x Abu Dhabi, UAEThursday 27 July 2017

A new manual on mental illness will hurt more than heal

Psychiatry seems to be creating new illnesses rather than eliminating old and existing ones.

Next Wednesday the American Psychiatric Association is set to publish a new edition of its Diagnostic and Statistical Manual (DSM).

This mental diagnostic system is widely used around the world, including in the UAE. But in the run up to the publication of its fifth edition (DSM 5), over 14,000 mental health professionals and more than 50 relevant organisations have signed a petition criticising its content.

The DSM is a tool to help clinicians identify psychiatric illnesses based on checklists of common symptoms. Once an illness has been diagnosed, the clinician proceeds with an appropriate course of treatment. At face value, the system seems reasonable but in reality it raises serious, heavily debated questions about the nature of existence, suffering and illness.

Initial investigations of the DSM focused on how reliable it was in helping to establish diagnoses. For example, if two doctors using the same DSM checklist see the same patient, a high rate of agreement is expected. Also, if a patient receives a diagnosis in May, it is expected that the patient will receive the same diagnosis a few months later. Unfortunately, that is often not the case.

Several studies have shown that the DSM and other diagnostic systems are far from reliable. One study following up a group of patients over two years reported that two fifths of psychiatric diagnoses were changed over the course of the study. People who were initially diagnosed as suffering from, say, bipolar disorder, had their diagnosis changed to schizoaffective disorder or vice versa. Studies have also found rates of diagnostic disagreement between psychiatrists as high as 64 per cent.

Similar concerns have been voiced about the DSM's validity. Where, for example, should we draw the line between illness and normal, common human experiences such as sadness? With reference to depression, many clinicians feel the diagnostic threshold - the line that separates normality from disorder - in the DSM's current edition is already far too low. In DSM 5, it will be even lower. And with reference to validity, what types of behaviours should be regarded as illnesses rather than life-style choices or eccentricities? For instance, internet addiction was discussed for possible inclusion in DSM 5.

One of the confirmed new illnesses appearing in DSM 5 will be known as "disruptive mood dysregulation disorder", which is to be diagnosed in children between the ages of 6 and 12 who tend to be cranky and irritable and exhibit disruptive outbursts more than three times per week. We might once have tried to moderate a child's tantrum by reminding them that a policeman takes naughty boys and girls away. In the future, psychiatrists may come to occupy this behaviour-modifying role.

The British Psychological Society (BPS) has been particularly constructive in its criticism of the DSM. In a 2011 statement to the system's publishers, the BPS expressed concern about the continuous medicalisation of natural and normal responses to distressing experiences. The members also suggested that classifying these problems as illnesses misses the social context, and often the social causes, of such problems.

The US National Institute for Mental Health (NIMH) recently announced that it would no longer be funding psychiatric research that utilised the DSM categories, preferring instead to support research that looks at symptoms that cut across categories. Professor Peter Kinderman, a vocal critic of the DSM 5, described this announcement from NIMH as a "kill shot" to the DSM.

Psychiatry seems to be intent on creating new illnesses rather than eliminating old ones. Professor Richard Bentall, another advocate of reforms to psychiatry, suggests the only ones that benefit from the DSM 5's broader categories and lower diagnostic thresholds are pharmaceutical companies and mental health professionals with busy private practices.

Many psychiatric illnesses are just common human experiences wrapped in a cloak of medical jargon and woven out of sophisticated biochemical theories. This cloak, in some cases, might be comforting, but it also masks the true nature of the problem and offers only drugs to numb the pain.

Within the context of the UAE, we should be particularly wary of the DSM 5, as this latest edition of "psychiatry's Bible" is likely to medicalise a lot of normal, culturally-appropriate responses to distress.

 

Justin Thomas is an assistant professor of psychology at Zayed University

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