for treatment considerations, which may nonetheless be modified by a high level of symptoms in other cross-cutting psychological domains such as cognition, anxiety, mood, addictions, somatic symptoms, and personality traits. However, the complexity of psychiatric disorders in no way abrogates the psychiatrist's obligation to provide treatments, including talk therapies and medications, that succeed in ameliorating symptoms and reducing suffering.

It should be recognized that mental disorders are by no means a modern construct; psychiatric disorders have existed since the beginning of recorded history. There have been tremendous strides in the last few decades in our ability to treat them while we remain ever vigilant of new research that can inform our efforts going forward. The DSM strives to be a living document that will continue to draw upon research and clinical experience as we endeavor to relieve the suffering of the millions of people worldwide who suffer the devastating effects of mental illness.

Darrel A. Regier, M.D., M.P.H.
Executive Director, American Psychiatric Institute for Research & Education
Vice-Chair, American Psychiatric Association DSM-5 Task Force


(1) Moncrieff J. Psychiatric Imperialism: The Medicalisation of Modern Living http://www.academyanalyticarts.org/moncrieff.htm

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    Posted By: Jon Sutton @ 13/07/2011 10:58 AM     News from the Psychologist  

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