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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Leader: The unresolved Eurozone crisis

The continent that once aspired to be a rival superpower to the US is now a byword for decline, and ethnic nationalism and right-wing populism are thriving.

The eurozone crisis was never resolved. It was merely conveniently forgotten. The vote for Brexit, the terrible war in Syria and Donald Trump’s election as US president all distracted from the single currency’s woes. Yet its contradictions endure, a permanent threat to continental European stability and the future cohesion of the European Union.

The resignation of the Italian prime minister Matteo Renzi, following defeat in a constitutional referendum on 4 December, was the moment at which some believed that Europe would be overwhelmed. Among the champions of the No campaign were the anti-euro Five Star Movement (which has led in some recent opinion polls) and the separatist Lega Nord. Opponents of the EU, such as Nigel Farage, hailed the result as a rejection of the single currency.

An Italian exit, if not unthinkable, is far from inevitable, however. The No campaign comprised not only Eurosceptics but pro-Europeans such as the former prime minister Mario Monti and members of Mr Renzi’s liberal-centrist Democratic Party. Few voters treated the referendum as a judgement on the monetary union.

To achieve withdrawal from the euro, the populist Five Star Movement would need first to form a government (no easy task under Italy’s complex multiparty system), then amend the constitution to allow a public vote on Italy’s membership of the currency. Opinion polls continue to show a majority opposed to the return of the lira.

But Europe faces far more immediate dangers. Italy’s fragile banking system has been imperilled by the referendum result and the accompanying fall in investor confidence. In the absence of state aid, the Banca Monte dei Paschi di Siena, the world’s oldest bank, could soon face ruin. Italy’s national debt stands at 132 per cent of GDP, severely limiting its firepower, and its financial sector has amassed $360bn of bad loans. The risk is of a new financial crisis that spreads across the eurozone.

EU leaders’ record to date does not encourage optimism. Seven years after the Greek crisis began, the German government is continuing to advocate the failed path of austerity. On 4 December, Germany’s finance minister, Wolfgang Schäuble, declared that Greece must choose between unpopular “structural reforms” (a euphemism for austerity) or withdrawal from the euro. He insisted that debt relief “would not help” the immiserated country.

Yet the argument that austerity is unsustainable is now heard far beyond the Syriza government. The International Monetary Fund is among those that have demanded “unconditional” debt relief. Under the current bailout terms, Greece’s interest payments on its debt (roughly €330bn) will continually rise, consuming 60 per cent of its budget by 2060. The IMF has rightly proposed an extended repayment period and a fixed interest rate of 1.5 per cent. Faced with German intransigence, it is refusing to provide further funding.

Ever since the European Central Bank president, Mario Draghi, declared in 2012 that he was prepared to do “whatever it takes” to preserve the single currency, EU member states have relied on monetary policy to contain the crisis. This complacent approach could unravel. From the euro’s inception, economists have warned of the dangers of a monetary union that is unmatched by fiscal and political union. The UK, partly for these reasons, wisely rejected membership, but other states have been condemned to stagnation. As Felix Martin writes on page 15, “Italy today is worse off than it was not just in 2007, but in 1997. National output per head has stagnated for 20 years – an astonishing . . . statistic.”

Germany’s refusal to support demand (having benefited from a fixed exchange rate) undermined the principles of European solidarity and shared prosperity. German unemployment has fallen to 4.1 per cent, the lowest level since 1981, but joblessness is at 23.4 per cent in Greece, 19 per cent in Spain and 11.6 per cent in Italy. The youngest have suffered most. Youth unemployment is 46.5 per cent in Greece, 42.6 per cent in Spain and 36.4 per cent in Italy. No social model should tolerate such waste.

“If the euro fails, then Europe fails,” the German chancellor, Angela Merkel, has often asserted. Yet it does not follow that Europe will succeed if the euro survives. The continent that once aspired to be a rival superpower to the US is now a byword for decline, and ethnic nationalism and right-wing populism are thriving. In these circumstances, the surprise has been not voters’ intemperance, but their patience.

This article first appeared in the 08 December 2016 issue of the New Statesman, Brexit to Trump