So…What happens next?

This was first posted on DXSUMMIT.ORG : A global platform for rethinking mental health on Wednesday 15^th May 2013

The idea that we’re on the cusp of a major paradigmatic shift in our thinking about psychiatric disorders is gaining ground. The proposed revision of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) of Mental Disorders franchise – DSM-5 – has prompted world-wide debate and discussion. The debates have identified serious inadequacies in the specific proposed revisions, and have also highlighted scientific, philosophical, practical and humanitarian weaknesses in the diagnostic approach and ‘disease model’ of psychological well-being that underpins the DSM (and ICD) franchise.

Diagnosis is Failing…

Many of us have highlighted the poor reliability, validity, utility, epistemology and humanity of psychiatric diagnoses. Psychiatric diagnoses fail to map onto any entity discernable in the real world, fail to predict the course of a person’s problems and fail to indicate which treatment options are beneficial. Psychiatric diagnoses do not map neatly onto biological findings, which are often nonspecific and cross diagnostic boundaries. So psychiatric diagnoses fail basic tests of science. They also have ethical failings. Diagnoses convey the idea that people’s difficulties can be understood in the same way as bodily diseases, and are used as pseudo-explanations for troubling behaviours.

These worries are catalyzed by the proposed revisions to DSM-5. These include a lowering of a swathe of diagnostic thresholds, which will inflate the assumed prevalence of mental health problems in the general population, continue to medicalise a range of normal social and interpersonal problems and see an increased emphasis on the supposed biological underpinnings of psychological distress. So, for example, we saw the proposal that grief, in essence, be pathologised. And, as if to drive the worries home, as the debate over DSM-5 gathered pace, we learned not only that 70% of the task force responsible for revising DSM-5 had financial links to pharmaceutical industry, entirely unsurprisingly – but also that physicians had already developed specific pharmaceutical products designed to “treat” grief.

It is, of course, very difficult to know whether the developing campaign (most notably at www.dsm5response.com) of opposition to DSM-5 is successful or not. There’s certainly a lot of media coverage (just look it up on the specific ‘news’ service of Google). But there are signs of significant change. Most significantly, a mere two weeks before the publication of DSM-5 (scheduled for 20^th May, 2013), the world’s largest funding body in the field of mental health – the USA’s National Institute for Mental Health (NIMH) – announced that it was no longer expecting to base funding decisions for research on the diagnostic codes in the DSM franchise.

This is dramatic news indeed. When the world’s largest source of funds announces that it’s lost faith in the world’s dominant psychiatric diagnostic scheme, something serious is happening. But it is also complex, and there’s still a significant debate to be had as to where we should go next. Many of the opponents of traditional psychiatric diagnoses complain that they place too much emphasis on biomedical factors and the attempt to emulate medical diagnoses. Instead, these critics argue, mental health care needs to place more emphasis on normality (not pathology), on social factors in the origin of mental health problems (rather than supposed biological causes), and on the need for psychosocial interventions (rather than medication). NIMH, however, has suggested exactly the opposite – that a greater emphasis on biomarkers and the relationship between biological processes and the identifiable problems that people report was a necessary basis for progress.

So…What Happens Next…?

In my opinion, we need a wholesale revision of the way we think about psychological distress. We should start by acknowledging that such distress is a normal, not abnormal, part of human life – we respond to difficult circumstances by becoming distressed. That does mean that there’s a problem to be solved, and a demand for help and assistance, but it doesn’t mean there’s a necessary pathology. We should also acknowledge that all human emotions, behaviours and thoughts depend on our brains – and our brains are of course biochemical engines ultimately dependent on our genetic inheritance. But that simply doesn’t mean that differences between us depend on biological differences; in fact it’s much more likely that individual differences owe more to circumstances than biology. For example, there’s very strong evidence that psychosocial factors such as poverty, unemployment and trauma are significant causes of psychological distress although, of course, genetic and developmental factors may influence how we react to these kinds of challenges. And finally, we should recognize that there is no easy ‘cut-off’ between ‘normal’ experience and ‘disorder’.

Problem List and Formulation

For me, the obvious alternative to psychiatric diagnosis is a very straightforward combination of a problem list and psychosocial case formulation.

All decent mental health professionals will guide their care of their clients on the basis of more than a diagnosis (one of the other reasons why they are fundamentally flawed), and so the idea that we should come up with a case formulation – a set of working hypotheses about what might link the person’s problems, what might have caused them, and what might help – is not radical.

Some international effort will be needed to develop a shared lexicon, but it is relatively straightforward to generate a simple list of problems that can be reliably and validly defined; for example, depressed mood, auditory hallucinations and intrusive thoughts. These aren’t – I must stress – alternative diagnoses. We do not have to assume that these problems co-vary as a consequence of underlying ‘illnesses’ (although, equally, there is no reason to exclude this possibility). There is no reason to assume that these phenomena cluster into discrete categories or other simple taxonomic structure. And we absolutely don’t have to assume that these problems are caused by underlying biological pathologies.

Proponents of diagnosis assume that such classifications are needed for communication between professionals, the planning of services, and – at least in the US – billing for services. But, of course, it’s perfectly straightforward for all kinds of services to plan, commission and (in those unfortunate nations that have not yet evolved socialized healthcare) bill for services on the basis of the identified problems and the services needed to put them right. As with many other areas of medicine, social services and wider civil society, professionals can communicate both between themselves and with their clients simply by saying what’s wrong, what the cause might be and what they suggest might be the best response. We don’t use diagnoses in other areas of public life, and we shouldn’t in what are, essentially, social and emotional problems.

Of course, traditional psychiatrists, and many members of the public, say that they find a diagnosis helpful and even comforting. But the truth is that this comfort comes from knowing that your problems are recognised (in both senses of the word), understood, validated, explained (and explicable) and that the person you’re speaking to has a decent plan to help you. A problems list and a formulation can do that. Paradoxically, better than a diagnosis – since, for example, two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ might have absolutely nothing in common, not even the same ‘symptoms’, any comfort from a diagnosis is likely to be illusory.

So, instead of re-inventing the biomedical DSM and ICD franchise, and instead of heading down an NIMH dead-end, we should encourage clinicians, working in multidisciplinary teams, to develop individual formulations consisting of a summary of an individual’s problems and circumstances, hypothesis about their origins and possible therapeutic solutions. This ‘problem definition, formulation’ approach rather than a ‘diagnosis, treatment’ approach would yield all the benefits of the current approach without its many inadequacies and dangers.