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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Don't blame Brexit on working-class anger - it's more worrying than that

White voters who identified as "English not British" backed Brexit.

For those of us who believe that the referendum result in favour of Brexit is an unmitigated disaster, the nominations for culprits are open. Former Liberal Democrat leader Nick Clegg made a compelling argument in the Financial Times that the blame lies squarely with Cameron and Osborne.

Clegg, who has first-hand experience of Tory duplicity, is scarcely a neutral observer. But that does not make him wrong. No doubt the PM and the Chancellor are the proximate cause, and should be held accountable by their parliamentary constituents, their party, and by the country as a whole - or what’s left of it if Scotland goes its own way.

Yet journalists and historians alike would do well to probe deeper causes of the referendum result. One obvious culprit is the British press, who, at best, failed to scrutinise the Leave Campaign’s claims and at worst actively abetted them. The New York Times has suggested that using the EU as a punching bag has helped sell papers (or at least generate clicks) in what is probably the most challenging climate for traditional journalism in two centuries.  Boris Johnson, it seems, is irresistible clickbait for the fourth estate. And as Nick Cohen has observed on Saturday, Johnson and Gove, both politician-journalists, have elevated mendacity in politics from an occasional vice to a lifestyle choice.

The search for deeper causes of the Brexit vote, however, cannot end with the press. A different electorate could have taken a different view, as they did in Scotland, which voted 2-1 to Remain.  What was the magic sauce?

Too many commentators, especially those on the Left, have blamed working-class anger. It’s all about social class, apparently. Lisa Mckenzie nearly predicted the result on that basis. Others use it simply to criticise Tory austerity politics. Blaming class can be woven into another favourite narrative - this is about lack of educational attainment. Anyone who has lived in Britain for any period of time knows the class system, the town-and-country divide, and intergenerational wealth disparities as important features of British life. 

Another favourite culprit is racism, as the Washington Post wondered on SaturdayOthers had the same thought, and racist attacks are on the rise. Given Nigel Farage’s antics in the weeks before the election, none of this is surprising. Amidst such scary stuff, many have tried to emphasise that most Brexit voters are not racist, but rather disillusioned with the rule of metropolitan elites. Douglas Carswell is one proponent of this argument, but he’s not alone. The Economist, in an effort to avoid talking about race, asserts that this result was about age, region and class.

Still, this kind of analysis is at best naïve and at worst disingenuous. 

As Lord Ashcroft’s polls suggest, it is only the white working class (if by this we mean C2/DE, though many in DE are unemployed) who voted for Brexit. In fact, those describing themselves as "in employment" generally voted to Remain. Those describing themselves as Asian, black or Muslims overwhelmingly voted Remain. By contrast, nearly six in ten white Protestants voted to leave. 

Brexit was a rejection of British multiculturalism. That is the real take-home message of the Ashcroft polls. Of those who see themselves as "English not British", 80 per cent voted to Leave, irrespective of social class. Those who see themselves as "British not English" voted 60 per cent for Remain. Similar patterns (and similar press involvement) can be found in the Quebec referendum of 1995, which failed by a narrower margin than Brexit succeeded.

Of non-Francophone voters in Quebec, 95 per cent voted to remain in Canada. Those who voted to leave, on the other hand, were rejecting Canadian multiculturalism. Quebecois separatism was seen as part of a struggle for cultural survival.  

Whether or not you call those attitudes racist, the advent of white English (and Welsh) nationalism is, for those of us who have taught modern European history, the truly ominous consequence of Brexit. Do not be fooled by the alternatives.

Dr D’Maris Coffman is a Senior Lecturer in Economics of the Built Environment at UCL Bartlett. Before coming to UCL in 2014, she was a Fellow and Director of Studies in History at Newnham College and a holder of a Leverhulme Early Career Fellowship in the Cambridge History Faculty.