Report on “DSM-5 and the
Future of Psychiatric Diagnosis” conference at the Institute of Psychiatry,
King’s College London (4th-5th June 2013)
Future of Psychiatric Diagnosis” conference at the Institute of Psychiatry,
King’s College London (4th-5th June 2013)
Véronique Voruz and Janet Haney
The DSM-5 has been all over the media of late. Lay members of the
public, service users and psy professionals have deplored the lack of
scientificity of the negotiation processes leading to the inclusion of
diagnoses and remarked upon the conflicts of interest playing themselves out
through pressure groups, and apparent in the position of some researchers. The
socio-political stakes of diagnoses, such as access to an educative or
financial support for some ‘conditions’ (such as Asperger), have been made
explicit. There has also been talk of the danger of overly medicalising
the human condition,[1] and even
of American imperialism and its exportation of psychiatric labels to the rest
of the world irrespective of cultural specificities.[2] As the
criticisms gathered momentum, the DSM was progressively exposed as a technology
of power-knowledge in the hands of the psychiatric profession in connection
with the pharmaceutical industry. It became obvious to most that the DSM was
neither about the subjective experience of mental illness, nor to the direction
of the treatment. Thus in the English-speaking world, criticisms came
from all angles months before it was even published:
public, service users and psy professionals have deplored the lack of
scientificity of the negotiation processes leading to the inclusion of
diagnoses and remarked upon the conflicts of interest playing themselves out
through pressure groups, and apparent in the position of some researchers. The
socio-political stakes of diagnoses, such as access to an educative or
financial support for some ‘conditions’ (such as Asperger), have been made
explicit. There has also been talk of the danger of overly medicalising
the human condition,[1] and even
of American imperialism and its exportation of psychiatric labels to the rest
of the world irrespective of cultural specificities.[2] As the
criticisms gathered momentum, the DSM was progressively exposed as a technology
of power-knowledge in the hands of the psychiatric profession in connection
with the pharmaceutical industry. It became obvious to most that the DSM was
neither about the subjective experience of mental illness, nor to the direction
of the treatment. Thus in the English-speaking world, criticisms came
from all angles months before it was even published:
- From
former DSM task force heads Robert Spitzer (DSM-III) and Allen Frances
(DSM-IV), for lack of transparency and reliability (methodological flaws);
- From
patients’ associations, defining themselves increasingly as ‘mental health
survivors’, such as SOAP [Speak Out Against Psychiatry], Hearing Voices,
or Mind, for lack of attentiveness to the subjective reality of so-called
mentally ill people and for ‘naturalizing’ their suffering;
Sticker
worn by the protestors outside the conference
worn by the protestors outside the conference
- From
‘psy’ associations like the British Psychological Society, the Critical
Psychiatry Network or Mental Health Europe, to name just a few of the
hundreds of bodies that declared against DSM-5, for various reasons
ranging from lack of empirical validity and insufficient emphasis on the
biological causes of mental illness to lack of focus on the singular
experiences of the patients. The psychiatrists of the CPN are already
drawing conclusions from the multiple failings of the DSM paradigm and
assert that their profession is at a turning point of its history; it is
time to move beyond any existing psychiatric paradigm. They argue that
psychiatry needs to re-invent itself both epistemologically and in its
practices, failing which it will lose its legitimacy. “The psychic life of
humans is discursive by nature”,[3]
they affirm in a collective statement piece challenging the bio-medical
model. Given that their orientation is, broadly speaking, Marxist, they
are proposing to think mental illness as a consequence of social
inequalities;
- From
NIMH [National Institute for Mental Health], a division of the American
Health Department and its director Thomas R. Insel, for insufficiently
drawing on neuroscientific research, in a probable bid for President
Obama’s Brain Initiative ($100 million allocated funds).
So the DSM is
lacking in many respects… It’s hard to think what attributes it still has. Given
the multiplicity of dissonant voices, and of grounds for controversy, only one
thing is clear: nobody has much of a clue as to what a mental disorder is any
more, and least of all as to what it could possibly mean to be mentally
healthy. In the DSM anyway, the border between disorder and normality is
reduced to a mere question of threshold for the same affect or symptom. Time to
re-read Canguilhem (The Normal and the
Pathological)!
lacking in many respects… It’s hard to think what attributes it still has. Given
the multiplicity of dissonant voices, and of grounds for controversy, only one
thing is clear: nobody has much of a clue as to what a mental disorder is any
more, and least of all as to what it could possibly mean to be mentally
healthy. In the DSM anyway, the border between disorder and normality is
reduced to a mere question of threshold for the same affect or symptom. Time to
re-read Canguilhem (The Normal and the
Pathological)!
A faltering
paradigm can be more fertile than a well-rehearsed discourse, so we decided to
attend the DSM-5 conference (hosted by the IoP at KCL early this month) to hear
what the architects and supporters of the DSM-5 had to say about the state of
their project. We took our inspiration from Eric Laurent’s extremely lucid article
in Lacan Quotidien n0 319:
Laurent predicted the end of the psychiatric paradigm and the reconfiguration
of the mental health discourse by the neurological paradigm. This reconfiguration
is still in the making but is signposted by NIMH with the introduction of RDoC
[Research Domain Criteria], initiating a mythical quest for objective signs of
mental illness using neuroimaging, genetic markers and objectively detectable
alterations in cognitive functions, in the domains of emotion, cognition and
behaviour.
paradigm can be more fertile than a well-rehearsed discourse, so we decided to
attend the DSM-5 conference (hosted by the IoP at KCL early this month) to hear
what the architects and supporters of the DSM-5 had to say about the state of
their project. We took our inspiration from Eric Laurent’s extremely lucid article
in Lacan Quotidien n0 319:
Laurent predicted the end of the psychiatric paradigm and the reconfiguration
of the mental health discourse by the neurological paradigm. This reconfiguration
is still in the making but is signposted by NIMH with the introduction of RDoC
[Research Domain Criteria], initiating a mythical quest for objective signs of
mental illness using neuroimaging, genetic markers and objectively detectable
alterations in cognitive functions, in the domains of emotion, cognition and
behaviour.
Scheduled to speak
were DSM-5 task force head David Kupfer as well as many eminent British and
American psychiatrists involved with the WHO, the ICD [International
Classification of Diseases, instrument of the WHO] task force, the DSM task
force, the Royal College of Psychiatrists, or again specialists of specific
diagnoses such as autism, Disruptive Mood Dysregulation Disorder, or the
discarded Attenuated Psychosis Syndrome. The only outsider to the
medical/psychiatric professions was Nikolas Rose, a well-known critical voice
in the fields of criminology, sciences of life, neuroscience and psychiatry,
and to our lay ears the sole voice of sanity.
were DSM-5 task force head David Kupfer as well as many eminent British and
American psychiatrists involved with the WHO, the ICD [International
Classification of Diseases, instrument of the WHO] task force, the DSM task
force, the Royal College of Psychiatrists, or again specialists of specific
diagnoses such as autism, Disruptive Mood Dysregulation Disorder, or the
discarded Attenuated Psychosis Syndrome. The only outsider to the
medical/psychiatric professions was Nikolas Rose, a well-known critical voice
in the fields of criminology, sciences of life, neuroscience and psychiatry,
and to our lay ears the sole voice of sanity.
To classify
The conference
started with opening remarks by Shitij Kapur, currently Dean and Head of School
at the IOP. His general argument was that in the days of yore things were
terrible because we did not have a classification of mental disorders; in fact
we had to make do with a mere three categories (hysteria, psychosis, other
disorders). Thankfully in the 1920s American psychiatrists came up with a
statistical manual sorting the asylum population into 22 disorders, and by the
mid-20th century psychiatric classifications began to include all
mental disorders. The premise of Professor Kapur’s talk was basically that the
main problem besetting psychiatry was unsatisfactory classification, hence the
thrust of the APA [American Psychiatric Association] in ceaselessly adjusting
its classification manual.
started with opening remarks by Shitij Kapur, currently Dean and Head of School
at the IOP. His general argument was that in the days of yore things were
terrible because we did not have a classification of mental disorders; in fact
we had to make do with a mere three categories (hysteria, psychosis, other
disorders). Thankfully in the 1920s American psychiatrists came up with a
statistical manual sorting the asylum population into 22 disorders, and by the
mid-20th century psychiatric classifications began to include all
mental disorders. The premise of Professor Kapur’s talk was basically that the
main problem besetting psychiatry was unsatisfactory classification, hence the
thrust of the APA [American Psychiatric Association] in ceaselessly adjusting
its classification manual.
These opening
remarks were followed by a historical talk by Professor Horwitz who recounted
how prior to WWII psychiatric classification concentrated on asylum
populations, with 21 of the 22 recognised disorders referring to psychotic
conditions. But after WWII returning soldiers presented different types of
disorders that could not be ascribed to biological or genetic factors since
they had been carefully screened before being sent out to fight. Further, their
disorders were clearly circumstantial (war neuroses, shell-shock etc.); they
also could not be treated through the asylum system. Thus the DSM-I was born,
in 1952, but unfortunately it was heavily influenced by psychoanalytic
psychiatry and differential diagnosis, and focused on neurotic conditions. The
DSM-I was very theoretical, and Professor Horwitz deplored that it was a manual
for clinicians, not for researchers.
remarks were followed by a historical talk by Professor Horwitz who recounted
how prior to WWII psychiatric classification concentrated on asylum
populations, with 21 of the 22 recognised disorders referring to psychotic
conditions. But after WWII returning soldiers presented different types of
disorders that could not be ascribed to biological or genetic factors since
they had been carefully screened before being sent out to fight. Further, their
disorders were clearly circumstantial (war neuroses, shell-shock etc.); they
also could not be treated through the asylum system. Thus the DSM-I was born,
in 1952, but unfortunately it was heavily influenced by psychoanalytic
psychiatry and differential diagnosis, and focused on neurotic conditions. The
DSM-I was very theoretical, and Professor Horwitz deplored that it was a manual
for clinicians, not for researchers.
Indeed, it became
very clear in the course of the conference that the main point of the DSM-5 was
to allow psychiatrists to 1) accurately fill in assessment forms; 2) bid for
research funding on certain conditions; 3) publish accredited articles
furthering their careers. There was hardly any mention at all of treatment, at
best the patient re-appeared from the perspective of symptom management.
Otherwise the whole conference was spent discussing accuracy of classification,
items on diagnostic instruments, and whether a particular diagnosis was the
same as another using ‘sophisticated’ statistical tools.
very clear in the course of the conference that the main point of the DSM-5 was
to allow psychiatrists to 1) accurately fill in assessment forms; 2) bid for
research funding on certain conditions; 3) publish accredited articles
furthering their careers. There was hardly any mention at all of treatment, at
best the patient re-appeared from the perspective of symptom management.
Otherwise the whole conference was spent discussing accuracy of classification,
items on diagnostic instruments, and whether a particular diagnosis was the
same as another using ‘sophisticated’ statistical tools.
Professor Horwitz
rejoiced that the DSM gradually moved away from being a clinician’s tool to
being a researcher’s one. That was because psychiatry, in order to re-assert
its waning professional dominance in the face of alternative disciplines such
as psychology and psychoanalysis, started to rely on the medical methodology of
controlled trials and statistical evidence instead of case studies. Robert
Spitzer’s DSM-III waged a successful war on the psychoanalytic framework and
introduced symptom-based, objective and measurable conditions. The result was
an a-theoretical manual, which Professor Horwitz specified as being agnostic as
to etiology: in other words, anyone with the symptoms has the disorder, and the
need for etiology goes “out of the window”.
rejoiced that the DSM gradually moved away from being a clinician’s tool to
being a researcher’s one. That was because psychiatry, in order to re-assert
its waning professional dominance in the face of alternative disciplines such
as psychology and psychoanalysis, started to rely on the medical methodology of
controlled trials and statistical evidence instead of case studies. Robert
Spitzer’s DSM-III waged a successful war on the psychoanalytic framework and
introduced symptom-based, objective and measurable conditions. The result was
an a-theoretical manual, which Professor Horwitz specified as being agnostic as
to etiology: in other words, anyone with the symptoms has the disorder, and the
need for etiology goes “out of the window”.
The DSM-III met
with instant success for reasons that had little to do with the efficacy of
treatment: it proved useful in organizing re-imbursement structures, it
provided professional legitimation to psychiatrists, it was endorsed by NIMH
and became the framework for research funding: for a time in the US it was
impossible to get funding without relying on a DSM category. It also proved
successful with parents, who were fed up with being held responsible for their
children’s disorders. Last but not least, pharmaceutical companies loved it
because they could target their drugs to specific diagnoses. The DSM-IV and 5
(the roman numerals were abandoned to signal the modernity of the new DSM…)
represent attempts at overcoming issues of co-morbidity and incorporating
biological findings. But the outcome is not as successful as the DSM-III, with
a proliferation of diagnoses often said to include all of the population (157
diagnoses, themselves divided into subsets…).
with instant success for reasons that had little to do with the efficacy of
treatment: it proved useful in organizing re-imbursement structures, it
provided professional legitimation to psychiatrists, it was endorsed by NIMH
and became the framework for research funding: for a time in the US it was
impossible to get funding without relying on a DSM category. It also proved
successful with parents, who were fed up with being held responsible for their
children’s disorders. Last but not least, pharmaceutical companies loved it
because they could target their drugs to specific diagnoses. The DSM-IV and 5
(the roman numerals were abandoned to signal the modernity of the new DSM…)
represent attempts at overcoming issues of co-morbidity and incorporating
biological findings. But the outcome is not as successful as the DSM-III, with
a proliferation of diagnoses often said to include all of the population (157
diagnoses, themselves divided into subsets…).
Professor Horwitz’s
talk was followed by an intervention by David Kupfer, head of DSM-5 task force.
Kupfer emphasized that the thrust of the task force had been to incorporate as
much research and empirical data into the DSM-5 in order to improve its
reliability and the validity of its diagnoses. For this purpose, the task force
received input from researchers from 13 countries, from psychologists, added
input from neuroscience and so forth. Basically Kupfer tried to defend the
DSM-5 by showing that everything had been done to improve its classificatory
reliability. Professor Rutter continued the morning session by outlining why
the psychiatric community needed a classification: 1) to communicate between
ourselves; 2) to regroup different types of individuals; 3) to direct
treatment.
talk was followed by an intervention by David Kupfer, head of DSM-5 task force.
Kupfer emphasized that the thrust of the task force had been to incorporate as
much research and empirical data into the DSM-5 in order to improve its
reliability and the validity of its diagnoses. For this purpose, the task force
received input from researchers from 13 countries, from psychologists, added
input from neuroscience and so forth. Basically Kupfer tried to defend the
DSM-5 by showing that everything had been done to improve its classificatory
reliability. Professor Rutter continued the morning session by outlining why
the psychiatric community needed a classification: 1) to communicate between
ourselves; 2) to regroup different types of individuals; 3) to direct
treatment.
After the first
three morning sessions it had become apparent that the main purpose of the
DSM-5 was to legitimize the psychiatric profession in its research and funding
activities, and the debate at the IOP would never challenge the idea that
classification was the way to go. Meanwhile, outside the IOP a demonstration
was going on, organized by people who saw themselves as survivors of psychiatry.
There were, even, representatives of the Citizens Commission on Human Rights
[CCHR], gathering information on ‘psychiatric damage’, or damage caused by
psychiatric treatment. Overheard conversation between two psychiatrists: “I
don’t understand why they are so angry at us. We are only trying to help
them.”
three morning sessions it had become apparent that the main purpose of the
DSM-5 was to legitimize the psychiatric profession in its research and funding
activities, and the debate at the IOP would never challenge the idea that
classification was the way to go. Meanwhile, outside the IOP a demonstration
was going on, organized by people who saw themselves as survivors of psychiatry.
There were, even, representatives of the Citizens Commission on Human Rights
[CCHR], gathering information on ‘psychiatric damage’, or damage caused by
psychiatric treatment. Overheard conversation between two psychiatrists: “I
don’t understand why they are so angry at us. We are only trying to help
them.”
A
‘survivor of psychiatry’ protesting outside the carefully guarded IoP.
‘survivor of psychiatry’ protesting outside the carefully guarded IoP.
‘Outsider’
Nikolas Rose then
took over, with a very measured sociological intervention pointing out that
diagnoses had above all social functions: sick leave, eligibility for
treatment, disability benefit, involuntary detention, epidemiology, research,
predictive tools, insurance, identification, cultural significance,
biopolitical importance, management of the disorderly, grouping of the
heterogeneous, and so forth. Given the huge relevance of the social functions
of diagnoses, Professor Rose underlined the responsibility of the people who
take on the responsibility of creating diagnostic categories. He drew attention
to the epistemological consequences of the unifying gaze of the DSM-5: one
third of the adult population are now said to suffer from a mental disorder in
any one year in Europe. The result of such a medicalization of the human
experience is the reduction of etiology to pathophysiology. Yet there is no
biological substrate to mental illness, and no boundary between ill/well-being.
The DSM method is to look at clinical phenomena and seek to correlate them to
neurobiological underpinnings. RDoC suggests to look at the brain and link
brain patterns to clinical phenomena – these two models fail to address the
definitional issue of 1) mental health; 2) mental disease. They also focus on
research at the expense of practice. He concluded by supporting the position of
the BPS: one should start with the specific experiences of the patient rather
than with the diagnosis.
took over, with a very measured sociological intervention pointing out that
diagnoses had above all social functions: sick leave, eligibility for
treatment, disability benefit, involuntary detention, epidemiology, research,
predictive tools, insurance, identification, cultural significance,
biopolitical importance, management of the disorderly, grouping of the
heterogeneous, and so forth. Given the huge relevance of the social functions
of diagnoses, Professor Rose underlined the responsibility of the people who
take on the responsibility of creating diagnostic categories. He drew attention
to the epistemological consequences of the unifying gaze of the DSM-5: one
third of the adult population are now said to suffer from a mental disorder in
any one year in Europe. The result of such a medicalization of the human
experience is the reduction of etiology to pathophysiology. Yet there is no
biological substrate to mental illness, and no boundary between ill/well-being.
The DSM method is to look at clinical phenomena and seek to correlate them to
neurobiological underpinnings. RDoC suggests to look at the brain and link
brain patterns to clinical phenomena – these two models fail to address the
definitional issue of 1) mental health; 2) mental disease. They also focus on
research at the expense of practice. He concluded by supporting the position of
the BPS: one should start with the specific experiences of the patient rather
than with the diagnosis.
Professor Nikolas Rose, Head of Department of Social
Sciences, Health and Medicine at KCL
Sciences, Health and Medicine at KCL
Despite Professor
Rose’s well-calculated intervention, the afternoon proceeded with a discussion
of specific diagnostic categories such as the autistic spectrum disorder, the
Disruptive Mood Disregulation Disorder and whether it was the same as ADHD, and
finally some very dodgy research from an ethicist (!) making children say that
Ritalin had a fantastic effect on them, showing their drawings – no doubt as
visual proofs.
Rose’s well-calculated intervention, the afternoon proceeded with a discussion
of specific diagnostic categories such as the autistic spectrum disorder, the
Disruptive Mood Disregulation Disorder and whether it was the same as ADHD, and
finally some very dodgy research from an ethicist (!) making children say that
Ritalin had a fantastic effect on them, showing their drawings – no doubt as
visual proofs.
To laugh or to cry?
Dr Clare Gerada
opened the second day by introducing herself to the conference as a GP, adding
quickly ‘forgive me for that’ (laughter). She then declared her ‘conflict of
interest:’ she was married to one of the speakers (laughter). She introduced
the first speaker (to whom she is definitely not married) as: Professor David
Clark, ‘the most cited psychologist of all time, more even than Eysenck’. This
time there was no laughter – had she meant to be ironic? If so, there was no
sign of it (Eysenck had been Professor of Psychology at the IoP between 1955
and 1983). David Clark’s work hugely affects that of Gerada, because he has
made CBT and IAPT available for her patients. He is currently Professor of
Experimental Psychology at the University of Oxford and Visiting Professor of
Psychology at the Institute of Psychiatry and is a leading figure behind the
‘success’ of the IAPT programme.
opened the second day by introducing herself to the conference as a GP, adding
quickly ‘forgive me for that’ (laughter). She then declared her ‘conflict of
interest:’ she was married to one of the speakers (laughter). She introduced
the first speaker (to whom she is definitely not married) as: Professor David
Clark, ‘the most cited psychologist of all time, more even than Eysenck’. This
time there was no laughter – had she meant to be ironic? If so, there was no
sign of it (Eysenck had been Professor of Psychology at the IoP between 1955
and 1983). David Clark’s work hugely affects that of Gerada, because he has
made CBT and IAPT available for her patients. He is currently Professor of
Experimental Psychology at the University of Oxford and Visiting Professor of
Psychology at the Institute of Psychiatry and is a leading figure behind the
‘success’ of the IAPT programme.
“For those of you who read the Observer” he said with a
knowing smile, “you will know that the BPS has come out with a rather strident
notice against the DSM”. The statement criticises the DSM as not scientific,
but as created through the efforts of committees and consensus”. Professor
Clark points out, in a gentle, quietly assured manner, that the DSM is “perhaps
more interesting to psychology than to most people”, adding “the DSM is a great
help when lobbying politicians”. He went on to acknowledge that “There are no
RCTs of generic CBT, they are all of specialized CBT with specific foci and
procedures”. Brushing aside the problems arising from that, Clark went on to
present power-point proof that CBT is, generically, more effective than
counselling in almost every case.
knowing smile, “you will know that the BPS has come out with a rather strident
notice against the DSM”. The statement criticises the DSM as not scientific,
but as created through the efforts of committees and consensus”. Professor
Clark points out, in a gentle, quietly assured manner, that the DSM is “perhaps
more interesting to psychology than to most people”, adding “the DSM is a great
help when lobbying politicians”. He went on to acknowledge that “There are no
RCTs of generic CBT, they are all of specialized CBT with specific foci and
procedures”. Brushing aside the problems arising from that, Clark went on to
present power-point proof that CBT is, generically, more effective than
counselling in almost every case.
Professor Wessely, ‘an epidemiologist by training’, had
some very funny slides, which the audience clearly enjoyed. One of them, a Gary
Larson (two almost identical fat men, one, the GP, saying to the other, the
patient, as he straps a rocket to his back: you’re allergic to the environment,
we’ve got to get you off the planet: the window is in front of the patient) was
so popular that a member of the audience requested that it continue to be
displayed after the talk is over. Wessely’s work focuses on the very serious
fact that more soldiers in the gulf war suffer from ‘mettle fatigue’ (a joke
courtesy of the Evening Standard) than in other recent wars. He presented
results on the ‘number needed to offend’ (laughter): the tricky business of
finding names for disorders that real men won’t baulk at (don’t even think of
using hysteria, he advised).
some very funny slides, which the audience clearly enjoyed. One of them, a Gary
Larson (two almost identical fat men, one, the GP, saying to the other, the
patient, as he straps a rocket to his back: you’re allergic to the environment,
we’ve got to get you off the planet: the window is in front of the patient) was
so popular that a member of the audience requested that it continue to be
displayed after the talk is over. Wessely’s work focuses on the very serious
fact that more soldiers in the gulf war suffer from ‘mettle fatigue’ (a joke
courtesy of the Evening Standard) than in other recent wars. He presented
results on the ‘number needed to offend’ (laughter): the tricky business of
finding names for disorders that real men won’t baulk at (don’t even think of
using hysteria, he advised).
After the coffee break Norman Sartorius (former
Director of the Division of Mental Health of WHO) chaired a most interesting session.
Vikram Patel was billed as speaking about ‘Why the DMS5 matter to global mental
health’. He stood up and said: “the DSM5 is irrelevant and risks undermining
global mental health”. Patel is Professor of International Mental Health at the
London School of Hygiene and Tropical Medicine.
Director of the Division of Mental Health of WHO) chaired a most interesting session.
Vikram Patel was billed as speaking about ‘Why the DMS5 matter to global mental
health’. He stood up and said: “the DSM5 is irrelevant and risks undermining
global mental health”. Patel is Professor of International Mental Health at the
London School of Hygiene and Tropical Medicine.
Felicity Callard, a historian and sociologist at Durham
university used her personal experience of being diagnosed in both the USA and
UK to say that this stuff is always situated in a particular place, time, and
set of relationships, it means different things to different people at
different times. She also noticed the prevalence of what she called ‘the male
voice’ in and around the DSM. A woman in the audience (also with personal
experience of psychiatric diagnosis) asked Sartorius if he would like to
comment on the male voices speaking about the DSM5? This distinguished man of
the world seemed to be genuinely confused: you want to know if I have voices,
he asked. The laugher in the auditorium compounded the confusion, and might
have precipitated the conference, just for a moment, into a rather more
interesting place.
university used her personal experience of being diagnosed in both the USA and
UK to say that this stuff is always situated in a particular place, time, and
set of relationships, it means different things to different people at
different times. She also noticed the prevalence of what she called ‘the male
voice’ in and around the DSM. A woman in the audience (also with personal
experience of psychiatric diagnosis) asked Sartorius if he would like to
comment on the male voices speaking about the DSM5? This distinguished man of
the world seemed to be genuinely confused: you want to know if I have voices,
he asked. The laugher in the auditorium compounded the confusion, and might
have precipitated the conference, just for a moment, into a rather more
interesting place.
After lunch Robin Murray (knighted in 2011, but
appearing without his title) took the chair with much gusto. Professor of
Psychiatric Research at the IoP, Robin seemed not to care who knew his opinion
about the Americans and their DSM5 and talked openly about the changes in
psychiatric and economic power. Murray’s task was to chair a particularly
interesting session, not only because it contained professors from Germany and
Switzerland, but also because it represented a controversy thrown up by the
DSM5: Attenuated Psychosis Syndrome – forming the base of two out of the four
presentations – has been dropped by the DSM5. The presentations were
particularly dense and compacted, as slide upon slide testified to the diligent
work of countless researchers in four different countries. I asked the woman
sitting next to me (who had popped in only for this session, as it was so
controversial) whether the loss of the diagnosis in DSM5 would mean loss of
funding for the unfortunate researchers. No she said, because they are in
Europe. Had they been based in the USA, the story would have been different.
appearing without his title) took the chair with much gusto. Professor of
Psychiatric Research at the IoP, Robin seemed not to care who knew his opinion
about the Americans and their DSM5 and talked openly about the changes in
psychiatric and economic power. Murray’s task was to chair a particularly
interesting session, not only because it contained professors from Germany and
Switzerland, but also because it represented a controversy thrown up by the
DSM5: Attenuated Psychosis Syndrome – forming the base of two out of the four
presentations – has been dropped by the DSM5. The presentations were
particularly dense and compacted, as slide upon slide testified to the diligent
work of countless researchers in four different countries. I asked the woman
sitting next to me (who had popped in only for this session, as it was so
controversial) whether the loss of the diagnosis in DSM5 would mean loss of
funding for the unfortunate researchers. No she said, because they are in
Europe. Had they been based in the USA, the story would have been different.
Meanwhile, a Kiwi psychiatrist (ripple of laughter) was
asking: ‘but does the APS have validity’. Murray replied:
asking: ‘but does the APS have validity’. Murray replied:
– ‘Hamburgers exist, but they have no validity’. Much
laughter, and then everyone joined in:
laughter, and then everyone joined in:
– So what should I write in my paperwork?
– Something vague and descriptive.
– So the DSM categories are subjective?
– Of course!
– That’s why you need so many entries in the manual!
– So you can choose the best fit …
– And everyone can get hold of some money!
– [ever so very much laughter].
The final ‘round table’ did what it could to re-present
a solid scientific face to the world, and to rally us back to ‘the cause’. Then
it fell to the local chief, Professor Shitij Kapur, to appeal to the audience
to put it all back together. He invited us to vote on whether the DSM5 would a)
make things worse, b) make things better, or c) make no difference at all. A
little more than half of the audience expressed a wish for (c).
a solid scientific face to the world, and to rally us back to ‘the cause’. Then
it fell to the local chief, Professor Shitij Kapur, to appeal to the audience
to put it all back together. He invited us to vote on whether the DSM5 would a)
make things worse, b) make things better, or c) make no difference at all. A
little more than half of the audience expressed a wish for (c).
Cynicism
Behind the veil of this theatrical vote, we could see
the reconfiguration of new alliances between research and politics taking
shape. The psychiatric profession, in its vast majority, is re-orienting it
research towards the objectively verifiable markers of mental illness,
preferably those that are in the brain. The DSM-5 is already obsolete. The British
psychiatrists present at the IoP openly stated that they only used the DSM to
fill in the required forms, choosing the diagnoses that will allow them to do
what they feel is appropriate in the circumstances. The conference brought a
real cynicism to light: diagnostic classification is used to fill in evaluation
forms, apply for research funding, and publish the peer-reviewed articles
necessary to promotion. During these two days, no one mentioned the question of
treatment, except from the perspective of symptom management.
the reconfiguration of new alliances between research and politics taking
shape. The psychiatric profession, in its vast majority, is re-orienting it
research towards the objectively verifiable markers of mental illness,
preferably those that are in the brain. The DSM-5 is already obsolete. The British
psychiatrists present at the IoP openly stated that they only used the DSM to
fill in the required forms, choosing the diagnoses that will allow them to do
what they feel is appropriate in the circumstances. The conference brought a
real cynicism to light: diagnostic classification is used to fill in evaluation
forms, apply for research funding, and publish the peer-reviewed articles
necessary to promotion. During these two days, no one mentioned the question of
treatment, except from the perspective of symptom management.
Janet Haney and
Véronique Voruz
Véronique Voruz
10 June 2013
[1] De-Medicalizing
Misery: Psychiatry, Psychology and the Human Condition, Rapley M., Moncrieff J. and Dillon J. eds.,
Palgrave Macmillan 2011.
Misery: Psychiatry, Psychology and the Human Condition, Rapley M., Moncrieff J. and Dillon J. eds.,
Palgrave Macmillan 2011.
[2] Crazy like Us: The Globalization of the
American Psyche, Ethan Watters 2011.
[3] Bracken
P. et al “Beyond the Current
Paradigm”, The British Journal of Psychiatry [2012] 201: 430-434, p. 432 pour la citation.
