9 de agosto de 2013

LQ 336 in English - Report on “DSM-5 and the Future of Psychiatric Diagnosis” conference at the Institute of Psychiatry, King’s College London




Report on “DSM-5 and the 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: 

  • 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;

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Sticker 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)!

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.

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. 

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.

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.

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.   

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”.

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…).

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.

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.” 

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A ‘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.

 
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Professor Nikolas Rose, Head of Department of Social 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.

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.

“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.

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).

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.

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.

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.

Meanwhile, a Kiwi psychiatrist (ripple of laughter) was asking: ‘but does the APS have validity’. Murray replied:
- ‘Hamburgers exist, but they have no validity’. Much 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).

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.


Janet Haney and 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.
[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.

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