The Mad, Mad World of Psychiatric Diagnosis

Is it time to tear up the rule book and design a system of mental health diagnosis that is user-friendly, scientific and weighs less than a small fridge? Connor Kinsella thinks we’re long overdue.

You’ve dimmed the lights, lit the candles, chilled the wine, smoothed down the Egyptian Cotton and put Barry White on repeat shuffle. But your partner seems far more interested in catching up on this week’s hot new blog from You forlornly pick up the CD cover and whisper “Sorry Barry. Not tonight.”  But you see, it’s not you, it’s your partner. Or more precisely, their HSDD. Eh? Oh sorry, I meant to say Hypoactive Sexual Desire Disorder.
I’m not making this up. This is a genuine diagnostic label plucked from the weird and labyrinthine world of psychiatric classification, where the everyday and the humdrum of human behaviour becomes labelled and filed as a ‘disorder’ and not your partner’s lack of enthusiasm for scented candles and a set of clean sheets.
There are two classification systems in use throughout the world of mental health care. In the UK and Europe, clinicians generally refer to the ICD-10 Classification of Mental and Behavioural Disorders published by the World Health Organisation, but clinicians and researchers worldwide also refer heavily to the American Psychiatric Association’s DSM-IV system.
Both systems provide a means of reference to both practitioners and research scientists, and have made considerable progress in moving mental health diagnosis away from ‘a case of the vapours’ or ‘nervous exhaustion’ and toward a scientifically valid and standardised means of being able to tell a patient they suffer from Schizophrenia, Bipolar Disorder or Anorexia Nervosa. Diagnostic classification has also paved the way for researching mental health conditions which, unlike most physical illnesses, are invisible to the blood test or scanner.
As a nurse I’ve spent many valuable hours helping people understand their emotions, thoughts and behaviours within the context of a psychiatric diagnosis and the treatment that is being offered to them. People who are unwell are generally more than happy to know exactly what is wrong with them. They want to be able to put a name to their collection of signs and symptoms, even where those signs and symptoms are clouded (as is often the case with mental health) by more than a little subjectivity. Psychiatrists can and do get it wrong for all sorts of reasons, but our current evidence base is certainly strong enough to be able to offer a firm and often reassuring definition to most people suffering most of the common mental disorders.
The American Psychiatric Association has for some years been working on the latest version of the DSM franchise, a term not inappropriate by way of the rather large financial income the AMA receives from its publication. The robustly named DSM-IV Task Force has been taking hits from all directions while it’s exclusively medical membership (itself a bone of contention) have sat on the various sub-committees coming up with shiny new diagnoses such as Disruptive Mood Dysregulation Disorder, which as far as I can glean could just as well be described as ‘Stroppy Teenagers Being Stroppy Disorder’. There is also a proposal  for a new Apathy Syndrome (a possible explanation for X-Factor’s less than sparkling viewing figures these last few weeks?) and another little beauty aiming straight at the heart of anyone reading this. Yep, you guessed it. Internet Addiction Disorder.
The critics are not just critical but fully tooled up with an arsenal of brickbats with which to slap the DSM-V Task Force hard across the buttocks, a phrase destined to have this blogger labelled with Sado-Masochistic Smutty Reference Disorder or it’s nearest relative. The British Psychological Society and the American Psychological Association have both weighed in with extensive criticisms of the proposed DSM-V prior to it’s publication in the Spring of 2013. But there are many, many more missiles being aimed at the Task Force and, lets face it, it’s hardly a moving target.
With diagnostic toolkits so loaded with the potential to change peoples lives, deny or facilitate state benefits such as Disability Living Allowance or Incapacity Benefit, and the template by which researchers worldwide base what is a growing and increasingly useful body of good science, do we really want labels based on a single case report written by an obscure psychiatrist which has no basis in research evidence nor any form of genuine scientific validity?

Do we really need, as is proposed by the DSM-V Task Force, even lower thresholds for diagnoses such as the already controversial Attention Deficit Hyperactivity Disorder, a ‘condition’ which has already made huge profits for the pharmaceutical industry and is set to become even more profitable with the suggested lowering of the bar?
For the jobbing mental health professional it is safe to say that a large percentage of both ICD-10 and DSM-IV is already of little or no use to anyone other than the odd psych-nerd playing Mental Health Trivial Pursuit with their psych-nerd friends. What both professionals and those who come to them for help really need is a diagnostic system which actually reflects this salient fact. Psychiatric diagnosis really isn’t rocket science.

Medics worldwide may secretly fantasise about that ’House moment’ where they wander into the clinic eating a sandwich and looking as if they’ve just got out of bed, casually saving the patient’s life just as they flatline with an incredibly obscure diagnosis that nobody else has heard of.

But in real life I would challenge any mental health professional to come up with more than a dozen clearly delineated, well researched diagnostic labels used in day-to-day psychiatric practice. Hippocrates came up with a quite reasonable psychiatric classification while most of us were still throwing spears at mammoths, so how have we managed to come up with such a convoluted and often meaningless plate of spaghetti as DSM and ICD?

Our diagnostic systems are already unwieldy, unscientific and wildly over-inclusive. Revised models ought to be filtering out the nonsense and returning us to some semblance of science and common sense. But DSM-V is scaring the pants off far too many well qualified observers for the critiques to be merely a hobby horse of those still clinging to battered copies of The Divided Self

Psychiatric diagnoses are big labels applied to many, many people and are far too important to be based on bad science, personal ego and a book that is often of more use as a door-stop than a frame of reference.

Right. I’m off to my analyst via the scented candle shop. Wish me and Barry luck. 

A Longer View of Winterbourne View

Thanks to a few sleepless nights of keyboard bashing and the odd complementary tweet from The Guardian’s @patrickjbutler his employers have kindly (and perhaps unwisely) invited me on to their new Social Care Comment site. Here’s my take on the aftermath of the Winterbourne View scandal.

There have been many initiatives, reports and government level strategies in recent years but few, perhaps none, have hammered at the ramparts of care for learning disabled adults with the force of BBC’s Panorama expose Undercover Care: The Abuse Exposed.
Broadcast on 31 May this year, Twitter exploded almost immediately in response to some of the most unwatchable scenes on television in many years. As the blogosphere and online communities followed not far behind in an eruption of public horror, it was clear that that the care of society’s most vulnerable people had hit a watershed. My own blog posts on the subject and the comments of many both on my own site and countless others made me realise I wasn’t alone in being unable to sleep that night and getting up out of bed to bash seven bells out of my laptop.
But the media bandwagon rolls on and even those most horrified by those scenes are once again tweeting about X-Factor or the bedroom antics of Premiership footballers. Those of us who work in social care might suspect that the status quo has resumed. The sadists within our ranks have resumed their water-boarding, and the senior executives of companies providing care can once again get back to a nice round of golf. So what, if anything, has changed in 133 days?
As a social care training provider my colleagues and I meet hundreds of support staff from local authorities, charities and other care providers up and down the country, and strange as it may seem in the few months since that edition of Panorama I’m left with a glass which is, if not quite half full, is certainly far from empty.
Firstly, we can look to the already well publicised structural changes that have taken place. Both Castlebeck and the Care Quality Commission (CQC) have not just been caught with their trousers down, but suffered the acute embarrassment of being caught in a very intimate moment by an elderly relative popping round for a surprise visit. “Coo-ee, the door was open and… oh dear!”
But my recent experience of running training for care staff perhaps tells us about more than the closure of poor quality homes and a rapid increase in CQC inspections. A public who once knew, saw or heard little about learning disabled people and assumed that it was still the NHS and local authorities providing for them now seems to have woken up to the fact that much of our social care system is now run at a very tidy profit by executives who think more of feeding a racehorse than meeting the needs of a young woman with autism.
Thanks to the Winterbourne View scandal and the subsequent demise of Southern Cross, we now seem now more capable of demanding the sort of excellent, small-scale services where individualised care is more than just an empty mission statement written on a dusty wall plaque. We might even argue that the average man or woman in the street is now much more aware that the care and support for their vulnerable relatives is worth a good deal more than a healthy bottom line, particularly when that comes at the price of shoddy management, poor staffing and a training culture which means little more than the annual fire lecture. 
But no television documentary is ever going to completely rid social care of the occasional rotten apple who, through a combination of individual inadequacy and limp supervision, will quickly go on to sour the rest of the fruit bowl. But we can hope that in the aftermath of Winterbourne View we can all blow the whistle and perhaps get those who could and should have been listening to realise that Panorama wasn’t just a one-off. We’re all watching now.  

Connor Kinsella is an author and training consultant at JCK Training