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Rewriting the rulebook on mental illness

Tom Feilden | 10:55 UK time, Wednesday, 28 July 2010

When does sadness over the loss of a loved one tip over into clinical depression? How do you tell the difference between schizophrenia and some other form of psychosis?

Defining what is, and what isn't, mental illness is actually quite a hard thing to do. Inevitably it's a subjective process based on a careful and formalised assessment by health care professionals. To help, mental health practitioners have traditionally relied on a classification system developed by the American Psychiatric Association and known as the Diagnostic and Statistical Manual of Mental Health, or DSM.

This diagnostic "bible" is currently being re-drafted - the first substantial re-write since 1994. But researchers here are growing increasingly concerned at a series of changes they say are being made to widen existing categories, and the addition of a staggering range of new conditions.

Writing in the Journal of Mental Health, professor Til Wykes claims the new definitions are so broad that, in future, almost no one will qualify as normal. She's worried about the implications of branding so many people, and particularly children, as mentally ill.

"It shrinks the pool of normality to a puddle" Professor Wykes says, "there are going to be fewer people who won't end up with a diagnosis of mental illness".

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One particularly Orwellian new addition is Psychosis Risk Syndrome, which singles out people who are thought to be at risk of developing a serious psychotic illness such as schizophrenia. Other new conditions under consideration include; mixed anxiety depression, binge eating and temper dysregulation disorder with dysphoria.

Dr Nick Callard, from the Biomedical Research Centre for Mental Health at the Maudsley NHS Foundation Trust, said labelling individuals as "at risk" of developing a disorder like schizophrenia was likely to cause a great deal of distress, and could expose them to social stigma and discrimination.

The researchers accuse the US authors of moving ahead of scientific progress in mental health, which has made relatively little headway over the last 16 years. The new edition of the DSM is due to appear in May 2013.


  • Comment number 1.

    As a mental health practictioner, I was surprised and a bit disappointed by Dr. Callard's apparently not hearing the interviewer's question about "normal." It seems he missed an opportunity to confront this mainstream idea that those who receive a mental health diagnosis are not "normal." To address the reality that most people will, at minimum, experience depression or anxiety at some point in their lifespan (irregardless of whether they need or seek help with these challenges). And the challenging professor Wykes somehow seems to be suggesting we should rewrite the diagnostic manual so as to create some level of 'acceptable suffering' on the theory that 'most people experience that.' I would argue that medical reimbursement concerns probably lie at the heart of this 'acceptable suffering' theory/approach.

  • Comment number 2.

    Do you think that the NHS Vital Signs prioritisation system seriously underweights the suffering caused by mental illness? Surely the awful agony mental ill-health causes throughout entire lifetimes, for the patient and also their family, including suicides, far outweighs many other medical conditions? A broken leg leads to a few months pain but nice warm wishes from others. People do not kill themselves over a broken leg....
    Perhaps the most important research now should be to examine this (survey people who have had mental and other ill-health, asking them to compare the suffering), and then to mount lobbying and public pressure for depression/anxiety to be moved into the key 'orange bands' (even if at the expense of less valuable acute or aged-life-extending spending).

  • Comment number 3.

    This comment was removed because the moderators found it broke the house rules. Explain.

  • Comment number 4.

    I think comment2 is spot on. However, I cannot imagine anything at all being done about it. Count the get well cards on the ward. Ask patients how many letters they receive from friends and family when given the diagnosis.

    Another point.
    Where are all the comments? There is no interest. Joe bloggs couldn't care less.

  • Comment number 5.

    I think that a lot of people who claim that they suffer from a mental illness are malingerers: it is the "bad back" of the 21st century.

    Psychosis Risk Syndrome could perhaps be used to make a pre-emptive strike on anti-social elements in society such as violent criminals. The evidence may not exist that shows that they are psychotic, but their behaviour could give cause for concern. With the right drug they could be neutralised.

  • Comment number 6.

    “Good Grief!”
    The DSM 5, is supposed to establish the boundary between mental disorder and normality.
    When DSM 5 is implemented, many people who experience completely normal grief would be labeled as having a depressive psychiatric problem. Suppose your child dies; you feel sad, take less interest, have little appetite or energy, can’t sleep…According to DSM 5, your condition is “major depressive disorder”.
    This seems inhuman.
    Grief allows us to work through life's traumas.
    When your child dies, are you supposed to shrug and say: “Well, he was a nice kid.”
    Some say that psychiatrists are in bed with drug companies; maybe some are, but on the whole, I don’t believe this. I believe the proposed changes come out of good intentions. It’s a fact that, during bereavement, some people do not emerge from their depression. The real question is when is psychiatric intervention warranted? And I believe the answer is best decided by family and friends.
    Remember Huxley’s “Brave New World” - As soon as one of the dehumanized “persons” experienced any discomfort, s/he would just pop the happiness pill.
    But normal grief is good for us, normal for us.
    The new DSM5 seems to be addresing fear. Fear of what? Any and all suffering, any and all intense emotion. So, maybe all DSM 5 needs is one new category entitled: “Suffering” with several levels of treatment – suffering just a little, suffering moderately, suffering greatly – each with its own little happiness pills.
    What frightens me (just a little) is that once you get labeled some awful things might happen to you like
    - endless medication(s) getting progressively stronger
    - the potential for the Government (like Hitler) rounding up all the "defectives" and eliminating them
    - inability to get a job because of med side-effects
    - insurance link between person, employer and insurance company because all would have to be involved in health cost decisions & insurance payments.

  • Comment number 7.


    I think you exaggerate the potential dangers of the greater use of psychiatric drugs. There will be no rounding up of people and trusted medical professionals will seek to give the best treatment possible to patients. I share your concerns that people who do not need psychiatric drugs will be prescribed them; but many people whose natures are violent will greatly benefit from taking psychiatric drugs.

    Other disorders that I have heard about are "Oppositional Defiance Disorder" and "Intermittent Explosive Disorder". These might be inappropriate. Everyone gets angry!


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