Time to Abolish Formal Psychiatric Diagnostic Systems: A Critique of The Usefulness in Psychiatric Diagnosis.
What would happen if we were to attach a psychiatric diagnosis to every emotion that arises within us? How might an individual feel, if each time they felt out of character a mental health condition was attributed to that distress as opposed to it being recognised as something that is momentary, somewhat due to social, cultural or environmental influences; which if those adverse experiences or factors were removed, it would alleviate the distress one feels, enabling them to explore their world freely. Leaving no space for self-prophesising behaviours following psychiatric diagnosis.
What about if we eternally associated a condition to a person who endured momentary distress such as postpartum depression following the birth of a child? The new mother’s struggle with adapting to the novel role, economic obligations, possible limited spousal support and finding the balance between differentiating her identity with new-borns.
The final ‘what if’ is, what would you say if you knew the mental health condition you were diagnosed with was voted into existence following three-hour arguments as to what symptoms should be accredited to Borderline Personality Disorder (BPD) no scientific data or genetic/twin studies to justify the inclusion of symptoms – and if the professionals could not decide on what symptoms an individual must display before being diagnosed with BPD, the clinicians would eventually decide by a vote? (Spitzer, 2012).
As controversial as it may seem, defining and deciding what criterion must be met in order to have an official psychiatric diagnosis according the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) is, historically, influenced by political and social forces underpinning the diagnostic system, causing scepticism amongst professionals on how useful psychiatric diagnosis really is. To help us explore the utility of psychiatric diagnosis, we will consider two key questions throughout the essay:
How reliable are the diagnostic categories?
Psychiatric diagnosis and pharmaceutical industry involvement.
How reliable are the diagnostic categories?
It could be argued that all psychiatric diagnosis to some extent are biased, in that the nature of what symptoms are to be associated with a condition have previously been constructed by professionals in the psychiatric field as opposed to utilising scientific evidence. Furthermore, what constitutes a mental health condition is largely dependent on social norms of an era, for example in the 1970’s homosexuality was considered a ‘sociopathic personality disorder’ which remained until 1973; today, there are progressive changes towards homosexuality – though some cultures and generations may still view homosexuality as something that is due to underlying mental health distress (Pew Research, 2020).
If psychiatry cannot determine what mental health condition a person may be experiencing using biological markers alone, how can we be certain that an individual classified as ‘schizophrenic’ or ‘bipolar’ is for sure, since the biochemical imbalance theory has no hard evidence to substantiate the claims (Cromby, 2013).
During an interview with Robert Spitzer (2012) the chair of the American Psychiatric Association’s task force of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) he stated that,
Our general principle was that if a large enough number of clinicians felt that a diagnostic concept was important in their work then we were likely to add it as a new category. That was essentially it. It became a question of how much consensus there was to recognise and include a particular disorder
Since the third edition of the DSM, amendments have been made obvious. However, there are still concerns among the psychiatric world regarding how reliable it is, experienced psychiatrists such as Allen J Frances M.D. (2012) have made their apprehensions with the DSM-5 clear, reporting that the ‘changes make no sense and should be ignored by professionals’.
One of the main concerns which can lead us to question the reliability of psychiatric diagnosis is the over-medicalisation of emotions such as grief; which might be a precursor to an individual temporarily enduring distress such as ‘Major Depressive Disorder’ (MDD). As commonly reported, definitions described of MDD include: persistent low mood, loss of enjoyment and pleasure in daily activities – today, these descriptions exclude cases where a person is recently bereaved.
Frances (2012) argues that medicalising grief as Depressive Disorder and substituting the pain for psychotropic medication creates a denial of a normal human response at the loss of a loved one as they near the end of their life, ultimately the pathologisation of grief and lowering of diagnostic thresholds presents risks in panic amongst the population and potential oversubscription and reliance of unnecessary medication.
Whilst we are not denying grief can serve as a precursor to depression, the co-morbidity and ambiguity of the symptoms outlined as depression such as; depressed mood most of the day, nearly every day, significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day, diminished ability to think or concentrate, or indecisiveness, nearly every day.
The heterogeneity of diagnostic criterion can see pathologies such as depression overlapping with other symptoms of conditions like Post-Traumatic Stress Disorder (PTSD). Young (2014), calculated that in the DSM-5 there are 270 million combinations of symptoms that would meet the criteria for both PTSD and major depressive disorder.
With this in mind, how can clinicians be assured that their diagnosis provided is accurate and one in which will put the client on the journey to recovery? Additionally, it is reported that psychiatrists have varying diagnostic preferences (Kirk & Kutchins, 1994) which means a client who comes in contact with mental health service could be ascribed multiple psychiatric diagnoses; all of which may not help to support the client and cause medicalisation of symptoms which remain misunderstood.
Worryingly, with the popularity of psychotropic medication (in particular anti-depressants) if clinicians battle with achieving accuracy in their diagnosis how can one be sure they receive the correct intervention. Furthermore, with the involvement of pharmaceutical industries where profiteering from sickness appears to dominate society, are psychotropics helping or hindering the mental health of the nation?
Psychiatric diagnosis and pharmaceutical industry involvement.
‘A pill for every ill’ appears to be the underlying marketing strategy from pharmaceutical companies on their quest to medicalise human emotions associated with mental health. Dr. David Kaiser (2014) reports that, Patients have been diagnosed with chemical imbalances, despite that no test exists to support such a claim, and that there is no real conception of what a correct chemical balance would look like
With this in mind, why do professionals still prescribe psychotropic medication and how do the pharmaceutical industries influence psychiatric diagnosis? Alternatively, should we instead ask how does psychiatric diagnosis uphold and justifythe promotion and sale of psychotropics by pharmaceutical companies?
Moncrieff’s (2013) drug-centred model suggests that psychoactive drugs do not target the cause of distress, for example she likens the administration of anti-depressants to those with a diagnosis of depression to be akin with providing alcohol to people with social anxiety; the problem is not effectively cured, instead only temporarily alters the brain state which can leave a door open for future relapse if the root cause of the sadness experienced is not dealt with.
Pharmaceutical industries are responsible to their shareholders, thus making a profit for and on behalf of investors supports the financial upkeep of said companies. The marketing strategies of such pharmaceutical organisations is heavily underpinned by the biological disease model (Timimi, 2008). As the marketing and prescribing of psychotropic medication continues, the question we can ask is whether this can influence (and to some extent uphold) the diagnostic system and the criterion included.
Though there is little empirical support on the chemical imbalance theory and the serotonin hypothesis (Moncrieff, 2022) to justify the selling and prescribing of psychotropic medication, they are both still concepts widely accepted by the public and promoted by professionals.
Pharmaceutical companies since the 1990s have promoted anti-depressants on the basis that people suffering with depression ‘must have low serotonin’, between 1998 and 2018 prescriptions of anti-depressants tripled (Bogowicz et al., 2021) with usage continuing to rise across the globe both on a short-term and long-term basis (Mojtabai & Olfson, 2010) – the underlying belief for users of the medication being that they have a chemical imbalance.
However, as it stands there is no evidence to substantiate claims such as the chemical imbalance theory, placebo-controlled trials using artificial depression rating scales signify only a ‘small’ difference between the placebo and psychotropics (anti-depressant). Moncrieff (2018) reports that in these trials’ mania scores will go down if a participant is provided with a psychoactive compared to a placebo. Inevitably, as the psychoactive alters the brain chemistry, the effects of the anti-depressant will create change in a person similar to one of sedation but this does not conclude that the psychoactive has helped to resolve the underlying distress.
Cosgrove et al., (2014) purports the major financial stake pharmaceutical industries had on the outcome of the recently published DSM-5. If we return to our earlier point made regarding the exclusion of bereavement as part of the Major Depressive Disorder diagnosis, Cosgrove et al., (2014) state that pharmaceutical industries were already operating on clinical trials of drugs that could be used to treat the new addition of disorders in the DMS-5 well before the publication in May 2013.
As expected, shareholders with a stake in pharmaceutical companies will expect to see a return on their company share, in turn meaning drug companies will need to generate and market past, present and future psychotropic drugs to achieve the expectation. This undoubtedly raises concerns around the probable bias of drug intervention for mental health distress, not only due to the financial interests attached to panel members of the American Psychological Association but with regards to how valid the categories in the diagnostic system are if every time a new disorder is created someone is set to make a large profit.
Is there anything good that come from the psychiatric diagnosis system?
Neoliberal societies and the economic policies enforced across the globe have shaped a dissatisfied population, with a huge transfer of wealth from public control to private ownership which sees people work longer hours for less money and reduced job security (Hamilton, 2003).
The idea that if we feel ‘low or depressed’ being due to a chemical imbalance instead of the fact that we are living in a society underpinned by neoliberal values of competition, instant gratification and consumerism which has seen our standard of living decrease may give justification for those who want their ‘suffering’ validated through a psychiatric diagnosis and treatment (Timimi, 2016).
With people being pushed into absolute poverty, increased usage of food banks of those who work full time whilst the billionaire class rise (Trussell Trust, 2022) how do families find the strength to get up and survive each day when what they feel may be a terrible misery; one in which they see no escape from, a misery where talking therapy is not sufficient, nor rapid, or a method that works for their distress?
Acknowledging distress in a person and providing a diagnosis can result in a sense of relief for the person, in that they may feel they can now receive a ‘cure’ for their mental health condition and a gateway for help or other benefits for example being temporarily excused from their social roles (Parsons, 1951).
With some of the benefits of the diagnostic system in mind, there could be an argument for the upkeep of psychiatric diagnoses and medical intervention if, from a sociological perspective it will enable people to function effectively and perform their societal duties; doing what needs to be done in order to prevent people effectively killing themselves, (Durkheim, 1951).
However, the dangers are in the self-fulling behaviours that can develop as a result of having a psychiatric label as some may find an attachment to their given diagnosis as a way to remain exempt from social roles, additionally there could be concerns with medication reliance.
Clinicians such as Peter Kinderman (2022) have proposed alternative ways of diagnosing individuals which sees a move away from the DSM criterion to a method that is primarily supported by the concept of formulation over diagnosis; changing the narrative from, what’s wrong with you to what happened to you.
From a humanistic perspective, it can be said in order to survive we require a sense of belonging, purpose, and growth if we are to become all that we are capable of being. If we work without cause or purpose, if we do not see a reflection of ourselves in the work we carry out, if we feel unheard, marginalised or that we do not belong – how long would it take before pathologising the distress that might inevitably arise for some given the formulation above?
Alternatively, how long would it take before a drug is created claiming to ‘cure your loneliness so that you can reach your full potential?’
References
Articles. (n.d.). Sami Timimi. Retrieved October 30, 2022, from https://www.samitimimi.co.uk/publications
Anti-Depressants Have Been Debunked: Joanna Moncrieff. (n.d.). Www.youtube.com. Retrieved October 30, 2022, from https://www.youtube.com/watch?v=r2nVAxf-c8A
admin. (2014, March 30). VIDEO: Do psychiatric drugs target an underlying disease? –. http://cepuk.org/2014/03/30/video-psychiatric-drugs-target-underlying-disease/
Ang, B., Horowitz, M., & Moncrieff, J. (2022). Is the chemical imbalance an “urban legend”? An exploration of the status of the serotonin theory of depression in the academic literature. SSM – Mental Health, 2, 100098. https://doi.org/10.1016/j.ssmmh.2022.100098
Allsopp, K., Read, J., Corcoran, R., & Kinderman, P. (2019). Heterogeneity in psychiatric diagnostic classification. Psychiatry Research, 279, 15–22. https://doi.org/10.1016/j.psychres.2019.07.005
Cosgrove, L., Krimsky, S., Wheeler, E. E., Kaitz, J., Greenspan, S. B., & DiPentima, N. L. (2014). Tripartite Conflicts of Interest and High Stakes Patent Extensions in the DSM-5. Psychotherapy and Psychosomatics, 83(2), 106–113. https://doi.org/10.1159/000357499