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

Photo: Getty Images
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The future of policing is still at risk even after George Osborne's U-Turn

The police have avoided the worst, but crime is changing and they cannot stand still. 

We will have to wait for the unofficial briefings and the ministerial memoirs to understand what role the tragic events in Paris had on the Chancellor’s decision to sustain the police budget in cash terms and increase it overall by the end of the parliament.  Higher projected tax revenues gave the Chancellor a surprising degree of fiscal flexibility, but the atrocities in Paris certainly pushed questions of policing and security to the top of the political agenda. For a police service expecting anything from a 20 to a 30 per cent cut in funding, fears reinforced by the apparent hard line the Chancellor took over the weekend, this reprieve is an almighty relief.  

So, what was announced?  The overall police budget will be protected in real terms (£900 million more in cash terms) up to 2019/20 with the following important caveats.  First, central government grant to forces will be reduced in cash terms by 2019/20, but forces will be able to bid into a new transformation fund designed to finance moves such as greater collaboration between forces.  In other words there is a cash frozen budget (given important assumptions about council tax) eaten away by inflation and therefore requiring further efficiencies and service redesign.

Second, the flat cash budget for forces assumes increases in the police element of the council tax. Here, there is an interesting new flexibility for Police and Crime Commissioners.  One interpretation is that instead of precept increases being capped at 2%, they will be capped at £12 million, although we need further detail to be certain.  This may mean that forces which currently raise relatively small cash amounts from their precept will be able to raise considerably more if Police and Crime Commissioners have the courage to put up taxes.  

With those caveats, however, this is clearly a much better deal for policing than most commentators (myself included) predicted.  There will be less pressure to reduce officer numbers. Neighbourhood policing, previously under real threat, is likely to remain an important component of the policing model in England and Wales.  This is good news.

However, the police service should not use this financial reprieve as an excuse to duck important reforms.  The reforms that the police have already planned should continue, with any savings reinvested in an improved and more effective service.

It would be a retrograde step for candidates in the 2016 PCC elections to start pledging (as I am certain many will) to ‘protect officer numbers’.  We still need to rebalance the police workforce.   We need more staff with the kind of digital skills required to tackle cybercrime.  We need more crime analysts to help deploy police resources more effectively.  Blanket commitments to maintain officer numbers will get in the way of important reforms.

The argument for inter-force collaboration and, indeed, force mergers does not go away. The new top sliced transformation fund is designed in part to facilitate collaboration, but the fact remains that a 43 force structure no longer makes sense in operational or financial terms.

The police still have to adapt to a changing world. Falling levels of traditional crime and the explosion in online crime, particularly fraud and hacking, means we need an entirely different kind of police service.  Many of the pressures the police experience from non-crime demand will not go away. Big cuts to local government funding and the wider criminal justice system mean we need to reorganise the public service frontline to deal with problems such as high reoffending rates, child safeguarding and rising levels of mental illness.

Before yesterday I thought policing faced an existential moment and I stand by that. While the service has now secured significant financial breathing space, it still needs to adapt to an increasingly complex world. 

Rick Muir is director of the Police Foundation