The latest ‘bible’ for psychiatrists, the DSM-5, may well be the last. Defining psychiatric disorders – though useful in itself – has gone a step too far, according to Laura Batstra, researcher at the Department of Special Needs Education and Child Care at the University of Groningen.
‘The idea behind the DSM (Diagnostic and Statistical Manual of Mental Disorders) is a good one: improving communication about psychiatric disorders between professionals. With the release of the third version of the DSM (published in 1980), which established criteria for each psychiatric disorder, such communication indeed improved. It meant that professionals talking about social anxiety, for example, knew which type of problems they were talking about. Unfortunately, the criteria themselves are starting to take over. For example, for certain types of treatment, health insurance companies will only reimburse patients who meet the criteria for a DSM-defined disorder.’
‘What we often forget is that a DSM “label” like ADHD is simply a description of a certain type of problematic behaviour. It is not a definitive finding of whether or not someone has a disease, like diabetes, which can be established by means of a test. A physical cause has not been found for any of the approximately 300 disorders described in the DSM, despite the fact that since 1980 a lot of money and research has been spent on this.’
‘So far, the results of brain research have offered little in the way of practical applications. At the same time, we have known for a long time that social factors such as poverty, socioeconomic disadvantage and unemployment are major risk factors for a number of different problems, and that psychiatric symptoms improve when people are moved to more favourable conditions.
As far as I am concerned, more resources should be spent on combating poverty and unemployment, but this is unlikely to happen in the short term. On the contrary, cuts are widespread, and more and more people are short of money and out of work. So mental health problems are going to increase, as will the demand for care. Unfortunately, this is at odds with the Dutch government’s policy of “de-medicalization”, which is aimed at using fewer labels.’
‘A DSM diagnosis is not only expensive and stigmatizing, it is also usually unnecessary for someone to receive the psychological help or remedial care they need. Psychological symptoms are often a sign that someone needs to change their life, to get more rest for example, or to learn certain skills such as assertiveness. Psychologists and educationalists are specialized in getting to the bottom of these underlying factors and supporting their clients (or clients’ parents) in making such changes in their lives.’
‘Together with Allen Frances, chair of the DSM-IV Task Force, I have developed a model that prevents over-diagnosis without risking under-treatment. We have called this model “stepped diagnosis” and it has already been welcomed by the Dutch Association of Psychologists ( Nederlands Instituut van Psychologen, NIP). The model involves health professionals taking a number of steps before making a DSM diagnosis. The first steps are normalization (is the client’s behaviour or feeling an expected response to circumstances?) and watchful waiting (does the client recover with time?). If necessary, these steps are then followed by a minimal intervention (such as e-health) or a more intensive intervention (brief counselling). Finally, if symptoms and dysfunction persist, the patient is referred to specialist care (for DSM diagnosis and pharmaceutical treatment if needed).’
‘A careful and cautious approach such as stepped diagnosis can be put to use to offset the recently published DSM-5, which once again designates an even greater number of human behaviours and emotions as disorders. For example, temper tantrums in children (Disruptive Mood Dysregulation Disorder) and forgetfulness in the elderly (Minor Neurocognitive Dysfunction) are now described in the DSM-5 as disorders. There is however increasing opposition within society to the medicalization of even more aspects of normal human nature. I therefore have my doubts whether the DSM-5 will be used on a large scale and this could well be the last edition.’
Laura Batstra (born 1973) graduated with distinction in psychology in 1997. She then joined the University Medical Center Groningen (UMCG) and in 2006 went on to work as a treating psychologist at an institute for child and youth psychiatry. Since June 2010, Dr Batstra has been a researcher and lecturer at the Department of Special Needs and Child Care at the University of Groningen.
Laura Batstra and Allen Frances have published an article in Dutch in the NIP’s monthly journal De Psycholoog:
Psychiatrische overdiagnostiek voorkomen zonder onderbehandeling te riskeren
This article is based on two other publications by the same authors:
Batstra L. & Frances, A. (2012) Diagnostic inflation: causes and a suggested cure. Journal of Nervous and Mental Disease, 200 (6), 474-9
Batstra L. & Frances, A. (2012) Holding the line against diagnostic inflation. Psychotherapy and Psychosomatics, 82, 5-10.
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