Comment on Peter Kinderman’s blog post

(Peter’s blog post.)

Peter Kinderman seems to be arguing that it doesn’t matter if an experience is classified as resulting from disease, illness, disorder, or a response to circumstance (genetically mediated or otherwise). People who have “obvious and quantifiable needs” should get the help they need with social challenges which may have led to the difficulties in the first place. They should have someone to talk to so they can make sense of what has happened. Removing the category of illness doesn’t remove distress, doesn’t mean people shouldn’t be helped. This makes a lot of sense.

Much has been said about the problems with diagnostic categories and with naïve reification to biological entities. You have disease D if and only if you have symptoms S1, S2, … Sn. Why do you have those symptoms? Why of course it’s because you have disease D. I think we can safely conclude, along with many others, that this is circular. An argument that we “need” diagnoses to care for people is unconvincing.

Should we completely throw away what has been collected in diagnostic tomes? I don’t think we should.

One complaint about DSM and ICD is that they cover all aspects of human experience. Most of us can find a diagnosis in there, especially if interpreting the descriptions broadly. But in many ways this is a strength — when naïve reification is eliminated. Denny Borsboom, Angelique Cramer and others have done important work extracting the individual complaints (e.g., loss of interest, thinking about suicide, fatigue, muscle tension) which make up diagnoses and modelling how they relate to each other (Borsboom, Cramer, Schmittmann, Epskamp, & Waldorp, 2011; Borsboom & Cramer, 2013). The individual descriptions and their interrelationships might gain in meaning when stripped of their diagnostic group.

Describing the sorts of situations people find themselves in and how they feel is crucial for conducting research and helping build up evidence for what works. When is talking therapy helpful? When might it make more sense for people to work four days a week rather than five? When should a focus be on interpersonal problems and who should be involved in sessions?

DSM-5 includes a chapter on “Other conditions that may be a focus of clinical attention” (American Psychiatric Association, 2013, pp. 715–727). It’s brief, making up only about 2% of the book, and should be expanded, however, it seems relevant to a psychosocial approach and could perhaps be combined with other descriptions of predicaments and problems. Example problems include:

  • High expressed emotion level within family
  • Spouse or partner violence
  • Inadequate housing
  • Discord with neighbour, lodger, or landlord
  • Problem related to current military deployment status
  • Academic or education problem
  • Social exclusion or rejection
  • Insufficient social insurance or welfare support

So, “DSM” is not synonymous with “biological”. There is again plenty to be built upon, despite its problems.

Kinderman argues that practitioners “can offer practical help, negotiate social benefits (which could be financial support, negotiated time off work, or deferred studies, for example), or offer psychological or emotional support.” It was great to see specific examples. Medication also likely has a place, especially when the mechanisms of action are conceptualized in a drug-centred way rather than keeping up the pretense that they cure a disease (Moncrieff & Cohen, 2005). I think we all should be doing more to elaborate how a meaningful psychosocial approach can work in practice.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Borsboom, D., & Cramer, A. O. J. (2013). Network analysis: an integrative approach to the structure of psychopathology. Annual Review of Clinical Psychology, 9, 91–121. doi:10.1146/annurev-clinpsy-050212-185608

Borsboom, D., Cramer, A. O. J., Schmittmann, V. D., Epskamp, S., & Waldorp, L. J. (2011). The small world of psychopathology. PloS ONE, 6(11), e27407. doi:10.1371/journal.pone.0027407

Moncrieff, J., & Cohen, D. (2005). Rethinking models of psychotropic drug action. Psychotherapy and Psychosomatics, 74, 145–153. doi:10.1159/000083999

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