What’s wrong with the DSM-5?

Tomorrow the British Psychological Society’s Division of Clinical Psychology will issue a statement proposing a paradigm shift in the way mental illness is understood. It’s timed to coincide with the publication later this month of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

According to today’s Observer, the statement will challenge the biomedical model of mental illness on which the DSM is based. If the Observer’s report is correct, the statement claims it is ‘unhelpful to see mental health issues as illnesses with biological causes’ and that ‘there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse’.

The statement is described as ‘provocative’. If it says what it’s quoted as saying, it certainly will be. There’s a discussion, also in today’s Observer, of two perspectives on mental illness between Simon Wessely (psychiatrist) and Oliver James (clinical psychologist).

I’m no fan of the DSM – I think it’s profoundly flawed – but not because it assumes that mental illnesses have biological causes. It’s because the framework commonly used to conceptualise mental illness and indeed, the whole of human experience, is also flawed. Many of the differences of opinion set out in today’s Observer could be resolved by re-framing the debate.

Re-framing the debate

– At conception, each of us has a unique set of genes; unique because of the way the genes from our parents have combined, and because of spontaneous variations that can occur during the division and recombination of DNA.

– Genes are expressed in the production of (mainly) proteins. The way genes are expressed is influenced by environmental factors, such as the mother’s diet and physiological state, infections, exposure to toxins etc.

– Gene expression and environmental influences result in each human being having a unique anatomy and physiology, although obviously, we each have a great deal in common with others of our species.

– Environmental influences, ranging from diet, through accidents or infections, to our interactions with others, continue to affect us throughout our lifespan.

– Our own behaviour, and that of others, influences us throughout our lifespan.

– Sometimes, gene expression and/or environmental influences result in outcomes that we label ‘illnesses’ – conditions which are seen as undesirable and as originating in the body or brain.

– We label some aspects of our functioning – perceptions, thoughts, feelings and behaviours – ‘mental’ processes, so perceptions, thoughts, feelings and behaviours that we or others find undesirable and appear to originate in the body or brain, are labelled ‘mental’ illnesses. This is a hangover from an era when mental and physical were seen as distinct. To the best of our current knowledge, ‘mental’ and ‘physical’ illnesses are both products of the interaction between genetic expression, environmental factors, and how people behave. That much is pretty clear. However, teasing out the causes of illness or even deciding whether a particular phenomenon is an illness, is challenging.

And that’s the nub of the problem. So what do we do about it?

What do we do about the DSM?

1. Abandon the idea that any human being is ‘normal’. Each of us has a unique genome, has experienced a unique environment, and has a unique behaviour pattern, so human beings will vary.

2. Abandon the idea that divergences from supposedly ‘normal’ perceptions, thoughts, feelings and behaviours are pathological – they might not be disorders, just variations.

3. Abandon the distinction between ‘mental’ and ‘physical’ – both are products of the interactions between genes, environment and behaviour.

4. Abandon the idea that because people have similar symptoms, they must have an illness, and it must be the same illness. Although the same illness can cause varied symptoms, similar symptoms can also have different causes.

5. If patients have perceptions, thoughts, feelings and behaviours that they or others find problematic, systematically investigate genes, physiology, disease, diet, lifestyle, behaviour, economic and social factors as causes. Support patient accordingly.

What not to do

There are major problems with the DSM. It assumes that some human perceptions, thoughts, feelings and behaviours are normal and that others aren’t. It makes an unhelpful distinction between mental and physical. It assumes that similar symptoms indicate a shared cause for those symptoms. It locates perceptions, thoughts, feelings and behaviours in the individual, when environmental factors, including other people’s behaviour, can be major influences.

But the problems with the DSM will not be resolved by replacing a model of mental illness that omits environmental factors (the so-called ‘biomedical model’) with one that omits biological factors. Bology, environment, and the behaviour of individuals and others around them, need to be taken into account.

Postscript

Incidentally, I’ve tackled the problem of symptoms and their underlying causes in more detail in my blog about autism, and the tendency to omit both biology and wider environment as possible causes for problematic issues in my blog about child development.

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