From the Frontline

The psychiatric oligarchs who medicalise normality

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3135 (Published 2 May 2012)
Cite this as: BMJ 2012;344:e3135

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Surely the greatest danger of over diagnosing of psychiatric issues is that the patient is then denied the normal corrective actions of society on patients lying at the edges of the "normal" range. Thus is you are just a bit difficult and because of that get nowhere in life then perhaps the penny will drop. If you are given a label of bipolar or Aspergers or personality issues then you have your career mapped out so no need to engage with the normal pathways of life to get back on track. Over diagnosis is self fulfilling. By being inapporpriately diagnosed patients will become iller because they no longer have access to the best therapy: life itself and reflection on your progress in it.

Competing interests: None declared

Graeme Mackenzie, GP

Cumbria, Cumberland Infirmary

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The advent of DSM-5 will most likely increase the number of individuals given a diagnosis of mental illness with widespread rippling effects in the health and social services sectors. The increase in diagnoses will inevitably herald a massive upsurge in prescribing, some of which will invariably be unwarranted. However the availability of labels will not necessarily lead to a deluge of psychiatrists grappling to use them. Generally, in making decisions related to diagnosis and treatment, clinicians are usually guided by the severity of symptoms, associated risks and impact on the level of functioning on the individual. They do not rely primarily on classification tools such as DSM or ICD as these are certainly not a substitute for clinical acumen. The reality, however, is that a fraction of patients desire a ‘label’ attributable to metal illness for a positive smorgasbord of reasons. Most notably, a diagnosis has become a ticket into the benefits system, and in today’s economic climate, one must remain vigilant in detecting this secondary gain. The issue of over diagnosing those with mental illness has not been helped by celebrity figures publicising their forage into the field of mental health. Bipolar affective disorder appears to be the latest trend with many patients actively seeking diagnosis by reporting symptoms which they believe suggest this disorder. Whilst not undermining those individuals suffering from severe mental illness, a significant proportion of patients presenting to psychiatric services do lie within the spectrum of normality. As psychiatrists, the challenge is often not giving patients a label but rather communicating to them that they do not have a treatable mental illness. As Des Spence pointed out, psychiatrists, and indeed all clinicians, have an obligation to ‘well’ individuals in society. Public education on what constitutes a treatable mental illness is needed to slam the brakes on a potential cataclysm, with a majority of people now not only meeting diagnostic criteria, but also actively seeking diagnostic labels for mental illness.

Competing interests: None declared

Lilian Obakpolo, ST6, General Adult Psychiatry

Ravinder Kaur, CT1,General Adult Psychiatry

Birmingham and Solihull Mental Health NHS Foundation Trust, Lyndon Clinic, Hobs Meadow, Solihull, B92 8PW

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Des Spence is right to oppose the idea of expanding the already over medicalising DSM 4 to DSM 5. I have however been tempted to enlarge on that old pithy categorisation of psychiatry: Sad: the heart sighs as the head has its way. Mad: the head shakes as the heart holds sway. Bad: the conscience crumbles as vice leads to folly. Glad: the voice sings, but too loud and too jolly!

Competing interests: None declared

Graham J C Smelt, ENT Surgeon

Calderdale and Halifax NHSFT, 780 New Hey Rd. Huddersfield HD3 3YJ

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I read with a now familiar sense of dread Dr Spence’s opinion piece on the long awaited publication of the fifth iteration of the Diagnostic and Statistical Manual (DSM).1 I would like to add my voice to those of the other psychiatrists alluded to by Dr Spence, horrified at the changes being proposed. I am not alone – more than 13, 000 mental health clinicians have made their opinion known in an open letter to the DSM-V Task Force.2 Our concern is valid, for where the DSM goes, the rest of the world follows. The World Health Organization will publish its own revision of disease taxonomy, the International Classification of Diseases in 2015 and will inevitably base much of its own disease definitions on the DSM. The consequences this will have for the NHS, moving as it is towards an even more diagnosis-oriented approach within mental health services will extend beyond just psychiatry’s confines, and will have ramifications on everything from prison care to public health policy. In my opinion, the sense has been removed from the DSM-V Task Force’s reasoning, leaving only the common. Worse, the most susceptible to these changes will be the most vulnerable in our society: the grieving elderly now labelled as depressed and the young prescribed antipsychotics for fear they may become psychotic later in life. Modern psychiatry, that most human of medical specialties (or at least the only one with no veterinary counterpart), finds itself at a crossroads, but unable to proceed for the mire of definition and redefinition that transfixes it. We have already redefined the doctor-patient relationship as that of client-provider and labelled our patients the users of services (with flagrant disregard for the insult in calling a person a user of anything). Our masters now seek to reduce even normal human experience to mere collections of symptoms, and worse still, into syndromes which have little relevance to academic research. Is psychiatry coming full circle? Are we psychiatrists still as subversive as once thought? I worry that the DSM-V will reinforce decades’ long views of psychiatry as coercive, constraining and there to serve the pockets of big Pharma. Though the authors of the DSM-V have valiantly tried to realign modern psychiatry with modern medicine, I fear that what they will succeed in doing is alienating it even more. Dr Spence’s opinion alone is testament to this, tinged as it is with a hint of prejudice as he writes of the concept of mental illness being mere opinion (instead of a continuum between normality and abnormality in which the putative marker of distinction is based on functioning and risk, much like diabetes mellitus or hypertension), or the implication that psychiatrists bear their responsibility to ‘the well’ lightly. Yet, I do agree that all society must take a stand against what is now labelled ‘the mayhem of modern psychiatry’. Psychiatrists, psychologists, and our allied colleagues already have in their tens of thousands; for if this is the direction of things to come, surely it is time for us all to collectively say not in our opinion? 1. Spence, D. From the frontline: The psychiatric oligarchs who medicalise normality. BMJ 2012; 344: e3135 2. Open letter to the DSM-V. Available online at: http://www.ipetitions.com/petition/dsm5/.

Competing interests: None declared

Parashar P Ramanuj, ST4 Psychiatry

South London and Maudsley NHS Foundation Trust, Lambeth Hospital, 108 Landor Road, London, SW9 9NU

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Still DSM V does not include the diagnosis of Dysphoric Social Attention Consumption Deficit Anxiety Disorder (DSACDAD), the official indication for a prescription of avafinetime-HCl(Havidol). Un unforgettable piece of Art published on the Internet under http://www.havidol.com reminds us about the therapeutic virtues of humor. I do quite sometimes prescribe a visit to it.

Competing interests: None declared

Thierry Buclin, Clinical Pharmacologist

University Hospital (CHUV), Lausanne, Switzerland

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Spence lays out a number of familiar arguments in his critique of the fast approaching DSM-5, namely biological reductionism, labelling and medicalisation as a proxy for capitalist greed. I have a degree of sympathy for these arguments and I find it particularly interesting that the examples Spence uses to add narrative power focus primarily on the expansion of diagnosis of mental illness in childhood and adolescence. He demonstrates that diagnosis with respect to mental illness is morally disputable. Let us be clear however that diagnosis in somatic illness, as has been discussed in much of the philosophical literature in this area, is by no means value free.1 The values are just harder to get at.

I found myself wondering as I read the article whether Spence was walking into a relativistic fog. It is important to take a step back and to answer whether we consider ourselves to be mental illness realists or anti-realists. I would suggest that even given his critique it is possible to demonstrate that mental illness exists. As Graham has recently written, mental illness may not be mind-independent but it is act-of-classification independent.2

Spence’s article serves to remind us of the enormity of current nosological questions facing psychiatry. Perhaps these questions are not about a tension between what has recently been described in another journal as “the slow journey towards pathophysiology” and the descriptive frameworks we are still reliant upon.3 That does not mean that we should reject the entire project of illness attribution as morally illegitimate however.

1. Fulford KWM, Thornton T, Graham G (2006). Oxford textbook of philosophy and psychiatry. Oxford: Oxford University Press.

2. Graham G (2010). The disordered mind: An introduction to philosophy of mind and mental illness. London: Routledge.

3. Leckman JF, Pine DS. (2012). Editorial commentary: challenges and potential of DSM-5 and ICD-11 revisions. Journal of child psychology and psychiatry. 53 (5), p449-453.

Competing interests: None declared

Jonathan Lyons, ST4 in child and adolescent psychiatry

Norfolk and Suffolk Foundation Trust, Mary Chapman House, Norwich

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You have the right words to reject the psychiatrization of life. Disappointment or fugitive sadness are not psychiatric symptoms but normal reactions of human beings. An agitated child is not a petty criminal nor a future juvenile delinquent, he has to be listened to and educated. We do not want that any act of our life enters the surgery room through Big Pharma drugs. Psychiatry is too serious to be given to psychiatric oligarchs. As a matter of fact, in medicine serious diseases are not managed enough and light illnesses are over treated. According to Ivan Illich and others, we have to resist normalization and emphasize autonomy versus heteronomy in our practice.

Competing interests: None declared

Jean-Claude Grange, General Practitioner

Cabinet de médecine générale, 16, rue Blaise Pascal 78200 Mantes-La-Jolie FRANCE

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Well done again to Des Spence. There are indeed many mental health professionals, including psychiatrists such as myself, who are deeply concerned about the direction of travel in our profession. We have moved away from what it is that is unique that we bring to health care, which is an understanding that meaning, relationships, and social context are all central to a deeper understanding of suffering (mental and physical) and its alleviation. Instead we have been promoting pale imitation of a simplistic 'diagnostic' medical model that is not supported by any strong and consistent evidence base. This has resulted, at least in part, from an unnecessary insecurity about our identity as doctors and from a shameful 'cosying' up to the pharmaceutical industry.

There are now active movements campaigning against DSM 5 (see for example http://www.ipetitions.com/petition/dsm5, which includes affiliations from many large international psychological and psychotherapeutic organisations), and I have started a petition to the UK Royal College of Psychiatrists entitled 'No More Psychiatric Labels' and calling for the abolition of using formal psychiatric systems like DSM and ICD
(see http://www.change.org/petitions/royal-college-of-psychiatrists-abolish-u... ).

The petition sets out the evidence based reasons for concluding that: Psychiatric diagnoses are not valid, use of psychiatric diagnosis increases stigma, using psychiatric diagnosis does not aid treatment decisions, long term prognosis for mental health problems has got worse, psychiatric diagnosis imposes Western beliefs about mental distress on other cultures, and alternative evidence based models for organizing effective mental health care are available.

To read the full evidence based arguments view the 'No More Psychiatric Labels' paper at http://www.criticalpsychiatry.net/?p=527 or view the petition letter.

Competing interests: None declared

Sami TIMIMI, Child and Adolescent Psychiatrist

Lincolnshire Partnership NHS FT, Horizons Centre, Homer House, Monson St, Lincoln.

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Des Spence once again vents his low opinion of psychiatry. The confidence of his assertions indicates that he clearly knows best. Unfortunately, his attitudes are only too familiar to those of us working in mental health services; prejudice dressed up as concern for patients and academic rigour.

I really don't recognise Spence's "Front line". He uses examples that have little relevance to mental health care practised by jobbing psychiatrists in the UK to support his opinion that we are in a mental health disaster zone. He clearly does not value psychiatrists and he is entitled to his opinions. However, as he is writing in an important medical journal I would encourage him to curb his prejudices and to write, for a change, about some of the enormous advances made in mental health care over the last 20 years. More effective medications and psychological treatments delivered by improved services including assertive outreach and crisis teams as well as early intervention in psychosis.

He should stop airing his selectively informed opinions for the sake of combative prose and think about patients.

Competing interests: None declared

William Bruce-Jones, Consultant Psychiatrists

Avon &Wiltshire Mental Health Partnership Trust, Hillview Lodge, Royal United Hospital, Combe Park, Bath

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Des Spence is correct in stating that the definition of "mental disorder" is one of opinion. A surely foundational question for psychiatry is what a "mental disorder" actually is.

One attempt at a definition would be the one used in the UK Mental Health Act--this might be expected to be rigorous since it legitimates involuntary detention: a mental disorder is “any disorder or disability of mind.” This is no definition at all, merely a tautology.

In fact psychiatry has no answer to the question “what is a mental disorder?”, and instead exalts a way of working it has devised: if there are sufficient phenomena at sufficient threshold, a mental disorder is declared to exist! This is as much alchemy as science.

Competing interests: None declared

derek a summerfield, hon sen lecturer

institute of psychiatry, maudsley hospital, london SE5 8BB

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