Drop the language of disorder: less medicalising and more understanding, please

Notes for a speech given at: Division of Educational & Child Psychology One-day Event - The Medicalisation of Childhood: Time for a Paradigm Shift; Old Trafford, Manchester, June 28^th 2013. These are my NOTES for the speech, the speech as delivered may have been different.

I have the utmost respect for medical colleagues, but the medicalization of childhood has gone too far. The recent revision of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-5) is a prime example of the creeping medicalisation of normal life. If our colleagues actually inform their care decisions on the basis of DSM-5 diagnoses, we would see millions of people with a range of perfectly understandable and normal problems diagnosed with mental illnesses. The consequences could be catastrophic - especially for vulnerable populations such as children and older people. Instead of understanding distress and offering help, people will be diagnosed and medicated, and the origins and causes of social problems will be minimised and ignored as doctors look for biological explanations and medical solutions.

We need to step back from the ‘diagnosis & treat’ mentality and understand people a little more.

There have ALWAYS been problems with psychiatric diagnosis. A rather remarkable editorial in the Times of Saturday July 22^nd, 1854 stated:

 “Nothing can be more slightly defined than the line of demarcation between sanity and insanity. Physicians and lawyers have vexed themselves with attempts at definitions in a case where definition is impossible. There has never yet been given to the world anything in the shape of a formula upon this subject which may not be torn to shreds in five minutes by any ordinary logician. Make the definition too narrow, it becomes meaningless; make it too wide, the whole human race are involved in the drag-net. In strictness, we are all mad as often as we give way to passion, to prejudice, to vice to vanity; but if all the passionate, prejudiced, vicious, and vain people in this world are to be locked up as lunatics, who is to keep the keys to the asylum?”

Diagnostic systems in psychiatry have always been criticised for their poor reliability, validity, utility, epistemology and humanity.

Reliability

Reliability, in this context, refers to the degree to which two clinicains or raters will agree that the criteria for a particular diagnosis are met. With great effort, and standardised approaches, it is possible for reliable diagnoses to be generated. But such practices are rarely adopted in clinical settings, and psychiatric diagnoses are worryingly unreliable, as the ‘field trials’ for DSM-5 have indicated.

At the same time, people change. Children change in particular. And children’s behavior is highly dependent on context – how a child behaves in setting A isn‘t necessarily how they behave in setting B.

Validity

And it’s worth pointing out that agreement between two raters, and agreement with specific criteria, does not confer validity. I am white, brown-eyed, English-speaking. I’m an unabashed atheist and socialist. If we were able, reliably and objectively, to assess whether I meet criteria for “tending to say things without thinking”, “easily distracted” and “likes shellfish, but dislikes salmon”, you could identify ‘Kinderman’s Syndrome’. Perhaps reliably. But that has no validity.

The poor validity of psychiatric diagnoses—their inability to map onto any entity discernable in the real world—is demonstrated by their failure to predict course or indicate which treatment options are beneficial, and by the fact that they do not map neatly onto biological findings, which are often nonspecific and cross diagnostic boundaries.

We do – and I need to stress this – know that human behavior is intimately associated with brain functioning. A wide range of phenomena – low mood, poor self-esteem, loss of social hierarchy…. hallucinations…. Fear of imminent persecution or threat … hopelessness… All these phenomena have biological as well as psychological and sociological aspects.

But, unfortunately for the authors of DSM-5, these psychological and biological processes don’t appear to map onto diagnostic categories. They do, as Joanna Moncrieff has suggested, make much more sense mapping onto the action of drugs. They also seem to have more coherence with genetic factors.

Ethics

These things have ethical aspects.

In epistemological terms, diagnoses convey the idea that people’s difficulties can be understood in the same way as bodily diseases. This means we look away from social – or educational – causes, and look inwards, to the functioning of the brain.

Worse still, diagnoses are used as pseudo-explanations for troubling behaviours - he did this because he has ADHD. There’s rarely the follow-up question of ‘why does he supposedly “have” this? – the explanation presumably being in his brain. And nobody questions the circularity of ‘we know he has ADHD because he can’t concentrate, and he can’t concentrate because he has ADHD.

This is seriously bad news… millions of kids – kids with problems, kids whom the education system is failing, kids with inadequate parents or incompetent teachers, are being labeled as mentally ill and drugged.

Notwithstanding… that, one blogger on an Oxford University Press site (Joel Paris, MD) tried to defuse this row by saying that “Clinicians need to communicate to each other, and even a wrong diagnosis allows them to do so”. So, let’s get this right… clinicians can’t agree, the diagnoses don’t reflect real-world entities, there are no reliable biomarkers, they don’t predict outcome or treatment and don’t indicate aetiology… But we need to communicate, and so we use these diagnoses… even if they’re wrong… a position presumably reflected in the suggestion by Dr Ronald Pies, professor of psychiatry at Tufts University, who suggested that invalidity was OK, because these are “heterogeneous diagnoses”… I’m not sure if being wrong is synonymous with ‘invalid’, but it’s close. And I’m not sure if ‘heterogeneous’ is quite the same as ‘invalid’, but it’s close.

DSM-5

If implemented, the DSM-V would lead to a lowering of a swathe of diagnostic thresholds. This would inflate the assumed prevalence of mental health problems in the general population. This might be good news for pharmaceutical companies, but is a potential threat to the general public and especially vulnerable populations such as children and older people.

It is important for all of us to ensure that our children learn appropriately to regulate their emotions and grow up with a sense of moral and social responsibility. But is it appropriate to invoke the concept of ‘disorder’ when children need extra help?

While DSM-5 itself should be ignored, we also need a wholesale revision of the way we think about psychological distress. We should acknowledge that such distress is a normal, not abnormal, part of human life—that humans respond to difficult circumstances by becoming distressed. It should recognise that there is no easy ‘cut-off’ between ‘normal’ experience and ‘disorder’, and that that psychosocial factors such as poverty, unemployment and trauma are the most strongly evidenced causal factors for psychological distress.

A valid and humane system for identifying, describing and responding to distress should reflect these principles.

An alternative

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—that humans respond to difficult circumstances by becoming distressed. Any system for identifying, describing and responding to distress should use language and processes that reflect this position. We should then recognise the overwhelming evidence that psychiatric symptoms lie on continua with less unusual and distressing mental states. There is no easy ‘cut-off’ between ‘normal’ experience and ‘disorder’. We should also recognise that psychosocial factors such as poverty, unemployment and trauma are the most strongly evidenced causal factors for psychological distress in adults although, of course, we must also acknowledge that other factors—for example, genetic and developmental—may influence the magnitude of the individual’s reaction to these kinds of circumstances. And we should understand that children, quintessentially, respond to their environments… to understand a child’s behavior, look around him.

There are alternative systems for identifying and describing psychological distress that may be helpful for the purposes of clinical practice, communication, record-keeping, planning and research, such as the operational definition of specific experiences or phenomena. 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; and the problems leading to a diagnosis of ADHD are perfect for this.

There is no reason to assume that these phenomena reflect underlying illnesses.

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 recognised (in both senses of the word), understood, validated, explained (and explicable) and have some relief.

Surely a description of a person’s real problems would suffice? A description of an individual’s actual problems would provide more information and be of greater communicative value than a diagnostic label.

For clinicians, working in multidisciplinary teams, the most useful approach would be 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.