The subjective nature of psychiatric diagnosis

Medicalising natural and normal responses to life experiences is a dangerous game.

This may be the year that makes you mad. A new psychiatrist’s bible will be published in May and already it’s mired in controversy. Many see it as a pretext for scandalous over-diagnosis and drug-pushing.

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, has enormous influence in shaping the way mental health research is carried out worldwide. It was first published in 1952 and the most recent edition appeared in 2000. It has taken over 12 years to agree on the contents of the fifth edition, DSM5.

One problem that people have with DSM5is that it will be oldfashioned: it will make no attempt to link behaviour or feelings to what is known about the physical states of the brain, in an era when neuroscience has made enormous advances in relating physiological issues with behavioural issues.

Take grief. Functional magnetic resonance imaging (fMRI) studies show that grieving people have higher activity in various regions of the brain, including the cerebellum and the posterior brainstem. We’ve all seen the results of this in ourselves or others: low mood, low motivation, loss of appetite.

Here’s the next problem: DSM5 will make it easier to medicalise natural human experience. After the new manual is published, psychiatrists will be able to diagnose people who have had two continuous weeks of this as suffering from depression, even if they are recently bereaved. What was normal behaviour last year will become a medical crisis.

The British Psychological Society and the American Psychological Association are among the mental health organisations that have raised concerns about such moves. Medicalising natural and normal responses to life experiences is a dangerous game. So far, more than 14,000 people have signed an open letter to the team drafting DSM5, expressing concern about some of the proposed changes “that have no basis in the scientific literature”. The letter argues that the changes “pose substantial risks to patients/clients, practitioners and the mental health professions in general”.

The pharma says

Particularly vulnerable, they argue, are children and the elderly. That’s because they are most at risk of having pharmaceutical solutions – many of which can have severe adverse side effects – foisted on them. And there’ll be more people and more conditions for which to prescribe drugs. DSM5 will lower the threshold of what it takes to get diagnosed with a disorder and will offer some new disorders, such as “disruptive mood dysregulation disorder”, a diagnosis for children who exhibit temper tantrums and get upset out of proportion to a situation.

Each positive diagnosis will be a candidate for drug treatment, which makes it particularly worrying that a study published in March last year identified strong ties between the pharmaceutical industry and those drafting DSM5.

The subjective nature of the psychiatric diagnosis has always been a problem. Freud knew this but his 1895 attempt at a “project for a scientific psychology” failed miserably. Back then, science had told us very little about the physiology and function of the brain. In 2013, it has revealed a lot more but there are still far too many gaps to claim that subjective analysis is redundant. Neuroscience is advancing fast; let’s hope we won’t need DSM6.

Michael Brooks’s “The Secret Anarchy of Science” is published by Profile Books (£8.99)

The new psychiatrist's bible is seen by many as a pretext for drug-pushing. Photograph: Getty Images

Michael Brooks holds a PhD in quantum physics. He writes a weekly science column for the New Statesman, and his most recent book is At the Edge of Uncertainty: 11 Discoveries Taking Science by Surprise.

This article first appeared in the 07 January 2013 issue of the New Statesman, 2013: the year the cuts finally bite

Getty
Show Hide image

In defence of orientalism, the case against Twenty20, and why Ken should watch Son of Saul

My week, from Age Concern to anti-semitism.

Returning late from a party I never much wanted to go to, I leap up and down in the middle of the Harrow Road in the hope of flagging down a taxi, but the drivers don’t notice me. Either they’re haring down the fast lane or they’re too preoccupied cursing Uber to one another on their mobile phones. My father drove a black cab, so I have a deep loyalty to them. But there’s nothing like being left stranded in NW10 in the dead of night to make one reconsider one’s options. I just wish Uber wasn’t called Uber.

Just not cricket

Tired and irritable, I spend the next day watching sport on television – snooker, darts, cricket, anything I can find. But I won’t be following the Indian Premier League’s Twenty20 cricket again. It’s greedy, cynical, over-sponsored and naff. Whenever somebody hits a boundary, cheerleaders in cast-off gym kit previously worn by fourth-form Roedean girls wave tinsel mops.

Matches go to the final over where they’re decided in a thrashathon of sixes hit by mercenaries wielding bats as wide as shovels. Why, in that case, don’t both teams just play a final over each and dispense with the previous 19? I can’t wait for the elegant ennui of a five-day Test match.

Stop! Culture police!

I go to the Delacroix exhibition at the National Gallery to shake off the sensation of all-consuming kitsch. Immediately I realise I have always confused Delacroix with someone else but I can’t decide who. Maybe Jacques-Louis David. The show convincingly argues that Delacroix influenced every artist who came after him except Jeff Koons, who in that case must have been influenced by David. It’s turbulent, moody work, some of the best of it, again to my surprise, being religious painting with the religion taken out. Christ’s followers lamenting his death don’t appear to be expecting miracles. This is a man they loved, cruelly executed. The colours are the colours of insupportable grief.

I love the show but wish the curators hadn’t felt they must apologise for Delacroix finding the North Africans he painted “exotic”. Cultural studies jargon screams from the wall. You can hear the lecturer inveighing against the “appropriating colonial gaze” – John Berger and Edward Said taking all the fun out of marvelling at what’s foreign and desirable. I find myself wondering where they’d stand on the Roedean cheer-leaders of Mumbai.

Taking leave of the senses

My wife drags me to a play at Age Concern’s headquarters in Bloomsbury. When I see where she’s taking me I wonder if she plans to leave me there. The play is called Don’t Leave Me Now and is written by Brian Daniels. It is, to keep it simple, about the effects of dementia on the families and lovers of sufferers. I am not, in all honesty, expecting a good time. It is a reading only, the actors sitting in a long line like a board of examiners, and the audience hunched forward in the attitude of the professionally caring.  My wife is a therapist so this is her world.

Here, unlike in my study, an educated empathy prevails and no one is furious. I fear that art is going to get lost in good intention. But the play turns out to be subtly powerful, sympathetic and sharp, sad and funny; and hearing it read engages me as seeing it performed might not have done. Spared the spectacle of actors throwing their bodies around and singing about their dreams against a backdrop painted by a lesser, Les Mis version of Delacroix, you can concentrate on the words. And where dementia is the villain, words are priceless.

Mixing with the proles

In Bloomsbury again the next day for a bank holiday design and craft fair at Mary Ward House. I have a soft spot for craft fairs, having helped run a craft shop once, and I feel a kinship with the designers sitting bored behind their stalls, answering inane questions about kilns and receiving empty compliments. But it’s the venue that steals the show, a lovely Arts and Crafts house, founded in the 1890s by the novelist Mary Ward with the intention of enabling the wealthy and educated to live among the poor and introduce them to the consolations of beauty and knowledge. We’d call that patronising. We’re wrong. It’s a high ideal, to ease the burden of poverty and ignorance and, in Ward’s words, save us from “the darker, coarser temptations of our human road”.

An Oscar-winning argument for Zionism

Speaking of which, I am unable to empty my mind of Ken Livingstone and his apologists as I sit in the cinema and watch the just-released Academy Award-winning Son of Saul, a devastating film about one prisoner’s attempt to hold on to a vestige of humanity in a Nazi death camp. If you think you know of hell from Dante or Michelangelo, think again. The inferno bodied forth in Son of Saul is no theological apportioning of justice or deserts. It is the evisceration of meaning, the negation of every grand illusion about itself mankind has ever harboured. There has been a fashion, lately, to invoke Gaza as proof that the Holocaust is a lesson that Jews failed to learn – as though one cruelty drives out another, as though suffering is forfeit, and as though we, the observers, must choose between horrors.

I defy even Livingstone to watch this film, in which the Jews, once gassed, become “pieces” – Stücke – and not grasp the overwhelming case for a Jewish place of refuge. Zionism pre-dated the camps, and its fulfilment, if we can call it that, came too late for those millions reduced to the grey powder mountains the Sonderkommandos were tasked with sweeping away. It diminishes one’s sympathy for the Palestinian cause not a jot to recognise the arguments, in a world of dehumanising hate, for Zionism. Indeed, not to recognise those arguments is to embrace the moral insentience whose murderous consequence Son of Saul confronts with numbed horror. 

This article first appeared in the 05 May 2016 issue of the New Statesman, The longest hatred