16-Feb-2013
K. S. JACOB
Psychiatric diagnoses continue to lack the predictive power required of hard
science. A new framework is needed to understand mental health, distress and
disease The American Psychiatric Association (APA) will release the fifth
edition of its Diagnostic and Statistical Manual (DSM-5) in May 2013. DSM-5 has
been years in the making. The process included planning sessions, international
research conferences, review of literature, a series of monographs, secondary
analysis of data and field trials involving hundreds of scientists and
clinicians, drawn from many countries and disciplines, and feedback from the
public. Many interest groups — neurologists, psychologists, insurance and
pharmaceutical industries, legal and forensic fraternity, military veterans and
anti-psychiatry groups — have been watching the process and outcome closely as
the DSM has a wide impact. The Indian Psychiatric Society also submitted its
views to the APA.
International standard The DSM-5 has pursued the basic framework adopted by its
forerunners, DSM-III and its successors DSM III R, IV and IV TR. DSM III, with
its atheoretical approach, objective diagnostic criteria and specific
exclusions, was revolutionary at the time of its introduction in 1980. Its
focus on standardised diagnosis and on improving inter-rater reliability had a
major impact on psychiatric practice and research. It soon became the
international standard.
The absence of laboratory tests to diagnose mental disorders forced psychiatry
to focus on clinical presentations for this purpose. The lack of pathognomonic
symptoms required the discipline to rely on identifying collections of symptoms
to define clinical syndromes. Psychiatric classifications include medical
conditions (e.g. delirium, dementia and psychiatric manifestations of medical
diseases), severe mental disorders (schizophrenia, bipolar disorders, psychotic
depression, and stupor) and stress-related conditions (e.g. depression, anxiety
and adjustment disorders). The DSM laid out objective criteria for diagnosis.
It offered differential diagnosis in order to distinguish similar conditions.
It allowed psychiatrists working around the globe to read from the same page.
It facilitated collaboration and comparison. It improved communication,
standardised research, increased, and improved the evidence base. A unified
language also helped mental health activism.
Despite major advances and significant progress, the DSM has many critics. Most
detractors are free with their criticism, without providing comprehensive
solutions to the complex issues facing people with mental illness. Defining
mental illness is no simple task. A single definition to partition health,
illness and disease has proved to be extraordinarily difficult. The diversity
of and heterogeneity within these conditions are major challenges. Typically,
patients emphasise distress and suffering, while psychiatrists diagnose and
treat “diseases.” Mental disorders include both disease and illness.
Nevertheless, diagnostic criteria for psychiatric disorders did not bridge the
classical disease-illness divide between physicians’ perspectives and patients’
subjective experience of sickness. In fact, the DSM resulted in language,
concepts and frameworks, which contrasted starkly with those held by patients,
impeding understanding of the illness experience and diminishing the role of
patient narratives. In addition, DSM could not overcome the fact that different
etiology and pathology can result in similar clinical presentations, and that a
particular cause can produce diverse clinical manifestations. Research and
specialist interests also increased manifold the number of diagnostic
categories.
Little regard for context The difficulty in separating disease from distress is
a major challenge. The DSM system emphasised symptom counts to identify
psychiatric categories, with little regard for the context (e.g. psychosocial
stress, personality, and coping). This strategy improves reliability of
diagnosis for non-psychotic conditions associated with psychosocial adversity,
but also includes people with normal responses to such difficulties. Psychiatry
tends to reify diagnosis, making abstract concepts concrete. Psychiatric
practice transmutes clinical syndromes (collection of symptoms) into diseases.
The DSM III also suppressed etiological debates about mental disorders and
placed them on the back burner. The biomedical model, which undergirds the
approach, became dominant, annihilating psychological, behavioural and social
conceptualisations. However, the APA argued that reliable diagnoses would
result in the recognition of underlying neurobiological substrates and
facilitate etiological research; it would lead to the development of new and
more effective treatments.
However, the frequent revisions of the DSM, with minor changes often based on
limited evidence, also prompted debates on the motivation of the APA. The
numerous minor and major disagreements with World Health Organisation’s
International Classification of Diseases (ICD) -10 diagnostic categories
supported the argument that most changes were arbitrary as there was no
agreement among international experts. The DSM had to contend with many charges
including medicalising normal reactions, lowering diagnostic thresholds to
create spurious “epidemics,” creating new categories without evidence, using
medication responses to define categories and playing into the hands of the
pharmaceutical industry.
Challenges to diagnosis
Defenders of the DSM argue that its primary purpose is to enable psychiatrists
to reliably identify individuals who seek clinical attention, and to facilitate
communication among clinicians and researchers. The field of psychiatry has to
grapple with the current state of knowledge with its inherent limitations. The
lack of laboratory diagnosis, poor understanding of genetic basis and
psychological vulnerability, and the need to provide categorical diagnosis for
phenomena which lie along a spectrum (e.g. depression, anxiety, cognitive
impairment and substance misuse) are difficult challenges.
The most ardent supporters of the DSM acknowledge its imperfections but argue
that it reflects our current understanding and state of the science. They
contend that DSM-5 is not an attempt to define normal and that being normal is
not the same as not having a DSM-5 diagnosis. They argue that having a
psychiatric diagnosis is not the same as being insane or crazy, stigmatising
labels, which do not apply to the vast majority of people with a DSM diagnosis.
They suggest that prescribing medication for any condition in preference to
time and labour-intensive psychological interventions is dependent on many
factors, including the economic realities of medical practice, and does not
necessarily imply medicalising normality.
Pressure from user groups
The use of a single set of criteria, useful to psychiatrists working in
specialist settings, in other locations (e.g. definitions for legal use and for
reimbursement, in primary care and across cultures) is not without problems.
There was also pressure from patient and user groups, as any changes to the
DSM-IV categories in the new revision would have affected their claims for
disability support and health insurance. Consequently, there were demands to
enlarge and to reduce the diagnostic net from different quarters.
A close examination of the DSM-5 suggests the maintenance of status quo.
Psychiatric diagnoses and theories, with their technical language, operational
criteria, elaborate classificatory systems and empirical data continue to lack
the predictive power required of hard science. Its diagnostic systems and
models do not explain many aspects of mental health and illness. Human
cognition, emotion and behaviour are complex, interconnected and under a
variety of influences (e.g. genetics and biology, psychological, social and
cultural forces), whose effects cannot be teased out under controlled
experimental conditions.
Nevertheless, psychiatric treatments help millions of people lead productive
lives. The DSM process and consultation was elaborate and transparent, seeking
opinions and evidence from people with diverse backgrounds. Despite its
shortcomings, it does reflect the current state of the science. Psychiatry, at
this moment in time, has been compared to biology before Darwin and astronomy
before Copernicus.
Thomas Kuhn in his book The Structure of Scientific Revolutions described three
stages: (i) normal science (routine scientific work) within existing paradigms
and a dedication to solving puzzles, (ii) serious anomalies produced by
research, which leads to a crisis, and finally (iii) resolution of the crisis
by the creation of a new paradigm.
Psychiatry today, with its attempt at solving the clinical puzzles and its many
anomalies, is awaiting a paradigm shift, which will not only clarify these
complex issues but will also provide for a new framework, insight and
understanding. Psychiatric research, despite its current attempts at testable
conjectures and refutations, is still within a paradigm that seems inadequate
for the complexity of the task. Psychiatry awaits its new dawn. (Professor
K.S. Jacob is on the faculty of the Christian Medical College, Vellore. The
views expressed are personal)
http://www.thehindu.com/opinion/lead/in-search-of-a-revolutionary-road/article4419552.ece
--
--
You received this message because you are subscribed to the Google
Groups "Mental Health Advocacy (News 'N Views) India" group.
To post to this group, send email to [email protected]
To unsubscribe from this group, send email to
[email protected]
For more options, visit this group at
http://groups.google.com/group/MhaNewsViewsIndia?hl=en
-------------
Affiliated Groups : MENTAL HEALTH ADVOCACY INDIA
[email protected]
Discussions on mental health law / policy / plan monitoring / human rights etc
[email protected]
India-specific news and views related to mental health
[email protected]
Information and support to carers of people with mental health issues
[email protected]
Mutual support and sharing of experiential knowledge, skills and social
learning amongst peers
---
You received this message because you are subscribed to the Google Groups
"Mental Health Advocacy (News 'N Views) India" group.
To unsubscribe from this group and stop receiving emails from it, send an email
to [email protected].
For more options, visit https://groups.google.com/groups/opt_out.
