DSM-5 'Future of Psychiatric Diagnosis' Conference at Institute of Psychiatry, 4/5 June 2013

Conference Report: ‘DSM-5 and the Future of Psychiatric Diagnosis’, Institute of Psychiatry, King’s College London (4th-5th June 2013)

The DSM-5 has been all over the media of late, generating criticisms from all angles months before it was even published: 

• from former DSM task force heads Robert Spitzer (DSM-III) and Allen Frances (DSM-IV), for lack of transparency and reliability;

• from patients’ associations such as SOAP [Speak Out Against Psychiatry], Hearing Voices, or Mind, for lack of attentiveness to the subjective reality of so-called mentally ill people;

• from ‘psy’ associations like the British Psychological Society, the Critical Psychiatry Network or Mental Health Europe, to name just a few of the hundreds of bodies that declared against DSM-5, for various reasons ranging from lack of empirical validity and insufficient emphasis on the biological causes of mental illness to lack of focus on the singular experiences of the patients;  

• from NIMH [National Institute of Mental Health], a division of the American Health Department and its director Thomas R. Insel, for insufficiently drawing on neuroscientific research, in a probable bid for President Obama’s Brain Initiative ($100 million allocated funds).

Given the multiplicity of dissonant voices, and of grounds for controversy, only one thing is clear: nobody has much of a clue as to what a mental disorder is any more, and least of all as to what it could possibly mean to be mentally healthy.

A faltering paradigm can be more fertile than a well rehearsed discourse, so we decided to attend the DSM-5 conference (hosted by the IOP at KCL early this month) to hear what the architects and supporters of the DSM-5 had to say about the state of their project. We took our inspiration from Eric Laurent’s extremely lucid article in Lacan Quotidien n0 319: Laurent predicted the end of the psychiatric paradigm and the reconfiguration of the mental health discourse by the neurological paradigm. This reconfiguration is still in the making but is signposted by NIMH with the introduction of RDoC [Research Domain Criteria], initiating a mythical quest for objective signs of mental illness using neuroimaging, genetic markers and objectively detectable alterations in cognitive functions, in the domains of emotion, cognition and behaviour.

Scheduled to speak were DSM-5 task force head David Kupfer as well as many eminent British and American psychiatrists involved with the WHO, the ICD [International Classification of Diseases, instrument of the WHO] task force, the DSM task force, the Royal College of Psychiatrists, or again specialists of specific diagnoses such as autism, Disruptive Mood Dysregulation Disorder, or the discarded Attenuated Psychosis Syndrome. The only outsider to the medical/psychiatric professions was Nikolas Rose, a well-known critical voice in the fields of criminology, sciences of life, neuroscience and psychiatry, and to our lay ears the sole voice of sanity. 

Day 1 by Véronique Voruz

The conference started with opening remarks by Shitij Kapur, currently Dean and Head of School at the IOP. His general argument was that in the days of yore things were terrible because we did not have a classification of mental disorders; in fact we had to make do with a mere three categories (hysteria, psychosis, other disorders). Thankfully in the 1920s American psychiatrists came up with a statistical manual sorting the asylum population into 22 disorders, and by the mid-20th century psychiatric classifications began to include all mental disorders. The premise of Professor Kapur’s talk was basically that the main problem besetting psychiatry was unsatisfactory classification, hence the thrust of the APA [American Psychiatric Association] in adjusting its classification manual.

These opening remarks were followed by a historical talk by Professor Horwitz who recounted how prior to WWII psychiatric classification concentrated on asylum populations, with 21 of the 22 recognised disorders referring to psychotic conditions. But after WWII returning soldiers presented different types of disorders that could not be ascribed to biological or genetic factors since they had been carefully screened before being sent out to fight. Further, their disorders were clearly circumstantial (war neuroses, shell-shock etc.); they also could not be treated through the asylum system. Thus the DSM-I was born, in 1952, but unfortunately it was heavily influenced by psychoanalytic psychiatry and differential diagnosis, and focused on neurotic conditions. The DSM-I was very theoretical, and Professor Horwitz deplored that it was a manual for clinicians, not for researchers.

Indeed, it became very clear in the course of the conference that the main point of the DSM-5 was to allow psychiatrists to 1) accurately fill in assessment forms; 2) bid for research funding on certain conditions; 3) publish accredited articles furthering their careers. There was hardly any mention at all of treatment, at best the patient re-appeared from the perspective of symptom management. Otherwise the whole conference was spent discussing accuracy of classification, items on diagnostic instruments, and whether a particular diagnosis was the same as another using ‘sophisticated’ statistical tools.   

Professor Horwitz rejoiced that the DSM gradually moved away from being a clinician’s tool to being a researcher’s one. That was because psychiatry, in order to re-assert its waning professional dominance in the face of alternative disciplines such as psychology and psychoanalysis, started to rely on the medical methodology of controlled trials and statistical evidence instead of case studies. Robert Spitzer’s DSM-III waged a successful war on the psychoanalytic framework and introduced symptom-based, objective and measurable conditions. The result was an a-theoretical manual, which Professor Horwitz specified as being agnostic as to etiology: in other words, anyone with the symptoms has the disorder, and the need for etiology goes “out of the window”.

The DSM-III met with instant success for reasons that had little to do with the efficacy of treatment: it proved useful in organizing re-imbursement structures, it provided professional legitimation to psychiatrists, it was endorsed by NIMH and became the framework for research funding: for a time in the US it was impossible to get funding without relying on a DSM category. It also proved successful with parents, who were fed up with being held responsible for their children’s disorders. Last but not least, pharmaceutical companies loved it because they could target their drugs to specific diagnoses. The DSM-IV and 5 (the roman numerals were abandoned to signal the modernity of the new DSM…) represent attempts at overcoming issues of co-morbidity and incorporating biological findings. But the outcome is not as successful as the DSM-III, with a proliferation of diagnoses often said to include all of the population (157 diagnoses, themselves divided into subsets…).

Professor Horwitz’s talk was followed by an intervention by David Kupfer, head of DSM-5 task force. Kupfer emphasized that the thrust of the task force had been to incorporate as much research and empirical data into the DSM-5 in order to improve its reliability and the validity of its diagnoses. For this purpose, the task force received input from researchers from 13 countries, from psychologists, added input from neuroscience and so forth. Basically Kupfer tried to defend the DSM-5 by showing that everything had been done to improve its classificatory reliability. Professor Rutter continued the morning session by outlining why the psychiatric community needed a classification: 1) to communicate between ourselves; 2) to regroup different types of individuals; 3) to direct treatment.

After the first three morning sessions it had become apparent that the main purpose of the DSM-5 was to legitimize the psychiatric profession in its research and funding activities, and the debate at the IOP would never challenge the idea that classification was the way to go. Meanwhile, outside the IOP a demonstration was going on, organized by people who saw themselves as survivors of psychiatry. There were, even, representatives of the Citizens Commission on Human Rights [CCHR], gathering information on ‘psychiatric damage’, or damage caused by psychiatric treatment. Overheard conversation between two psychiatrists: “I don’t understand why they are so angry at us. We are only trying to help them.” 

Nikolas Rose then took over, with a very measured sociological intervention pointing out that diagnoses had above all social functions: sick leave, eligibility for treatment, disability benefit, involuntary detention, epidemiology, research, predictive tools, insurance, identification, cultural significance, biopolitical importance, management of the disorderly, grouping of the heterogeneous, and so forth. Given the huge relevance of the social functions of diagnoses, Professor Rose underlined the responsibility of the people who take on the task of creating diagnostic categories. He drew attention to the epistemological consequences of the unifying gaze of the DSM-5: one third of the adult population are now said to suffer from a mental disorder in any one year in Europe. The result of such a medicalization of the human experience is the reduction of etiology to pathophysiology. Yet there is no biological substrate to mental illness, and no boundary between ill/well-being. The DSM method is to look at clinical phenomena and seek to correlate them to neurobiological underpinnings. RDoC suggests to look at the brain and link brain patterns to clinical phenomena – these two models fail to address the definitional issue of 1) mental health; 2) mental disease. They also focus on research at the expense of practice. He concluded by supporting the position of the BPS: one should start with the specific experiences of the patient rather than with the diagnosis.

Despite Professor Rose’s well-calculated intervention, the afternoon proceeded with a discussion of specific diagnostic categories such as the autistic spectrum disorder, the Disruptive Mood Disregulation Disorder and whether it was the same as ADHD, and finally some very dodgy research making children say that Ritalin had a fantastic effect on them.

Day 2 by Janet Haney

Dr Clare Gerada (Chair of Council of the Royal College of General Practitioners) opened the second day by introducing herself to the conference as a GP, adding ‘forgive me for that’ [laughter]. She then declared her “conflict of interest” – she was married to one of the speakers [laughter]. She introduced the first speaker (to whom she is not married) as Professor David Clark, “the most cited psychologist of all time, more cited even than Eysenck”. This time there was no laughter – had she meant to be ironic? Eysenck had been Professor of Psychology at the IOP between 1955 and 1983 and was famous for his controversial ideas about race and intelligence. David Clark’s work hugely affects that of Gerada, she said, because he has made CBT available for her patients. He is currently Professor of Experimental Psychology at the University of Oxford and Visiting Professor of Psychology at the Institute of Psychiatry and is a leading figure behind the ‘success’ of the IAPT programme.

“For those of you who read the Observer”, he said with a wry smile, “you will know that the BPS has come out with a rather strident notice against the DSM. The statement criticises the DSM as not scientific, but as created through the efforts of committees and consensus.” Professor Clark pointed out, in a gentle yet cynical manner, that the DSM is “perhaps more interesting to psychology than to most people”, adding that “the DSM is a great help when lobbying politicians”. He went on to say “there are no RCTs of generic CBT”. Pausing only to survey the effect of this revelation on the audience, he then pressed home his advantage by presenting Powerpoint proof that CBT is more effective than counselling in almost every case. This slide was not reproduced in the conference file, and I could not see any reference to the study that produced the results. No-one laughed, who would dare?

Professor Wessely, “an epidemiologist by training”, had some very amusing slides, which the audience clearly enjoyed. One of them a Gary Larson cartoon: two almost identical men, one (the doctor) saying to the other (the patient) as he straps a rocket to the latter’s back, “You’re allergic to the environment, we’ve got to get you off the planet”; the patient is aimed for easy exit out through the window. This was so popular that a member of the audience requested that it continue to be displayed after the talk was over. Wessely’s work focuses on the very serious fact that more soldiers deployed in the Gulf War suffer from ‘mettle fatigue’ (a headline of a report by the Evening Standard) than do those involved in other recent wars. He presented results on the “number needed to offend” [laughter – this time playing on an epidemiological phrase “the number needed to treat”]: the tricky business of finding names for disorders that real men won’t baulk at (“don’t even think of using hysteria”, he advised).

After the coffee break Norman Sartorius (former Director of the Division of Mental Health of the World Health Organisation) chaired the session. Vikram Patel was billed as speaking about “Why the DSM-5 matters to global mental health”, but when he stood up he said: “The DSM-5 is irrelevant and risks undermining global mental health.” The finer point that he wanted to make was that the conflicts of interest visible around the DSM-5 “threatens the growing momentum [of support] among donors and governments” in those parts of the world where psychiatry had yet to dominate. Patel is Professor of International Mental Health at the London School of Hygiene and Tropical Medicine.

Felicity Callard, a historian and sociologist at Durham University, used her personal experience of being diagnosed in both the USA and the UK to say that this stuff is always situated in a particular place, time, and set of relationships, and that it means different things to different people at different times. But she also noticed the prevalence of what social scientists call ‘the male voice’ that discusses the DSM. A woman in the audience (also with personal experience of psychiatric diagnosis) asked Sartorius if he would like to comment on the male voices speaking about the DSM-5? This distinguished man of the world seemed to be genuinely confused: “You want to know if I have voices?” he asked. The laugher swelled up again.

After lunch Robin Murray (knighted in 2011, but appearing without his title) took the chair with much gusto. Professor of Psychiatric Research at the IOP, Murray seemed not to care who knew his opinion of those Americans and their DSM-5 and talked openly about the shifts in psychiatric and economic power. Murray’s task was to chair a packed session, featuring professors from Germany (Klosterkötter) and the Netherlands (Van Os), as well as USA (Carpenter) and UK (McGuire). This session revolved around the controversial dropping of Attenuated Psychosis Syndrome from the DSM-5. The presentations were particularly dense and compact, as slide upon slide testified to the diligent work of researchers with access to varying levels of technology in four different countries (a neuroimaging machine won ‘hands down’ for the man from the IOP). I asked the psychologist next to me (who had popped in to the conference for this session only because it was so controversial and affected her own research) whether the loss of the label in DSM-5 would mean loss of funding for the unfortunate researchers. No, she said, because they are in Europe. Had they been based in the USA, the story would have been different.

Meanwhile, a Kiwi psychiatrist [laughter] was asking: “but does the APS have validity”. Murray replied:
- Hamburgers exist, but they have no validity. [Much laughter, and then everyone joined in]
- So what should I write in my paperwork?
- Something vague and descriptive.
- So the DSM categories are subjective?
- Of course!
- That’s why you need so many entries in the manual!
- So you can choose the best fit …
- And everyone can get hold of some money!
- [much laughter].

The final ‘round table’ did what it could to re-present a solid scientific face, and to rally us back to that cause. Then it fell to the local chief, Professor Shitij Kapur, to appeal to the audience to put it all back together. He invited us to vote on whether the DSM-5 would a) make things worse, b) make things better, or c) make no difference at all. Someone insisted on a time frame (a year, was proposed), but no-one asked ‘better for who? or ‘in what way?’ so the insights about finance, power and prestige were easily swept aside. More than half of the audience went for (or shall we say “expressed a wish”) for option (c).

Behind the veil of this theatrical vote the shifting alliances of research and politics pin their hopes on objectively verifiable markers, preferably in the brain. Meanwhile, yesterday’s protesters and other outsiders are massing at the IOP doors, awaiting the “Maudsley Debate”: Enabling or Labelling? This House believes that psychiatric diagnosis has advanced the care of people with mental health problems. Satorius is speaking ‘for’, Callard is speaking ‘against’, and Wessley is in the chair. (PS. The vote:  For 144.  Against 109. Abstain 18.)