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Diagnosis, Dissent and the DSM

By Tim Hannan

The publication of the DSM-5 prompts debates over the science of diagnosing and treating mental illness.

Last year’s publication of the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) elicited much discussion among mental health professionals, chiefly over whether the changes introduced accorded with the best available scientific research. The debate over evidence in turn opened the door for somewhat less reasoned pronouncements centred on opposition to science-based practice in medicine in general, and to whether diagnoses should be made at all.

This debate continues to rear its head, as seen in last month’s conScience column (AS, Nov 2014, p.38). The author, Dr Gloria Wright, argued that psychiatric taxonomies such as DSM-5 list an ever-increasing number of conditions, and that this now includes what “previous generations may have seen as human dilemmas rather than mental disorders”.

While no specific disorders were named, it was suggested that, in contrast to “genuine mental illness”, new conditions now enable diagnoses to be conferred on non-mentally ill individuals, such as grandmothers with unique personalities and 14-year-old boys with a contrary streak. Wright proposed that “designer labels” have been newly created to serve “big business”, bewailing that children as young as three are given psychotropic medication and that e-health records are “available to almost anyone”.

As I do not share this dystopian vision of our mental health system, or of the practitioners who inhabit it, I would like to offer a few thoughts. The space available here prevents a thorough critique of all of the matters raised by Wright, but I will comment on the arguments against diagnosis per se, and on some of her more colourful anecdotes.

First, should the grandmother with the unique personality, or the adolescent with an oppositional disposition, receive a diagnosis of a mental illness? Of course not! But these are straw men, and misrepresent the purpose and practice of clinical diagnosis – which is to identify, describe and understand significant psychological problems in order that clinicians are able to select, tailor and implement evidence-based interventions. Diagnosis is concerned with distress and dysfunction, not just difference.

Second, is it really necessary to have so many disorders specified in a diagnostic taxonomy? Well, diagnosis often involves a process of differentiating between two types of presentation. Advances in genetics, neurobiology, clinical psychology and neuropsychology have revealed that not all presenting problems are the same, and controlled clinical trials have demonstrated that certain conditions respond better to specific treatments than others.

So we know that it is important to move beyond talking broadly about “anxiety”, “bedtime problems” or “learning problems” to carefully distinguishing between social phobia and generalised anxiety, between a night terror and a nightmare, and between autism and intellectual disability. And we also know that it is critical to determine whether Grandma is grumpy or clinically depressed, and whether Bart is being contrary or is affected by a recognisable neurodevelopmental disorder.

What of the 3-year-old on psychotropic medication? In 25 years as a practising child psychologist, I have been aware of just a handful of cases in which a severely distressed toddler was treated with medication: in each, this was prescribed as one component of treatment when non-pharmacological options were proving ineffective. These rare cases are the exceptions that prove the rule: giving toddlers medication is a very uncommon practice.

However, the use of these anecdotes by critics of diagnosis is revealing, as it indicates a basic misunderstanding about the treatment of psychological disorders. Although it is suggested that diagnostic systems are developed to serve the “big business” manufacturers of medications, the overwhelming majority of childhood disorders are not treated by medication but through psychological interventions. This is true not only for common behavioural and emotional problems, but also for many conditions known to have a strong neurobiological component, such as obsessive-compulsive disorder: according to clinical guidelines, the first-line interventions are psychological, not pharmacological. The “anti-medication” argument against diagnosis is not well-founded if one examines modern clinical practice.

Ultimately, the utility of a diagnostic system such as DSM-5 depends on whether it provides an informed understanding of a client’s difficulties, which then facilitates the selection and implementation of effective treatments. If it doesn’t, then diagnosis would indeed just be a social construct reflecting the agendas of big business, and we would have to abandon any suggestion of scientific rigour in the assessment and treatment of clients with mental illnesses. However, the evidence for the efficacy of psychological treatments for specific conditions demonstrates the critical role of diagnosis, and of broad diagnostic taxonomies, in the assessment and treatment of psychological distress.

Tim Hannan is an Associate Professor of Clinical Psychology at Charles Sturt University, and the Past President of the Australian Psychological Society.