Please SIGN THE PETITION to prevent DSM-5 from compromising patient safety and scientific integrity.

 

Statement of Concern – Complete Version

 

Note: DSM-5 refers to the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders; a handbook for psychiatric diagnosis and classification, scheduled for publication for 20th May, 2013.

 

Statement of Concern about the Reliability, Validity, and Safety of DSM-5

We, the undersigned, are concerned that the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5):

  • Includes many diagnostic categories with questionable reliability, which may lead to misleading assumptions about their scientific validity;

Prior to the publication of DSM-III in 1980, psychiatric diagnoses were frequently criticized for their substandard reliability, as clinicians too commonly disagreed on diagnostic decisions even when presented with the same information. Thus, a major impetus for those who developed the diagnostic model featured in DSMs III and IV was the improvement of interrater reliability, or the likelihood that two or more professionals would agree on a particular diagnosis (Feighner et al., 1972; Spitzer, Forman, & Nee, 1979). This goal was achieved with marked success, leading to hopes that the next step of achieving validity (i.e., empirical support for the real-world legitimacy of DSM-defined mental disorders) was close within reach (see Robins & Guze, 1970). However, subsequent research –and in fact a large body of data collected over the last 30 years– did not yield consistent validity evidence for DSM-defined categorical diagnoses. Instead, the gradual accumulation of inconsistent data has led some researchers to call for a root-and-branch review of diagnostic classification in psychiatry.

The DSM-5 development process was –especially at first– one effort to conduct that review. In the words of DSM-5 Task Force members (Regier, Narrow, Kuhl, & Kupfer, 2009), “As we began the DSM-V developmental process in 1999, a major concern was to address a range of issues that had emerged over the previous 30 years,” including “the basic definition of a mental disorder” (para. 7). There was hope for a “paradigm shift” in psychiatric diagnosis (Kupfer, First, & Regier, 2002, p. xix), and even though that aspiration has since been pushed to the back-burner (Kendler et al., 2009), the new manual will be published with markedly liberal revisions to DSMs III and IV.

The DSM-5 field trials (conducted in one phase, due the cancellation of plans for a second phase revealed an unexpected change from the previous two editions of the manual: reliability estimates for many major disorder categories had dropped well below not only those for DSM-III/IV-designed disorders, but also below commonly accepted standards (see Frances, 2012c). Furthermore, primary care doctors (family physicians and general practitioners) were not included in the field trials (American Psychiatric Association, 2011), despite the fact that they provide the majority of mental health treatment (Wang et al., 2007) and prescribe the majority of psychiatric medications (Mark, Levit, & Buck, 2009).

A primary tenet of empirical research holds that reliability is a necessary precondition for validity, as scientists cannot make stable claims about a concept that fluctuates empirically or lacks consensus among observers. Thus, before achieving common reliability standards, it is premature and untenable to introduce the DSM-5 revisions into hospitals, clinics, and general practice. Clinical research, likewise, should seek to establish psychometric stability before proceeding on the assumption that DSM-5 diagnostic categories are valid empirical entities. Epidemiological investigations may suffer from inconclusive findings and lack of continuity with research conducted using previous diagnostic definitions.

  • Did not receive a much-needed and widely requested external scientific review;

We recognize and appreciate that numerous professionals have worked hard to produce DSM-5, and have done so in good faith. However, many experts in the field have also spoken out in good faith about flaws in the document, and most of these flaws have not been resolved by the DSM-5 Task Force.

On January 9, 2012, the Open Letter Committee of the Society for Humanistic Psychology (Division 32 of the American Psychological Association) called for an external scientific review of the DSM-5 proposals by an independent group of researchers who are not affiliated with DSM-5 or the American Psychiatric Association (the full text can be found here: http://dsm5-reform.com/the-open-letter-committee-calls-for-independent-review-of-dsm-5/). This request was made in light of widespread reservation about the scientific status and safety of DSM-5 among mental health professionals and patient advocacy groups. An open letter to the DSM-5 Task Force and the American Psychiatric Association detailing these concerns (http://www.ipetitions.com/petition/dsm5/) was endorsed by more than 14,000 individuals and over 50 professional organizations, including 16 divisions of the American Psychological Association.

  • May compromise patient safety through the implementation of lowered diagnostic thresholds and the introduction of new diagnostic categories that do not have sufficient empirical backing;

DSM-5 has been criticized for lowering numerous diagnostic thresholds, i.e., reducing the number and severity of diagnostic criteria that are considered sufficient for a diagnosis to be made. The anticipated result is broad increase in the number of persons who qualify for a diagnosis of mental disorder, especially among individuals whose symptoms would have been considered subclinical in DSMs III and IV. In the third draft of the manual (formerly available for public viewing on dsm5.org), lowered diagnostic thresholds appeared in the proposed definitions for Generalized Anxiety Disorder, Somatic Symptom Disorder, Bulimia Nervosa, and Alcohol Use Disorder, among other diagnoses.

DSM-5 also introduces new disorders that did not appear in earlier editions of the manual. Among them: Premenstrual Dysphoric Disorder, Disruptive Mood Dysregulation Disorder, Somatic Symptom Disorder, and Mild Neurocognitive Disorder. These new diagnoses have generated significant controversy as a result of their questionable research backing and their potential for application to vulnerable populations, including children, the elderly, and persons with chronic medical illnesses. Some of the feared consequences of these new categories are as follows:

  • Somatic Symptom Disorder (a modification of the Somatoform Disorders in DSM-IV-TR) includes a new stipulation that will allow for the diagnosis of mental disorder in persons with chronic medical illness complaining of excessive pain. As a result, doctors may prematurely jump to the conclusion that “it’s all in the head” (Frances, 2012b, para. 3).
  • Disruptive Mood Dysregulation Disorder may be diagnosed in children and adolescents displaying significant mood swings (temper tantrums), which may be developmentally normal and resolve without treatment. Although the new category was invented with the aim of precluding the controversial practice of diagnosing Pediatric Bipolar Disorder, the latter diagnosis never existed in previous editions of the manual due to its questionable validity.
  • Mild Neurocognitive Disorder appears to describe normal cognitive decline that may be expected in elderly populations. Over-diagnosis of mental disorder and psychiatric treatment in the elderly –especially elderly populations in nursing homes– is already a nationwide problem in the US and other countries.
  • Premenstrual Dysphoric Disorder transforms severe PMS into a psychiatric disorder. In the past, similar proposals have been excluded from previous editions of the DSM due to substantial controversy and attention from women’s rights groups because of the risk of pathologizing women’s experience.

Altogether, the lowering of diagnostic thresholds and introduction of new disorders in DSM-5 has led to increasing concern about patient safety. Though it has been suggested that psychotropic medication may not be the first line of treatment for some of these diagnoses, the vast majority of psychiatric diagnoses are made in fast-paced treatment settings by general medical practitioners who do not have time to critically evaluate the research literature behind the DSM and often have few alternatives to prescribing medications.

Our duty in the medical and helping professions is, first and foremost, to do no harm. Thus, as mental health practitioners and researchers, we are greatly concerned about the introduction of empirically questionable diagnostic concepts into psychiatric and general medical practice.

  • Is the result of a process that gives the impression of putting institutional needs ahead of public welfare.

Several aspects of the DSM-5 development process reflect an apparent prioritization of institutional needs above patient safety and general public welfare. For example, the DSM-5 field trials were designed for implementation in two stages; the first was intended to address reliability, the second quality control. The second stage of the field trials was ultimately cancelled due to delays in the development process. Despite the importance of assessing quality control before the manual is used in patient care, DSM-5 will proceed with its expected May 2013 publication. For more information about the conduct and findings of the DSM-5 field trials, see Frances (2012a).

Additional concerns about the DSM-5 development process include hiring of a pubic relations firm (GYMR) to influence public opinion about the manual through a PR website (http://dsmfacts.org/), the lack of external scientific evaluation of the proposals, and the lack of a formal forensic review.

Because of the above, we fear that DSM-5:

  • May result in the mislabeling of mental illness in people who would fare better without a psychiatric diagnosis;

We have no doubt that many of the issues considered by DSM-5 constitute clinical and societal problems. It is worrying that many people are so affected by economic crises that they contemplate taking their own lives. Excessive alcohol or recreational drug use are dilemmas for individuals and societies. We have aging populations, troubled and disruptive children. It is a marker of humanitarian progress that we attempt to help people in distress. But, to take one example of many, it is unhelpful to suggest that a child throwing temper tantrums or a woman experiencing ‘period pains’ is mentally ill. It is unhelpful to suggest that a consumer seeking help from medical doctors is, by virtue of multiple complaints or visiting multiple doctors, mentally ill. Clients and the general public are negatively affected by the continued and continuous medicalization of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences that demand helping responses, but which do not reflect illnesses so much as normal individual variation. The mental health professions are uniquely suited for helping to create a better global society. But the application of inappropriate psychiatric labels is not a solution.

  • May result in unnecessary and potentially harmful treatment, particularly with psychiatric medication;

It is highly likely that, if a person receives a diagnosis under DSM-5, recommended treatment will involve medication. Recently, mounting empirical evidence has suggested that psychiatric medication, though helpful when used properly, may lead to iatrogenic consequences when used inappropriately. For example, antipsychotic medications, which are increasingly used to treat non-psychotic symptoms such as depression and anxiety, may lead to metabolic syndrome, obesity, diabetes, Parkinson’s-like movement disorders, neurocognitive decline, psychotic symptoms, reduced brain volume, and significantly shortened lifespan (Ho, Andreasen, Ziebell, Pierson, & Magnotta, 2011; Olfman & Robbins, 2012; Robbins, Higgins, Fisher, & Over, 2011; Whitaker, 2010). .

  • May divert precious mental health resources away from those who most need them.

Mental health problems affect one person in every four, making them the leading cause of disability worldwide (World Health Organization, 2012), at an estimated cost of $2,500 billion in 2010 (Bloom et al, 2011). The provision of high-quality and appropriate mental health care is an urgent global issue. Although the aspiration to improve the well-being of all citizens may be laudable, the use of scientifically unstable diagnoses will only confuse a complex picture and lead to the inappropriate investment of scarce resources. Since mental health problems disproportionately affect poor and socially excluded people, questionable diagnostic systems risk further disadvantaging the most vulnerable.

Committee Members

Richard Bentall; Professor of Clinical Psychology, University of Liverpool, UK

Mary Boyle; Emeritus Professor of Clinical Psychology, University of East London, UK

Pat Bracken; Consultant Psychiatrist and Clinical Director of Mental Health Services, West Cork, Eire

Joanne Cacciatore; Assistant Professor; Arizona State University School of Social Work, USA

Tim Carey; Associate Professor, Flinders University, Australia

David Castle; Professor of Psychiatry, University of Melbourne, Australia

Jack Carney; Licenced Psychologist, Alabama, USA

Anne Cooke; Clinical Psychologist, Canterbury Christ Church University, UK

Jacqui Dillon; Chair; Hearing Voices Network, UK

Suman Fernando; Consultant Psychiatrist, UK

Daniel Fisher; Consultant Psychiatrist, National Empowerment Centre, USA

Dave Harper; Reader in Clinical Psychology, University of East London, UK

Louis Hoffman; Continuing Education Coordinator, Society for Humanistic Psychology, USA

Lucy Johnstone; Clinical Psychologist, Bristol UK

Dayle Jones; Associate Professor, University of Central Florida, USA

Sarah Kamens; Society for Humanistic Psychology, USA

Peter Kinderman; Professor of Clinical Psychology, University of Liverpool, UK

Patrick Landman; Psychiatrist and Psychoanalyst; Paris, France

Eleanor Longden; Psychologist, London UK

Jason McCarty; Psychotherapist, British Columbia, Canada

Nancy McWilliams; Psychologist and Psychoanalyst, Rutgers University, USA

Gordon Milson; Clinical Psychologist, Manchester, UK

Bradley Olsen; President-Elect, Division 48 of American Psychological Association; President, Psychologists for Social Responsibility, Chicago, USA

Ana Padilla; University College London, London UK

Richard Pemberton; Chair, British Psychological Society Division of Clinical Psychology, UK

Dave Pilgrim; Professor of Health and Social Policy, University of Liverpool, UK

John Read; Professor of Clinical Psychology, University of Auckland, NZ

Melissa Raven; Research Fellow, Flinders University, Australia

Brent Robbins; President, Society for Humanistic Psychology, Div32 American Psychological Association, USA

Dave Traxsom; Educational Psychologist, UK

Sara Tai; Senior Lecturer in Clinical Psychology, University of Manchester, UK

Phil Thomas; Honorary Visiting Professor, University of Bradford, formerly consultant psychiatrist, UK

Sam Thompson; University of East London, UK

Sami Timimi; Consultant Psychiatrist, UK

Steve Trenchard; Chair, International Society for the Psychological Treatment of Schizopnrenia and other Psychoses

Martin Whitely; MLA, Parliament of Western Australia, Australia

References

American Psychiatric Association. (2011, March 18). Protocol for DSM-5 field trials in routine clinical practice settings. Retrieved 17 March from http://www.dsm5.org/Research/Documents/DSM5%20FT%20RCP%20Protocol%2003-19-11%20revlc.pdf

Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S. … Weinstein, C. (2011) The global economic burden of noncommunicable diseases. Geneva: World Economic Forum. Retrieved from http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf

Feighner, J. P., Robins, E., Guze, S. B., Woodruff, R. A., Winokur, G., & Munoz, R. (1972). Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 26, 57-63. http://archpsyc.jamanetwork.com/article.aspx?articleid=490573

Frances, A. (2012a, October 31). DSM-5 field trials discredit the American Psychiatric Association. Huffington Post. Retrieved from http://www.huffingtonpost.com/allen-frances/dsm-5-field-trials-discre_b_2047621.html

Frances, A. (2012b, December 28). Mislabeling medical illness as mental disorder. DSM-5 in Distress: Psychology Today. Retrieved February 18, 2013 from http://www.psychologytoday.com/blog/dsm5-in-distress/201212/mislabeling-medical-illness-mental-disorder

Frances, A. (2012c, May 6). Newsflash from APA meeting: DSM-5 has flunked its reliability tests. Psychology Today: DSM-5 in Distress. Retrieved from http://www.psychologytoday.com/blog/dsm5-in-distress/201205/newsflash-apa-meeting-dsm-5-has-flunked-its-reliability-tests

Ho, B-C., Andreasen, N. C., Ziebell, S., Pierson, R., & Magnotta, V. (2011). Long-term antipsychotic treatment and brain volumes. Archives of General Psychiatry, 68, 128-137. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476840/

Mark, T. L., Levit, K. R., & Buck, J. A. (2009). Datapoints: psychotropic drug prescriptions by medical specialty. Psychiatric Services, 60(9), 1167. Retrieved from http://ps.psychiatryonline.org/data/Journals/PSS/3889/09ps1167.pdf

Olfman, S., & Robbins, B.D. (2012). Drugging our children. Santa Barbara, CA: Praeger. http://www.abc-clio.com/product.aspx?isbn=9780313396830

Papanikolaou, P. N., Churchill, R., Wahlbeck, K., & Ioannidis, J. P. (2004). Safety reporting in randomized trials of mental health interventions. American Journal of Psychiatry, 161(9), 1692-1697. Retrieved from http://ajp.psychiatryonline.org/article.aspx?articleid=177043

Regier, D. A., Narrow, W. E., Kuhl, E. A., & Kupfer, D. J. (2009). The conceptual development of the DSM-V. American Journal of Psychiatry, 166(6), 645-650. Retrieved from http://ajp.psychiatryonline.org/article.aspx?articleid=100852

Robbins, B.D., Higgins, M., Fisher, M., & Over, K. (2011). Conflicts of interest in research on antipsychotic treatment of pediatric bipolar disorder, temper dysregulation disorder, and attenuated psychotic symptoms syndrome: Exploring the unholy alliance between big pharma and psychiatry. Journal of Psychological Issues in Organizational Culture, 1(4), 32-49. http://onlinelibrary.wiley.com/doi/10.1002/jpoc.20039/abstract

Robins, E., & Guze, S. B. (1970) Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. American Journal of Psychiatry, 126, 983-987. http://ajp.psychiatryonline.org/article.aspx?articleID=151746

Spitzer, R. L., Forman, J. B., & Nee, J. (1979). DSM-III field trials: I. initial interrater diagnostic reliability. American Journal of Psychiatry, 136, 815-817.

​Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Borges, G., Bromet, E. J. … Wells, J. E. (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet, 370(9590), 841-850. Retrieved from

Whitaker, R. (2010). Anatomy of an epidemic. New York, NY: Random House. http://www.amazon.co.uk/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing/dp/0307452425/ref=sr_1_1?ie=UTF8&qid=1363113445&sr=8-1

World Health Organization. (2012) Global status report on non-communicable diseases 2010. Geneva: World Health Organization. www.who.int/nmh/publications/ncd_report_full_en.pdf

 

 

Watch Keynote Presentation The Personal is Political Online

 
 
 
 
 
 

Here is a link to my recent presentation ‘The Personal is the Political’ which was filmed at the Critical Perspectives and Creative Responses to Experiences of Trauma and Distress Conference at University College Cork, Ireland:

http://panopto.ucc.ie/Panopto/Pages/Viewer/Default.aspx?id=45a4bb2c-6001-4a66-b5f1-bdec5e120f0e

This was a fantastic free event, attended by over 450 people over two days was organised by the School of Nursing & Midwifery & School of Applied Social Studies:

http://www.ucc.ie/en/nursingmidwifery/OurConferences/Title-175942-en.html 

and Critical Voices Network Ireland. See: http://www.criticalvoicesnetwork.com/ 

 

 

New Foreign Correspondent for Mad in America

I am thrilled to have been invited to become a foreign correspondent for the Mad in America web site – see: http://www.madinamerica.com/

I will be writing about the important and innovative work of the Hearing Voices Movement alongside many eminent colleagues, critical thinkers and activists working together to bring about an essential revolution in the world of mental health.

You can read my first post here: http://www.madinamerica.com/2013/01/the-hearing-voices-movement-beyond-critiquing-the-status-quo/

About Mad in America:

The site is designed to serve as a resource and a community for those interested in rethinking psychiatric care in the United States and abroad. We want to provide readers with news, stories of recovery, access to source documents, and the informed writings of bloggers that will further this enterprise.

The bloggers on this site include people with lived experience, peer specialists, psychiatrists, psychologists, social workers, program managers, social activists, attorneys, and journalists. While their opinions naturally vary, they share a belief that our current system of psychiatric care needs to be vastly improved, and, many would argue, transformed.

We also want to provide readers with the opportunity to add their voices to this discussion. We encourage readers to leave comments (see comment policy below), and to submit recovery stories and op-ed submissions. We encourage our readers to visit our forums to further this communal discussion.

Finally, we are commissioning original journalism, both in video and print, that explore on-going efforts to remake care in the U.S. and abroad, and also investigate the problems and deficiencies with the current drug-based paradigm of care.

We welcome feedback and comments on how we can improve this website, and continue to build an online community that can be a societal force for change.

Our Legal Organization

When we started this initiative, we investigated whether it would be better to operate as a non-profit organization, or as a C corporation. We chose the latter, as it provided us with a quicker and easier way to obtain initial funding from “investors” for creating the website and supporting its development. The president of the C Corp is Robert Whitaker. The other board members are Louisa Putnam, Kermit Cole, Laura Delano, and Matthew Cohen.

For on-going revenue to sustain this initiative, we are entirely dependent on support from our readers. We do not host advertisements and do not sell data about our readers to anyone.

Policy for Posting Comments

Please see our guidelines for posting comments on this site.

Support

Mad In America is supported entirely by user donations. Please click here to join in support of our mission.

Exciting new Hearing Voices Research & Development Fund in USA

Hearing Voices Research & Development Fund

http://femhc.org/Giving.aspx#Hearing_Voices_Research__Development_Fund

The Hearing Voices Research and Development Fund has been established to advance the development of the Hearing Voices Approach in the U.S. The Project was created by Gail A. Hornstein, Professor of Psychology at Mount Holyoke College, and Jacqui Dillon, National Chair of the Hearing Voices Network in England, who have been working together for 10 years to bring new approaches to understanding and coping with voice hearing.

Background
People who hear voices, see visions, or experience other extreme states often end up being diagnosed as psychotic (usually with schizophrenia) and a poor prognosis. The medications which have routinely been prescribed for such patients since the 1950s are effective for some but not for others, and even when they do work, their benefits typically diminish over time, while destructive physical and psychological side effects become increasingly problematic. Hearing voices in particular remains a challenge for many, many patients even after they have been tried on every possible medication over many years, and continues to be seen by many psychiatrists as a “treatment-resistant” symptom.

Hearing Voices Approach
For the past 25 years, the Hearing Voices Network – an international collaboration of professionals, people with lived experience, and their families and friends – has been working to develop an alternative approach to coping with voices, visions, and other extreme states that is empowering and useful and does not start from the assumption that people who have these experiences suffer from a chronic illness. A large body of research data, published in major professional journals, now provides support for key aspects of this approach (see references below), and the hundreds of peer-support groups that have developed in 20 countries around the world are enabling voice hearers – even those who have been chronically disabled – to learn to cope more effectively or rid themselves of the negative effects of their voices. These groups are now starting to spread across the US, but the lack of a systematic program for training potential facilitators and others interested in incorporating HVN’s work into their research or teaching is holding the United States back from being able to offer this effective, community-based psychosocial alternative to the current risky practice of large-dose, long-term treatment with (usually multiple) medications.

Hearing voices peer-support groups offer a safe place for people to share their experiences of voices, visions, tactile sensations and other unusual experiences and perceptions. People meet together to help and support each other, to exchange information, and to learn from one another’s coping strategies. Groups also offer an opportunity for people to accept and “live with voices” in a way that enables them to regain some control over their lives.

The situation in the US stands in striking contrast to that of other countries. For example, England (a country with a population of 60 million) has 180 hearing voices groups, and Denmark (a country of 5 million) has several dozen, whereas the US, with its population of over 300 million, currently has only about 15. The fund will support the development of HVN groups across the US by providing a systematic program of training that will create a network of hearing voices peer-support groups in key centers in each region of the country. Participants will be selected using a rigorous model in which mental health professionals and voice hearers collaborate in an intensive shared learning experience that equips them to apply HVN’s concepts and methods to the creation of positive alternatives for people diagnosed with psychosis.

Hearing Voices Research
The fund will also support a research study to provide the kinds of basic phenomenological descriptions of the voice hearing experience that have become increasingly essential to other research in this area.

Even though more and more researchers have become interested in investigating the complexities of voice hearing in and of itself (as opposed to treating it simply as one of a number of so-called “positive symptoms” of schizophrenia), the lack of a clear identification of the defining characteristics and significance of the experience for voice hearers makes it difficult to compare results across different studies. In addition, as colleagues from HVN have highlighted in their work (see references below), there is no evidence for the standard assumption that patients who hallucinate cannot articulate the triggers, contextual variability, or meaning of their experiences. The few phenomenological studies that have been conducted thus far demonstrate clearly that understanding the subjective experience of voice hearers themselves is essential to the ultimate effectiveness of any intervention designed to help them.

The Foundation for Excellence in Mental Health Care

We are a group of scientists, psychiatrists, researchers, public policy analysts, users and providers of mental health services, philanthropists, and community members that formed The Foundation for Excellence in Mental Health Care to find and promote the best ways to achieve long-term recovery and help people with mental health challenges to thrive.

The Foundation was established in response to nationwide interest in Robert Whitaker’s book, Anatomy of an Epidemic, and the desire to examine existing research, create support for new innovative research and programs, and sponsor symposia to build a new paradigm of care that focuses on long-term recovery and wellness. 

Strong evidence demonstrates that our 25-year long over-reliance on a purely medical model has not advanced mental health recovery. The number of individuals diagnosed with “chronic mental illness”, disabling enough to place them on the Social Security roles has tripled since 1987.

The Foundation has established a Scientific Advisory Committee and Community Advisory Committee to guide our activities of mental health reform.

For More Information:
www.hearing-voices.org
www.intervoiceonline.org
www.hearingvoicesusa.org
www.gailhornstein.com
www.jacquidillon.org

Selected References
Beavan, V. (2011). Towards a definition of “hearing voices”: A phenomenological approach. Psychosis: Psychological, Social and Integrative Approaches, 3, 63-73.

Dillon, J. (2006, November). Collective voices. Open Mind.

Dillon, J. and E. Longden (2012) Hearing voices groups: Creating safe spaces to share taboo experiences. In M. Romme and S. Escher (eds.), Psychosis as a personal crisis: An experience-based approach. London: Routledge.

Honig, A., M. Romme, B. Ensink, S. Escher, M. Pennings and M. Devries (1998). Auditory hallucinations: A comparison between patients and non-patients. Journal of Nervous and Mental Disease, 186, 646-651.

Hornstein, G.A. (2009). Agnes’s Jacket: A Psychologist’s Search for the Meanings of Madness. New York: Rodale Books. (UK edition, with a new introduction, PCCS Books, 2012)

Johns, L.C., J. Y. Nazroo, P. Bebbington and E. Kuipers (2002). Occurrence of hallucinatory experiences in a community sample and ethnic variations. British Journal of Psychiatry, 180, 174-78.

Lakeman, R. (2002). Making sense of the voices. International Journal of Nursing Studies, 38, 523-531.

Martin, P.J. (2000). Hearing voices and listening to those that hear them. Journal of Psychiatric and Mental Health Nursing, 7, 135-141.

Romme, M. and S. Escher (1989). Hearing voices. Schizophrenia Bulletin, 15, no. 2, 209-216.

Romme, M. and S. Escher (eds.). (1993; 2nd ed. 1998). Accepting Voices. London: MIND Publications.

Romme, M. and S. Escher (1996). Empowering people who hear voices. In G. Haddock and P. Slade (eds.), Cognitive Behavioral Interventions with Psychotic Disorders. London: Routledge, pp.137-150.

Romme, M. and S. Escher (2000). Making Sense of Voices: A Guide for Mental Health Professionals Working with Voice-Hearers. London: MIND Publications.

Romme, M. and S. Escher (2005). Trauma and hearing voices. In W. Larkin and A. Morrison (eds.) Trauma and Psychosis: New Directions for Theory and Therapy. London: Routledge.

Romme, M., S. Escher, J. Dillon, D. Corstens and M. Morris (eds.). (2009). Living with Voices: 50 Stories of Recovery. Ross-on-Wye, UK: PCCS Books.

Romme, M., A. Honig, E.O. Noorthoorn and S. Escher (1992). Coping with voices: An emancipatory approach. British Journal of Psychiatry, 161, 99-103.

Sayer, J., S. Ritter and K. Gournay (2000). Beliefs about voices and their effects on coping strategies. Journal of Advanced Nursing, 31, 1199-1205.

Royal College of Psychiatrists: Abolish use of formal psychiatric diagnostic systems like ICD & DSM

Abolish use of formal psychiatric diagnostic systems like ICD & DSM

Psychiatric diagnoses are not valid.
Use of psychiatric diagnosis increases stigma.
Using psychiatric diagnosis does not aid treatment decisions.
Long term prognosis for mental health problems has got worse.
Psychiatric diagnosis imposes Western beliefs about mental distress on other cultures.
Alternative evidence based models for organizing effective mental health care are available.

 
To sign the petition please go to this link:

To read the full evidence based arguments view the ‘No More Psychiatric Labels’ paper at
http://www.criticalpsychiatry.net/?p=527 which is reproduced below:

Modern Western psychiatry has secured many important advances in the care of people with mental distress. We have a variety of pharmacotherapies that can help manage distressing symptoms alongside an even greater variety of psychotherapeutic approaches that help people in distress make sense of their experiences and find new ways to deal with them. The old asylums have been emptied and community care has developed a rich variety of services from early intervention to crisis management. Researchers have identified many biological and environmental factors associated with greater likelihood of having or developing mental health problems and so our understanding of mental distress has improved. Reflecting this, the academic community, studying mental distress from a variety of angles has grown in numbers and sophistication with many journals and thousands of articles being published each year. These are worthy achievements and this progress has no doubt helped thousands of people across the world.

However, despite all these achievements, psychiatric theory and practice has reached an impasse. Prevention has proved elusive with mental health diagnoses becoming more not less common despite a large increase in services in most developed countries. There still isn’t a diagnosis listed in the major psychiatric diagnostic manuals (such as ICD and DSM) that is associated with any sort of physical test and so, unlike the rest of medicine, aetiology has an insignificant part to play in organising diagnostic practice. Whilst reliability in making diagnoses has improved for some research purposes, this does not necessarily translate to clinical practice and the more important issue of validity remains poorly addressed. Most importantly there is no evidence to show that using psychiatric diagnostic categories as a guide for treatment leads, through evidence based choices, to improved outcomes. There is some evidence to suggest that applying a psychiatric diagnosis and theoretical models associated with them instead leads to a worse outcome for some.

This campaign therefore proposes that the time has come to help theory and practice in mental health move beyond this impasse by abolishing formal psychiatric diagnostic systems like ICD and DSM. By incorporating the latest evidence from epidemiology, cross-cultural studies and treatment outcome studies, the campaign highlights the extent to which the data is inconsistent with the dominant, diagnostic based, medical model remaining as the organising paradigm for practice. Continuing to use formal diagnostic systems to organise research, training, assessment, and treatment for those in mental distress is inconsistent with an evidence based approach capable of improving outcomes. Whilst the important task of sketching out what services may look like once we discard ICD and DSM from routine clinical practice is not the primary purpose of this campaign, a few pointers are also mentioned to highlight that alternative paradigms are already available and easy to incorporate into practice and in a way that can improve outcomes.

Aetiology

The failure of basic science research to reveal any specific biological abnormality or for that matter any physiological or psychological marker that identifies a psychiatric diagnosis is well recognised. Unlike the rest of medicine, which has developed diagnostic systems that build on an aetiological framework, psychiatric diagnostic manuals such as DSM-IV and ICD-10 have failed to connect diagnostic categories with any aetiological processes. Thus there are no physical tests referred to in either manual that can be used to help establish a diagnosis. The critique that highlights the lack of progress on aetiology is not limited to those less biologically minded psychiatrists as researchers in genetics are also arguing that the use of categorical diagnoses (such as schizophrenia) is handicapping their studies too, where, they argue, a dimensional approach seems more appropriate;3,4 although it should be noted that dimensional approaches in the rest of medicine often focuses on a very small percentage of ‘outliers’ (e.g. growth hormone treatment for short stature) rather than the large numbers currently attracting the gaze of psychiatry.

The one notable exception to the lack of aetiological organisation is the diagnosis ‘Post Traumatic Stress Disorder’ (PTSD) which attributes symptoms to being the direct result of trauma. This diagnosis did not develop out of new scientific discoveries but as a result of legal procedures (the construction of ‘PTSD’ came largely as a result of legal battles involving US military veterans of the Vietnam War) and its use implies that other diagnoses are not related to trauma. However, there is a substantial body of evidence linking states regarded as the most serious in psychiatry, such as the experience of hearing voices and psychosis, to trauma and abuse including sexual, physical and racial abuse, poverty, neglect, and stigma. 5, 6,7,8,9,10,11,12,13,14 This is why it is important to attempt to understand psychotic experiences in the context of the person’s life story. Not to do so can be harmful because it obscures and mystifies the origins of problematic experiences and behaviour that has the potential to be understood.14

Validity

If we were to apply the standards found in the rest of medicine then the validity of a diagnostic construct depends on the extent to which it represents a naturally occurring category. If it does, then there should be some identifiable biological property in those who have the diagnosis that can distinguish them from those who don’t. Despite years of searching for biological correlates, the failure of basic science research to reveal any specific biological marker for any psychiatric diagnostic category reveals that current psychiatric diagnostic systems do not share the same scientific security of belonging to the biological sciences as the rest of medicine. Mainstream practice understandably views this as a problem. However, the attempted solution of continuing to spend the bulk of mental health research time and effort trying to correct this deficit by relentlessly searching for evidence of biological correlates continues to deliver nothing clinically useful. Our failure to find biological correlates should not necessarily be seen as weakness. Instead of continuing with scientifically and clinically fruitless research we should view this failure as an opportunity to review the dominant paradigm in order to develop one that better fits the evidence.

Invalid anomalies are prevalent in DSM/ICD. For example, in DSM defined ‘depression’ there is one exception to the diagnosis (even if the patient has the required number of symptoms for the required number of weeks) – bereavement. This is anomalous in at least two ways. Firstly it breaks the ‘rule’ that diagnostic categories in DSM are descriptors that do not imply aetiology. Secondly, because bereavement is considered a ‘normal’ reaction, even if the full complement of DSM defined symptoms of depression are present, then one must ask: why is ‘bereavement’ specifically singled out? Why are many other life problems for which intense sadness is a common response – such as losing a job, break up of a marriage, bullying and so on – not also counted as legitimate exceptions?16

The frequency with which patients are given more than one diagnosis also raises a concern about the specificity of diagnostic categories. Widespread co-morbidity (making more than one diagnosis in order to encompass patients’ problems) indicates basic deficiencies in our understanding of the natural boundaries of even the most severe conditions we are diagnosing in psychiatry.17,18,19 It is also common to find the ‘dominant’ diagnosis changing in any individual, almost exclusively on a subjective rather than empirical (such as physical test results) basis. Unlike in the rest of medicine where the reason for the patient’s symptoms is clarified by a diagnosis, psychiatric diagnoses serve empirically as nothing much more than descriptors. Thus, when a clinician claims that a patient is ‘really’ depressed, or has ADHD, or has bipolar disorder, or whatever, not only are they trying to turn something based on subjective opinion into something that appears empirical, but they are engaging with the process of reification (turning something subjective into something ‘concrete’). The problem with turning concepts into something that appears as if it exists as a fact in the natural world is that it can cause ‘tunnel vision’ for all concerned; a dominant story that limits alternative more functional possibilities for any individual.20 Thus if someone believes ADHD is a ‘real’ disorder that exists in their brains and is potentially lifelong, that person and those who know them may come to act according to this belief, thus helping to fulfil its prophecy.

There is also a poor correspondence between levels of impairment and having the required number of symptoms for many psychiatric diagnoses (even though ‘impairment’ is often included in the diagnostic criteria). Literature reviews and field trials to examine clinical significance criteria were not included in the preparation of DSM-IV. Thus many below the threshold for a diagnosis have higher levels of impairment than those above, with many who reach the cut off for a diagnosis having relatively low levels of impairment. 21,22,23

Reliability

Reliability is the extent to which clinicians can agree on the same diagnoses when independently assessing a series of patients. Over the last thirty years or so, academic psychiatrists have worked hard to improve the reliability of psychiatric diagnoses. This is partly in response to critics of psychiatry who pointed out that many of the common diagnoses in use at the time were meaningless because of poor levels of agreement between psychiatrists about key symptoms. Rosenhan’s 1973 study spurred on new attempts to ‘standardise’ diagnostic practice after he demonstrated that psychiatrists were often unable to discriminate between sane and psychotic people.24 Formal diagnostic systems like DSM and ICD attempted to address these problems by imposing diagnostic agreement on the profession through the use of standardised check-lists of symptoms for diagnostic criteria. Because of the repeated claim that this approach has improved reliability significantly, the diagnostic systems now in use give the impression of being reliable in an empirically verifiable way.

However, analysis of the studies involved in developing the first diagnostic manual that took this approach of ‘operationalising’ diagnosis through the check list of symptoms approach (DSM-III), found no diagnostic categories for which reliability in these studies was uniformly high. The ranges of reliability for major diagnostic categories were found to be very broad and in some cases ranged the entire spectrum from chance to perfect agreement, with the case summary studies (in which clinicians are given detailed written case histories and asked to make diagnoses – an approach that most closely approximates what happens in clinical practice) producing the lowest reliability levels.25 No studies of the reliability of DSM as a whole when used in natural clinical settings have shown uniformly high reliability, with many finding reliability ratings that are not that different than those in the pre-DSM-III studies. 25,26,27 To overcome this, developers of subsequent DSMs have simply de-emphasised the reliability problem, claiming this to have already been solved by the approach developed in preparing DSM-III.

Treatment and outcome

The technological paradigm is the dominant one that organises the way psychiatric services and treatments are delivered in most industrialised countries. This paradigm is predicated on the assumption that the technical aspects of medical and psychological care are of primary importance, and that these can be applied through making diagnoses and then applying corresponding treatment protocols.

However, there is a large literature on psychotherapy confirming that it is generally speaking a safe and effective intervention for common mental health problems as studied in Western populations, but there is little to suggest that a positive outcome is strongly related to selecting the ‘correct’ psychotherapeutic technique and much to suggest that the ‘common factors’ such as developing a strong therapeutic alliance, are more important.28,29,30 For example, several studies have shown that most of the specific features of Cognitive Behaviour Therapy (CBT) can be dispensed with, without adversely affecting outcomes. 31,32 The same holds for other forms of psychotherapy for depression. For example, The National Institute of Mental Health’s Treatment of Depression Collaborative Research Project (TDCRP), the largest trial to date comparing different treatments for depression (CBT, Inter-Personal Therapy [IPT], anti-depressants, and placebo) found that patients in each group had significant improvements, with no overall difference in outcome between each treatment group. However, the best predictor of outcome across all four groups was the quality of the relationship between patient and therapist (as perceived by the patient) early in treatment. 33,34, 35, 36

Recent meta-analyses have drawn similar conclusions. The quality of the therapeutic alliance accounts for most of the within-therapy variance in treatment outcome, and is up to seven times more influential in promoting change than treatment model. 28,37 Such data, when combined with the observed superior value, across numerous studies, of clients’ assessment of the relationship in predicting the outcome, makes a strong empirical case that the non-specific aspects of psychotherapy, or ‘know-how’ in building a strong therapeutic alliance, are more important than specific techniques being used. This is also evident in ‘real life’ clinical encounters not just research projects. For example, in a review of over 5000 cases treated in a variety of National Health Service settings in the UK, only a very small proportion of the variance in outcome could be attributed to psychotherapeutic technique, as opposed to non-specific effects such as the therapeutic relationship.38

The same principles can be found operating when using psychoactive drug treatments (that non-specific factors are more important than matching a drug to a diagnosis). Thus a number of psychiatrists have argued that instead of correcting imbalances, the evidence supports the view that pharmacological agents may be conceptualised as inducing particular psychological states which, though not specifically related to diagnosis, is nonetheless the basis for their usefulness.39 This reflects clinical practice where the few categories of psychoactive medications used in psychiatry (the SSRIs, major tranquilisers, benzodiazepines, Lithium, and anti-epileptics) are often used in a non-diagnosis specific way. For example, SSRIs are claimed to be efficacious in conditions as disparate as borderline personality disorder, depression, obsessive compulsive disorder, anorexia nervosa, bulimia, panic disorder, social phobias, and so forth. As a psychoactive substance SSRIs would appear to do ‘something’ to the mental state, but that something is not diagnosis specific. Like alcohol, which will produce inebriation in a person with schizophrenia, obsessive compulsive disorder, depression, or someone with no psychiatric diagnosis, SSRIs will also impact individuals in ways that are not specific to diagnosis. Similarly, major tranquilisers (misnamed anti-psychotics) have also been advocated for the treatment of depression, anxiety disorders, bipolar affective disorder, personality disorders, ADHD, as well as schizophrenia, a list that contains considerable overlap with that found for SSRIs.

Many psychiatric drug treatments, like psychological treatments, rely more on non-specific factors than disease-specific therapeutic effects. For example, it is generally assumed that drugs marketed as ‘antidepressants’ work through their pharmacological effects on specific neurotransmitters in the CNS, reversing particular states of ‘chemical imbalance’. However, the evidence points to placebo effects being more important than any neuro-pharmacological ones. Thus several meta-analyses have concluded that most of the benefits from ‘antidepressants’ can be explained by the placebo effect, with only a small amount of the variance (about 20%) attributable to the drug, a small amount moreover that is unlikely to be clinically significant for the vast majority of patients.40,41 Studies investigating the degree to which non-technical factors such as therapeutic relationship affect outcome, have found that even with psychoactive drug treatments these factors are far more influential than the drug alone. Thus having a good relationship with the prescribing doctor is a stronger predictor of a positive response to an ‘anti-depressant’ than just taking the drug regardless of who prescribes it. 28,42

The lack of treatment specificity is not limited to the more common and less severe presentations. Thus, although drugs marketed as ‘antipsychotic’ are often claimed to reverse a biochemical imbalance in psychotic patients, no such imbalance has been demonstrated. Furthermore, researchers have long been aware of a perplexing finding in cross-cultural studies. Research, including that carried out by the World Health Organisation, over the course of 30 years and starting in the early 1970s, shows that patients outside the United States and Europe have significantly lower relapse rates and are significantly more likely to have made a ‘full’ recovery and show lower degrees of impairment when followed up over several years despite most having limited or no access to ‘anti-psychotic’ medication. It seems that the regions of the world with the most resources to devote to mental illness – the best technology, medicines, and the best-financed academic and private-research institutions – had the most troubled and socially marginalised patients.43 Once again the impact of our psychiatric technologies seem to be minimal compared to common factors, in this case most likely to be the effects of ‘extra-therapeutic’ factors such as family support, community cohesion and tolerance for behaviours and experiences considered a sign of ‘illness’ and ‘dangerousness’ in the West.

Prognosis

Unlike the rest of medicine, no overall improvement in prognosis has been demonstrated in Europe and North America over the past century for those diagnosed with a mental disorder. Some studies indicate the opposite, that compared to the pre-psychopharmacology period there are more patients who have developed chronic conditions such as chronic schizophrenia than in the past. For example, in 1955, there were around 350 thousand adults in the US state and county mental hospitals with a psychiatric diagnosis. During the next three decades (the era of the first generation psychiatric drugs), the number categorised as disabled from mental illness rose to 1.25 million. By 2007 the number of people categorised as disabled mentally ill grew to more than 4 million adults. Similarly, the numbers of youth in America categorised as having a disability because of a mental condition leapt from around 16 thousand in 1987 to 560 thousand in 2007.44

Studies that have compared outcomes for psychotic disorders such as schizophrenia have repeatedly found that outcomes are better in poorer, non-developed countries when compared to richer, more industrialised ones.41 For example, the World Health Organisation’s international outcome in schizophrenia studies found that after 2 years about two thirds of the patients in the poor countries were doing well compared to only a third of the patients in the developed countries. The researchers concluded that “being in a developed country was a strong predictor of not attaining a complete remission.”45 Thus the progress attributable to modern mainstream psychiatric diagnostic based practice does not extend to improved prognosis.

One problem with medical model diagnostic approaches is that many of the diagnoses (such as schizophrenia, bi-polar disorder, dysthymia, ADHD, autism, OCD etc.) are conceived as conditions that are genetic and lifelong in nature (i.e. conceived as chronic conditions that are ‘hard-wired’ with little chance of making a complete recovery), where the best one can hope for is gaining some control over symptoms (through, for example, life-long use of medications). This constructs and often imposes a narrative of despair on those diagnosed with these ‘chronic’ conditions. As such psychiatric diagnoses can foreclose meaning by transforming a range of experiences and possible meanings that can be applied to these experiences into a narrow disease framework, limiting the cultural imagination to expecting largely negative outcomes.

Prognosis for those with mental disorders is also further hampered by the stigma associated with the medical model.46 Nearly all studies that have looked at the question of public attitudes toward mental illness have found an increase in biological causal beliefs across Western countries in recent years.47 However, biological attributions for mental illness are overwhelmingly associated with negative public attitudes such as a belief that patients are unpredictable and dangerous with associated fear of them and greater likelihood of wanting to avoid interacting with them. 48 Conversely, in studies where members of the public are given a psychosocial explanation for the sufferer’s symptoms (such as serious life events, loss, trauma etc.) they are much less likely to give negative attributions.48 Yet again, the ‘medical model’ diagnostic approach has a significantly negative impact causing an increase in stigma rather than a reduction.

Similar findings emerge in personal stories of those diagnosed with a ‘mental illness’. Through social action, the survivor movement has created safe spaces in which individuals can start the process of telling their own stories. Many of these stories show that users of mental health services felt stigmatised and marginalised by a psychiatric diagnosis, experiencing this as something that leads to the loss of ‘citizenship’.46,49 Being labelled with a chronic ‘genetic’ condition such as ‘schizophrenia’ interferes with a person’s identity and biography. Indeed, the presence of ‘insight’ (as defined by doctors) in schizophrenia has been found to lower self-esteem and can lead to despair and hopelessness.50 Paradoxically, it has been found that the presence of this type of ‘insight’ (meaning accepting you are mentally ill and need medical treatment) is negatively correlated with emotional well-being, economic satisfaction and vocational status. 51,52, 53 Thus accepting the medical model attitude to diagnosis brings expectations of a gloomy outlook with lifelong dependency on psychiatric treatment and little chance of a good recovery. For some therefore, rejecting the diagnosis (or ‘lack of insight’) may be understood as a positive way of coping with the implications of the diagnosis for personal identity.52,53

In summary it seems we now have good evidence that the diagnostic ‘illness like any other illness’ approach is likely to be contributing to a worse prognosis for those diagnosed, not better.

Colonialism

For the last few decades Western mental-health institutions have been pushing the idea of ‘mental-health literacy’ on the rest of the world. Cultures are viewed as becoming more ‘literate’ about mental illness the more they adopted Western biomedical conceptions of diagnoses like depression and schizophrenia. This is because of a belief that ‘modern’, ‘scientific’ approaches reveal the biological and psychological basis of psychic suffering and so provide a rational pathway to dispelling pre-scientific approaches that are often viewed as harmful superstitions. In the process of doing this we not only imply that those cultures that are slow to take up these ideas are therefore in some way ‘backward’, but we also export disease categories and ways of thinking about mental distress that were previously uncommon in many parts of the world. Thus conditions like depression, post-traumatic stress disorder, and anorexia appear to be spreading across cultures, replacing indigenous ways of viewing and experiencing mental distress.54,55 In addition to exporting these beliefs and values, Western drug companies see in such practice the potential to open up new and lucrative markets.54,56

Despite copious evidence from research in the non industrialised world, that shows the outcomes for major ‘mental illnesses’, is consistently better than in the industrialised world and particularly amongst populations who have not had access to drug based treatments,43,44,45 the World Health Organisation, together with the pharmaceutical industry, has been campaigning for greater ‘recognition’ of mental illnesses in the non-industrialised world, basing their assumptions on the idea that ICD/DSM descriptions are universally applicable categories.57 Like other marketing campaigns, this strategy has the potential to open up huge new markets for psychiatric drugs that maybe ineffective and can have serious side effects, at the same time as painting indigenous concepts of, and strategies to deal with, mental health problems, as being based on ignorance, despite their obvious success for these populations.

The idea of the individual as the locus of the self is a relatively recent Western invention and such a framework creates the psychological pre-conditions necessary for accepting the ‘atomised’ social worlds that have been created. Yet, mental well-being seems closely connected to social and economic factors. Several international studies have concluded that more important than poverty per se is the degree of inequality. Thus the greater the inequality (in economic and social resources) in any society, the poorer is the mental health of that society.58,59,60,61,62

A more subtle source of impact on cultural beliefs is due to psychiatric diagnoses inadvertently setting standards for ‘normality’, by categorising what emotional and behavioural traits and experiences should be considered ‘disordered’. As the criteria for diagnoses are arrived at by subjective judgments rather than objective evidence (being literally voted in or out of existence by committees), they will have an automatic bias toward the cultural standards found in economically dominant societies (who also tend to control what counts as ‘knowledge’ globally). This sets in motion a diagnostic system vulnerable to institutional racism in the dominant societies and colonialism in others, as other standards of normality will, at least to some extent, come to be viewed as ‘primitive’, ‘superstitious’ etc. and their populations will be viewed as needing to be (psycho)educated. As a result then, for the majority of the world, all manner of complex somatic/emotional complaints have to be re-categorised, spiritual explanations have to be denounced, parenting practices viewed as oppressive and so on.

Thus imposing Western medical model DSM/ICD style psychiatry on non-Western populations risks a number of things including: adoption of Western psychiatric notions of ‘psychopathology’ to express mental distress, undermining of existing cultural strategies for dealing with distress, more not less stigma for those with mental health problems, and the imposition of an individualistic approach that may marginalise family and community resources and divert attention from social injustice.

Cultural and Public policy impact

Despite adopting a DSM/ICD approach causing many problems for translating the subjective process of attaining a psychiatric diagnosis into a reliable and objective one in clinical practice; it has nonetheless had a significant impact on service provision and public and professional beliefs about mental distress. As a result of popularising the diagnostic systems created by DSM/ICD, it is widely argued that a significant proportion of the population suffers from mental illness, that this amounts to a significant economic burden, and that there is a strong case for investing in improved mechanisms of detection and treatment for these disorders. Across several surveys in the industrialised nations only about a third of those identified as suffering a mental health problem (according to DSM/ICD criteria) sought or were interested in seeking professional help.63,64,65,66 This has been interpreted as unsatisfactory case detection, provision and treatment, due to public and professional ignorance. However, there is little evidence to support the idea that popularising mental health diagnoses, convincing professionals and the public about the high prevalence of mental disorders, and convincing policy makers of the need to diagnose and treat more people, benefits the mental health of the society.

In order to increase rates of diagnosis and treatment, a variety of campaigns have been undertaken. For example, in the UK the Royal College of Psychiatrists and Royal College of General Practitioners launched their ‘Defeat Depression’ campaign in the early nineties. 67 It was intended to raise public awareness of depression, reduce stigma, train general practitioners in recognition and treatment, and make specialist advice and support more readily available. Unfortunately, evaluations of treatment and education guidelines in the UK following the ‘Defeat Depression’ campaign failed to detect significant improvements in clinical outcome.68,69,70 However, other effects of the campaign included a rapid increase in antidepressant prescribing and increased medicalisation of unhappiness and distress. As has been noted above, medicalisation of mental distress through promotion of the idea that mental health problems are best understood as ‘illness like any other illness’, increases rather than decreases stigma.

Unlike other areas of public health, mental health in those societies with the most developed services appears to be the poorest. In such societies ‘epidemics’ of psychiatric diagnoses (e.g. ADHD, autism, depression, bipolar disorder) have only emerged and become popularised in recent years. Whilst there are complex political, social and cultural reasons for this, they are in part based on new categories and ideas about personhood, the nature of distress etc. and so are at least in part the result of creating, broadening and popularising psychiatric diagnoses.

Conclusion

For any diagnostic system to establish itself as a scientifically useful paradigm that leads to greater knowledge of the natural world, it should be able to show that the categories ‘carve nature at its joints’ such as being able to demonstrate distinct aetiological links. For any diagnostic system to establish itself as clinically useful it must show that use of diagnostic labels aids treatment decisions in a way that impacts on outcome. As reviewed above there is little evidence to support the ICD/DSM paradigm being able to provide either the basis for collecting scientifically useful knowledge or clinically useful treatment decisions. There is much evidence to suggest that instead they can cause significant harm. The only evidence based conclusion that can be drawn is therefore that formal psychiatric diagnostic systems like ICD and DSM should be abolished.

New paradigms

Relying on DSM/ICD diagnostic categories to organise research, services, and treatment does not contribute to improved outcomes for those experiencing mental distress and is associated with considerable harm.

Alternatives to ICD/DSM are therefore needed. We can and should do better. We have all the evidence we need to work on re-organising our approaches locally, nationally, and internationally to develop services that are evidence based and can reduce the amount of harm DSM/ICD has caused at the same time as improving outcomes. New paradigms that draw on the existing evidence for what improves outcomes and that incorporates the views of those who matter most – service users – can easily be developed and implemented. The following represents some good starting points:

1. Aetiology: As discussed in this paper there is a strong association between trauma, particularly early childhood trauma, and adversity and the subsequent development of mental disorders including psychosis. There is also a strong association between the degree of socio-economic inequality and levels of mental distress in any society. Other associations include dietary, lifestyle, family functioning and attachments. Research that examines the relationship between contextual factors and degrees of impairment, without trying to link them to formal psychiatric categories, has a greater likelihood of succeeding in developing useful scientific knowledge about mental distress. Moving the focus away from the eugenic-like search for genetic and neurological abnormalities will allow for greater acceptance of human diversity, and decrease the likelihood of human rights, political and social issues being inappropriately medicalised. Given the strong relationship between increasing acceptance of the diagnostic medical model and increasing stigma, abolition of DSM/ICD will also help in the fight against stigma.

2. Clinical: Decades of outcome research into treatment of psychiatric disorders shows, that despite the development of many new techniques, the outcomes being achieved in studies 40 years ago are similar to those being achieved now. In other words our advances in therapeutic techniques have not yet led to improvement in overall outcomes for service users. Research has found that certain intra-therapeutic factors such as the therapeutic alliance has a much greater effect on outcome than model or technique used and that extra-therapeutic factors such as social support has an even greater impact on outcome than intra-therapeutic ones.28,30,42 A variety of studies (in areas as diverse as psychotherapy services, community mental health services, substance misuse, and marital counselling) have found that incorporating ideas from this outcome literature, such as using session by session feedback on outcome and therapeutic alliance, can improve outcomes.30,42 The message from this research is that services can improve outcomes, not by using diagnostic categories to choose treatment models, but by concentrating instead on developing meaningful relationships with service users that fully includes them in decision making processes. International service user led movements, such as the ‘recovery’ movement, that focus on the inclusion of people in recovery from mental health problems as collaborators in research, service development, and treatment model development provide good examples of how this evidence can be developed to change institutional culture.71,72,73 Services in non-Western settings should be able to incorporate local beliefs and practices and the wholesale export of Western ethno-psychiatry can be stopped.

Developing the knowledge base and services in this manner would give mental health services and practitioners a better chance of improving the lives of those they work with. It will also help with breaking long standing barriers between mental health services and the rest of medicine, by allowing the mental health professions to focus on developing paradigms that are evidence based and which properly incorporates an understanding of how physical and mental well-being are closely related to each other. These non-diagnostic based paradigms can then assist in helping the many patients who present with physically unexplained symptoms or chronic conditions, which inevitably impact on their mental well-being, without needing to label them as ‘mentally ill’.

The real gift of psychiatry is what it can offer the rest of medicine that is more unique to this field, which is an understanding of the person in their context. Psychiatry has to sit at the confluence of a variety of disciplinary discourses (Sociology, anthropology, psychology, philosophy, medicine, cultural studies, politics, theology etc.) and it is this broader understanding of the human and their health and well-being that psychiatry ‘brings to the table’. By lazily importing the diagnostic model from general medicine we end up miss-selling and under-utilising the unique skills the profession of psychiatry brings to healthcare by the ‘dumbing down’ of what we do into simplistic diagnosis driven protocols that has more to do with successful consumer culture marketing than science. Changing to more evidence compatible paradigms is now long overdue.

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Sami Timimi
Consultant child and Adolescent Psychiatrist
Director of Medical Education
Lincolnshire Partnership Foundation NHS Trust
Visiting Professor of Child and Adolescent Psychiatry
Faculty of Health and Social Sciences
Lincoln University
 
International Critical Psychiatry Network

See my Author’s page on the ICPN website
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Mental Health Campaigners Welcome New Book About Schizophrenia

The letters, journals and scribbled observations of David, diagnosed with schizophrenia, have been collated for a new book.

A positive piece published in the Guardian, 5th July 2011 by Mary O’Hara about this important new book – David’s Box: The journal and letters of a young man diagnosed as schizophrenic, 1960-1971, for which I have written a foreward.

http://www.guardian.co.uk/society/2011/jul/05/schizophrenia-journals-davids-box

What is your Opinion of Psychiatric Diagnosis?

This is an important paper written by Steven Coles and colleagues about psychiatric diagnosis. What do you think? Have your say!

What is your Opinion of Psychiatric Diagnosis?

What is your view on psychiatric diagnosis? Should the diagnosis of schizophrenia be abolished as the Campaign for the Abolition of the Schizophrenia Label wish? For both those working in mental health services and those on the receiving end, how important is diagnosis to your life? There are many different views on psychiatric diagnosis from fierce advocates to those who decry the practice. A number of survivors, academics, professionals, and service users have criticised diagnosis. However, within mental health services psychiatric diagnosis remains dominant. Psychiatrists (and other professionals) claim they use diagnosis to understand people’s experiences, behaviour and distress.  Diagnosis shapes how services are organised, who will be helped and how services will support or “treat” people. Psychiatric diagnosis also has a major impact on whether people are detained against there will in hospital – the civil liberties of people with a psychiatric diagnosis are at a greater risk than anyone else in society (other than suspected terrorists). Diagnosis influences whether people are forced to take major tranquilizers (“antipsychotics”), and whether they receive financial benefits.

Despite the immense controversy surrounding diagnosis, my experience is that the debates around diagnosis are not openly discussed between staff or with people using (or forcibly brought into) mental health services. Psychiatric diagnosis has become an everyday and often unquestioned part of mental health practice. Is this simply because critics of diagnosis have weak arguments? Is it because the scientific basis of psychiatric diagnosis is so strong? Is there no alternative? A group of Clinical Psychologists working in East Midlands Adult Mental Health Services have looked at the issue of psychiatric diagnosis and written a position paper (Coles & SPIG, 2010). They conclude that “psychiatric diagnosis does not meet its scientific and expert claims” and does not deserve to be so dominant in mental health services.

The East Midlands group highlighted a number of negative effects of psychiatric diagnosis. They note that diagnosis places the cause of difficulties on the individual; the group feel more attention should be paid to people’s life experiences, such as abuse, poverty, discrimination and disempowerment. The position paper also observes that the language of diagnosis is barrier to communication between staff and people using services. Furthermore, diagnosis is not aware that it is based upon dominant western (often male) ideas of what is normal, and ignores that other cultures and subcultures might have different or a broader idea of what is normal. The paper also notes some modest alternatives to moving beyond diagnosis (for access to the document see www.bps.org.uk/dcp-sigpr/publications-%26-documents/publications_home.cfm).

The East Midlands Paper is accessible at the above link, as well as on the Hearing Voices Network website. The group is hoping to open up a debate around diagnosis and would welcome people’s thoughts on the paper and on diagnosis. The East Midlands paper suggests that the current dominance and use of diagnosis is part of the problem and not part of the solution as psychiatry claims. What do you think? What is your experience of diagnosis?

References

Coles, S. & SPIG (2010).  Position on Psychiatric Diagnosis. East Midlands: Psychosis and Complex Mental Health Special Interest Group

Steven Coles

Clinical Psychologist

steven.coles@nottshc.nhs.uk

The Hearing Voices Network – “The Freedom to Hear Voices”: The Hearing Voices Movement

Psychology, Mental Health and Distress is a groundbreaking new text from John Cromby, David Harper and Paula Reavey. Whereas other texts are structured by diagnostic categories and are biologically reductive, this book places biology as well as the experience of distress itself in its social, cultural and historical context.

 Key Features:

  • Offers a wealth of case stories to portray the reality of living with distress and stimulate class discussion 
  • Fully informed by current experimental, qualitative and theoretical psychological research including research into hearing voices
  • Includes a chapter authored by those with first-hand experience of mental health services, ensuring your students understand the nuances of this emotionally charged and often controversial topic

Features additional contributions by renowned figures including Professor Richard Bentall, Professor John Read, psychiatrist and researcher Joanna Moncreiff and campaigner and Chair of the Hearing Voices Network, Jacqui Dillon among others.

See link for further information: http://www.palgrave.com/products/title.aspx?pid=280329

Download flyer: CrombyHarper&Reaveyflyer