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| Mental Health is on a continuum from normality to abnormality. |
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Excellent Open Access Issue -August 2010 - to inform public debate on DSM5(Due 2013).(Courtesy of Informa) | ||||||||
EDITORIAL
Diagnosis, diagnosis, diagnosis: towards DSM-5
TIL WYKES & FELICITY CALLARD
King’s College London and the NIHR Biomedical Research Centre for Mental Health at the South
London and Maudsley NHS Foundation Trust and Institute of Psychiatry, Kings College London, UK
The allocation of diagnoses in psychiatry has always been controversial.
Diagnoses usually
indicate possible treatments, as well as determining who will receive support from health and
social services. Some regard the formulation and sharing of a psychiatric diagnosis as itself
therapeutic, in that psychological symptoms can be given meaning and effectively discussed
with the patient (e.g., Brody & Waters, 1980). However, detractors also comment on how
diagnosis can medicalize patterns of behaviour (Conrad, 2007) as well as the human
condition itself (Chodoff, 2002), compound stigma (Sartorius, 2002), pre-determine which
interventions are deemed appropriate, and also narrowly define the frameworks through
which mental health problems might be addressed. The production of an updated diagnostic
manual exposes these controversies, and this has certainly been the case in recent
discussions of the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders, published by the American Psychiatric Association. Initially, we were led to believe
that there would be sweeping changes that would include an increased ‘‘dimensional’’ rather
than categorical approach to disorders that would better describe phenomena that are
continuous and lacking clear boundaries, and would allow clinicians a rating of severity.
However, this emphasis has decreased over time. Along the way, there have been critics of
the confidentiality agreements that have to be signed by the working group members (see
Collier, 2010), the rush to field trials before the end of the process, and also the likelihood
that sub-syndromal diagnoses will be introduced. The initial drafts of the diagnostic system
are now available for public review and comment (www.dsm5.org), with the expectation of
version five of the manual (known as DSM–5) being published in May 2013. It is important
to stress that changes in the manual are backed up by informed opinion, complex
negotiations between committee members, as well as clear research evidence, and that there
is usually a force of conservatism that prevents major changes. This is clear in looking at the
current release. However, even small changes can have unintended consequences. Changes
to the previous version seem to have contributed to three false positive ‘‘epidemics’’
(Frances, 2010) – high rates of attention deficit hyperactivity disorder, autistic disorder, and
childhood bipolar disorders. Clearly, there were other factors that also contributed, in
particular drug companies marketing drugs for these diagnoses directed not only at doctors
There are of course different diagnostic systems.
The one proposed by the World Health
Organization called the International Classification of Diseases (ICD–10) is similar but not
identical to the system devised in DSM–5, and its current revision to ICD–11 is likely to
produce similar difficulties as for DSM–5. However, we have concentrated here on DSM–5
as it is very influential not only in the USA but also across the world in both Western and
non-Western cultures as medical education takes a more global form. It has become
prevalent in defining groups who are the participants for research studies. In fact it is hard
to use any other system when trying to publish in prestigious journals, many of which
are US-based. This pervasive influence of the DSM criteria has even been termed ‘‘The
Americanization of Mental Illness’’ (Watters, 2010).
The current release for public consideration includes proposals for new diagnoses – including
mixed anxiety depression, binge eating, psychosis risk syndrome and temper dysregulation
disorder with dysphoria – where the symptoms are shared with the general population. It is also
proposed that the threshold for inclusion for some existing disorders be lowered, and a few (but
not many) diagnoses are scheduled for removal. Most of these changes imply a more inclusive
system of diagnoses where the pool of ‘‘normality’’ shrinks to a mere puddle.
There are specific problems associated with potential ‘‘diagnoses’’ which are made in
advance of knowing that a disorder will in fact present itself.
This is the case for the Psychosis Risk Syndrome.
In this ‘‘disorder’’, attenuated symptoms of schizophrenia are
present which, in some cases, may lead to a later florid onset of psychosis. The reason for
identifying this is because many clinicians believe that early treatment will provide benefits
and avert some of the toxic effects of psychotic experiences. This belief has some validity,
which is currently being further tested, but it is not, as yet, based on sound evidence and
there are clear negative consequences of such a diagnosis for those concerned, particularly
issues of stigma covered, for example, by Ben-Zeev, et al. (2010). There is also the obvious
problem of providing diagnoses to some who will never experience the full-blown disorder,
usually known as the problem of false positives. It is a bit like telling ten people with the
common cold that they are ‘‘at risk for pneumonia syndrome’’ when only one is likely to get
the disorder. In addition, one of those people might also have developed pneumonia because
they had a predisposition which was nothing to do with the presence of attenuated
symptoms, for instance they might be HIV positive. Their proneness to the disorder was
therefore entirely unrelated to the preceding cold. If this were to be replicated in the
Psychosis Risk Syndrome, then identifying the diagnosis would have negative consequences
for many who would never develop the disorder in terms of increased stigma and possible
discrimination, as well as in terms of changing their very sense of personhood (in being
described as a person ‘‘at risk’’ of developing a disorder commonly regarded with great
apprehension). As well as the distress likely to be experienced by themselves and their
families, and the suffering entailed by treatment irrespective of whether it is drug or
psychological therapy, the logic entailed by Psychosis Risk Syndrome might also divert
attention away from understanding the underlying causes of schizophrenia.
What is diagnosis for?
Making a diagnosis is not – as many might mistakenly imagine – an essential part of treatment decisions.
It may be one of the reasons, but clinicians also use a range of other
information to make judgements over treatment, and making a diagnosis in psychiatry rarely
leads directly to a recipe for treatment success. Treatment success is, after all, highly
depenndent on the relationship between the clinician and the patient, as well as the patient’s
own views about treatment acceptability as well as their personal circumstances. However,
diagnoses might be useful in providing both patients and families with the recognition that
the array of symptoms is known, ‘‘real’’, and that it may lead to treatment. Diagnoses
are also accepted by society as reasons for a claim for health and social care services,
as well as providing the patient with ‘‘a mantle for his [sic] distress that society will accept’’
(Cassell, 1976).
The framework of psychiatric diagnosis employed in the DSM operates by assuming that
disorders are stable entities that transcend their embodiment in, and meaning for, any
individual patient (Lakoff, 2005). Such a model, of course, eases the task of developing and
operationalizing treatment as well as research protocols. But a number of philosophers,
sociologists, medical anthropologists and service user researchers have pointed to the complex
way in which diagnoses can help to bring into being the very phenomena and self-attributions
that they purport to describe, as well as produce varied responses from individuals living
‘‘under the description’’ of a psychiatric diagnosis (Horn, Johnstone, & Brooke, 2007.
Given the public interest and the debates within the newspapers and other media, the
editors of the Journal of Mental Health thought that it was timely to produce a special section
that deals with the question of diagnosis in more detail. The papers are mostly critical of
current conceptualizations of psychiatric diagnosis, but do make some suggestions about
how these may be changed.
editors of the Journal of Mental Health thought that it was timely to produce a special section
that deals with the question of diagnosis in more detail. The papers are mostly critical of
current conceptualizations of psychiatric diagnosis, but do make some suggestions about
how these may be changed.
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