Psychobabble: Rewriting the bible

By Keir Liddle

The Diagnostic and Statistical Manual of mental disorders, sometimes referred to as psychiatry’s bible,  is about to be published in it’s fifth revision (the DSM-5) and the process of revision has been no less controversial within psychiatry and psychology than previous revisions. A DSM revision is often met with a clamour for new disorders to be recognised and included by various psychiatrists and psychologists, as well as for major and minor changes being made to existing categories.

The clamour for new disorders to be registered in the latest revision of the Diagnostic and Statistical Manual is nothing new: see this post looking at the proposal to enter “Extreme racism“ or this post on paraphiliac coercive disorder. Some of these proposed classifications are more valid then others and have a greater weight of evidence to support their inclusion. I should point out that I am no Szass inspired anti-psychiatry ideologue but that I do believe there are certain diagnostic categories that are perhaps unnecessary and well covered by others.

For instance I am somewhat unconvinced that social anxiety disorder  is a distinct category in of itself as opposed to a component of another psychological issues. Be it generalised anxiety disorder, panic disorder or the like: in some cases I wonder if it would be more appropriate to classify it in terms of a social phobia. However I am always open to re-evaluating my position on this or any other diagnostic cateogry in the light of evidence. I would also stress that I don’t doubt that there is a highly distressing condition that has an huge impact on individuals daily lifes – just that I think it’s part of a wider disorder than a distinct separate one. I also welcome attempts to combine Aspergers and Autistic spectrum disorders as I feel this makes a great deal of sense given the commonalities between the two diagnoses.

A growing concern among clinical psychologists, particularly in the UK, is the medicalisation that is perceived as inherent to adding some diagnoses and expanding the criteria for others. Asides from the two, rather extreme, examples I have blogged on and linked to above there are, I feel, legitimate concerns being raised about the changes proposed for generalised anxiety disorder that might lead to the “worried well” being pathologised, and altering the criteria for depression so they might include people experiencing grief.

The British Psychological Society (BPS) have similar and wider ranging concerns over potential medicalisation and published this response (full text) to the latest DSM-5  draft. The meat of the BPS criticism is as follows:

“We have particular concerns over the draft’s consideration of the inclusion of a range of highly contentious ‘disorders’. These include Attenuated Psychosis Syndrome, which could be seen as an opportunity to stigmatise eccentric people, and to lower the threshold for achieving a diagnosis of psychosis, Gender Dysphoria (especially in children and adolescents) and a range of conduct disorders such as Oppositional Defiant Disorder – diagnosed when a child is ‘headstrong’ or ‘wilful’.”

The Society is concerned that such diagnostic systems fall short of the criteria for legitimate medical diagnoses. It recommends a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that mental ill-health is on a spectrum with ‘normal’ experience, and that psychosocial factors such as poverty, unemployment and trauma are important causal factors.

I find much to agree with in the response from the BPS and share their concerns that any expansion of DSM criteria must be undertaken with great care and due attention to detail. Not that I necessarily think that this revision has been approached in anything other than a totally diligent and professional way I just fear that there appears a trend towards expansion not refinement of diagnostic criteria that is problematic in some, if not many, areas. Although I feel they have over-egged the pudding by claiming there are undeniable social causes for many of the disorders. Certainly what appear to be social causes may just be what is the more accessible explanation for a mental state or issue. Human beings do after-all have a tendency towards post-hoc rationalisation and making a narrative of their experiences. However I do agree that with the trend towards expansion of diagnostic criteria that a lot more attention has to be paid to potential environmental causal factors such as poverty, unemployment and trauma. I also agree that much of the DSM does neglect an individuals relational context.

Though while I find the main thrust of the BPS response convincing I am less convinced by the potential solution offered: case formulations, the psychodynamic equivalent of a physician understanding the pathophysiology of a patient’s medical problem. A wholesale revision of how mental distress is thought about and shifting away from a top-down to a bottom-up system is suggested and this seems as ambitious as it is unlikely to occur.

In short I think the BPS response highlights some very salient issues with the draft DSM-5 and I hope that these will be addressed. As for moving wholesale onto a new diagnostic standard? I fear that may be throwing the proverbial baby out with the bath water.

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0 Responses to Psychobabble: Rewriting the bible

  1. Brainduck says:

    I appreciate the move towards dimensional assessment, and a symptom-focused, trans-diagnostic approach. ISTM to make much more sense to look at what is actually happening to a patient, rather than try to lump people with disparate symptoms into categories like ‘schizophrenia’ or ‘eating disorder’.

  2. I certainly agree that to an extent many of the DSM criteria can seem like wastebasket diagnoses (In the sense of chuck everything in here that doesn’t go anywhere else).

    I appreciate the changes being proposed for affective disorders like Bipolar but a more symptomatic approach might be called for.

    My only worry given the BPS seeming stance of wariness towards drug therapy is that such an approach might make it more likely that mental health patients end up on an ever increasing number of pills to address individual symptoms rather than the attempt now to treat heterogeneous conditions and symptoms with homogeneous drugs.

    That really could, if we aren’t careful, lead to further medicalisation and a boom time for unscrupulous pharma companies.

  3. PJ says:

    I’m unconvinced that outside of the US, in the UK context for instance, where mental health services are not (yet) dependent on the grace of insurance companies, that the DSM actually has that much influence on how psychiatric services are delivered. Certainly in my day-to-day work I do not refer to DSM or even ICD – these are, to a significant extent, research tools, and very many patients (or ‘clients’ if you want) I see probably don’t qualify for any specific diagnostic label.

    Non-medical members of the ‘multi-disciplinary team’ already focus on a ‘problem based approach’ rather than on diagnostic categories. It seems to me that a lot of the battles that occur around issues like this are fought by those with massive axes to grind without having any real influence on everyday practice.

  4. Hannah Winfield says:

    Hi. This is a bit late but I just wanted to mention that case formulations are not psychodynamic – they are used in CBT as well. I wasn’t sure about your point about social anxiety disorder – surely is just a synonym for social phobia?

  5. My point is that I don’t think it constitutes a diagnostic category all of it’s own. It either falls under the remit of a phobia or get generalised anxiety. Apologies for tue inaccurate wording used there.

    The case formulation approaches use originated in psychodynamics – though I understand it is not exclusively psychodynamic I am perhaps guilty of muddying the waters above.

    I may edit the above article to reflect these errors.


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