Specialists hit back at psychologists who want to ditch biomedical diagnoses

BMJ 2013; 346 doi: (Published 20 May 2013) Cite this as: BMJ 2013;346:f3273
  1. Zosia Kmietowicz
  1. 1BMJ

Specialists in both psychiatry and psychology came to the defence of classification systems for mental illnesses last week, after clinical psychologists called for diagnostic labels to be abandoned in favour of a conceptual system not based on a “disease” model.

Recorded at the press conference

The British Psychological Society’s Division of Clinical Psychology, which represents more than 10 000 practitioners, issued a statement on 17 May damning diagnoses such as schizophrenia, personality disorder, and bipolar disorder because they have “limited reliability and questionable validity.”1

“Psychiatric diagnosis is often presented as an objective statement of fact, but is, in essence, a clinical judgement based on observation and interpretation of behaviour and self-report, and thus subject to variation and bias,” the statement said.

Instead, the division said that there needed to be “a paradigm shift in relation to functional psychiatric diagnoses . . . [with] an approach that is multi-factorial, contextualises distress and behaviour, and acknowledges the complexity of the interactions involved in all human experience.”

But Nick Craddock, professor of psychiatry at the University of Cardiff and director of the National Centre for Mental Health in Wales, said that while no classification system was perfect, diagnostic rigour underpinned both mental health research and clinical practice.

He spoke on 17 May at a journalists’ briefing on psychiatric classifications, ahead of the publication of the fifth edition of the Diagnostic and Statistical Manual (DSM-5) at the American Psychiatric Association’s annual meeting later that day.2

“I have been a major critic of the DSM approach. But although there are shortcomings, I still believe absolutely that we must maintain the scientific and thoughtful approach where we try to bring together evidence—psychological, social, biological—and deliver the best help we can for people coming with problems. This is absolutely the wrong time to be going back to the 40 year old argument [of psychiatric classification]. It is really absolutely ridiculous,” he said.

Craddock said he did not believe that science had advanced sufficiently in the 17 years since the DSM’s fourth edition was published in 1994 to warrant the new edition. “For the practising clinicians, making change is difficult. There is a lot of sense in making a change when there is really a lot of evidence to justify it is going to make difference and it is worth all the pain and the effort.”

The fixation in the media on quirky new diagnoses in DSM-5, such as internet addiction, shyness in children, and hypersexual disorder, is not helpful. “These are not that important to clinicians. What is important to them are subtle changes, such as a new criteria for diagnosing a core disorder,” said Craddock.

David Clark, professor of experimental psychology at the University of Oxford and honorary fellow of the British Psychological Society, said that the statement from the clinical psychologists “completely ignored” the fact that the mental health classification systems relied equally on underlying psychological processes and biological ones.

He said that distinctive diagnoses had led to targeted research and new treatment approaches.

In the late 1980s, anxiety was simply classified as being phobic neurosis or anxiety neurosis. But now there is also panic disorder, post-traumatic stress disorder, social anxiety disorder, and obsessive compulsive disorder, said Clark.

“[Post-traumatic stress disorder] is about intrusive memories, and to get good results you have to use very specialised memory related therapy techniques, but those techniques have no relevance in social anxiety disorder, where video feedback is much more powerful,” he told the briefing.

“If we abandoned classification, it would be difficult to know what treatment to give. For example, there is no place for memory related techniques in social anxiety disorder—panic disorder treatment focuses much more on talking about physical symptoms and helping people to understand their true cause by a lot of experiential exercises.”


Cite this as: BMJ 2013;346:f3273