Allen J Frances M.D.

Saving Normal


Does It Make Sense To Scrap Psychiatric Diagnosis?

A debate on shifting paradigms

Posted Oct 28, 2013

I am always sceptical of suggested new 'paradigm shifts' and worry that ambitiously striving for them will wind up causing more harm than good.

One example– DSM 5 failed so badly precisely because it promised a 'paradigm shift' in psychiatric diagnosis. This self imposed pressure to produce bold innovations led to poorly considered decisions that may mislabel as mentally ill millions of normal enough people who would do better left alone.

Another example– The National Institute of Mental Health has neglected the current needs of the mentally ill because of its preoccupation with producing a 'paradigm shift' in understanding the neural networks that cause psychiatric problems. In the process, NIMH has become almost exclusively a brain research institute at the expense of what should be a more balanced agenda- one that would also include other crucial tasks like psychosocial research, health services research, and public advocacy to ensure better care and housing for the severely mentally ill.

NIMH is over-promising that it can eventually deliver dramatic neuroscience breakthroughs to transform the diagnosis and treatment of mental illness—when past experience teaches that its new findings will likely be very slow in coming, piecemeal, and difficult to translate into better clinical care.

Meanwhile NIMH is ignoring the current sorry state of mental health services that have resulted in one million shamefully neglected psychiatric patients being inappropriately warehoused in prisons. Dreams of the future potential of a neuroscience 'paradigm shift' have blinded NIMH to the crying needs of patients in the present.

Third example– the Division of Clinical Psychology (a sub-section of the British Psychological Society) has issued a statement announcing its own opposite brand of radical 'paradigm shift.' While paying superficial lip service to the role of brain in generating mind, the DCP suggests abandoning altogether what it regards as an overly restrictive biomedical model- it would eliminate any role for psychiatric diagnosis and instead focus on the role of external stressors in generating symptoms.

Dr Lucy Johnstone, a contributor to the DCI statement, has been its most articulate and energetic supporter. Writing here in a personal capacity, she requested we have this dialogue to sort out areas of potential agreement and continuing disagreement.

Lucy writes: "Let me start by saying that I admire Allen’s courage in speaking out against the limitations of psychiatric diagnosis. He concluded his recent discussion with Eleanor Longden with a long list of their areas of agreement, which I endorse."

"It is important to acknowledge that there are also some significant areas of disagreement in the general debate, and this post is an attempt to explore them honestly and respectfully."

"They are to do with the biomedical model on which psychiatry is based; that is, the assumption that mental distress is mainly caused by biological dysfunctions in the brain and body, perhaps triggered by life stresses."

"The alternative view can be summarised as the belief that people break down for reasons in their lives and relationships—loss, trauma, abuse, poverty, discrimination, domestic violence and so on. These experiences are bound to be reflected in the brain and body in some way, but the evidence suggests that even the most extreme forms of mental distress can be understood in the context of life circumstances and the sense that people have made of them; in other words, by asking not ‘What is wrong with you?’ but ‘What has happened to you?’"

"Supporters of the traditional psychiatric view do not divide neatly by profession. It is disputed by some psychiatrists, and held with various degrees of conviction across and within the other mental health professions. Likewise, service users and carers have a range of opinions. Feelings can run high and critics of psychiatry are often told that they are extreme, divisive, polarising, ‘anti-psychiatry’ and so on. These are not helpful responses; rather, they are attempts to suppress legitimate challenges to the orthodoxy. We must stick to criticising ideas, not people."

"We are at a crossroads in psychiatry. Supporters claim that science will one day identify the biomarkers that have so far eluded detection, so that psychiatric diagnosis will have a sound basis and psychiatry’s status as a branch of medicine will finally be justified. Critics argue that after decades of failed research, it is time to replace this model by a trauma-informed perspective, as described above. I share their view that the biomedical paradigm has comprehensively failed. Now, with some of America’s most senior psychiatrists admitting that psychiatric diagnoses are not valid, that we haven’t actually found the faulty genes or brain dysfunctions, and that medication can actually worsen outcomes, it may be on the brink of collapse."

"One day science, or survivor protest, or both, will decide the issue once and for all. In the meantime, in a spirit of wishing to find a workable way forward, I suggest that we have a conversation with service users along these lines: ‘Some people would call your experiences bipolar/schizophrenia/personality disorder, but we currently have no evidence that there really is such an illness. This means that medication isn't best understood as treatment for an illness, although it may be helpful. Other people argue that it is better to try and understand your feelings in terms of what has happened to you, without using these labels. It’s your choice as to how you prefer to see your problems. What would make most sense to you?'"

"I suggest that in our current state of uncertainty, this is the only intellectually, professionally and ethically respectable position to take. It doesn’t involve firing psychiatrists, or abandoning medication. It simply requires us to be honest about the situation we are in, and to offer service users genuinely informed choices. Is this a compromise that will allow us to move forward together?"

Thanks, Lucy. We do have much more agreement than first meets the eye, but do disagree on emphasis.

We are of one mind on that the strict adherence to a reductionistic, biomedical, brain science model is simplistic, oversold, misses the always important psychological and social factors involved in causing emotional problems, and is limiting and bad for patients.

We agree that all mental distress must be understood in the context of the person's psychology, past and current stressors, and social supports (or lack thereof).

We agree that there are many different ways of understanding and dealing with emotional difficulties and that strident competition among these is unhelpful.

We agree that limitations in current knowledge of the complexity of brain and behavior call for humility and tolerance of uncertainty.

But then there are our areas of continuing disagreement. I fear that you would replace biological reductionism with a psychosocial reductionism that is equally incomplete, and potentially harmful to patients. Human nature encompasses the complex interaction of biological, psychological, and social factors and understanding and treating psychiatric symptoms requires adequate recognition of each. The biological model has been greatly oversold and medication has been greatly overused- but both remain essential if kept in their proper place.

We also disagree on whether the neuroscience effort has failed. In my view, the research has been enormously successful in helping us understand normal brain functioning and that over time, in very small steps, this will result in a better understanding of abnormal brain functioning. We can't expect more from neuroscience than it can quickly deliver, but we shouldn't discount its role altogether.

I also disagree that our current system of psychiatric diagnosis can suddenly be abandoned and replaced with your narrow psychosocial approach. We all agree that psychosocial factors are important in the onset of all symptoms, but you have not yet translated this general truth into any specific and well tested method. You would have to bring a great deal of evidence to the table before giving 'paradigm shifting' advice to strike out in such a radically new direction. Instead, your suggestions are completely untried and untested- a useful call to future research, but not legitimate grounds for a radical change in current everyday clinical practice. Any new 'paradigm shifting' system of treating patients requires careful vetting for risks before it will be ready for prime time.

My long experiences working on the DSM method of psychiatric diagnosis have made me (perhaps more than anyone) acutely aware of all its limitations, blindspots and weaknesses- and I have been pointing them out for more than thirty years. Psychiatric diagnosis is just one piece of a complicated puzzle, but (with all its limitations) it is still a useful piece. I would definitely not trust a clinician who restricted himself to a simple minded application of DSM diagnosis, but I would equally worry about a clinician who ignored psychiatric diagnosis altogether.

We also disagree about the role of psychiatric medication. I have persistently warned the public and clinicians against the excessive use of unnecessary psychiatric medication to treat problems that are no more than an expectable part of everyday life. And I have always been a practising psychotherapist who advocates therapy as first line treatment for symptoms that are of mild to moderate severity. But for severe psychiatric problems, medication is usually essential- psychotherapy may also be of great help, but is not enough. I am worried about making medicine seem only optional even to those who desperately need it. This sounds good on paper, but misses the clinical reality and can do great harm to those who will not get better without it.

The integrated bio/psycho/social model has a long tradition and remains the best guide to clinical practice. It has always been threatened by reductionisms that would privilege one component over the others- but this interacting tripod of bio/psycho/socialapproaches is unstable and incomplete without the firm support of all three of its legs. In my view, it is equally mistaken to call for a premature 'paradigm shift' tilting toward biology (as was suggested by DSM and NIMH) or a 'paradigm shift' tilting toward the psychosocial (as was suggested by the DCP). An integrated bio/psycho/social model is essential to understanding each patient and also to unite the mental health professions.

And we certainly need to be united. Mental health care is terribly disorganized and grossly underfunded, especially (but not exclusively) in the US. I think we should find a unified voice to advocate for better care, not be distracted by debates about paradigm supremacy—especially since all three paradigms are absolutely necessary.