Study Explores Service Users’ Views on Diagnostic Criteria

Researchers investigate service users' lived experiences and their views on mental disorder classifications.


A new study, published in The Lancet, analyzed service-users’ perspectives on diagnostic criteria. Data collected from various focus groups in the US, UK, and India could be influential in the January 2022 release of the International Code of Diagnostics, eleventh edition (ICD-11).

“It is essential to gain an understanding of the way that service users respond to the content of the major diagnostic systems as this could enhance clinical utility and help to avoid potential unintended negative consequences,” writes lead author Corinna Hackmann, from the Department of Research and Development, Norfolk and Suffolk NHS Foundation Trust.

Mental health classifications are designed to offer guidance to clinicians and researchers but often include technical language that creates barriers to those receiving the diagnosis. When the language used to classify mental health disorders is out of touch with lived experiences, individuals may feel labeled, misunderstood, or stigmatized. Reducing the gap between service-user perspectives and diagnostic language could improve research, promote mental health participation, and work to decolonize the current diagnostic approach through community involvement.

A goal for the newest edition of the ICD set by the World Health Organization (WHO) is to “enhance the clinical utility and global applicability of the ICD-11 diagnostic guidelines.” The authors of the study explain that this work is in line with “the mental health recovery and disability rights philosophy of ‘nothing about us without us.’”

Their study aimed to gain an understanding of how individuals approach the current language used in the ICD-11 classifications and the way this captures, or misses, their lived experiences. Adults with at least one of five disorders – depressive episodes, generalized anxiety disorder, schizophrenia, bipolar type 1 disorder, and personality disorder – from the UK, USA, and India participated in focus groups discussing the language and new features proposed in the ICD-11.

“Participants were provided with two parallel versions of the relevant diagnostic guidelines to give feedback on: a version taken from WHO’s draft clinical descriptions and diagnostic guideline (CDDG) for ICD-11 mental disorders, and a summary of this guideline in an accessible lay language (produced for this project by medical professionals and reviewed by the research team, including service users). We also aimed to explore the service user responses to the lay version of the guidelines.”

Transcripts of the 157 individuals who participated in the 60-120 minute group discussions were coded and thematically analyzed. A high degree of inter-rater reliability was confirmed to ensure accuracy. Themes were compiled and created “the basis of co-produced recommendations for WHO, which included features that could be added or revised to better reflect lived experience and changes to language that was confusing or objectionable to service users.”

Notably, service-users critiqued classifications for missing the “internal felt-experience” of the disorder, including emotional, psychological, and bodily experiences.

“Participants identified additional features for all diagnoses. These additional features mainly reflected internal experience (e.g., pain or distress). Many additional features could be externally observed (e.g., interpersonal difficulties) but even for these features, much of the feedback centered on felt-experience,” Hackmann and colleagues write.

The schizophrenia focus group identified the most features missing from classifications. For example, a participant described interpersonal difficulties they face that were not represented in the diagnosis: “I like to do things my way. My father and my brother criticize some of my actions… They may not understand the reason, but there is a reason for it that I can’t explain to anyone.”  

Participants from the bipolar 1 focus group noted positive aspects that are missing from classifications. For example, one participant stated: “I do feel it should have something about creativity in it because I think that [it is] an important aspect of mania.”

Multiple groups identified misleading language used in existing classifications. Participants suggested removing confusing and misleading words such as “bizarre,” “maladaptive,” retardation,” “disorganized,” and “neuro-vegetative.”

Margaret Swarbrick, co-author and Director of Practice Innovation and Wellness at Rutgers University Behavioral Health Care, wrote that the researchers “discovered that the current draft reflected an external perspective of these conditions rather than the perspective of the person’s lived experience.”

“This is a needed perspective for clinicians and researchers. Participants appreciated the non-technical summaries, which suggest that using such common language would go a long way in bridging the communication gap between the people being diagnosed and clinicians.”

This is the first study to systematically seek service users’ perspectives on the ICD-11 classifications, an essential and missing step in the creation of diagnostic criteria. The coproduced report has been submitted to WHO, which will be reviewed and considered for incorporation into the 2022 version.

The researchers conclude:

 “Crucially, our study validates the essential engagement of service users and the essential role of co-production. As shown in this Health Policy, such practices have the potential to enhance the descriptive accuracy and maximize the acceptability of the guidelines from the service user perspective: a key constituent group for whom the system is crucially relevant.”



Hackmann, C., Balhara, Y. P. S., Clayman, K., Nemec, P. B., Notley, C., Pike, K., … & Swarbrick, M. (2019). Perspectives on ICD-11 to understand and improve mental health diagnosis using expertise by experience (INCLUDE Study): an international qualitative study. The Lancet Psychiatry. (Link)


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  1. …one…[“BP”] participant stated: “I do feel it should have something about creativity in it because I think that [it is] an important aspect of mania.”

    OMG! It’s not enough that the insanity factory profits off falsely positioning creativity (the hallmark of what it means to be human) as correlated with “mania”, but the example CHOSEN here is one that continues to support rather than dispel of this ugly age old myth. This is the perpetuation of the very discrimination one would have hoped this study was debunking but all it really exposes is how deep this ridiculous myth is ingrained in the unthinking public consciousness.

    This is, in fact nothing BUT a stereotype against artist as a group historically discriminated against- this is an example of DISCRIMINATION.

    Way too many artists, struggle to find a place in the financially driven economy.
    The myths,memes and con job shrinks use to lure financially insecure artists include carrots like, “you’re in good company with other genius’s.

    Creativity is NOT a disease!

    As a prolific artist, inventor and writer who has spent my life around gifted people, I have NEVER had or witnessed a “manic” episode by another human being.

    No other skill set or profession is so easily lead to agree that their work is the bi-product of some mis- attributed symptom of “MI”. It is beyond insulting and it has got to stop. The time, effort and learning that goes into perfecting ones skills is belittled and rendered a joke by these labels.

    My investigation into artist labeled “mentally ill” points to the most likely culprit of any so called symptoms of “MI” being caused by toxic materials that were poisoning them. This phenomenon continues to be prevalent to this day as mos materials we use are toxic and must be used with know how and care. And the fact that it is difficult to earn a living off of the skills we labour to share with a world that either completely over values or completely under values our contributions.

    Artists need to wake up and stop throwing others under the bus with their attempts to lump us all into this ugly group that they themselves have tragically (out of ignorance) bought into. These individuals may well have personal problems, but painting all artists with the “crazy” brush is flat out discrimination. Own your sh– but do NOT smear it on me or anyone else with the brains, spirit and ingenuity to boldly create and envision novel ways of looking and seeing the world.

    I want to see what the other labeled “BP”s had to say about “creativity” as some kind of disease. This is the most insulting, ill thought out damaging and dangerous idea imaginable.
    It literally makes me want to vomit, scream and file a much needed law suit.

    ©JMG 8/12/19 MH, AB, CA

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    • I agree that this could be misused but the “manic-depression” with regard to artists is not a myth. The fact is that any true artist is, by definition, one who plumbs the depths and scales the heights of the human soul – his/her own – in search of their personal inner truth (“Know Thyself”.) Which, if going deep enough, one discovers universal truths summed up in John Gardner’s quote, “Art begins in a wound, an imperfection–a wound inherent in the nature of life itself–and is an attempt either to live with the wound or heal it. It is the pain of the wound which impels the artist to do his work, and the universality of woundedness in the human condition which makes the work of art significant as medicine or distraction.”

      But, because the majority live in such a deadened/numbed out/zoned out state most of the time they easily see this as an abnormality, a mental illness. Jungian analyst Robert Johnson does an excellent historical overview of this in his book, “Ecstasy,” showing how ecstasy became so suspect. So, for me, the problem is about not wanting to see these states of being labeled as a symptoms of illness at all. Bipolar disorder I’ve heard some clinicians say is a “catch-all” diagnosis for anyone who is intensely alive. And all of nature, of which we are a part, is bipolar in nature. No? In short, it is a crock of b.s.

      So, regardless of any disagreement on the particulars, I totally get your outrage!

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  2. I accept none of these pathetic money making schemes these Charlatans stoop to in order to earn a living off of other peoples ignorance.
    I do however remain ethically concerned about the lies, disinformation, myths, stereotyping and discrimination that naive people are trapped into living and in turn spewing about the planet. The stink of this stupidity harms us all not. There is nothing IMO, more tragic than living a life of lies.
    Its only as simplistic as raising a finger, if you choose to disengage and that’s not where I’m at.
    These lies disabled me and almost cost me my life and I’ve watched way too many people die and kill themselves and I’m not OK with that.
    The day people pushing this fraud start going to prison where they belong, is the day that the finger and a smile will suffice for me. Until then, I’ll keep presenting logical intelligent alternatives to why some artist might experience symptoms of forbidden human distress.
    Sorry if this sounds terse, shitty day:))

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  3. Thanks for this informative piece, Jessica. Unfortunately, I am quite disappointed in what appears to have been the main goal of the survey: to simply add a little context and different words to the diagnostic labels which does nothing to expose the arbitrary and stigmatizing labels – many, if not all, of which should not even be considered illnesses but simply part of the spectrum of the human condition that we all share.

    I recall reading a collection of articles by clinicians in a tome titled, “Traumatic Stress Disorder,” many years ago. Many of the authors were European. There are two things stated in that book that still stand out in my mind. The first is that the European medical community, (at least at that time,) regarded “98% of all so-called mental illnesses are symptoms of PTSD.” The second, which I found both funny and tragic, was that the only reason Americans call PTSD “post”-traumatic is because the only times we have ever even looked at it was post- WWI, WWII, Korean War, and Vietnam. Though, I think since the 9/11, the Iraq-Afghanistan wars there has been a definite sea change.

    In any case, I’m disturbed by this survey. It seems, at least on the surface, to be inviting service users to collude in the labeling of people – just with more “acceptable” and easy to understand language. I would denounce it entirely if it weren’t for the recent release of the WHO’s QualityRights initiative. I can see they are seriously addressing the issues facing psychiatry today and I suspect, (or at least I hope,) this survey is a step in gently coaxing the anxious psychiatrists along.
    Regardless, “a change is gonna come”!

    Thanks again. It’s good to know so many scholars and professionals are concerned with the current state of affairs in this field.

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