The Diagnostic and Statistical Manual

The Diagnostic and Statistical Manual: A history of critiques of psychiatric classification systems Craig Newnes Critiquing psychiatry’s Diagnostic and Statistical Manual (DSM) can be viewed as both a thankless and impossible task In constructing psychiatry’s bible numberless professionals have debated and promoted the classification and aetiology of madness espousing, along the way, contradictory and complicated systems of nosology and cause – as if they could somehow step outside their necessarily limited perspective on human conduct and take a detached view Deconstruction is no different; attempting to summarize the myriad influences on why certain schemes (e.g., diagnosis) prosper and others fail is likely to provoke suspicions of hubris This chapter addresses two particular (possibly hubris-defying) questions in relation to the latest DSM; are the objections so different from previous attempts to derail psychiatric nosologies and will these objections make more than a cosmetic difference? Classifying conduct This section examines some of the history of attempts to classify human behaviour as different types of madness and explores the historical consistency of critiquing these attempts Before the nineteenth century, though rich in detail, references to insanity were made in molar (all or none) terms Behavioural criteria (signs) had been the basis for melancholia, mania and dementia, subjective experience barely figuring The establishment of a truly Descriptive Psychopathology took around a hundred years, from the 1820s to the First World War.1 Plato and Aristotle had regarded reason as the defining human characteristic, a characteristic vulnerable to the perturbations of the passions Madness could be easily detected through observation, mental states only being occasionally referred to According to Berrios,2 it wasn’t until the 1830s that books on insanity came to include clinical vignettes and reports of subjective experience, so called “elementary” symptoms (p17) He goes on to note the “marked difference” over a period of barely fifty years between the work of Haslam, Rush and Pinel and that of Esquirol, Morel and Tuke There were few diagnostic groupings prior to the 1830s; melancholia, mania, phrenitis, delirium, paranoia, lethargy, carus and dementia were the main ones As new nosologies appeared so did new categories; others, like carus and phrenitis, disappeared The mid-nineteenth century is rich ground for historians attempting to chart the bewildering variation in psychiatric nomenclature In Germany first Krafft-Ebing in 1867 and then Westphal used a technical term – Zwangsvorstellung – to refer to irresistible thoughts (obsessions in modern parlance) In France, Falret in 1866 had already used the term obsession and Morel had written on emotion as contributing to obsessional aetiology Later Luys brought subjective experience to the fore by defining obsessions as private, individual events By the end of the century Esquirol, Ball, Magnan, Kahlbaum, Kraepelin and Maudsley were merely some of the more renowned nosologists to have produced extensive and competing classifications of psychiatric morbidity In 1906 the Joint College of the Royal College of Physicians of London drew up the fourth edition of the Nomenclature of Diseases, forerunner to the International Classification of Diseases, now in its tenth edition The publication of yet another classificatory scheme was not universally welcomed: in his Presidential address to the American Medico-Psychological Association Charles Hill the following year observed the only diagnosis omitted was, “the classifying mania of medical authors.”3 Over a hundred years later his wry comment found a sympathetic response in Levy’s proposed category, Pervasive Labelling Disorder.4 The origins of DSM The first official, largely Kraepelinian, classificatory system in the US was produced by the forerunner of the American Psychiatric Association – the American MedicoPsychological Association – in 1918 There were 22 principal groups of mental disorder Two mood disorders – manic-depressive psychosis and involutional melancholia – were listed “Affective Disorders” were introduced by the Standard Veteran’s Administration classification in 1951 The first DSM, produced the following year, was similar to the VA system; “Affective Disorders” became “Affective Reactions” In all, DSM-I described 112 different diagnostic categories The ontogenesis of DSM-I was a more fraught, contested and drawn out process than the simple summary above might imply Grob5 notes that, “classification systems are neither inherently self-evident nor given,” and, “although nosological debates dealing with mental disorders were (and are) phrased in scientific and medical language, they were shaped by…the social origins and ideological, political and moral commitments of psychiatrists; their desire for legitimacy…(and)…the broader social and intellectual currents prevalent…” (p.421).6,7 Nineteenth century psychiatrists and alienists had long believed that mental illness was precipitated by a combination of psychological and environmental factors which might include improper living conditions For many, the innumerable forms of human conduct were barely explicable and impossible to classify Following Esquirol, for example, Ray, in 1838, had divided insanity into idiocy and imbecility for those with congenital defects and a second group where lesions were the probable cause of either mania or dementia In the same volume he explicitly denied that any classification “could be rigorously correct, for such divisions have not been made by nature and cannot be observed in practice.”8 Despite such doubts, by 1885, a group of American psychiatrists under the direction of Clark Bell, President of the New York Medico-legal Society, had followed British counterparts in producing an eight-fold categorization of mental disorder, a slight increase on the seven-fold nosologies of the International Congress of Alienists (1867) and the Association of Medical Superintendents of American Institutions for the Insane (1869) Only a year later Bell found himself rejected by Pliny Earle, a grand figure in US alienism, on approaching him for help with yet another classificatory system Earle’s discouraging response has been echoed by critics to the present day: “…no classification of insanity can be erected on a pathological basis…for…the pathology of the disease is unknown…we are forced to fall back upon the apparent mental condition, as judged from the outward manifestations.” Grob notes that, in the absence of clear indication of organic injury or decay, psychiatrists had no hesitation in looking for environmental factors in insanity; sexual excess, diet, housing, misdirected education, domestic, financial and occupational difficulties were cited in an ever-lengthening list Pre-dating, by over 150 years, the technique of “Problem Formulation” embraced by UK Clinical Psychologists and acknowledging the lack of utility of classificatory systems, Samuel B Woodward, the first President of the Association of Medical Superintendents of American Institutions for the Insane (now the American Psychiatric Association) had already recognized that therapy was, “independent of any nosological system, but, rather had to reflect the unique circumstances presented by each individual case.” In fact, as detailed by Valenstein, 10 an obsession with technologies of intervention led psychiatrists to attempt a host of deadly interventions based on putative theories of organic aetiology rather than an analysis of personal and environmental factors unique to the individual For Smail11 similar, if less physically dangerous, techno-procedures are avidly pursued by clinical psychologists Of the 22 groups in the first Statistical Manual for the Use of Institutions for the Insane twenty represented forms of disorder assumed to have biological foundations These included psychosis with arterial sclerosis, general paralysis, Huntington’s Chorea, and psychoses with brain tumour, cerebral syphilis, pellagra and epilepsy The preference for somatic nosology might be explained by the fact that the overwhelming majority of psychiatrists dealt with hospitalized patients with severe physical impairments Between 1918 and 1942 the Statistical Manual went through ten editions, the tenth making provision for psychoneuroses and behaviour disorders – almost certainly a response to the observation that soldiers could be returned to the battle-field of the Second World War within days of treatment involving little more than rest and companionship, an outcome that common sense suggested could not be achieved if their distress had an organic substrate DSM Between 1948 and its publication in 1952 the APA Committee on Nomenclature and Statistics had circulated for comment a draft DSM-I to numerous organizations and individuals The social, cultural and medico-technological climate post Second World War had been transformed from that immediately after the First World War when the first Statistical Manual for the Use of Institutions for the Insane had appeared Mental disorders were now divided into two main categories; disturbance resulting from impairment of brain function (trauma, alcoholism, multiple sclerosis, etc) and disorders resulting from an inability to adjust The second group was further divided into psychotic and psychoneurotic disorders Post-war, the psychiatric community, influenced by psycho-dynamic theory, moved towards a position whereby mental health and illness were on a continuum and sought to treat more individuals diagnosed as psychoneurotic The Group for the Advancement of Psychiatry went further, urging a preventative psychiatry aimed at social action; including, “a conscious and deliberate wish to change society.”12 Again, there are contemporary echoes here; Psychology, Politics and Resistance and the Community Psychology Section of the British Psychological Society both advocate social change DSM-II was published in 1968 Like Bell, in 1885, its authors turned their sights to the wider community for corroboration and collaboration Influenced by the eighth edition of the International Classification of Diseases (ICD-8), affective reactions became major affective disorders, now including involutional melancholia and listing psychotic depressive reaction separately The overall number of disorders rose to 163 Robert Spitzer, lead author of DSM-III, a volume now containing 265 disorders and published in 1980, has the following to say about how the committee approached the challenge of categorizing mood disorders, “In the absence of such evidence (for etiology [sic] as a classificatory device) categories are grouped together if they share important clinical-descriptive features This includes all of the depressions and manias regardless of severity, chronicity, course, or apparent associations with precipitating stress” 13 (p.75) The reader is referred to Jackson14 for an extensive exploration of theories of the construction and treatment of depression, for example, and its forebear melancholia Jackson charts the history of the diagnosis from humoral postulants of the fifth century BCE to the publication of DSM-III in 1980 He notes numerous attempts by, amongst others, Samuel Johnson, Tuke, Pinel, Esquirol, Morel, Krafft-Ebing, Kraepelin, Meyer, Henry Maudsley and Freud to categorize and delineate forms of distress variously described as melancholia, involutional melancholia, insanity and psychonerosis; “depression” he notes as, “a relative latecomer to the terminology for dejected states.” (p5) In 1725 Blakemore writes of “being depressed into deep Sadness and Melancholy,” while in 1801 David Daniel Davis’s translation of Pinel’s Treatise on Insanity, rendered l’abbattement as “depression of spirits.” Aetiology has been as debated as classification, psychological theorizing being as varied as physiological explanations For Esquirol, for example, season, climate, gender, age, idleness and scholarliness vied with “organic lesions of the lungs” and “displaced colons” as putative causative factors Potential treatments included Moral Medicine (aimed at a sympathetic lifting of the spirits), a clear sky, exercise, attention to diet, baths and coitus By 1980 Spitzer and his colleages, in publishing DSM-III, agreed on a scheme wherein depression was classified as an affective disorder sub-divided into bipolar and major depressions and further into cyclothymic, dysthymic and (again) into atypical bipolar disorders and atypical depressions By the mid 1980s aetiological theories included loss, learned helplessness, separation anxiety, life events, cognitive distortions, genetics, endocrine changes and depletion or excess of neurotransmitters Aidan Kelly claims that some of these changes incorporated into DSM-III were provoked by a ‘crisis’ in psychiatry during the 1970s when a group of critics from within the discipline (e.g., Ronnie Laing and David Cooper, leaders of the anti-psychiatry movement) questioned psychiatry’s standing as the authority on mental health issues.15 Psychiatry’s reaction to its critics was to change how mental illness was talked about by re-incorporating psychological and sociological factors into a bio-psycho-social (BPS) model.16 DSM-III and IV were subsequently written to incorporate more BPS language in their criteria A new feature of DSM-III was its multiaxial orientation, Axis I describing symptombased disorders, Axis II personality disorders The remaining three axes specified medical conditions (an intriguing feature in a nosology supposedly articulating all psychiatric disorders as medical phenomena), severity of stressors and the best level of psychological functioning during the preceding year.17 The all-encompassing nature of the new volume was commented on by Jay Katz, a professor of psychiatry at Yale: “If you look at DSM-III you can classify all of us under one rubric or another of mental disorder.”18 Szasz 19 notes that Katz’s statement was not followed by any comment to the effect that such a position rendered the concept of mental illness meaningless Freud, Marie Jahoda and Karl Menninger were amongst many Psy professionals to already be on record as suggesting that we were all mentally ill at one time or another, to a greater or lesser degree This position enables those frequently critical of the diagnostic endeavour, for example, clinical psychologists, to have their cake and eat it; distress can be normalized or placed on a continuum wherein it is the suffering of the individual (or others, e.g., the family) or the temporary apparent inability to function socially (so called ‘problems in living’) which dictate the need for professional intervention At no point in this enterprise does the professional ask what right he or she has to interfere with a stranger’s distress DSM-IIIR, DSM-IV and DSM IV-TR were published in 1987, 1994 and 2000 respectively The 265 diagnoses in DSM-III duly increased to 292 for DSM-IIIR and 365 for both the later editions Perhaps the profession had finally recovered from the one disorder still not listed – Pervasive Labelling Disorder.20 The debates within and about the various classifications of madness are too numerous to elucidate here From Hellenic dichotomous systems simply differentiating normality from insanity via the more complex systems of Kraepelin and his contemporaries to the recent return to a more descriptive and deceptively detailed nosology surrounding the publication of DSM-5, 21 physicians, mad-doctors, alienists, psychiatrists and psychologists have dissected nomenclature supposedly offering objective descriptions of both the conduct of the insane and reasons for the insanity That their descriptions are based on frequently second hand reports or clinical examples featuring only one diagnosed person seems to have provoked little concern That some of these practitioners and theorists were themselves mad or incarcerated in asylums for the insane has been of interest only to historians Berrios,22 for example, notes the ways in which some nineteenth century French writers lost no credibility for their theories despite being asylum patients at the time; indeed, some modern psychologists have gained credibility by openly declaring their diagnoses and symptomatology Peter Chadwick, a psychologist, for example, has this to say, “Discomforting though it is to admit it, I have been insane…Psychological knowledge is no insurance policy against madness (p5) It was helpful to me to regard myself as having had an illness, by gradual re-employment and by (marriage to) a woman who makes her points (during conflict) only by attacking my behaviour not my character It was very helpful to mix with people who ‘called a spade a spade.’(p6) Sending patients back into exactly the same scenario in which they became ill is, quite simply, a disaster (p8)23, 24 In the UK ex-patient, patient and survivor groups have gained ground in influencing policy Rufus May, a clinical psychologist, is but one example of a professional with a previous psychiatric diagnosis regularly consulted by government in relation to policy and praxis In Europe, the European Network of Users and Survivors of Psychiatry is consulted by the World Health Organization and, on a global scale, the World Network of Users and Survivors employs Human Rights specialists to advocate for the rights of survivors as citizens.25 These “critics from experience” are not new: in 1843 Dorothea Dix – a schoolmistress who had witnessed the mixing of the insane with criminals in Boston jail whilst conducting a Sunday school service – addressed the state legislature in Massachusetts By 1855 she had addressed the general assembly in North Carolina, Congress in Washington, met with Tuke at the York retreat and embarked on a government-backed survey of lunatic asylums in Scotland By then the Alleged Lunatics’ Friends Society had formed in Britain to advocate for more humane treatment of the incarcerated insane Criticizing DSM-5 What follows addresses recent criticisms to the proposed DSM-5 focusing on the official response of the British Psychological Society The proposed publication of DSM-5 engendered numerous criticisms, by the British Psychological Society26, the Australian Psychological Society, and an online petition supported by over fifty mental health associations.27 Critics from within psychiatry included the chair of the DSM-IV taskforce Allen Frances.28 The BPS response was prepared by, amongst others, Professor Peter Kinderman, Chair of the Division of Clinical Psychology (DCP), Susan van Scoyoc, DCP committee member and member of the Division of Heath Psychology (DHP), Dr David Harper, Professor David Pilgrim and Professor Richard Bentall, all members of the DCP, Lucy Johnstone, committee member of the DCP and Dr Amanda C de C Williams, member of both the DCP and the DHP The critical psychiatry background of some of these authors is well established David Pilgrim has post-graduate qualifications and a considerable bibliography in the fields of clinical psychology, psychotherapy and sociology; he has been a foremost critic of the professional ambitions of clinical psychology.29 Lucy Johnstone, ex-director of the Bristol clinical psychology doctorate was one of the first clinical psychologists in the UK to outline, in book form, the abuse inherent in psychiatric practice.30 David Harper, Reader at the University of East London Clinical Psychology Doctoral Programme has repeatedly exposed the solipsistic theorizing around the concept of paranoia31 and Richard Bentall’s work includes two renowned volumes psychologizing madness.32 In a similar vein both Johnstone and Harper are contributing authors to De-medicalizing Misery.33 It is as psychologists that these authors’ expertise is utilized As Smail, however, has noted, it is not possible to separate action from the vested interest of the actor, even, perhaps especially, when that actor is an authorized professional.34 The introduction to the response begins; “The British Psychological Society thanks the American Psychiatric Association (APA) for the opportunity to respond to the DSM-5 Development.” It is unfortunate that UK psychology, as represented by the BPS, “thanks” the APA Thomas Szasz35 would have seen this kind of gesture as one profession supporting – despite certain reservations – a system used to rob citizens of agency through designation of illness, a position mirrored in the work of Peter Breggin;36 both psychiatrists, the work of Szasz and Breggin remains something of a rearguard attempt to undermine the psychiatric project.37 Jeffrey Masson, ex director of the Freud Archive, goes further in his comparison of psychiatric practice with rape; rape is not something society should try to refine but something which is already illegal, a fate he sees as psychiatry’s just desserts 38 Wolfensberger’s concept of “death-making” can equally be used to suggest that psychiatric praxis is designed to kill body, spirit or both and should be banned.39 An alternative statement from an organization apparently standing for individual agency and the application of genuine scientific endeavour might read, “The British Psychological Society rejects all nosologies of human conduct as un-scientific and, in the case of DSM-5, yet another technological praxis which will only further the interests of psychiatric practitioners, the pharmacological industry and state control.” Such a statement would betray the very raison d’être of the discipline, a discipline which continues to profit from statistically-driven notions of abnormality Equally, such a statement would jeopardize the Society’s position as a politically neutral “Learned Body” 10 The paragraph ends, “ the continuum with normality is ignored people who describe normal forms of distress like feeling bereaved after three months, or traumatised by military conflict for more than a month, will meet diagnostic criteria.” Here, the authors of the response make a knowledge claim concerning “normality.” Foucault57 has argued, it is the discourse of “normality” which frames the Psy project – in effect, the powers that be delineate “normality” by defining “abnormality.” For these authors then, it would be within the “norm” to feel “bereaved after three months.” But, if human beings are, indeed, “individuals” then what is “normal” for one person will be unfamiliar or uncomfortable for another and, as we have seen, suffering is now one legitimized way into human service agencies – both personal suffering and suffering experienced by those around the individual Hence, though on some professionally determined continuum of normal conduct grief of, say, five years might be seen as “pathological” it is only when the individual expresses that grief in socially unwanted ways or complains of being too unhappy to function as she did before the bereavement that these norms are brought into action It is power rather than distress which renders the individual subject to a professional gaze wherein “norms” have purchase.58 The response goes on to give what, a first sight, is a detailed critique of the various diagnostic categories incorporated into DSM-5 Closer examination, however, reveals two paragraphs repeated in the majority of comments on particular diagnoses These are, “As stated in our general comments, we are concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which not reflect illnesses so much as normal individual variation,” and, “We believe that classifying these problems as ‘illnesses’ misses the relational context of problems and the undeniable social causation of many such problems For psychologists, our well-being and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives.” 19 For these authors, medical diagnosis, as part of the medicalization of madness project, “negatively effects” the public One advantage of receiving a diagnosis in the UK, however, is the entitlement to Disability Living Allowance and other state financial benefits For some, a diagnosis is a person’s “get out of jail free card.” 59 As previously noted, it is undeniably the case that the iatrogenic effects of receiving medication or psychological intervention based on psychiatric diagnoses are undesirable for the individuals concerned The last part of the first sentence, however, defies an analysis of meaning: “… natural and normal responses to their experiences; responses which undoubtedly have distressing consequences.” “Natural and normal responses” are, surely, experiences as is the distress in “distressing consequences.” This part of the sentence thus translates as, “natural and normal experiences to their experiences, experiences which undoubtedly (lead to) experiences.” Further comment is un-necessary Using psychological notions to understand the BPS response Lucy Johnstone, herself an author of the BPS response offers a list of the ways in which psychiatrists silence criticism of their theories, diagnosis and practice.60 The list will be familiar to any such exchange at a case conference Johnstone includes “irrelevant personal statement(s), disqualifying the counter-evidence” and “attributing all improvement to medical intervention.” (p.32) This author once had a copy of Breggin’s Toxic Psychiatry thrown at him by an enraged child psychiatrist during a similar debate According to Johnstone, “Quoting important sounding research” (p.32) is another discounting manoeuvre To close readers of the BPS response this might appear ironic; the two page introductory General Comments section addends seven references To criticize such praxis is to criticize the essence of scientific discourse, a discourse wholly dependent on the notion that “research” is a necessary endeavour and publication axiomatic.61 20 In her chapter in De-medicalizing Misery62 Mary Boyle, author of the definitive critique of the schizophrenia concept,63 notes that psychology focuses on intra-psychic attributes and, “has invented a great many of them…” (p.28 – my italics) and in the case of, for example, hearing voices and expressing unusual beliefs has no hesitation in suggesting a list of psychological supposedly “abnormal” causative factors; “…defective judgement; abnormal perceptual biases; defective speech processing mechanisms; defective reality testing; parasitic memories; pathologically stored linguistic information; deficits in internal monitoring systems and an abnormal self-serving bias …” The list goes on … (p.29) According to Boyle’s analysis psychology has “extreme insecurity” about its acceptance as a science (p.37) “… by minimizing or denying the importance of life experiences and social context … mainstream psychology gains the double advantage of both appearing more ‘scientific’ and also avoiding the risk of the powerful by seeming to implicate them in the distress of others …” (p39) “… there is more going on here than a craving to be recognized as a science … Modern psychology presents its subject matter as the study of individual minds …” Citing Sampson, Boyle continues, “…this choice of subject matter functions to maintain the ideological and social status quo … by cutting people off … from effective action to change their actual circumstances rather than their subjective understanding…” (p.38)64 Though, as quoted above, Boyle attributes an individualized concept – “extreme insecurity” – to a discipline as a whole rather than to individual psychologists (itself a rhetorical device implying specialist knowledge), the phrase resonates Applying a more individualistic analysis it seems that envy, particularly financial envy, is a more accurate, if less complimentary attribution; in over twenty years as director of a Department of Psychological Therapies with more than 75 Psy professionals, this author witnessed hundreds of accusations that psychiatrists were paid too much and few claims of “insecurity.” This position is ruthlessly explicated by David Smail in his discussion of 21 how individual psychological and psychotherapeutic practitioners tend to explore the internal and invisible worlds of their patients rather than their material circumstances.65 A fundamental problem There remains the fundamental problem that the notion of “mental” in the idea of “mental health” is, again, a concept not an entity with physical substance The construct includes feelings (“emotions” to the psychologist) and thoughts (“cognitions”) That these concepts cannot be seen and cannot be assumed to follow physical laws of the “A leads to B” variety seems of little concern to practitioners of numerous “cognitive” therapies 66 The point, despite psychologists claiming to map “the mind” and offering “mental health services,” was not lost on Kraepelin who said, over a hundred years ago, “… in the strictest sense we cannot speak of the mind becoming diseased.” 67 This dilemma has not prevented the British Psychological Society members joining a “Faculty of Psychosis and Complex Mental Health Problems” (my italics) Who defines what should be regarded as “complex” in the illusory world of “mental” health is open to question, though for these faculty members that such a world should exist is self evident It is possibly too much to suggest that psychologists should first demonstrate what they mean by “mental” before going on to demonstrate effectiveness with those deemed as experiencing “not particularly complex” mental health problems Criticism and change This final section briefly summarizes the process of classification of conduct and critiques of that classification to date and suggests that this history might lead to the, possibly unpopular conclusion that such praxis will continue From this analysis the publication of revised and enlarged DSM-5 is predicted Plato and Aristotle, both philosophers, recognized that madness could only be observed The defining human characteristic, reason, was disturbed by the passions and it was the loss of reason that could be inferred from unusual speech or behaviour 22 The first published texts both classifying examining possible explanations for such loss of reason appeared in France in the early 19th century These were soon followed by increasingly large classificatory systems in Germany, Britain and the US Their publication met with both philosophical analysis and suggestions for revision from the putative discipline of psychiatry As we have seen (for example, Earle quoted previously), such criticism could be biting and cogent Indeed the accuracy of the criticism that internal physical substrate or mental operations could only be inferred from observing conduct rather than directly seen might have given less determined nosologists pause for thought.68 Instead, criticism was incorporated and systems refined; melancholia, mania, phrenitis, delirium, paranoia, lethargy, carus and dementia had already given way to the 24 disorders listed in the tenth edition of the Statistical Manual in 1942, two of which suggested adverse environments as a possible cause The revised Statistical Manual appeared as DSM-I in 1952, now with 112 diagnoses From Plato to the mid 19th century (some two thousand two hundred years) had seen a five-fold increase in disorders described The next 100 years saw a further five-fold increase Only sixty years later the publication of DSM-5 came close to another five-fold increase with 500 diagnoses Critics of this exponential increase have included Kraepelin himself, Spitzer (the lead author of DSM-III ) and, now, Frances (lead author of DSM IV-TR69 ) Frances,70 in noting the “incredible” cost of $199 for the latest edition suggests, “the APA has sunk more than $25 million into DSM-5 and wants to recoup as much of its investment as it can.” The change in diagnoses ensures that all practicing psychiatrists will require a copy in order to mark patients as “mentally ill.” That they are mentally ill is confirmed by the sleight of hand to be found in the APA’s descriptor of itself at the end of DSM-5, “DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders APA is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, 23 including substance use disorders.”71 The paragraph encapsulates most of the problems in the diagnostic enterprise and key reason for diagnostic praxis identified by numerous critics: “clinicians and researchers” confirm the expert status of Psy professionals who part of a “medical” (rather than, for example, social control) specialty specializing in “mental illnesses” (rather than “disorders” though “substance use disorders” can be treated) In short, “disorders are illnesses because we, the experts, say they are.” 72 The “Highlights of Changes from DSM-IV-TR to DSM-5” supplement accompanying DSM-573 notes, in addition, that a “suicide concern scale” is now included to be used “regardless of diagnosis.” “Intent” can only be inferred Thus, the scale cannot measure suicidal intent but will reveal how concerned the assessor might be and will, no doubt, lead to diagnosis and intervention In relation to the possible diagnosis of depression resulting from the use of the scale, the assessor now has an increased nosology The melancholia of Aristotle now becomes a “depressive disorder” with eight variants.74 Prospective research on new disorders includes initiatives for “Short Duration Hypomania, Caffeine Use Disorder, Internet Gaming Disorder.” It seems but a short step to “Momentary Hypomania, Tea Use Disorder and Facebook Addictive Disorder.” We shall need to await a revised DSM-5 to see if these are regarded as discrete or overlapping categories; anyone suddenly joining three Facebook groups while drinking a fifth cup of tea will be diagnosable The term, “mental retardation” is now replaced with “intellectual disability and Despite the name change, the deficits in cognitive capacity beginning in the developmental period, with the accompanying diagnostic criteria, are considered to constitute a mental disorder.” Thus, mental retardation (learning disability in the UK) becomes a “disorder” and, by definition according to the APA a “mental illness.” 24 Rationales for the increase in diagnostic categories include an increasing refinement in Descriptive Pathology, increased heritability or “genetic predisposition,”75 to psychosis and depression, the stress of post-industrial life, the vested interest of professionals or the pharmacological industry, government policy and the absorption of pseudo-diagnosis into the language of the general public to the extent that non-psy-professionals self-diagnose online before seeking confirmation and medication or therapy from certified practitioners It is now common-place, for example, for people to describe friends, family or complete strangers who happen to appear on television as “schizophrenic” or “depressed.” In similar vein, troublesome children are seen as “having” ADHD and those struggling at school, having first been insulted as “mongs” (a derivative of the learning disability category Mongol, itself abandoned by psychologists forty years ago) are now described by class-mates as “speshes” (taken from the assessment-determined “Special Needs” grouping) These changes have been consistently criticized by psychiatrists, psychologists, feminists, politically-minded Psy professionals, service recipients and human rights groups The critique by the BPS, analysed above, is particularly striking in this regard due the Society’s conspicuous failure to similarly criticize previous versions of DSM Nor has the Society insisted that members simply stop using diagnoses So, whither the Diagnostic and Statistical Manual? A graph of the increase in diagnoses would make uneasy viewing for critics The growth in diagnoses suggests that any new edition of DSM is likely, by 2020, after a brief plateau, to contain 1000 disorders Whether the number of diagnoses rises or not bears little relation to the diagnostic rate or the consequences for those diagnosed Despite no change in the criteria, for example, of ADHD, in the UK the number of children so diagnosed rose from 20,000 to 300,000 in the lifetime of DSM-IIIR.76 Between 1994 and 2003 UK prescriptions for stimulants (e.g., Ritalin®) rose from 6,000 to 345,000, a change not accounted for by the publication of DSM IV-TR in 2000.77 Between 1996 and 2003 the percentage boys in American schools diagnosed as ADHD and prescribed stimulants rose from six to 17 per cent.78 Similarly, the number of therapies for an ever-increasing range of distress have increased from 25 around one hundred in the 1960s to over 500 today.79,80 In the UK, at least, one advantage of diagnosis is disappearing; since the Layard Report81 those claiming state benefits have been offered Cognitive Behavioural Therapy (CBT) by an army of newly trained Independent Access to Psychological Therapies (IAPT) workers If claimants not return to work after from 6-12 hourly sessions their benefits are reduced or cut thus neatly inverting the supposed cause and effect of unemployment; instead of being depressed “because” the individual is out of work, the person is unemployed “because” of a diagnosed condition which must be “treated.”82 The absence of decent jobs for the majority doesn’t enter the equation at this level though doubtless it occurs to IAPT workers and their patients The act of diagnosis is now ubiquitous; newspapers frequently suggest that celebrities, historical figures (Van Gogh and Churchill are good examples here), and sportspeople (often, in the UK, footballers) are depressed Simultaneously media outlets report the latest medical break-through for those diagnosed with Alzheimer’s Disease or depression (only by reading to the end of the piece will the reader find the break-through has been predicted due to an experiment on rats) The widespread use of the Internet by individuals and groups with vested interests, whether they be identity reinforcing chatrooms for those diagnosed as Borderline Personality Disorder or Psy-industry supported help-lines and web-sites83 implies that increasingly refined descriptors of conduct will be incorporated into professional and public discourse The critics will remain – rather like water on a duck’s back Notes: Berrios, G.E (1996) The History of Mental Symptoms: Descriptive psychopathology since the nineteenth century Cambridge: Cambridge University Press Berrios op.cit Hill, C.G (1907) quoted in Grob, G.N (1991) Origins of DSM-I: A study in appearance and reality American Journal of Psychiatry, 148:4, 421-431 26 Levy, D.A (2010) A Proposed Category for the Diagnostic and Statistical Manual of Mental Disorders (DSM): Pervasive Labeling Disorder Journal of Critical Psychology, Counselling and Psychotherapy, 10, Grob, G.N (1991) Origins of DSM-I: A study in appearance and reality American Journal of Psychiatry, 148:4, 421-431 Grob op.cit In similar vein Moncrieff sees the promotion of treatable psychiatric disorders like depression as arising in factors out-with scientific (or clinical) work Instead, corralling depression was (and continues to be) a political act; psychiatry’s attempt to integrate with general medicine and improve its status while disengaging from the power base of the asylum Moncrieff, J (2011) The Myth of the Antidepressant: An historical analysis In: M Rapley, J Moncrieff and J Dillon (eds) De-medicalizing Misery: Psychiatry, psychology and the human condition Basingstoke: Palgrave Macmillan For a history emphasizing scientific progress the reader is directed to Michael Stone’s Healing the Mind: A history of psychiatry from antiquity to the present London: Pimlico (1998) which charts the inexorable progress of psychiatry towards ameliorating the suffering of those who are diagnosed in increasingly precise ways before being treated by more and more refined technologies Debates are duly reported and Stone locates the rationales for progress in praxis within brief autobiographical sketches of leaders in the field A critical stance - indeed, any genuine analysis – is avoided leaving the likes of Rosen unscathed, Bettleheim avoided, Masson unmentioned and Laing’s “experiment” dismissed as a “dismal failure”(p 216) In a work of over 500 pages it must rate as something of an achievement to neither mention Foucault nor Thomas Szasz Isaac Ray, A Treatise on the Medical Jurisprudence of Insanity (1838) quoted in Grobop.cit Grob op.cit 10 Valenstein, E (1986) Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness New York: Basic Books 11 Smail, D (1996) How to Survive Without Psychotherapy London: Constable 12 Grob op.cit 27 13 Spitzer, R.L., Endicoot, J., Woodruff, Jnr R.A., and Andreasen, N (1977) Classification of Mood Disorders In: G Usdin (ed), Depression: Clinical, biological and psychological perspectives New York: Brunner/Mazel 14 Jackson S.W (1986) Melancholia and depression New Haven: Yale University Press 15 Kelly, A (2011) The evolution of DSM and some implications for clinicians’ practice Journal of Critical Psychology, Counselling and Psychotherapy, 12, 4, 233-238 16 Pilgrim, D (2002) The BPS model in Anglo-American psychiatry: Past, present and future? Journal of Mental Health, 11(6), 585-594 17 Stone, M (1998) Healing the Mind: A history of psychiatry from antiquity to the present London: Pimlico 18 Katz (1983) quoted in Szasz, T (1987) Insanity: The idea and its consequences Chichester: John Wiley & Sons 19 Szasz, T (1987) Insanity: The idea and its consequences Chichester: John Wiley & Sons 20 Levy op.cit 21 American Psychiatric Association (APA) (2013) Diagnostic and statistical manual of mental disorders-5 American Psychiatric Association, Washington, DC 22 Berrios op.cit 23 Chadwick, P (1997) Learning from patients Clinical Psychology Forum, 100, 5-10 24 Note how for Chadwick it is the utility of seeing his madness as an illness which is emphasized, a utility which, for others, might include access to State benefits or the reduction of blame Whatever the consequences (often these can include a career as a psychiatric or psychological patient subject to a variety of toxic interventions) of Chadwick’s position and despite the seductiveness of his prose he tacitly categorizes madness as mental illness and mental illness as illness For a discussion of similar sleights of hand see Szasz, op.cit Newnes, C (2007) Are we all mad? The Journal of Critical Psychology, Counselling and Psychotherapy, 7, 3, 191-194, Barker, P., and Buchanan-Barker, P (2010) No Excuses: The reality cure of Thomas Szasz Journal of Critical Psychology, Counselling and Psychotherapy, 10,2, 69-75, Yoeli, J., and Morgan, A (2011) Mental Illness as ‘An Illness Like Any Other.’: A critical review Journal of Critical Psychology, Counselling and Psychotherapy, 11,4, 217-225 28 25 Minkowitz, T (2011) Why mental health laws contradict the CRPD: An application of Article 14 with recommendations to States parties Journal of Critical Psychology, Counselling and Psychotherapy, 11, 3, 187-192 26 http://apps.bps.org.uk/_publicationfiles/consultation-responses/DSM-5%202011%20- %20BPS%20response.pdf 27 http://www.ipetitions.com/petition/dsm5/ 28 http://www.huffingtonpost.com/allen-frances/dsm-5-reliability-tests_b_1490857.html 29 See, for example, Pilgrim, D (2007) The survival of psychiatric diagnoses Social Science & Medicine, 65,3, 536-47 and Rogers, A., and Pilgrim, D (2010) A Sociology of Mental Health and Illness, 4th edn Maidenhead: Open University Press 30 Johnstone, L (2000) Users and Abusers of Psychiatry: A critical look at psychiatric practice London: Routledge 31 Harper, D.J (1994) The professional construction of “paranoia” and the discursive use of diagnostic criteria British Journal of Medical Psychology, 67, 2, 131-143 32 Bentall, R.P (1990) Reconstructing Schizophrenia London: Routledge and (2003) Madness Explained: Psychosis and human nature Harmondsworth: Penguin Bentall is also series editor of the PCCS series, Straight-talking introductions to mental health problems: 2009 and continuing 33 Rapley, M., Moncrieff, J., and Dillon, J (eds) (2011) De-medicalizing Misery: Psychiatry, psychology and the human condition Basingstoke: Palgrave Macmillan 34 Smail D (2005) Power, interest and psychology Ross-on-Wye: PCCS Books 35 Szasz, T (1994) Cruel Compassion: Psychiatric control of psychiatry’s unwanted Chichester: John Wiley & Sons 36 Breggin, P (1991) Toxic Psychiatry: Why therapy, empathy and love must replace the drugs, electroshock, and biochemical theories of the ‘new psychiatry.’ New York: St Martin’s Press 37 In the UK the work of the Critical Psychiatry Network represents an in-house attempt to subvert the psychiatric project, albeit without relinquishing the right to interfere with the lives of others via professional authority See, for example, Bracken, P., and Thomas, P (2010) From Szasz to Foucault: On the role of critical psychiatry Philosophy, Psychology and Psychiatry, 17, 3, 219-228 29 38 See, for example, Masson, J M (1988) Against Therapy: Emotional tyranny and the myth of psychological healing London Harper Collins 39 Wolfensberger, W (1987) The New Genocide of Handicapped and Afflicted People New York: University of Syracuse “Deathmaking” refers to human service practices causing spiritual or physical harm (including hastening death) to their recipients Notably, DSM-5 lists neuroleptic-induced brain disorders such as Tardive Dyskinesia as ‘mental disorders’ rather than iatrogenic assaults See, Newnes, C (2011) Toxic Psychology In: M Rapley, J Moncrieff and J Dillon (eds) op.cit 40 BPS op.cit 41 Goldie, N (1977) The division of labour among the mental health professions In M Stacey, M Reid, C.Heath and R.Dingwall (Eds) Health and the Division of Labour London: Croom Helm 42 Leo, J (1985) Battling over Masochism Time, Dec 2, 76 43 Cromby, J., Diamond, B., Kelly, P., Moloney, P., Priest P & Smail D (eds) (2006) Critical and Community Psychology Special issue of Clinical Psychology Forum, 163, June 44 Heriot-Maitland, C., Knight, M., & Peters, E (2012) A qualitative comparison of psychotic-like phenomena in clinical and non-clinical populations British Journal of Clinical Psychology, 51(1), 37-53 45 Rosario, V A (1997) The Erotic Imagination: French histories of perversity New York: Oxford University Press 46 Moncrieff, J (2007) The Myth of the Chemical Cure: a critique of psychiatric drug treatment Basingstoke: Palgrave MacMillan 47 Szasz op.cit 48 Moncrieff op.cit 49 Pickles, C (2011) Lives without Reason? The imperialism of scientific explanation in psychology The Journal of Critical Psychology, Counselling and Psychotherapy, 11, 4, 208-216 50 A Libertarian position the principle advocate for which in relation to psychiatry has been Thomas Szasz; see Barker, P., and Buchanan-Barker, P (2010) No Excuses: The 30 reality cure of Thomas Szasz Journal of Critical Psychology, Counselling and Psychotherapy, 10,2, 69-75 51 Farber, S (1993) From victim to revolutionary: An interview with Leonard Frank In: Madness, Heresy, and the Rumour of Angels: The revolt against the mental health system Chicago and La Salle: Open Court 52 Newnes, C (2011) Toxic Psychology In: M Rapley, J Moncrieff and J Dillon (eds) De-medicalizing Misery: Psychiatry, psychology and the human condition Basingstoke: Palgrave Macmillan 53 BPS op.cit 54 See, for example on-line tests for Asperger’s Syndrome (http://iautistic.com/test_AS.php), Autistic Spectrum Disorder (http://www.wired.com/wired/archive/9.12/aqtest.html), Depression – sponsored by Pfizer and NHS Direct (http://www.nhs.uk/Tools/Pages/depression.aspx), Attention Deficit Hyperactivity Disorder (http://www.dore.co.uk/learningdifficulties/adhd/?gclid=CM-N9N2Xv7ICFUEMfAodiR4Ang) and Schizophrenia (http://psychcentral.com/quizzes/schizophrenia.htm) 55 Widiger, T A (ed) (2012) The Oxford Handbook of Personality Disorders Oxford: Oxford University Press 56 Graham, John, R (2012) MMPI-2: Assessing Personality and Psychopathology, Fifth Edition Oxford: Oxford University Press 57 Foucault, M.(1973) Madness and Civilization: A History of Insanity in the Age of Reason New York: Vintage 58 Smail, D (2005) Power, Interest and Psychology: Elements of a social materialist understanding of distress Ross-on-Wye: PCCS Books 59 Newnes, C and Holmes, G (1999), Introduction In: C Newnes, G Holmes, and C Dunn (eds) This is Madness: A critical look at psychiatry and the future of mental health services Ross on Wye: PCCS Books 60 Johnstone, L (1997) Psychiatry: are we allowed to disagree? Clinical Psychology Forum, 100, 31-34 31 61 For a parody of the need to quote research see, Newnes, C (1992) References Clinical Psychology Forum 42, 27-29 62 Boyle, M (2011) Making the world go away, and how psychology and psychiatry benefit In: M Rapley, J Moncrieff and J Dillon (eds) op cit 63 Boyle, M (2002) Schizophrenia: A Scientific Delusion? 2nd edn London: Routledge 64 Boyle op.cit 65 Smail op.cit 66 See, Ryle, G (1949) The Concept of Mind London: Hutchinson 67 Kraepelin, E (1901) Lectures on Clinical Psychiatry New York: Hafner 1968 68 Grob op.cit 69 For a discourse analytic deconstruction of the DSM-IV project see: Crowe, M (2000) Constructing normality: a discourse analysis of the DSM-IV Journal of Psychiatric and Mental Health Nursing, 7, 69–77 70 Frances, A (2013) DSM-5 in Distress Psychology Today January 23 71 American Psychiatric Association op.cit 72 Szasz op.cit 73 American Psychiatric Association (APA) (2013) Diagnostic and statistical manual of mental disorders-5 Supplement: Highlights of Changes from DSM-IV-TR to DSM-5 American Psychiatric Association, Washington, DC 74 American Psychiatric Association op.cit 75 Joseph, J (2003) The Gene Illusion: Genetic research in psychiatry and psychology under the microscope Ross-on-Wye: PCCS Books 76 Baker, E and Newnes, C (2005) The discourse of responsibility In: C Newnes and N Radcliffe (eds) Making and Breaking Children’s Lives Ross-on-Wye: PCCS Books 77 Timimi, S and Radcliffe, N (2005) The rise and rise of ADHD In: C Newnes and N Radcliffe Making and Breaking Children’s Lives Ross-on-Wye: PCCS Books 78 Timimi, S and Radcliffe, N op cit 79 Szasz, T (1978) The Myth of Psychotherapy: Mental healing as religion, rhetoric and repression Syracuse: Syracuse University Press 80 Feltham, C (2013) Counselling and Counselling Psychology: A Critical Examination Ross-on-Wye: PCCS Books 32 81 Layard, R., Clark, D., Bell, S., Knapp, M., Meacher, B., Priebe, S., Turnberg, L., Thornicroft, G., & Wright, B (2006) The depression report; A new deal for depression and anxiety disorders The Centre for Economic Performance’s Mental Health Policy Group, LSE 82 Pickles op cit 83 See, for example the test sponsored by Pfizer and NHS Direct for Depression at: (http://www.nhs.uk/Tools/Pages/depression.aspx), 33 ... David Pilgrim and Professor Richard Bentall, all members of the DCP, Lucy Johnstone, committee member of the DCP and Dr Amanda C de C Williams, member of both the DCP and the DHP The critical... psychological and psychotherapeutic practitioners tend to explore the internal and invisible worlds of their patients rather than their material circumstances.65 A fundamental problem There remains the. .. has the Society insisted that members simply stop using diagnoses So, whither the Diagnostic and Statistical Manual? A graph of the increase in diagnoses would make uneasy viewing for critics The