Mind’s Introlude

dsm5In an old piece for the New Statesman, Nick Cohen anticipated the latest Diagnostic and Statistical Manual of mental illness:

The first edition (DSM-I) was published in 1952. It was a pamphlet which listed a mere 60 disorders. At 134 pages, the 1968 second edition might have been mistaken for a novella. The third, in its revised version of 1987, had 567 pages and was longer than most novels. DSM-IV, the current dictionary of delusion, was published in 1994 and would be easier to handle if it had appeared in two volumes. It has 886 pages and even in paperback weighs 3lb 4oz. DSM-V will be out in 2011. No one is expecting a haiku.

Nick’s critique is a familiar one if you follow mental health – the idea of ‘diagnostic inflation’, that psychiatry has a tendency to medicalise everything and increasingly passes off all kinds of bad or common behaviour as some sort of clinical disorder. As he says, ‘Whether you are happy or sad, neat or messy, chaste or promiscuous, bumptious or withdrawn, fat or thin, drunk or sober, you have the symptoms of a mental disorder.’

Since Nick’s article the backlash against the DSM has grown to the extent that this weekend, the Observer reported that the Division of Clinical Psychology has attacked the concept of psychiatric diagnosis altogether, saying that ‘diagnoses such as schizophrenia, bipolar disorder, personality disorder, attention deficit hyperactivity disorder, conduct disorders and so on [are of] limited reliability and questionable validity’. This raised my eyebrows. I can see why concepts such as ‘disruptive mood dysregulation disorder’ could be called into question, but claiming that a diagnosis of bipolar psychosis is essentially of ‘limited reliability and questionable validity’ is a huge step.

You can see why people want to move away from the medical model. Too many service users have antidepressants thrown at them when talking therapies would be far more helpful. The DCP wants to gear treatment more towards the social factors and bad experiences that influence all of us. Dr Lucy Johnstone said that ‘there is no evidence that these experiences are best understood as illnesses with biological causes. 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.’ Who could argue with that, for practically no one outside of Nietzschean fantasy can be stripped of the influence of the past. Joyce wrote that ‘When the soul of man is born in this country there are nets flung at it to hold it back from flight. You talk to me of nationality, language, religion. I shall try to fly by those nets.’ But he was dreaming. Most of us get caught in the nets at some point.

And yet I feel some scepticism about this somewhat drastic swerve in approach, for many reasons. First is that there are ingrained predispositions towards mental illness. Far sighted neurologists like Steven Pinker have spent years fighting the simple lie that we are an empty canvass and nothing else. His argument is to accept that to some extent we do have destiny coded into our skin and we have to deal with that as best we can. There is a fascinating recent piece by the neurocriminologist Adrian Raine about how brain development can affect a predisposition to criminal acts. The idea of predestination led us into some very scary places during the twentieth century. However the work of serious researchers like Raine can’t be as easily dismissed as quack phrenology.

A completely social model of mental illness also has little to say to people with normal backgrounds who nevertheless develop terrifying distress and chaotic lives. They can be all too casually derided as attention seekers. Nothing in my stable childhood explains the anxiety and depression I developed as an adult. Nor would a social model provide much insight into the lives of high born people I have known who went completely off the rails.

There is also kookiness in this view of life. Ladies and gentlemen, I give you Oliver James, celebrity psychologist and author of the bestselling Affluenza, which proved that mental illness was caused by godless Western materialism. Post crash, he’s still plugging that thesis, claiming again that ‘Thirty years of Thatcher and ‘Blatcher’ turned us into a nation of ‘affluenza’-stricken, shop-till-you-drop, ‘it could be you’, credit-fuelled consumer junkies.’ The lost souls in the crisis centres of working class neighbourhoods are not distinguished by an excess of designer shopping trips and cheap easy credit. James’s theories are regarding as liberal in a liberal age, but they are animated by an old conservative-religious impulse that a shot of austerity sharpens the soul.

More useful is the response from Simon Wessely of the Royal College of Psychiatrists, who writes that while the DSM isn’t perfect, it at least tries to map the territory and many service users find diagnosis the first step to recovery or at least management. (As Terry Pratchett said of Alzheimer’s, to kill the demon you first have to speak its name.) The truth is that saying ‘it’s all society’ is as reductive as saying ‘it’s all chemicals’ – surely the key is in understanding how external influences impact on whatever predispositions we might have. That’s our best shot at fighting the nightmares that may engulf all of us. This is where science becomes an art.

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2 Responses to “Mind’s Introlude”

  1. Chrissie Says:

    It’s nice to read balanced view of this. So many people seem to take violently to one side or other other – something which is getting more common all over, sadly.

  2. pocketapocketaqueep Says:

    Richard Bentall in his Madness Explained gave what I found to be the most convincing analysis of what I think he called the post-Kraepelin consensus, that is, that symptoms cluster into so many concrete, fixed, biological units, which can be studied and systematised. He argued for a symptom-led approach. Despite the many potential advantages of his system, and the wisdom of his book as a whole, I’m not entirely sold on this. For one thing, I have worked in the field of mental health, specifically young adults with behavioural disorders, and I saw hundreds of kids with those very clusters of symptoms: each was an individual, each ‘presented’ differently, yes, but in the case of at least two of those diagnoses which I found consistently to be the most predictive, they had a great deal in common.

    I have always worried about the DSM, though. Research has been led in the field by psychopharmacologists for years, and it is, I believe, these same people who sit on the board of the DSM advising on new diagnoses, the diagnostic criteria which inform them and so forth. To me, there is a huge conflict of interests here. A new disorder is a new market.

    That such forces are at work is underscored for me by the fact that one of the diagnoses dropped from the DSM V, Asperger’s syndrome, is both one of those known to be least amenable to drug treatment, and also, as millions of parents, support workers, and ‘aspies’ know, it is one of those diagnoses most consistently supported by evidence, the symptoms clustered much the same in individual after individual in a statistically predictable ratio of perhaps every population group known to science.

    Instead, the DSM V has a number of those disorders which, quite unlike schizophrenia, unlike depression unipolar and bipolar, unlike attention deficit disorder, read like the bullet points from some kind of screenwriting course brainstorming session.

    I once read up on Oppositional Defiant Disorder when one of my students, a swaggering streetwise type with always a clever word to say and a way of charming anybody he came upon, was diagnosed with the condition. I am not sure I was any the wiser.

    I’m not saying that he didn’t have problems, but that I’m not sure the diagnosis was a fit for his problems. You could make it fit. I’ve had exes who have made their horoscope fit every day of their lives and will continue to do so. If challenged, they would give lengthy reasonings and it would sound pretty convincing, but I wouldn’t have professionals do the same with the DSM. I’ve seen the professionals at work. I’ve seen them get confused over the simplest, most clear cut diagnoses there are.

    So, what I’m perhaps saying is that we should take depression, unipolar and bipolar, as a benchmark. Anybody who feels that a certain number of symptoms do not tend to cluster together involving low mood, suicidal ideation, inability to imagine anything positive in the future, or in oneself etc etc., has not lived very much or made many insights into the people around them.

    When we don’t have such strong, regularly observed and reinforced evidence to go on, then we leave the territory of diagnostic criteria and enter a area where case studies are valuable.

    I don’t know. There is a long way to go before it will be possible to discuss mental health in a sensible manner without somebody dismissing it or writing off those of us who have suffered one thing or another. I am on the autistic spectrum for sure. I have attention deficit disorder, and I suffer periodically from depression. I think I know how to deal with all of these things pretty well, but I’ve dealt with psychiatrists and read x number of case histories and feel strongly that the coherence of these disorders varies considerably and that the manner in which some of them are nominated bears no relation whatever to the years of accumulated data and case studies which led to the criteria which define depression. This concerns me.

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