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Psychiatric diagnosis: impersonal, imperfect and important

  • Nick Craddock (a1) and Laurence Mynors-Wallis (a2)
Summary

Psychiatric diagnosis is in the spotlight following the recent publication of DSM-5. In this article we consider both the benefits and limitations of diagnosis in psychiatry. The use of internationally recognised diagnoses, although insufficient alone, is part of a psychiatrist's professional responsibility to provide high-quality, evidence-based care for patients.

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Corresponding author
Nick Craddock, Department of Psychological Medicine and Neurology, Henry Wellcome Building, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK. Email: craddockn@cardiff.ac.uk
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Declaration of interest

None.

Footnotes
References
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1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-5). APA, 2013.
2 Gornall, J. DSM-5: a fatal diagnosis? BMJ 2013; 346: f3256.
3 Davies, J. Cracked. Why Psychiatry is Doing More Harm Than Good. Icon Books, 2013.
4 Spence, D. Bad medicine: bipolar II disorder. BMJ 2011; 342: d2767.
5 Wykes, T, Callard, F. Diagnosis, diagnosis, diagnosis: towards DSM-5. J Ment Health 2010; 19: 301–4.
6 Timimi, S. “No more psychiatric labels” petition. BMJ 2012; 344: e3534.
7 Kendell, RE. The Role of Diagnosis in Psychiatry: 176. Blackwell Scientific Publications.
8 Kupfer, DJ, First, MB, Regier, DA. A Research Agenda for DSM-V. American Psychiatric Association, 2002.
9 Craddock, N, Owen, MJ. Rethinking psychosis: the disadvantages of a dichotomous classification now outweigh the advantages. World Psychiatry 2007; 6: 8491.
10 Maj, M. Psychiatric diagnosis: pros and cons of prototypes vs. operational criteria. World Psychiatry 2011; 10: 81–2.
11 Insel, T, Cuthbert, B, Garvey, M, Heinssen, R, Pine, DS, Quinn, K, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry 2010; 167: 748–51.
12 Aldhous, P, Coghlan, A. A revolution in mental health. New Sci 2013; 2916: 89.
13 Craddock, N, Owen, MJ. The Kraepelinian dichotomy – going, going … but still not gone. Br J Psychiatry 2010; 196: 92–5.
14 Craddock, N, Kerr, M, Thapar, A. The right call. Open Mind 2010; 163: 67.
15 Rethink Mental Illness. The Abandoned Illness: A Report by the Schizophrenia Commission. Rethink Mental Illness, 2012.
16 Farmer, AE, Williams, J, Jones, I. Phenotypic definitions of psychotic illness for molecular genetic research. Am J Med Genet (Neuropsychiatr Genet) 1994; 54: 365–71.
17 Leucht, S, Hierl, S, Kissling, W, Dold, M, Davis, JM. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry 2012; 200: 97106.
18 Casey, BJ, Craddock, N, Cuthbert, BN, Hyman, SE, Lee, FS, Ressler, KJ. DSM-5 and RDoC: progress in psychiatry research? Nat Rev Neurosci 2013; 14: 810–4.
19 Insel, T. NIMH Director's Blog: Transforming Diagnosis, 29 April 2013. NIMH, 2013 (http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml).
20 White, PD, Rickards, H, Zeman, AZ. Time to end the distinction between mental and neurological illnesses. BMJ 2012; 344: e3454.
21 Royal College of Psychiatrists. Good Psychiatric Practice (3rd edn). (College Report CR154). Royal College of Psychiatrists, 2009.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Psychiatric diagnosis: impersonal, imperfect and important

  • Nick Craddock (a1) and Laurence Mynors-Wallis (a2)
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eLetters

Craddock and Mynors-Wallis' assault on thinking

James A. Rodger
28 March 2014

Debates about the validity and utility of psychiatric diagnoses have for long been a bone of contention between and within different professional and user groups. This was clearly borne out in the nearly 70 rapid responses (http://www.bmj.com/content/322/7278/95?tab=responses) to a BMJ article in 2001 by Derrick Summerfield (1), in which he proposed that Post Traumatic Stress Disorder was a social construct with little clinical utility. Responses were emotive and polarised, with an equal mixture of both patients and professionals in each camp--divided between those who felt a diagnoses were important and life-changing, and those who felt outraged and negated by the medicalisation of social suffering. In their recent editorial Craddock and Mynors-Wallis' (2) frame this diagnostic debate in terms of "benefits and limitations" (p93); later even possible "disadvantages" (p94) are acknowledged but mention of potential "harms" is conspicuously absent.

They advocate "embracing complexity" (p93) but for the rest of their article this does not ring true. They reel off the standard list of apparent advantages to diagnosis: providing reassurance, reducing blame, shame, and stigma but without reference to research findings; and nowhere in their paper is any service user-led or collaborative research cited.

Also conspicuously absent in their list is the necessity of a diagnosis to guide treatment. Is this is a tacit acknowledgement that there is little evidence to support such a claim and that, in mental health care at least, "common factors" linked to the therapeutic alliance alongside extra-therapeutic factors explain the majority of treatment variance (3)? In spite of this they then go on to assert "there are no issues about diagnosis (or treatment) that are unique to psychiatry" (p94) (for the counter-argument see (3) and related correspondence).

Their erroneous linkage between diagnosis and stigma reduction also stands out as particularly misleading. There is now an abundance of evidence, including a comprehensive review published last year in this journal (4), that biomedical framing of mental illness tends to increase personal and social stigma, and public desire for distance.

The authors may counter that a diagnosis does not imply biological causality, and they appear to endorse the standard biopsychosocial frame of reference. The problem is, as Roland Littlewood (5) points out it is more or less impossible to simultaneously hold a "personalistic" view of the self as agentic and intentional, while at the same time subscribing to a "naturalistic" view of being a product of biology, or even of the environment. One position always elides into the other. If this is true for professionals, it is certainly true for patients. And the dominant cultural understanding of diagnoses is that of biology, as it is with de facto psychiatric practice (6).

Craddock and Mynors-Wallis appear to want to be reasonable; identifying themselves, with other psychiatrists, as "reflective and tolerant of strongly opposing views and ideologies" (p94). First however they resort to an unsubstantiated moral and emotive appeal to their position: "this can be to our patients disadvantage if we allow these views [i.e. critical of standard diagnostic practices] to be unopposed by suggesting that our patients are somehow less deserving of a psychiatric diagnosis than a physical one." Then just in case we are still equivocating, using the College's Good Psychiatric Practice to bring us into line (as if this too was some ahistorical and acultural document), they pronounce: "This [use of standardised diagnosis] is not an issue of personal choice for a practitioner. It is a professional responsibility for the patient" (p95). Their penultimate reference (entitled "Time to end the distinction between mental and neurological illness") betrays their own ideological foray.

Of course if diagnosis is understood in the broader sense of a thorough going, descriptive and summative attempt at understanding a patient's struggles, respectful of personal meaning and unblinded to issues of power and social context (the latter often being harder to change than biology, in which it may then of course be reflected (7)), then we too might endorse Craddock and Mynors-Wallis' position. But in terms of a reverence to standardised manuals (whether DSM or ICD) that lack true nosological validity, even by their own standards and whose utility is, at best questionable (8), and which in effect serve to obscure key psychosocial antecedents (7), we would also argue our patients deserve better.

There is little space for wider critique (but see (8)) and discussion of alternatives here but if mature science is comfortable with dissent and debate (and indeed sees this as necessary for progression) this editorial seems a misplaced attempt to close down discussion--first through unsubstantiated emotive appeal, then the threat of professional censure--in order to maintain a fa?ade of professional consensus. While we might wonder what lies behind such a move, we would advocate a more far-reaching attempt at embracing complexity. In particular as we have argued elsewhere (3), in attending to issues of power, meaning, social context, and the therapeutic alliance, alongside but not reduced to biology, we have much to offer the rest of medicine, who are also beginning to grapple with related issues (9,10).

References1. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. BMJ. 2001 Jan;322(7278):95-8. 2. Craddock N, Mynors-Wallis L. Psychiatric diagnosis: impersonal, imperfect and important. BJP. 2014 Feb 1;204(2):93-5. 3. Bracken P, Thomas P, Timimi S, Asen E, Behr G, Beuster C, et al. Psychiatry beyond the current paradigm. BJP. 2012 Dec 1;201(6):430-4. 4. Angermeyer MC, Holzinger A, Carta MG, Schomerus G. Biogenetic explanations and public acceptance of mental illness: systematic review of population studies. The British Journal of Psychiatry. 2011 Nov 1;199(5):367 -372. 5. Littlewood R. Pathologies of the West: an anthropology of mental illness in Europe and America. Continuum International Publishing Group; 2002. 6. Barrett RJ. The Psychiatric Team and the Social Definition of Schizophrenia: An Anthropological Study of Person and Illness. Cambridge University Press; 1996. 7. Krieger N. "Bodies Count," and Body Counts: Social Epidemiology and Embodying Inequality. Epidemiologic Reviews. 2004 Jul 1;26(1):92-103. 8. Timimi S. No More Psychiatric Labels: Campaign to Abolish Psychiatric Diagnostic Systems such as ICD and DSM. Self & Society. 2013;40(4):6-14. 9. Das A. The "rest of medicine" and psychiatry: why paradigms would differ. BJP. 2013 Jun 1;202(6):463-463. 10. Sharpe M. Psychological medicine and the future of psychiatry. BJP. 2014 Feb 1;204(2):91-2.
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Conflict of interest: None declared

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