Response  to the American Psychiatric Association: DSM-5 Development

The Briish Psychological Society thanks the American Psychiatric Association (APA) for the opportunity to respond to the DSM-5 Development.

The British Psychological Society (“the Society”), incorporated by Royal Charter, is the learned and professional body for psychologists in the United Kingdom. The Society is a registered charity with a total membership of almost 50,000.

Under its Royal Charter, the objective of the Society is "to promote the advancement and diffusion of the knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of members by setting up a high standard of professional education and knowledge".

The Society is committed to providing and disseminating evidence-based expertise and advice, engaging with policy and decision makers, and promoting the highest standards in learning and teaching, professional practice and research.  The Society is an examining body granting certificates and diplomas in specialist areas of professional applied psychology.

We are content for our response, as well as our name and address, to be made public.  We are also content for the APA to contact us in the future in relation to this response.  Please direct all queries to:-

Consultation Response Team, The British Psychological Society,

48 Princess Road East, Leicester, LE1 7DR.

Email: consult@bps.org.uk       Tel: (0116) 252 9508

This response was prepared on behalf of the Society by Professor Peter Kinderman, CPsychol, AFBPsS, Chair of the Division of Clinical Psychology (DCP), with contributions from Susan van Scoyoc, CPsychol, CSci, AFBPsS, committee member of the DCP and member of the Division of Heath Psychology (DHP); Dr David Harper, CPsychol, AFBPsS,  Professor David Pilgrim CPsychol, AFBPsS, and Professor Richard Bentall, FBPsS, all members of the DCP; Lucy Johnstone, CPsychol, AFBPsS, committee member of the DCP; Dr Amanda C de C Williams, CPsychol, member of both the DCP and the DHP, and Professor Pamela James, CPsychol, AFBPsS, committee member of the Division of Counselling Psychology.  We would like to thank Berry Neil for informing aspects of this response.  We hope you find our comments useful.

Dr C A Allan, CPsychol, CSci, AFBPsS

Chair, Professional Practice Board

DSM-5 2011

British Psychological Society response, June 2011

Page 1 of 26

General Comments

The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation....

The putative diagnoses presented in DSM-V are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements, with little confirmatory physical 'signs' or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity. Diagnostic categories do not predict response to medication or other interventions whereas more specific formulations or symptom clusters might (Moncrieff, 2007). Finally, disorders categorised as ‘not otherwise specified’ are huge (running at 30% of all personality disorder diagnoses for example).

Personality disorder and psychoses are particularly troublesome as they are not adequately normed on the general population, where community surveys regularly report much higher prevalence and incidence than would be expected. This problem – as well as threatening the validity of the approach – has significant implications. If community samples show high levels of ‘prevalence’, social factors are minimised, and the continuum with normality is ignored. Then many of the people who describe normal forms of distress like feeling bereaved after three months, or traumatised by military conflict for more than a month, will meet diagnostic criteria.

In this context, we have significant concerns over consideration of inclusion of both “at-risk mental state” (prodrome) and “attenuated psychosis syndrome”. We recognise that the first proposal has now been dropped – and we welcome this. But the concept of “attenuated psychosis system” appears very worrying; it could be seen as an opportunity to stigmatize eccentric people, and to lower the threshold for achieving a diagnosis of psychosis Diagnostic systems such as these therefore fall short of the criteria for legitimate medical diagnoses. They certainly identify troubling or troubled people, but do not meet the criteria for categorisation demanded for a field of science or medicine (with a very few exceptions such as dementia.) We are also concerned that systems such as this are based on identifying problems as located within individuals - this is the problem of methodological individualism. This misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our well-being and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives.

The Society recommends a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or ‘symptoms’ or ‘complaints’. Statistical analyses of problems from community samples show that they do not map onto past or current categories (Mirowsky, 1990, Mirowsky & Ross, 2003). We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety etc)? These would be more helpful too in terms of epidemiology.

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. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses.

We believe that a description of a person’s real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person’s problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives. There is ample evidence from psychological therapies that case formulations (whether from a single theoretical perspective or more integrative) are entirely possible to communicate to staff or clients. We therefore believe that alternatives to diagnostic frameworks exist, should be preferred, and should be developed with as much investment of resource and effort as has been expended on revising DSM-IV. The Society would be happy to help in such an exercise.

References

Mirowsky, John. 1990. "Subjective Boundaries and Combinations in Psychiatric Diagnosis." Journal of Mind and Behavior 11(3): 407- 24.

Mirowsky, John, and Catherine E. Ross. 2003. Social Causes of Psychological Distress, 2nd Edition. New Brunswick, N.J.: Aldine Transaction

Moncrieff J (1995) Lithium revisited. “A re-examination of the placebo-controlled trials”. The British Journal of Psychiatry. 167: 569-573

Moncrieff, J (2003) “Clozapine v. conventional antipsychotic drugs for treatment-resistant schizophrenia: a re-examination”. The British Journal of Psychiatry. 183: 161-166

Moncrieff, J (2007) The Myth of the Chemical Cure: a critique of psychiatric drug treatment. (1 vols). Palgrave MacMillan: Basingstoke, Hampshire

Moncrieff J, & Kirsch I (2005) “Efficacy of antidepressants in adults”. BMJ 331 : 155 doi: 10.1136 Moncrieff, J & Timimi, S (2010) “Is ADHD a valid diagnosis in adults? No”. BMJ 2010; 340:c547 doi: 10.1136/bmj.c547