Brits: American psychiatry needs new theoretical frame

Ever since the American Psychiatric Association launched its multi-million dollar diagnostic industry with the publication of the DSM-III in 1980, the approach to successive editions has been to tinker, fiddle, and tweak: Change a diagnostic threshold here; reword a criterion there; remove an outdated label and add two or three more in its place.

Meanwhile, the underlying structure is so shoddy and out of touch with reality that the best thing to do would be to tear the whole thing down and start over. That's the message of the British Psychological Society, the UK’s 50,000-member professional body for psychologists, responding to the latest draft of the Diagnostic and Statistical Manual. The APA had invited the Society to comment on the DSM-5, currently due out in 2013.

The Society 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 putative diagnoses presented in DSM-5 are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements, with little confirmatory physical 'signs' or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations.

The Society critiqued a range of proposed changes in the DSM, including major changes to the personality disorders as well as (of particular relevance to forensic practitioners) the sexual paraphilias. Particular concern was expressed over a proposed "attenuated psychosis syndrome." This proposal is "very worrying" to the British psychologists, as it will "stigmatize eccentric people" and lower the threshold for prescribing potentially harmful antipsychotic medications.

More broadly, the Society commented, the DSM diagnostic system's limited focus leads practitioners to ignore the relational and environmental contexts for psychological problems:

The Society recommends a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly evidenced causal factors.

Retreat from diagnostic labeling urged

Rather than "applying preordained diagnostic categories," the Society recommends cataloging specific symptoms or complaints, such as "hearing voices" or "feelings of anxiety."

Statistical analyses of problems from community samples show that they do not map onto past or current categories…. While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognized, … understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of 'schizophrenia' or 'personality disorder' may possess no two symptoms in common, it is difficult to see what communicative benefit is served.... We believe that a description of a person’s real problems would suffice…. There is ample evidence from psychological therapies that case formulations (whether from a single theoretical perspective or more integrative) are entirely possible to communicate to staff or clients. We therefore believe that alternatives to diagnostic frameworks exist, should be preferred, and should be developed with as much investment of resource and effort as has been expended on revising DSM-IV.

The 26-page statement is available HERE.