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

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Mister Lizard is not at home to bailiffs – he is eating salmon pâté by the river

Why is it that when people answer the question “What’s the worst thing anyone’s ever said to you?” in the Guardian questionnaire they never say, “You’ve been served”?

Summer’s nearly over. I look at the angle of the sunlight as it strikes the back terrace of the Hovel. I have been here long enough to use the terrace as a gnomon marking the passage of the year. I need, like the protagonists of Withnail and I, to go to the countryside to rejuvenate.

Last week when the Perseids were meant to be in full flow I asked frantically on a social medium for people to chum me along on a midnight walk on Hampstead Heath. In the end my new friends A— and her husband, C—, together with his new friend (whose initial I have forgotten, but he is Australian, if that helps), stepped up to the plate and after a couple at the Flask we went on a wide-ranging tour, which was a bust as far as seeing meteors – or my favourite tree – went, but was still hugely enjoyable. At about 2 am they packed me into an Uber and I went home happy, but I still felt as if I could do with more countryside.

The next few days made me even more anxious to get out of London. There are ominous signs that some serious roadworks are going to be taking place outside my bedroom window any day now. A bailiff came and rang the doorbell and I didn’t have the heart, or the nerve, to say that Nicholas Lezard was not at home at the moment and, is, in fact, on a walking tour of Patagonia now I come to think of it, due back some time next year. I just took the piece of paper into my hands as if it were a chicken come home to roost.

The previous day, presumably the same bailiff had come round and asked if Mr Lizard was in, and my housemate gallantly – and quite truthfully – said “no”. (Why is it that when people answer the question “What’s the worst thing anyone’s ever said to you?” in the Guardian questionnaire they never say, “You’ve been served”? Maybe it’s because they haven’t ever been.) In addition, as I said last week, the cleaning lady is on holiday and the Hovel is starting to look distinctly seedy.

So, then I get a call from a person who once featured quite prominently in this column, some time ago. This person is bored and wants me to go to his or her town and alleviate his or her boredom. This person and I parted company in circumstances that were far from ideal some time ago, and only recently have diplomatic relations been resumed.

It is too late, I say, for me to get on the train now; but when I have reviewed the book I am meant to be reviewing, I will hop on the train tomorrow around noon. And so I do, despite some monkey business from the departures board at King’s Cross, which tells passengers the 12:44 has been cancelled, then hasn’t been, then has, then hasn’t after all, while the 12:14 has slipped away like a thief in the night without telling anyone it was doing so.

I wonder if my return to the town of ——— is wise. As a dog returneth to its vomit, so doth a fool return to his folly. And the burnt hand fears the fire. Look, I say to myself, all we’re doing is going to have a picnic by the river. As we buy our supplies, the stallholder at the market asks if I am my companion’s husband. “No, he’s my picnic buddy,” he or she replies. “Never heard it called that before,” says the stallholder.

And the day passes perfectly pleasantly. We have two bottles of wine, cheese and smoked salmon pâté with crusty bread. People in punts drift past us, with varying degrees of competence. I remember it is A-level results day and call the eldest boy to ask how he’s done. He’s done well enough, it turns out, to get a place at university, though he feels obliged to point out that his results came in exactly a year ago. This is the kind of thing that happens when the number of children you have exceeds your mental bandwidth.

Later on, a porter from the college behind which we are picnicking asks me if I am a member, or an alumni. “Alumnus,” I correct him gently, hoping that this should establish my credentials. He asks for my name, and he radios the porters’ lodge to check my veracity. For some reason it takes him several goes to get my name right.

One of these goes is “Lizard”. We offer him some cheese, but he refuses, on the grounds that he has just had a banana and a cup of tea. I could live in a guest room here, I reflect, at not much higher rent than one pays in London. And the beauty of it is that the police, and presumably bailiffs, have to ask permission to go through the gates. 

Nicholas Lezard is a literary critic for the Guardian and also writes for the Independent. He writes the Down and Out in London column for the New Statesman.

This article first appeared in the 25 August 2016 issue of the New Statesman, Cameron: the legacy of a loser