According to this article in The Guardian, tomorrow the British Psychological Society’s Division of Clinical Psychology (DCP) will be releasing a statement calling for a “paradigm shift” in how mental health is understood. They are expressing concerns about the diagnostic assumptions being made by the DSM.
What’s fascinating is that the DCP’s problem with the DSM-5 is the opposite of the issue that the NIMH cited (and I wrote about last week). According to Dr. Lucy Johnstone, who helped draft the DCP statement, a chief concern was the focus on biological causality:
On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse.
I think most medical anthropologists would agree, without denying the interaction of biology: chemical interactions with the environment, diet and nutrition, genetics and epigenetics, etc.
That groups are taking such diametrically opposed views in criticizing the same publication makes me wonder if the DSM-5 is being used as a scapegoat for long-held resentments and a catalyst for change. I don’t see the DSM as either particularly biological or sociocultural, but neither is it a moderate middle ground between two extreme views. It seems that each side is interpreting the DSM to create a foil for its goals.
In a letter on the National Institute of Mental Health website, Director Thomas Insel announced that NIMH will be “re-orienting its research away from DSM categories.” He comments that the DSM has had reliability but not validity:
In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.
I had a moment of hope, that perhaps they would be looking beyond reported symptoms to cultural and structural as well as biological factors. Instead, NIMH is launching the Research Domain Criteria (RDoc) project to develop a classification system of its own. NIMH support in the future will be for research that cuts across DSM categories and fits the assumptions of RDoC (the emphasis is mine):
- A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
- Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
- Each level of analysis needs to be understood across a dimension of function,
- Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment
I’m not a doctor and I do believe that many illnesses that we see as “mental disorders” have a basis in chemical imbalances or biological disease. However, this sort of institutional bioreductionism worries me. It seems like a quest for magic bullet solutions rather than an understanding of the complex factors inside and outside the patient that contribute to what he or she is experiencing.
DSM-5* launches on the 22nd of this month and the ripples of its drop could be tsunami-sized for some communities. We’ve written previously about DSM-5 controversy here and here. The Wired article that we linked to was written by psychotherapist Gary Greenberg, who offers a harsh critique of the new DSM — and any DSM and psychiatry as a whole — in his new work The Book of Woe: The DSM and the Unmaking of Psychiatry. I haven’t read the book yet, but The Atlantic has an interview with Greenberg: The Real Problems with Psychiatry. It’s worth a critical read, along with the comments on the interview.
I agree with several of Greenberg’s points, perhaps the ones in which he’s most in sync with Allen Frances, but on others his approach is so antithetical to medical anthropology that I was arguing aloud as I read them. Consider his lack of distinction between illness, disease, and disorder and sentences like, “If they don’t have real diseases, they don’t belong in real medicine.” If he’s so opposed to the APA being the judge of psychiatric diagnostic criteria, I wonder whom he would appoint to be the arbiter distinguishing real from non-real diseases or even real from non-real medicine.
As I read the piece, I wondered if perhaps Greenberg was just not a good interviewee. Though other things he’s written have a cynical edge, the tone seemed off and there were inconsistencies. According to Greenberg’s website, he didn’t know that the format of the Atlantic piece was going to be Q&A with verbatim quotes, and he admits that he “said some pretty intemperate things… but only a couple are embarrassing.” Ah, that makes more sense. I’ll have to take a look at the book to get a better understanding of his arguments.
* The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition.
The National Psychologist, January/February 2013 issue page 6, publishes 2 articles: 1) about Psychiatric association approval of DSM-5 publication in spite of complaints from the professional field and 2) how Psychologist organizations react to DSM-5. Both are scanned in one document.
It is worth considering how construction of diagnosis is interrelated with political biomedical authority. The process might not necessarily benefit the individual but it leads to creation of compliant body and collectively a member of Foucalian society.
While following a trail of links from an article about Manti Te’o’s imaginary girlfriend, I rediscovered this excellent article from The Stranger (a weekly newspaper in Seattle) about people — mostly women — who lie about illnesses online. It’s a terribly interesting read.
“Munchausen by Internet” is not considered a unique illness, though that was debated for the DSM-V, but is a form of Munchausen Syndrome in which a person fakes his/her own illnesses. (There is also Munchausen by proxy, the most common example of which is a mother who exploits exaggerated or imaginary illnesses in her child.)
It’s easy to say that these illness fabricators are pathetic or predatory, emotional vampires who feed on the sympathy of others. However, I find myself thinking about Ong’s work with Malaysian factory workers, Nichter’s “Idioms of Distress”, or accounts of spirit possessions (mostly of women) in various cultures. Should we consider this an individual psychiatric disorder when the condition centers around relationships with others? Why is it largely a female phenomenon? Is this a culture bound syndrome?
Here are some pieces by or about Al Frances, a very articulate critic of the proposed DSM-V.