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Thursday, June 16, 2011

British Psychological Society Critiques DSM-5


The British Psychological Society

The British Psychological Society responds to the new DSM-5.   A prior blog post looked at some criticism of the DSM-5.  The British Psychological Association offers a more formal, 26-page critique.  The entire document can be found here.  The first part of the critique is posted for your review.

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The Society is 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 do not reflect illnesses so much as normal individual variation.

We therefore do welcome the proposal to include a profile of rating the severity of different symptoms over the preceding month. This is attractive, not only because it focuses on specific problems (see below), but because it introduces the concept of variability more fully into the system. That said, we have more concerns than plaudits.

The putative diagnoses presented in DSM-V are clearly based largely on social norms, with 'symptoms' that all rely on subjective judgments, with little confirmatory physical 'signs' or evidence of biological causation. The criteria are not value-free, but rather reflect current normative social expectations. Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity.

Diagnostic categories do not predict response to medication or other interventions whereas more specific formulations or symptom clusters might (Moncrieff, 2007).

Finally, disorders categorised as ‘not otherwise specified’ are huge (running at 30% of all personality disorder diagnoses for example).

Personality disorder and psychoses are particularly troublesome as they are not adequately normed on the general population, where community surveys regularly report much higher prevalence and incidence than would be expected. This problem – as well as threatening the validity of the approach – has significant implications. If community samples show high levels of ‘prevalence’, social factors are minimised, and the continuum with normality is ignored. Then many of the 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.

In this context, we have significant concerns over consideration of inclusion of both “at-risk mental state” (prodrome) and “attenuated psychosis syndrome”. We recognise that the first proposal has now been dropped – and we welcome this. But the concept of “attenuated psychosis system” appears very worrying; it could be seen as an opportunity to stigmatize eccentric people, and to lower the threshold for achieving a diagnosis of psychosis

Diagnostic systems such as these therefore fall short of the criteria for legitimate medical diagnoses. They certainly identify troubling or troubled people, but do not meet the criteria for categorisation demanded for a field of science or medicine (with a very few exceptions such as dementia.) We are also concerned that systems such as this are based on identifying problems as located within individuals.  This misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our wellbeing 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.

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