Lets drop the labels! Stop patholigising normality. Professor Peter Kinderman – University of Liverpool – states ‘Ditch the language of disorder’
Professor Peter Kinderman states:
‘Ditch the language of disorder’
Professor Peter Kinderman (University of Liverpool), presented to the SPRiG group on the 28th September 2012,recently gave the following encouragement for mental health professionals to ‘ditch the language of disorder’:
“Children have tantrums, people get forgetful as they age. We all feel depressed or anxious from time to time. Most people understand these issues, and would feel alarmed to hear that healthcare insurers would pay out for absent-mindedness, or that a healthcare regulatory agency had approved a drug to treat childhood temper tantrums.
But if you are dealing with a child diagnosed with “disruptive mood dysregulation disorder”, or a middle-aged man diagnosed with “mild neurocognitive disorder”, then you’re in business.
Psychiatrists can bill health insurers for treating the condition, and pharmaceutical companies have an opportunity for profit.
Indeed, if it turns out that an existing drug coming to the end of its licence is effective in ‘treating’ the ‘condition’, that’s a new market for an old drug.
These two ‘disorders’, proposed for inclusion in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, due to be launched in May 2013, highlight how a bad system is threatening to become even worse—continuing the pathologising of normality, lowering a swathe of diagnostic thresholds and inflating the apparent prevalence of mental health problems, especially in vulnerable populations such as children and older people.
The DSM is arguably the single most influential document in the research and treatment of mental illness. It defines what counts as a disorder, matches symptoms to conditions and shapes research and treatment worldwide. Because the top journals are American, for example, UK researchers face pressure to fit their questions to the DSM mould.
But the approach to mental health defined by the DSM serves the interests of the US medical-industrial complex more than patients or clinicians. Epidemiological studies reveal that the diagnostic criteria even for well-known diagnoses such as schizophrenia simply fail to reflect what people experience.
These diagnoses also fail to predict outcome or indicate appropriate treatment, which makes them of limited use to clinicians. They are equally limiting for researchers. The idea of diagnosis offers patients hope that their problems will be understood and relieved. But too often, this hope is spurious.
It is, of course, vital to define our research focus. But there is considerable overlap both between diagnoses and biological and environmental causal factors. On the other hand, the same label can cover very different phenomena: two people with a diagnosis of schizophrenia, for example, may have no two symptoms in common and may have become distressed for completely different reasons.
The APA has been canvassing views on the proposed changes to the DSM—its stakeholder review closed on 15 June—catalysing international criticism in the process. But, instead of revising the DSM, we need a wholesale revision of the way we think about psychological distress.
We should start by acknowledging that such distress is a normal part of life. In what sense is it a ‘disorder’, for example, to be traumatised by the experience of war?
We should then recognise the overwhelming evidence that there is no easy cut-off between normal experiences and disorder. Most scientific evidence supports the idea that a complex, individual interaction between biological, social and psychological factors leads to psychological distress.
And the most important causes of distress are psychosocial factors such as poverty, unemployment and trauma. The DSM, by emphasising the language of disorder, undermines a humane response by implying that these experiences are abnormal.
There is a genuine need to identify and describe psychological distress for the purposes of clinical practice, communication, record keeping, planning and research. So we need an alternative to the discredited and invalid diagnostic categories currently on offer. We should operationally define specific experiences or phenomena.
It is relatively straightforward to generate a simple list of problems that can be reliably and validly defined; low mood, auditory hallucinations, intrusive thoughts, and so on.
With some effort, a shared international lexicon could be developed. Clinicians working in multidisciplinary teams could then develop individual formulations—scientifically grounded hypotheses as to the origins of these problems, the factors that maintain them, and possible therapeutic solutions.
This ‘problem, definition, formulation’ approach, rather than the ‘diagnosis, treatment’ approach taken in the DSM would yield all the benefits of the current approach without its many inadequacies and dangers.
It is sad that we continue to apply an outdated and inappropriate system to psychological distress, but these are exciting times—there is an opportunity to propose a more scientific and useful approach.
The next few months could see a major shift in how we think about mental health.”
Reproduced from Research Professional, Research Fortnight,