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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We argue over Charlie Gard, but forget those spending whole lives caring for a disabled child

The everyday misery of care work is hidden behind abstract arguments over life and death.

“Sometimes,” says the mother, “I wish we’d let him go. Or that he’d just been allowed to slip away.” The father agrees, sometimes. So too does the child, who is not a child any more.

On good days, nobody thinks this way, but not all days are good. There have been bright spots during the course of the past four decades, occasional moments of real hope, but now everyone is tired, everyone is old and the mundane work of loving takes a ferocious toll.

When we talk about caring for sick children, we usually mean minors. It’s easiest that way. That for some parents, the exhaustion and intensity of those first days with a newborn never, ever ends – that you can be in your fifties, sixties, seventies, caring for a child in their twenties, thirties, forties – is not something the rest of us want to think about.

It’s hard to romanticise devotion strung out over that many hopeless, sleepless nights. Better to imagine the tragic mother holding on to the infant who still fits in her loving arms, not the son who’s now twice her size, himself edging towards middle-age and the cliff edge that comes when mummy’s no longer around.

Writing on the tragic case of Charlie Gard, the Guardian’s Giles Fraser claims that he would “rain fire on the whole world to hold my child for a day longer”. The Gard case, he argues, has “set the cool rational compassion of judicial judgement and clinical expertise against the passion of parental love”: “Which is why those who have never smelled the specific perfume of Charlie’s neck, those who have never held him tight or wept and prayed over his welfare, are deemed better placed to determine how he is to live and die.”

This may be true. It may also be true that right now, countless parents who have smelled their own child’s specific perfume, held them tightly, wept for them, loved them beyond all measure, are wishing only for that child’s suffering to end. What of their love? What of their reluctance to set the world aflame for one day more? And what of their need for a life of their own, away from the fantasies of those who’ll passionately defend a parent’s right to keep their child alive but won’t be there at 5am, night after night, cleaning out feeding tubes and mopping up shit?

Parental – in particular, maternal – devotion is seen as an endlessly renewable resource. A real parent never gets tired of loving. A real parent never wonders whether actually, all things considered, it might have caused less suffering for a child never to have been born at all. Such thoughts are impermissible, not least because they’re dangerous. Everyone’s life matters. Nonetheless, there are parents who have these thoughts, not because they don’t love their children, but because they do.

Reporting on the Gard case reminds me of the sanitised image we have of what constitutes the life of a parent of a sick child. It’s impossible not to feel enormous compassion for Charlie’s parents. As the mother of a toddler, I know that in a similar situation I’d have been torn apart. It’s not difficult to look at photos of Charlie and imagine one’s own child in his place. All babies are small and helpless; all babies cry out to be held.

But attitudes change as children get older. In the case of my own family, I noticed a real dropping away of support for my parents and disabled brother as the latter moved into adulthood. There were people who briefly picked him up as a kind of project and then, upon realising that there would be no schmaltzy ending to the story, dropped him again. Love and compassion don’t conquer all, patience runs out and dignity is clearly best respected from a distance.

All too often, the everyday misery of care work is hidden behind abstract arguments over who gets the right to decide whether an individual lives or dies. I don’t know any parents who truly want that right. Not only would it be morally untenable, it’s also a misrepresentation of what their struggles really are and mean.

What many parents who remain lifelong carers need is adequate respite support, a space in which to talk honestly, and the recognition that actually, sometimes loving is a grim and hopeless pursuit. Those who romanticise parental love – who, like Fraser, wallow in heroic portrayals of “battling, devoted parents” – do nothing to alleviate the suffering of those whose love mingles with resentment, exhaustion and sheer loneliness.

There are parents out there who, just occasionally, would be willing to set the world on fire to have a day’s respite from loving. But regardless of whether your child lives or dies, love never ends. 

Glosswitch is a feminist mother of three who works in publishing.