The following statement was posted on the Critical Psychiatry Network website in the UK on 23rd May 2013.
The Critical Psychiatry Network is concerned with the way the controversy over the publication of DSM-5 is being portrayed in the media and by some academic psychiatrists. The issues raised by the DSM are complex and require careful and studied consideration. There are two aspects in particular that concern us. These relate to the portrayal of the controversy as a guild dispute, and the polarisation of the debate as one of nurture versus nature.
1. Portrayal of the controversy as a guild dispute
A number of reports in the media have portrayed the storm of criticism of DSM-5 as a guild dispute driven by professional rivalries between psychologists and psychiatrists[i]. This may have arisen because the DSM is a product of the American Psychiatric Association, and in the UK the debate in the media has been polarised as one between clinical psychologists and psychiatrists[ii]. This gross oversimplification is not supported by the evidence. Many psychiatrists are deeply concerned about the limitations and failings of diagnosis in psychiatry. These concerns were expressed in a recent special article co-authored by twenty-nine Members and Fellows of the Royal College of Psychiatrist, published in the British Journal of Psychiatry[iii] in December 2012.
The paper points out that since its origins in the early part of the nineteenth century, psychiatry has faced a fundamental question that remains unanswered: can a medicine of the mind work with the same epistemology as a medicine of the tissues. In recent decades, there has been a concerted effort to ignore this question and psychiatry has approached the ‘mind’ as if it was simply another organ of the body. It has assumed that problems with our feelings, thoughts, behaviours and relationships can be grasped with the same sort of diagnostic and scientific tools that are used to investigate problems with our livers, hearts and lungs. This model has not served psychiatry well. Whether we like it or not, mental problems resist both explanation in terms of simple causal models and categorization in terms of singular diagnostic categories. Over the last half a century leaders within the profession of psychiatry, academics who have devoted their professional lives to discovering the biological basis of psychosis, have acknowledged that biological and neurosciences have failed to establish the validity of a single psychiatric diagnosis [iv] [v] [vi] [vii] [viii]. Moreover, there are serious doubts about the nature and quality of the evidence for the effectiveness of most psychiatric drugs1 . Apart from their obvious mind-numbing effects, it has not been demonstrated that any type of drug used to treat mental health problems has any specific, or targetted action. The idea that psychiatric drugs correct underlying chemical imbalances or any other presumed abnormality is no more than a myth[ix].
2. Epistemological polarisation.
We are also concerned about the way that some commentators, particularly from within academic psychiatry, question the importance of environmental factors in understanding psychosis. Many psychiatrists disagree with this position, and find such accusations unhelpful. Psychiatry has always prided itself on being an eclectic profession, one that recognises the importance of holistic approaches to understanding and responding to people who use mental health services. Biological, neureodevelopmental and genetic factors have little role to play in explaining psychosis because they are incapable of accounting for the complexity of consciousness and embodied experience[x]. In contrast, personal narratives of adversity have a central role in understanding how people cope with, and recover from, psychosis[xi] [xii]. To deny the importance of these factors is to deny the importance of finding meaning in suffering, a prerequisite for recovery.
Our view is that there is an urgent need for a measured debate about psychosis and distress, one that engages with the scientific evidence that a wide variety of experiences of adversity including childhood trauma and racism are linked to the development of psychosis in adulthood [xiii] [xiv] [xv] [xvi] [xvii] [xviii] [xix]. We believe that an important outcome of such a debate would be forms of psychiatric practice that engage fully with the diverse understandings that service users and carers have of their experiences. However, the very nature of mental problems demands that we move beyond positivistic approaches to research and scientific modeling. We believe that there is an urgent need to promote collaborative research with service users about the nature of mental illness itself as well as looking at what helps people in their struggles towards recovery.
The controversy over DSM-5 is not a guild dispute or turf war. Psychiatrists, psychologists, and mental health professionals across the disciplines reject medical type diagnoses like DSM-5 as ways of describing the varied human experiences that we call mental disorders and support ways of formulating these that capture their complexity and diversity. There are many other voices engaged in the debate over the future of psychiatric diagnosis who share our concerns. The Hearing Voices Network has expressed serious reservations about DSM-5, and rightly drawn attention to the importance of the perspectives of experts by experience in the debate about the controversy[xx]. Mental Health Europe, a non-governmental organisation that represents a diverse range of perspectives, including experts by experience, carers and professionals from a range of disciplines has also expressed deep concern about DSM-5 and the future direction of psychiatric diagnosis[xxi]. Many psychiatrists, too, share these concerns, and we will continue to support the need for, and contribute to an informed public debate about the limitations and failings of psychiatric diagnosis symbolised by DSM-5. The DSM is incapable of capturing the full range of experiences of distress in the way that narrative formulation can.
[i] See, for example, Frank Furedi’s article in The Independent Friday 17th May 2013, accessed at http://www.independent.co.uk/voices/comment/despite-what-the-dsm-implies-medical-intervention-is-not-always-the-answer-to-mental-health-issues-8621109.html on 20th May 2013
[ii] See http://www.guardian.co.uk/science/2013/may/12/dsm-5-conspiracy-laughable accessed 20th May 2013
[iii] Bracken, P., Thomas, P., Timimi, S. et al (2012) Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201:430-434.
[iv] Robins, E. & Guze, S. (1970) Establishment of Diagnostic Validity in Psychiatric Illness: Its Application to Schizophrenia. American Journal of Psychiatry, 126, 983 – 987
[v] Kendler, K. (1980) The Nosological Validity of Paranoia (Simple Delusional Disorder) Archives of General Psychiatry, 37, 699 – 706.
[vi] Andreasen, N. (1995) The Validation of Psychiatric Diagnosis: New Models and Approaches. American Journal of Psychiatry, 152, 161 – 162.
[vii] Kendell, R. & Jablensky, A. (2003) Distinguishing Between the Validity and Utility of Psychiatric Diagnoses. American Journal of Psychiatry; 160:4–12
[viii] Anckarsäter, H. (2010) Beyond categorical diagnostics in psychiatry: Scientific and medicolegal implications. International Journal of Law and Psychiatry, 33, 59–65.
[ix] Moncrieff, J. (2008) The Myth of the Chemical Cure: A critique of Psychiatric Drug Treatments. Basingstoke, Palgrave Macmillan.
[x] Tallis, R. (2011) Aping Mankind: Neuromania, Darwinitisand the Misrepresentation of Humanity. Durham, Acumen.
[xi] Davidson L. Living Outside Mental Illness: Qualitative Studies of Recovery in Schizophrenia. New York University Press, 2003.
[xii] Mancini MA, Hardiman ER, Lawson HA. Making sense of it all: consumer providers’ theories about factors facilitating and impeding recovery from psychiatric disabilities. Psychiatr Rehabil J 2005; 29: 48–55.
[xiii] Read, J., van Os, J., Morrison, A., Ross, C. (2005) Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112: 330–350, DOI: 10.1111/j.1600-0447.2005.00634.x
[xiv] Read J, Perry BD, Moskowitz A & Connolly J. (2001)The contribution of early traumatic events to schizophrenia in some patients: A traumagenic neurodevelopmental model. Psychiatry;64:319-45.
[xv] Read, J, Bentall, R. & Fosse, R. (2009) Time to abandon the bio-bio-bio model of psychosis: Exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms. Epidemiologia e Psichiatria Sociale, 18, 4, 299-310
[xvi] Boydell. J., van Os, J., McKenzie, K., Allardice, J., Goel, R., McCreadie, R., Murray, R. (2001) Incidence of schizophrenia in ethnic minorities in London: ecological study into interactions with environment British Medical Journal; 323 doi: http://dx.doi.org/10.1136/bmj.323.7325.1336
[xvii] Janssen, I., Hanssen, M., Bak, R., Bijl, V, De Graaf, R., Vollebergh, W., McKenzie, K. & Van Os, J. (2003) Discrimination and delusional ideation British Journal of Psychiatry, 182, 71 – 7 6.
[xviii] Karlsen, S. & Nazroo, J. (2002) Relation Between Racial Discrimination, Social Class, and Health Among Ethnic Minority Groups American Journal of Public Health 92, 624 – 631.
[xix] Karlsen, S. & Nazroo, J., McKenzie, K., Bhui, K. & Weich, S. (2005) Racism, psychosis and common mental disorder among ethnic minority groups in England. Psychological Medicine, 35, 1795–1803. doi:10.1017/S0033291705005830
[xx] See http://www.hearing-voices.org/about-us/position-statement-on-dsm-5/ accessed 20th May 2013
[xxi] See http://www.mhe-sme.org/news-and-events/mhe-press-releases/dsm5_more_harm_than_good.html accessed 20th May 2013