Mental disorder

In 1973, the American psychologist David Rosenhan sent eight healthy people, and also himself, to visit mental institutions and claim they were hearing voices. All were certified mad; some were incarcerated for a month. Rosenhan’s paper, “On Being Sane in Insane Places,” created a media sensation and a crisis in psychiatry. Doctors, it seemed, unlike suspicious fellow patients, could not tell a lucid stooge from a lunatic.

The ensuing controversy led to the tightening of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM), the “psychiatrists’ bible” that lists mental disorders and their symptoms. The DSM, first published in 1952, is produced by the American Psychiatric Association (APA), which, every decade or two, assembles a hundred or so mental health professionals to review disorders in the light of new science or shifting cultural norms.

A DSM review process is underway, with a new edition—DSM-5—due for publication in 2013. But psychiatry is again facing a Rosenhan moment: DSM-5 vastly expands the boundaries of mental illness, so that many people previously thought merely eccentric or mildly troubled could now be classified as mentally disordered. Grieving relatives will be labelled “depressed,” hotheads will now suffer from “temper dysregulation,” and forgetful seniors will be diagnosed with “mild neurocognitive decline.” More people will be caught in the diagnostic net, and potentially medicated, exposing them to side effects, plus all the professional and social difficulties that a diagnosis brings. Allen Frances, who edited the DSM-4, has come out of retirement to denounce DSM-5 as a “wholesale imperial medicalisation of normality” and a “bonanza for the pharmaceutical industry.”

A final draft is scheduled to come out in May and a period of public consultation will follow. But opposition is already considerable. A petition of protest has garnered 11,500 signatures, largely from members of the American Psychological Association, the American Counselling Association and the British Psychological Society. There was an outpouring of criticism in Britain and Simon Wessely, from the Institute of Psychiatry in London, noted: “By 1917 the American Psychiatric Association recognised 59 disorders, rising to 128 in 1959, 227 in 1980, and 347 in the last revision [DSM-5]. Do we really need all these labels?” Lucy Johnstone, a consultant clinical psychologist, said the DSM “cannot be reformed… it should be abandoned.” But the APA stands by its product: “We are confident that the DSM-5 will be based on the most reliable scientific and clinical data.”

Frances regrets permitting, under his editorship, the expansion of bipolar diagnoses to children. One example “attenuated psychosis risk” syndrome, was intended to capture mildly disturbed young adults who might develop full-blown psychosis. But as many as 90 per cent of them don’t. His biggest fear, Frances says, is “diagnostic inflation leading to excessive and inappropriate medication use. DSM-5 contains many reckless and highly consequential suggestions based on extremely weak science. New diagnoses can be more dangerous than new drugs and need more careful vetting and regulatory approval than can be provided by any one professional organisation.”

The APA has reacted to Frances’s comments by pointing out that he stands to lose royalties from sales of DSM-4 when the new manual comes out. In reply, Frances has said he makes “about $10,000 a year,” from DSM-4. However, the DSM manual earns the APA more than $5m a year.

In the US, the DSM is central to mental health diagnosis. In Britain and the EU, the reference for mental health is the International Classification of Diseases and Related Health Problems (ICD), an inventory of physical and mental illnesses, regarded as the global standard and approved by the World Health Organisation. But while the ICD dominates in clinical diagnosis, the DSM dominates research—newly minted syndromes create more opportunities for academics and drug companies, and their names enter popular culture. In Britain we associate hyperactive kids with their DSM label, “attention deficit hyperactivity disorder,” not with their ICD description “hyperkinetic.” For this reason, changes to the DSM are of significance to medical science everywhere.

Peter Tyrer, professor of community psychiatry at Imperial College and editor of the British Journal of Psychiatry, questions whether DSM-5’s new classifications represent new modes of suffering, or the search, by academics, for new fiefdoms. Soon, clinicians from both rich and poor countries will start updating the most recent ICD manual, and speculation has begun that it may classify some disorders differently from the DSM. Divergence of the two systems, coupled with disillusionment with one, may boost the ICD’s claim to offer a truer picture of human anguish