Diagnosis and society

Citation

McKenzie, K. (2012), "Diagnosis and society", Ethnicity and Inequalities in Health and Social Care, Vol. 5 No. 4. https://doi.org/10.1108/EIHSC-07-2013-0008

Diagnosis and society

Article Type: Editorial From: Ethnicity and Inequalities in Health and Social Care, Volume 5, Issue 4

In May 2013 the American Psychiatric Association (APA) published the fifth version of the Diagnostic Statistical Manual (DSM5) (American Psychiatric Association 2013). It has led to significant controversy (British Psychological Society, 2012; American Psychological Association, 2012).

The DSM is just one of three systems of diagnosis which are used worldwide. It is not the most used system but is preferred in research and by many pharmaceutical companies, regulating bodies and health insurers because it is very rule based. The other systems are the international classification of disease (ICD) published by the World Health Organization which is used in more countries across the globe than the DSM and the Chinese Classification of Mental Disorders which is a hybrid of the DSM and ICD systems but also includes 40 culture specific diagnoses and is used in some parts of East Asia.

Changes in the way psychiatrists diagnose always cause controversy. This is in part because a small group of people decide what may be classed as an illness and what is not but, in reality, diagnostic systems reflect not only how that small group of diagnosticians see the world but also what the world asks, or is happy for, psychiatrists to do. Changes in DSM, like any system, say as much about current zeitgeist as it does about psychiatrists. Diagnosis is strategic, political and cultural.

DSM history

The history of diagnosis and indeed DSM gives a snapshot of changing perceptions of mental illness and how leaders in psychiatry in the USA have responded to external forces. Over time the diagnoses have become more elaborate. About 26 percent of the US population may have some sort of psychological disorder if they were interviewed using a diagnostic instrument (Kessler et al. 2005).

It is not clear that that was ever the intention and some including people who have presided over some the biggest expansions in diagnosis in the DSM would argue that the system has lost its way (Frances, 2013).

Initial attempts at diagnostic systems were driven by need and were pragmatic. The first official attempt at developing a classification system in the USA was for the 1840 census. Governments worldwide were starting to take responsibility for the mentally ill. States were building huge hospitals and so getting a handle on the possible volume and cost of this enterprise was important. There was one category “idiocy/insanity” reflecting the need that the USA had for information. The government was not interested in complex ideas of the psyche or symptoms. They were interested in people who could not function in society and they may have to look after.

By 1917 with the new mental hospitals full, the National Committee of Mental Hygiene and members of what was to become the APA decided it would be useful to have a more detailed diagnostic system to help work out who needed what treatment. They developed a manual for the use of institutions, which had 22 diagnoses (Greenberg et al. 2004).

The impact of war ushered in a new need for diagnosis. First World War had left a large number of psychological casualties and it was hoped that better assessment before entering the services could prevent this. In 1943, Medical 203 was devised, published and adopted by all US Armed Forces, psychiatrists returning from military duty and the Veterans Administration. (Houts, 2000).

But things really changed when global politics became involved. It seems that at this time the clear function of the US mental illness diagnostic system was lost.

In 1949, the World Health Organization released the sixth version of the ICD and included a section on mental disorders. But, post-Second World War the USA was in the ascendancy. The new era was based on winning hearts and minds. US ideas and the export of the American dream were central to the new political landscape. Rather than accept the ICD classification, the USA decided it needed to define the mind for itself. In 1952 the APA produced an adapted version of Medical 203 and sent it to 10 percent of its membership for approval. The agreed document, DSMI, listed 106 mental disorders. DSM II was published 16 years later and listed 182 disorders (McKenzie, 2013).

Both DSM-I and DSM-II were based on the theories of psychodynamic therapists. They were discursive rather than descriptive. Disorders were considered reflections of broad underlying conflicts or maladaptive reactions to life problems. They were not well defined and did not do a good job in decreasing the subjectivity of diagnoses. They soon got into trouble. For instance, there was a backlash because homosexuality was considered an illness. Furthermore, studies in the late1960s showed that rates of diagnosis of schizophrenia were much higher in the USA than nearly all of the rest of the world. And on top of that an influential paper in the journal Science demonstrated that sane people with minimal symptoms would be diagnosed and treated under DSMIII as if they had severe mental illnesses (WHO, 1973; Rosenhan, 1973).

Though heterogeneity of rates of illness could have been considered acceptable, higher rates of schizophrenia and inaccuracy in the diagnostic system were not. The reaction was DSMIII. It aimed to improve the uniformity and validity of psychiatric diagnosis and to sort out the problem of over-diagnosis of schizophrenia. Psychodynamic theories of pathology were abandoned. Diagnosis was made on symptoms alone and these were clearly defined. The number of diagnostic categories increased to 265. And, interestingly, the chair of the DSMIII committee later criticized what he had done saying that it led to the medicalization of 20-30 percent of the population who may not have had any serious mental problems (McKenzie, 2013).

The next iteration, DSMIV moved away from making a diagnosis on symptoms alone because it was argued that symptoms that caused no problem to an individual should not be considered an illness. In order for a diagnosis to be made the problems had to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

Though this added a subjective element and made diagnoses nimble enough to be used in many different contexts, it also caused difficulties based on the fact that impairment of social functioning depends on what you are being asked to do.

Including society and culture

The journey of DSM had been from a specific and narrow remit to an unspecified attempt to categorize and measure human behavior.

Culture and society had been included variably along the way. Parts of society had been important in setting the question: i.e. we need a diagnostic system for x, y, or z. Some were also involved in looking for and identifying trusted professionals to work on the project. The culture of professionals was important in deciding how to frame the answer, for instance, by deciding which theories were used to define symptoms and illness. Lastly in DSMIV, the subjective element to defining symptoms put culture and society in the middle of the fundamental building blocks of diagnosis.

However, it is not clear that the inclusion of culture and society has been well thought through or that the right people have been at the table to guide psychiatrists in making those decisions. It may be that a wider consideration of the place of culture could have been included in the conceptualization of the philosophical and scientific basis of the project. This may have specifically helped because the current controversies are based on the fact that the project has become very large and the critiques, such as the biomedical bias (British Psychological Society, 2012) are in part a reflection of differences in the way professions view the world.

The central difficulty is that rather than trying to stick to a specific goal as the original systems in the USA did, DSM5 tries to give guidance to clinicians about all human behaviors that could cause problems and to classify them. There are problems with using current medical diagnostic logic to do this in psychiatry. Though medical conditions reflect discrete problems with clear pathology, psychiatric diagnoses may not result from a clear discrete pathological problem and so are not discrete entities. Symptoms may reflect a variety of underlying issues. Putting them together and saying they constitute an illness only works if there is pathology to back it up. There is rarely specific pathology in mental health disorders. Medical logic is used by psychiatrists because they are doctors and because the classification systems used in the rest of medicine are considered scientific. But it may be that medical science works well for illnesses of the brain but may be less good at helping to define mental illness.

A further example of how this plays out is the use of function as important in deciding on whether an issue is a symptom. Function is an interaction between the individual and the environment. So if function is important then it is not clear that a system focussed on the individual is sufficient. In order to make an accurate diagnosis ideally we would need to be able to assess both the individual and their environment. We would need better understanding the social forces that shape their world. These forces would be different for different countries and for different groups within a country.

If symptoms are not just problems that the individual has but are problems that the individual has in their interaction in the world then there are at least two targets for treatment: the individual, and society.

If 20-30 percent of people are having problems then it could be argued that this should lead to a discussion about whether we construct society to support people psychologically or whether we want to continue the process of individualizing, diagnosing and treating the problems people have with the way we have set up society. The issue of public health psychiatry comes very quickly to the fore and the importance of advocacy and social change.

The future of cross culturally valid diagnoses

The logical extension from the fact that neither of the current super-powers is happy for others to define madness in their countries is that diagnosis can be seen as strategic. In addition there may be difficulties importing DSM diagnoses to other countries because they are so based on one culture. The DSM does not attempt to be universal. It is produced by the APA for America, though it includes some ideas from other experts in high-income countries.

ICD is more international. But I was unable to identify where different psychological perspectives and indigenous systems of classification were included in the overall conceptualization of how diagnoses are made. I have been unable to find an articulation of a reliable system for including the diversity of ideas from across the world in ICD. I have not seen a system developed to draw consent from different cultural groups in any systematic way before labeling the ICD as international.

Problems with the lack of demonstrated cross-cultural validity of many psychiatric diagnoses makes comparisons between countries difficult. Ignoring, this major problem, the issue that many of us deal with is within country problems, where marginalized groups have variable rates of mental health problems. In general, socio-economic hardship increases the rates of mental illness and decreases the rates of recovery. There may be a buffering effect in some ethnic groupings with cultural attitudes decreasing the risk but in others the interaction between minority and majority cultures is problematic.

Current diagnostic systems do not include a proper cultural dimension and do not properly capture these issues.

The aim here is not to demonize the DSM or other diagnostic systems. The process is being driven by well-meaning people who are trying to do their best. But it may be that there are some fundamental questions that need to be answered if we are to develop proper systems.

The first is why are we doing this? The initial systems in the USA had a clear function but it is not clear that our current systems are as focussed.

Second, who should be at the table and why? Given our conceptualization of symptoms as based in the interaction between individuals and society, who else apart from physicians needs to help define diagnoses?

Third, how do we get consent from communities, different cultures and countries to produce some standard diagnoses if we want to and what does that look like?

Fourth, how do we document and try to include different socio-cultural perspectives of mental health problems?

Fifth, do we want to continue diagnosing individuals when we know that many of the issues are social? If not how do we properly include the social forces that shape mental illness in our diagnosis.

And last, what should the extent of our system of diagnosis be, given that for most diagnoses there are no treatments and for those where there is treatment it is not available to most people in most places in the world?

Perhaps answers to these questions would help us both understand and deal with the controversy that is DSM before the ICD produces its new mental health manual in a couple of years time.

References

American Psychological Association (2012), “Petition against DSMV”, available at: www.ipetitions.com/petition/dsm5/ (accessed 12 July 2013)

American Psychiatric Association (2013), “DSM5 task force”, available at: www.dsm5.org/Pages/Default.aspx (accessed 12 July 2013)

British Psychological Society (2012), “Statement of DSMV”, available at: www.bps.org.uk/news/society-statement-dsm-5

Frances, A. (2013), “DSM in distress psychology today”, available at: www.psychologytoday.com/blog/dsm5-in-distress

Greenberg, S., Shuman, D.W. and Meyer, R.G. (2004), “Unmasking forensic diagnosis”, International Journal of Law and Psychiatry, Vol. 27 No. 1, pp. 1-15

Houts, A.C. (2000), “Fifty years of psychiatric nomenclature: reflections on the 1943 War Department Technical Bulletin, Medical 203”, J Clin Psychol, Vol. 56 No. 7, pp. 935-67

Kessler, R.C., Chiu, W.T., Demler, O. and Walters, E.E. (2005), “Prevalence, severity, and co morbidity of twelve-month DSM-IV disorders in the National Co morbidity Survey Replication (NCS-R)”, Archives of General Psychiatry, Vol. 62 No. 6, pp. 617-27

McKenzie, K. (2013), “Mind games”, available at: http://thewalrus.ca/mind-games (accessed 12 July 2013)

Rosenhan, D.L. (1973), “On being sane in insane places”, Science, Vol. 179 No. 4070, pp. 250-8

WHO (1973), Report of the International Pilot Study of Schizophrenia, Vol. I, World Health Organization, Geneva