The International Critical Psychiatry Network (ICPN)

No More Psychiatric Labels

Posted on | May 21, 2011 | 22 Comments

Campaign to Abolish Psychiatric diagnostic Systems such as ICD and DSM (CAPSID)1,2

 

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Summary

 

  1. Psychiatric diagnoses are not valid.
  2. Use of psychiatric diagnosis increases stigma.
  3. Using psychiatric diagnosis does not aid treatment decisions.
  4. Long term prognosis for mental health problems has got worse.
  5. It imposes Western beliefs about mental distress on other cultures.
  6. Alternative evidence based models for organizing effective mental health care are available.

Introduction

Modern Western psychiatry has secured many important advances in the care of people with mental distress. We have a variety of pharmacotherapies that can help manage distressing symptoms alongside an even greater variety of psychotherapeutic approaches that help people in distress make sense of their experiences and find new ways to deal with them. The old asylums have been emptied and community care has developed a rich variety of services from early intervention to crisis management. Researchers have identified many biological and environmental factors associated with greater likelihood of having or developing mental health problems and so our understanding of mental distress has improved. Reflecting this, the academic community, studying mental distress from a variety of angles has grown in numbers and sophistication with many journals and thousands of articles being published each year. These are worthy achievements and this progress has no doubt helped thousands of people across the world.

However, despite all these achievements, psychiatric theory and practice has reached an impasse. Prevention has proved elusive with mental health diagnoses becoming more not less common despite a large increase in services in most developed countries. There still isn’t a diagnosis listed in the major psychiatric diagnostic manuals (such as ICD and DSM) that is associated with any sort of physical test and so, unlike the rest of medicine, aetiology has an insignificant part to play in organising diagnostic practice. Whilst reliability in making diagnoses has improved for some research purposes, this does not necessarily translate to clinical practice and the more important issue of validity remains poorly addressed. Most importantly there is no evidence to show that using psychiatric diagnostic categories as a guide for treatment leads, through evidence based choices, to improved outcomes. There is some evidence to suggest that applying a psychiatric diagnosis and theoretical models associated with them instead leads to a worse outcome for some.

This campaign therefore proposes that the time has come to help theory and practice in mental health move beyond this impasse by abolishing formal psychiatric diagnostic systems like ICD and DSM. By incorporating the latest evidence from epidemiology, cross-cultural studies and treatment outcome studies, the campaign highlights the extent to which the data is inconsistent with the dominant, diagnostic based, medical model remaining as the organising paradigm for practice. Continuing to use formal diagnostic systems to organise research, training, assessment, and treatment for those in mental distress is inconsistent with an evidence based approach capable of improving outcomes. Whilst the important task of sketching out what services may look like once we discard ICD and DSM from routine clinical practice is not the primary purpose of this campaign, a few pointers are also mentioned to highlight that alternative paradigms are already available and easy to incorporate into practice and in a way that can improve outcomes.

Aetiology

The failure of basic science research to reveal any specific biological abnormality or for that matter any physiological or psychological marker that identifies a psychiatric diagnosis is well recognised. Unlike the rest of medicine, which has developed diagnostic systems that build on an aetiological framework, psychiatric diagnostic manuals such as DSM-IV and ICD-10 have failed to connect diagnostic categories with any aetiological processes. Thus there are no physical tests referred to in either manual that can be used to help establish a diagnosis. The critique that highlights the lack of progress on aetiology is not limited to those less biologically minded psychiatrists as researchers in genetics are also arguing that the use of categorical diagnoses (such as schizophrenia) is handicapping their studies too, where, they argue, a dimensional approach seems more appropriate;3,4 although it should be noted that dimensional approaches in the rest of medicine often focuses on a very small percentage of ‘outliers’ (e.g. growth hormone treatment for short stature) rather than the large numbers currently attracting the gaze of psychiatry.

The one notable exception to the lack of aetiological organisation is the diagnosis ‘Post Traumatic Stress Disorder’ (PTSD) which attributes symptoms to being the direct result of trauma. This diagnosis did not develop out of new scientific discoveries but as a result of legal procedures (the construction of ‘PTSD’ came largely as a result of legal battles involving US military veterans of the Vietnam War) and its use implies that other diagnoses are not related to trauma. However, there is a substantial body of evidence linking states regarded as the most serious in psychiatry, such as the experience of hearing voices and psychosis, to trauma and abuse including sexual, physical and racial abuse, poverty, neglect, and stigma. 5, 6,7,8,9,10,11,12,13,14 This is why it is important to attempt to understand psychotic experiences in the context of the person’s life story. Not to do so can be harmful because it obscures and mystifies the origins of problematic experiences and behaviour that has the potential to be understood.14

Validity

If we were to apply the standards found in the rest of medicine then the validity of a diagnostic construct depends on the extent to which it represents a naturally occurring category. If it does, then there should be some identifiable biological property in those who have the diagnosis that can distinguish them from those who don’t. Despite years of searching for biological correlates, the failure of basic science research to reveal any specific biological marker for any psychiatric diagnostic category reveals that current psychiatric diagnostic systems do not share the same scientific security of belonging to the biological sciences as the rest of medicine. Mainstream practice understandably views this as a problem. However, the attempted solution of continuing to spend the bulk of mental health research time and effort trying to correct this deficit by relentlessly searching for evidence of biological correlates continues to deliver nothing clinically useful. Our failure to find biological correlates should not necessarily be seen as weakness. Instead of continuing with scientifically and clinically fruitless research we should view this failure as an opportunity to review the dominant paradigm in order to develop one that better fits the evidence.

Invalid anomalies are prevalent in DSM/ICD. For example, in DSM defined ‘depression’ there is one exception to the diagnosis (even if the patient has the required number of symptoms for the required number of weeks) – bereavement. This is anomalous in at least two ways. Firstly it breaks the ‘rule’ that diagnostic categories in DSM are descriptors that do not imply aetiology. Secondly, because bereavement is considered a ‘normal’ reaction, even if the full complement of DSM defined symptoms of depression are present, then one must ask: why is ‘bereavement’ specifically singled out? Why are many other life problems for which intense sadness is a common response – such as losing a job, break up of a marriage, bullying and so on – not also counted as legitimate exceptions?16

The frequency with which patients are given more than one diagnosis also raises a concern about the specificity of diagnostic categories. Widespread co-morbidity (making more than one diagnosis in order to encompass patients’ problems) indicates basic deficiencies in our understanding of the natural boundaries of even the most severe conditions we are diagnosing in psychiatry.17,18,19  It is also common to find the ‘dominant’ diagnosis changing in any individual, almost exclusively on a subjective rather than empirical (such as physical test results) basis. Unlike in the rest of medicine where the reason for the patient’s symptoms is clarified by a diagnosis, psychiatric diagnoses serve empirically as nothing much more than descriptors. Thus, when a clinician claims that a patient is ‘really’ depressed, or has ADHD, or has bipolar disorder, or whatever, not only are they trying to turn something based on subjective opinion into something that appears empirical, but they are engaging with the process of reification (turning something subjective into something ‘concrete’). The problem with turning concepts into something that appears as if it exists as a fact in the natural world is that it can cause ‘tunnel vision’ for all concerned; a dominant story that limits alternative more functional possibilities for any individual.20 Thus if someone believes ADHD is a ‘real’ disorder that exists in their brains and is potentially lifelong, that person and those who know them may come to act according to this belief, thus helping to fulfil its prophecy.

There is also a poor correspondence between levels of impairment and having the required number of symptoms for many psychiatric diagnoses (even though ‘impairment’ is often included in the diagnostic criteria).  Literature reviews and field trials to examine clinical significance criteria were not included in the preparation of DSM-IV. Thus many below the threshold for a diagnosis have higher levels of impairment than those above, with many who reach the cut off for a diagnosis having relatively low levels of impairment. 21,22,23

Reliability

Reliability is the extent to which clinicians can agree on the same diagnoses when independently assessing a series of patients. Over the last thirty years or so, academic psychiatrists have worked hard to improve the reliability of psychiatric diagnoses. This is partly in response to critics of psychiatry who pointed out that many of the common diagnoses in use at the time were meaningless because of poor levels of agreement between psychiatrists about key symptoms. Rosenhan’s 1973 study spurred on new attempts to ‘standardise’ diagnostic practice after he demonstrated that psychiatrists were often unable to discriminate between sane and psychotic people.24 Formal diagnostic systems like DSM and ICD attempted to address these problems by imposing diagnostic agreement on the profession through the use of standardised check-lists of symptoms for diagnostic criteria. Because of the repeated claim that this approach has improved reliability significantly, the diagnostic systems now in use give the impression of being reliable in an empirically verifiable way.

However, analysis of the studies involved in developing the first diagnostic manual that took this approach of ‘operationalising’ diagnosis through the check list of symptoms approach (DSM-III), found no diagnostic categories for which reliability in these studies was uniformly high. The ranges of reliability for major diagnostic categories were found to be very broad and in some cases ranged the entire spectrum from chance to perfect agreement, with the case summary studies (in which clinicians are given detailed written case histories and asked to make diagnoses – an approach that most closely approximates what happens in clinical practice) producing the lowest reliability levels.25 No studies of the reliability of DSM as a whole when used in natural clinical settings have shown uniformly high reliability, with many finding reliability ratings that are not that different than those in the pre-DSM-III studies. 25,26,27 To overcome this, developers of subsequent DSMs have simply de-emphasised the reliability problem, claiming this to have already been solved by the approach developed in preparing DSM-III.

Treatment and outcome

The technological paradigm is the dominant one that organises the way psychiatric services and treatments are delivered in most industrialised countries. This paradigm is predicated on the assumption that the technical aspects of medical and psychological care are of primary importance, and that these can be applied through making diagnoses and then applying corresponding treatment protocols.

However, there is a large literature on psychotherapy confirming that it is generally speaking a safe and effective intervention for common mental health problems as studied in Western populations,but there is little to suggest that a positive outcome is strongly related to selecting the ‘correct’ psychotherapeutic technique and much to suggest that the ‘common factors’ such as developing a strong therapeutic alliance, are more important.28,29,30 For example, several studies have shown that most of the specific features of Cognitive Behaviour Therapy (CBT) can be dispensed with, without adversely affecting outcomes. 31,32 The same holds for other forms of psychotherapy for depression. For example, The National Institute of Mental Health’s Treatment of Depression Collaborative Research Project (TDCRP), the largest trial to date comparing different treatments for depression (CBT, Inter-Personal Therapy [IPT], anti-depressants, and placebo) found that patients in each group had significant improvements, with no overall difference in outcome between each treatment group. However, the best predictor of outcome across all four groups was the quality of the relationship between patient and therapist (as perceived by the patient) early in treatment. 33,34, 35, 36

Recent meta-analyses have drawn similar conclusions. The quality of the therapeutic alliance accounts for most of the within-therapy variance in treatment outcome, and is up to seven times more influential in promoting change than treatment model. 28,37 Such data, when combined with the observed superior value, across numerous studies, of clients’ assessment of the relationship in predicting the outcome, makes a strong empirical case that the non-specific aspects of psychotherapy, or ‘know-how’ in building a strong therapeutic alliance, are more important than specific techniques being used. This is also evident in ‘real life’ clinical encounters not just research projects. For example, in a review of over 5000 cases treated in a variety of National Health Service settings in the UK, only a very small proportion of the variance in outcome could be attributed to psychotherapeutic technique, as opposed to non-specific effects such as the therapeutic relationship.38

The same principles can be found operating when using psychoactive drug treatments (that non-specific factors are more important than matching a drug to a diagnosis). Thus a number of psychiatrists have argued that instead of correcting imbalances, the evidence supports the view that pharmacological agents may be conceptualised as inducing particular psychological states which, though not specifically related to diagnosis, is nonetheless the basis for their usefulness.39 This reflects clinical practice where the few categories of psychoactive medications used in psychiatry (the SSRIs, major tranquilisers, benzodiazepines, Lithium, and anti-epileptics) are often used in a non-diagnosis specific way. For example, SSRIs are claimed to be efficacious in conditions as disparate as borderline personality disorder, depression, obsessive compulsive disorder, anorexia nervosa, bulimia, panic disorder, social phobias, and so forth. As a psychoactive substance SSRIs would appear to do ‘something’ to the mental state, but that something is not diagnosis specific. Like alcohol, which will produce inebriation in a person with schizophrenia, obsessive compulsive disorder, depression, or someone with no psychiatric diagnosis, SSRIs will also impact individuals in ways that are not specific to diagnosis. Similarly, major tranquilisers (misnamed anti-psychotics) have also been advocated for the treatment of depression, anxiety disorders, bipolar affective disorder, personality disorders, ADHD, as well as schizophrenia, a list that contains considerable overlap with that found for SSRIs.

Many psychiatric drug treatments, like psychological treatments, rely more on non-specific factors than disease-specific therapeutic effects. For example, it is generally assumed that drugs marketed as ‘antidepressants’ work through their pharmacological effects on specific neurotransmitters in the CNS, reversing particular states of ‘chemical imbalance’. However, the evidence points to placebo effects being more important than any neuro-pharmacological ones. Thus several meta-analyses have concluded that most of the benefits from ‘antidepressants’ can be explained by the placebo effect, with only a small amount of the variance (about 20%) attributable to the drug, a small amount moreover that is unlikely to be clinically significant for the vast majority of patients.40,41 Studies investigating the degree to which non-technical factors such as therapeutic relationship affect outcome, have found that even with psychoactive drug treatments these factors are far more influential than the drug alone. Thus having a good relationship with the prescribing doctor is a stronger predictor of a positive response to an ‘anti-depressant’ than just taking the drug regardless of who prescribes it. 28,42

The lack of treatment specificity is not limited to the more common and less severe presentations. Thus, although drugs marketed as ‘antipsychotic’ are often claimed to reverse a biochemical imbalance in psychotic patients, no such imbalance has been demonstrated. Furthermore, researchers have long been aware of a perplexing finding in cross-cultural studies. Research, including that carried out by the World Health Organisation, over the course of 30 years and starting in the early 1970s, shows that patients outside the United States and Europe have significantly lower relapse rates and are significantly more likely to have made a ‘full’ recovery and show lower degrees of impairment when followed up over several years despite most having limited or no access to ‘anti-psychotic’ medication. It seems that the regions of the world with the most resources to devote to mental illness – the best technology, medicines, and the best-financed academic and private-research institutions – had the most troubled and socially marginalised patients.43 Once again the impact of our psychiatric technologies seem to be minimal compared to common factors, in this case most likely to be the effects of ‘extra-therapeutic’ factors such as family support, community cohesion and tolerance for behaviours and experiences considered a sign of ‘illness’ and ‘dangerousness’ in the West.

Prognosis

Unlike the rest of medicine, no overall improvement in prognosis has been demonstrated in Europe and North America over the past century for those diagnosed with a mental disorder. Some studies indicate the opposite, that compared to the pre-psychopharmacology period there are more patients who have developed chronic conditions such as chronic schizophrenia than in the past. For example, in 1955, there were around 350 thousand adults in the US state and county mental hospitals with a psychiatric diagnosis. During the next three decades (the era of the first generation psychiatric drugs), the number categorised as disabled from mental illness rose to 1.25 million. By 2007 the number of people categorised as disabled mentally ill grew to more than 4 million adults. Similarly, the numbers of youth in America categorised as having a disability because of a mental condition leapt from around 16 thousand in 1987 to 560 thousand in 2007.44

Studies that have compared outcomes for psychotic disorders such as schizophrenia have repeatedly found that outcomes are better in poorer, non-developed countries when compared to richer, more industrialised ones.41 For example, the World Health Organisation’s international outcome in schizophrenia studies found that after 2 years about two thirds of the patients in the poor countries were doing well compared to only a third of the patients in the developed countries. The researchers concluded that “being in a developed country was a strong predictor of not attaining a complete remission.”45 Thus the progress attributable to modern mainstream psychiatric diagnostic based practice does not extend to improved prognosis.

One problem with medical model diagnostic approaches is that many of the diagnoses (such as schizophrenia, bi-polar disorder, dysthymia, ADHD, autism, OCD etc.) are conceived as conditions that are genetic and lifelong in nature (i.e. conceived as chronic conditions that are ‘hard-wired’ with little chance of making a complete recovery), where the best one can hope for is gaining some control over symptoms (through, for example, life-long use of medications). This constructs and often imposes a narrative of despair on those diagnosed with these ‘chronic’ conditions. As such psychiatric diagnoses can foreclose meaning by transforming a range of experiences and possible meanings that can be applied to these experiences into a narrow disease framework, limiting the cultural imagination to expecting largely negative outcomes.

Prognosis for those with mental disorders is also further hampered by the stigma associated with the medical model.46 Nearly all studies that have looked at the question of public attitudes toward mental illness have found an increase in biological causal beliefs across Western countries in recent years.47 However, biological attributions for mental illness are overwhelmingly associated with negative public attitudes such as a belief that patients are unpredictable and dangerous with associated fear of them and greater likelihood of wanting to avoid interacting with them. 48 Conversely, in studies where members of the public are given a psychosocial explanation for the sufferer’s symptoms (such as serious life events, loss, trauma etc.) they are much less likely to give negative attributions.48 Yet again, the ‘medical model’ diagnostic approach has a significantly negative impact causing an increase in stigma rather than a reduction.

Similar findings emerge in personal stories of those diagnosed with a ‘mental illness’. Through social action, the survivor movement has created safe spaces in which individuals can start the process of telling their own stories. Many of these stories show that users of mental health services felt stigmatised and marginalised by a psychiatric diagnosis, experiencing this as something that leads to the loss of ‘citizenship’.46,49 Being labelled with a chronic ‘genetic’ condition such as ‘schizophrenia’ interferes with a person’s identity and biography. Indeed, the presence of ‘insight’ (as defined by doctors) in schizophrenia has been found to lower self-esteem and can lead to despair and hopelessness.50 Paradoxically, it has been found that the presence of this type of ‘insight’ (meaning accepting you are mentally ill and need medical treatment)  is negatively correlated with emotional well-being, economic satisfaction and vocational status. 51,52, 53 Thus accepting the medical model attitude to diagnosis brings expectations of a gloomy outlook with lifelong dependency on psychiatric treatment and little chance of a good recovery. For some therefore, rejecting the diagnosis (or ‘lack of insight’) may be understood as a positive way of coping with the implications of the diagnosis for personal identity.52,53

In summary it seems we now have good evidence that the diagnostic ‘illness like any other illness’ approach is likely to be contributing to a worse prognosis for those diagnosed, not better.

Colonialism

For the last few decades Western mental-health institutions have been pushing the idea of ‘mental-health literacy’ on the rest of the world. Cultures are viewed as becoming more ‘literate’ about mental illness the more they adopted Western biomedical conceptions of diagnoses like depression and schizophrenia. This is because of a belief that ‘modern’, ‘scientific’ approaches reveal the biological and psychological basis of psychic suffering and so provide a rational pathway to dispelling pre-scientific approaches that are often viewed as harmful superstitions. In the process of doing this we not only imply that those cultures that are slow to take up these ideas are therefore in some way ‘backward’, but we also export disease categories and ways of thinking about mental distress that were previously uncommon in many parts of the world. Thus conditions like depression, post-traumatic stress disorder, and anorexia appear to be spreading across cultures, replacing indigenous ways of viewing and experiencing mental distress.54,55 In addition to exporting these beliefs and values, Western drug companies see in such practice the potential to open up new and lucrative markets.54,56

Despite copious evidence from research in the non industrialised world, that shows the outcomes for major ‘mental illnesses’, is consistently better than in the industrialised world and particularly amongst populations who have not had access to drug based treatments,43,44,45 the World Health Organisation, together with the pharmaceutical industry, has been campaigning for greater ‘recognition’ of mental illnesses in the non-industrialised world, basing their assumptions on the idea that ICD/DSM descriptions are universally applicable categories.57 Like other marketing campaigns, this strategy has the potential to open up huge new markets for psychiatric drugs that maybe ineffective and can have serious side effects, at the same time as painting indigenous concepts of, and strategies to deal with, mental health problems, as being based on ignorance, despite their obvious success for these populations.

The idea of the individual as the locus of the self is a relatively recent Western invention and such a framework creates the psychological pre-conditions necessary for accepting the ‘atomised’ social worlds that have been created. Yet, mental well-being seems closely connected to social and economic factors. Several international studies have concluded that more important than poverty per se is the degree of inequality. Thus the greater the inequality (in economic and social resources) in any society, the poorer is the mental health of that society.58,59,60,61,62

A more subtle source of impact on cultural beliefs is due to psychiatric diagnoses inadvertently setting standards for ‘normality’, by categorising what emotional and behavioural traits and experiences should be considered ‘disordered’. As the criteria for diagnoses are arrived at by subjective judgments rather than objective evidence (being literally voted in or out of existence by committees), they will have an automatic bias toward the cultural standards found in economically dominant societies (who also tend to control what counts as ‘knowledge’ globally). This sets in motion a diagnostic system vulnerable to institutional racism in the dominant societies and colonialism in others, as other standards of normality will, at least to some extent, come to be viewed as ‘primitive’, ‘superstitious’ etc. and their populations will be viewed as needing to be (psycho)educated. As a result then, for the majority of the world, all manner of complex somatic/emotional complaints have to be re-categorised, spiritual explanations have to be denounced, parenting practices viewed as oppressive and so on.

Thus imposing Western medical model DSM/ICD style psychiatry on non-Western populations risks a number of things including: adoption of Western psychiatric notions of ‘psychopathology’ to express mental distress, undermining of existing cultural strategies for dealing with distress, more not less stigma for those with mental health problems, and the imposition of an individualistic approach that may marginalise family and community resources and divert attention from social injustice.

Cultural and Public policy impact

Despite adopting a DSM/ICD approach causing many problems for translating the subjective process of attaining a psychiatric diagnosis into a reliable and objective one in clinical practice; it has nonetheless had a significant impact on service provision and public and professional beliefs about mental distress. As a result of popularising the diagnostic systems created by DSM/ICD, it is widely argued that a significant proportion of the population suffers from mental illness, that this amounts to a significant economic burden, and that there is a strong case for investing in improved mechanisms of detection and treatment for these disorders. Across several surveys in the industrialised nations only about a third of those identified as suffering a mental health problem (according to DSM/ICD criteria) sought or were interested in seeking professional help.63,64,65,66 This has been interpreted as unsatisfactory case detection, provision and treatment, due to public and professional ignorance. However, there is little evidence to support the idea that popularising mental health diagnoses, convincing professionals and the public about the high prevalence of mental disorders, and convincing policy makers of the need to diagnose and treat more people, benefits the mental health of the society.

In order to increase rates of diagnosis and treatment, a variety of campaigns have been undertaken. For example, in the UK the Royal College of Psychiatrists and Royal College of General Practitioners launched their ‘Defeat Depression’ campaign in the early nineties. 67 It was intended to raise public awareness of depression, reduce stigma, train general practitioners in recognition and treatment, and make specialist advice and support more readily available. Unfortunately, evaluations of treatment and education guidelines in the UK following the ‘Defeat Depression’ campaign failed to detect significant improvements in clinical outcome.68,69,70 However, other effects of the campaign included a rapid increase in antidepressant prescribing and increased medicalisation of unhappiness and distress. As has been noted above, medicalisation of mental distress through promotion of the idea that mental health problems are best understood as ‘illness like any other illness’, increases rather than decreases stigma.

Unlike other areas of public health, mental health in those societies with the most developed services appears to be the poorest. In such societies ‘epidemics’ of psychiatric diagnoses (e.g. ADHD, autism, depression, bipolar disorder) have only emerged and become popularised in recent years. Whilst there are complex political, social and cultural reasons for this, they are in part based on new categories and ideas about personhood, the nature of distress etc. and so are at least in part the result of creating, broadening and popularising psychiatric diagnoses.

Conclusion

For any diagnostic system to establish itself as a scientifically useful paradigm that leads to greater knowledge of the natural world, it should be able to show that the categories ‘carve nature at its joints’ such as being able to demonstrate distinct aetiological links. For any diagnostic system to establish itself as clinically useful it must show that use of diagnostic labels aids treatment decisions in a way that impacts on outcome. As reviewed above there is little evidence to support the ICD/DSM paradigm being able to provide either the basis for collecting scientifically useful knowledge or clinically useful treatment decisions. There is much evidence to suggest that instead they can cause significant harm. The only evidence based conclusion that can be drawn is therefore that formal psychiatric diagnostic systems like ICD and DSM should be abolished.

New paradigms

Relying on DSM/ICD diagnostic categories to organise research, services, and treatment does not contribute to improved outcomes for those experiencing mental distress and is associated with considerable harm.

Alternatives to ICD/DSM are therefore needed. We can and should do better. We have all the evidence we need to work on re-organising our approaches locally, nationally, and internationally to develop services that are evidence based and can reduce the amount of harm DSM/ICD has caused at the same time as improving outcomes. New paradigms that draw on the existing evidence for what improves outcomes and that incorporates the views of those who matter most – service users – can easily be developed and implemented. The following represents some good starting points:

1. Aetiology: As discussed in this paper there is a strong association between trauma, particularly early childhood trauma, and adversity and the subsequent development of mental disorders including psychosis. There is also a strong association between the degree of socio-economic inequality and levels of mental distress in any society. Other associations include dietary, lifestyle, family functioning and attachments. Research that examines the relationship between contextual factors and degrees of impairment, without trying to link them to formal psychiatric categories, has a greater likelihood of succeeding in developing useful scientific knowledge about mental distress. Moving the focus away from the eugenic-like search for genetic and neurological abnormalities will allow for greater acceptance of human diversity, and decrease the likelihood of human rights, political and social issues being inappropriately medicalised. Given the strong relationship between increasing acceptance of the diagnostic medical model and increasing stigma, abolition of DSM/ICD will also help in the fight against stigma.

2.  Clinical: Decades of outcome research into treatment of psychiatric disorders shows, that despite the development of many new techniques, the outcomes being achieved in studies 40 years ago are similar to those being achieved now. In other words our advances in therapeutic techniques have not yet led to improvement in overall outcomes for service users. Research has found that certain intra-therapeutic factors such as the therapeutic alliance has a much greater effect on outcome than model or technique used and that extra-therapeutic factors such as social support has an even greater impact on outcome than intra-therapeutic ones.28,30,42 A variety of studies (in areas as diverse as psychotherapy services, community mental health services, substance misuse, and marital counselling) have found that incorporating ideas from this outcome literature, such as using session by session feedback on outcome and therapeutic alliance, can improve outcomes.30,42  The message from this research is that services can improve outcomes, not by using diagnostic categories to choose treatment models, but by concentrating instead on developing meaningful relationships with service users that fully includes them in decision making processes.  International service user led movements, such as the ‘recovery’ movement, that focus on the inclusion of people in recovery from mental health problems as collaborators in research, service development, and treatment model development provide good examples of how this evidence can be developed to change institutional culture.71,72,73 Services in non-Western settings should be able to incorporate local beliefs and practices and the wholesale export of Western ethno-psychiatry can be stopped.

Developing the knowledge base and services in this manner would give mental health services and practitioners a better chance of improving the lives of those they work with. It will also help with breaking long standing barriers between mental health services and the rest of medicine, by allowing the mental health professions to focus on developing paradigms that are evidence based and which properly incorporates an understanding of how physical and mental well-being are closely related to each other. These non-diagnostic based paradigms can then assist in helping the many patients who present with physically unexplained symptoms or chronic conditions, which inevitably impact on their mental well-being, without needing to label them as ‘mentally ill’.

The real gift of psychiatry is what it can offer the rest of medicine that is more unique to this field, which is an understanding of the person in their context. Psychiatry has to sit at the confluence of a variety of disciplinary discourses (Sociology, anthropology, psychology, philosophy, medicine, cultural studies, politics, theology etc.) and it is this broader understanding of the human and their health and well-being that psychiatry ‘brings to the table’. By lazily importing the diagnostic model from general medicine we end up miss-selling and under-utilising the unique skills the profession of psychiatry brings to healthcare by the ‘dumbing down’ of what we do into simplistic diagnosis driven protocols that has more to do with successful consumer culture marketing than science. Changing to more evidence compatible paradigms is now long overdue.

 

References

 

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Sami Timimi

March 2011

 

Category: No More Psychiatric Labels

Comments

22 Responses to “No More Psychiatric Labels”

  1. Robbie Lloyd
    May 24th, 2011 @ 3:01 am

    Dear Sami,
    Thank you for a comprehensive and well argued position paper on why the psy-ed industries are unnecessary and a curse. I have just finished my PhD, modelling community-based, self-help, peer-supported rehabilitation reform, and support for people living with intellectual disability. This work has led to The All Fruits Theory, which argues that acceptign difference and diversity in consciousness is a good thing, and we can all benefit from the rich diversity among us. Like Queer Theory, it says that powerful elites should not decide who is labelled with what categories. Please write if you’d like to share some more info.

  2. Leif Elinder
    May 24th, 2011 @ 6:01 pm

    Dear all

    DSM has moved away from traditional diseases to arbitary constructs and to the medicalizing of normal life. Behavioral problems are wrongly being portrayed as congenital illnesses. This trend has resulted in the so called ”disease mongering” – the effort by the pharmaceutical companies and others with financial interests to enlarge the market for medical treatment by convincing often healthy people that they are sick.
    Thus DSM has become more of a political document than a scientific one. Decisions regarding inclusion or exclusion of disorders take place by majority vote and under conflict of interest rather than by indisputable scientific data and validity concerns. Therefore I fully support Professor Timimis momentous initiative.

    Leif Elinder

  3. Heart & Soul of Change Project » Blog Archive » Networker Articles and an Anti-Labeling Campaign
    May 30th, 2011 @ 4:25 pm

    [...] Psychiatric Labels’ campaign to abolish diagnostic systems like ICD and DSM. Check it out at http://www.criticalpsychiatry.net/?p=527 Support the campaign at [...]

  4. Gaynor Boileau
    June 1st, 2011 @ 11:36 am

    Thank you for such a clear explanation of the real benefits of psychotherapy and psychiatry. Undoubtedly chemical intervention can help people who are struggling to feel mentally well. And without doubt, the most important aspect of talking therapy is the relationship of trust. I work (as a psychotherapist) with many clients who have a diagnostic label and are taking medication. I often use diagnostic terms because clients expect to hear them and also I think it is important to ‘know my enemy’. I do hope for a time when I will be working alongside the psychiatrist with a greater and shared understanding of our roles.

  5. Peter J. Gordon
    June 5th, 2011 @ 9:40 am

    It is about time the psychiatric profession listens without reacting defensively.

    This is a well written, fully considered piece from a doctor that I rate very highly. To ease suffering we must not label so much of life as ‘disorder.’

    The medical model needs to embrace a world view. If you like I am a ‘biological citizen’ but I am also much more than such frame of rerence can convey. The same is thus obviously true for suffering.

    Research in mental suffering will forever struggle if the dark tree of classification only grows more burdened.

  6. Dr. Terry Lynch
    June 8th, 2011 @ 6:56 pm

    I fully support this campaign. Psychiatry is largely a construct, a particular way of interpreting human distress. It is fundamentally highly unscientific, in that major claims of biochemical brain imbalances and other putative physical causes are made with confidence and certainty, which is never backed up by tests. Psychiatry is therefore fundamentally a belief system and behaves accordingly, treating genuine questioners as heretics. In my work I have found that the often subtle emotional and psychological aspects of people diagnosed as suffering “mental illnesses” are key, yet they are regularly missed, especially by the majority of the medical profession, who generally do not value emotional and psychological aspects, as they are not part of the belief system, and they have not been sufficiently taught how to work with these. Psychiatry is not fit for purpose.

  7. Suman Fernando
    June 12th, 2011 @ 3:15 pm

    The worldwide imposition of psychiatric diagnoses is a form of imperialism whereby locally relevant ways of seeing and understanding spiritual and real-life problems are being medicalised and prepared for marketing by big pharma. I have seen personally the damage being done in Sri Lanka and the program I am involved in has sugested an approach to mental health service devlopement based on mental health promotion plus community consultation (see details in my website).

    Suman Fernando

  8. Dr Richard House
    October 17th, 2011 @ 9:34 pm

    Dear Sami,
    This is a brilliant initiative and I hope everyone who supports this just and noble cause will urge all their friends and colleagues to join it. For far too long, self-interested pharmaceutical and professional psychiatric interests have brazenly annexed unto themselves the claim to be ‘scientific’, when in reality, these psychiatric practices – when subjected to searching critical, GENUINELY scientific scrutiny – can quite easily be shown to be entirely bogus science – as you have shown so expertly in many of your own writings. We CAN shift the ‘Zeitgeist’! – and we surely will!
    All the best,
    Richard House
    Senior Lecturer in Psychotherapy and Counselling
    University of Roehampton, London

  9. STOP DSM
    November 1st, 2011 @ 5:56 pm

    Groups and institutions that support the Manifesto of Barcelona, ​​Buenos Aires and Brazil for clinical psychopathology no statistica

    ACCEP (Associació Catalana per a la Clínica i l’Ensenyament de la Psicoanàlisi) Barcelona
    Acippia( Asociación cultural para la formación e investigación en psicoterapias psicoanalíticas). Madrid
    Acto analítico. Intervenciones para la salud y el bienestar psico-social. Barcelona.
    Acto, Centro de Asistencia Psicoanalítica, Psiquiátrica y Psicológica (Barcelona)
    Apertura. Estudio, Investigación y Transmisión del Psicoanálisis (Barcelona)
    Area 3. Asociación para el Estudio de Temas Grupales, Psicosociales e Institucionales. Madrid
    Area Infancia y Adolescencia de la Dirección de Salud Mental del Ministerio de Salud de la Provincia de Santa Fe -Rep. Argentina-
    Asociacion Española de Psico-Somatoterapia
    Asociación Análisis freudiano en España. ( Madrid)
    Asociación de Profesionales del Hospital de Niños Ricardo Gutierrez. Buenos Aires (Argentina)
    Asociación Escuela Argentina de Psicoterapia para Graduados. (Rep. Argentina)
    Asociación Española de Historia del Psicoanálisis. AEHP. (Barcelona)
    Asociación Estatal de Profesionales de la Sexología (España)
    Asociación Galega de Saúde Mental.
    Asociación Gallega de Psicoanálisis
    Asociación para la Docencia e Investigación en Salud Mental de Eivissa y Formentera. ADISAMEF (Baleares)
    Asociación Psicoanalítica Argentina (APA). Sociedad componente de la Asociación Psicoanalítica Internacional -IPA- y de la Federación Psicoanalítica de América Latina -FEPAL.
    Associació Catalana de Psicoteràpia Psicoanalítica. ACPP. Barcelona
    Associació Cultural Dansalut. Barcelona
    Association des Psychologues freudiens (France)
    Association Psychanalyste dans la Cité (Bagnols-sur-Cèze, Languedoc-Roussillon -France-)
    Aula de Psicoanálisis (Barcelona)
    Carreras de Especialización en Psicoanálisis con Niños y en Psicoanálisis con Adolescentes de la Universidad de Ciencias Empresariales y Sociales (en convenio con la Asociación de Psicólogos de Buenos Aires) (Argentina)
    CDIAP-Mollet Centre de Desenvolupament Infantil i Atenció Precoç, de Mollet del Vallès (Barcelona)
    Ce.sa.men.de (Buenos Aires -Rep. Argentina)
    Centre d’Higiene Mental de Cornellà (Cornellà -Barcelona-)
    Centre de Psicologia Clínica Provençals, Barcelona – España
    Centro Comunitario de Protección y Desarrollo Estudiantil Santa Rosa de Valencia, (Venezuela)
    Centro de Orientación Sociolaboral y Clínica “El Molinet”. Alicante, España
    Centro Françoise Dolto. (Palencia – Castilla y León. España).
    Centro regional Zona Atlántica de la Universidad Nacional del Comahue (CURZA) Rep. Argentina
    Centro Studi e Ricerche Scuola di Prevenzione Josè Bleger
    Cercle d’estudis en Salut Mental del Vallès (Barcelona)
    CET Despertares. (Eceiza – Rep. Argentina)
    Colegio Profesional de Psicólogos de Salta (Argentina)
    CONVOCA, Asociación de Atención Psicológica. Barcelona, España.
    CPPL (Recife-PE) Brasil
    EAP B-25 de Badia i Barberà del Vallès (Barcelona)
    Equip Clínic CIPAIS. Barcelona
    Equipo de investigación “Efectos sociales de la globalización del DSM-V” de la Facultad de Psicología de la Universidad de Rosario (Argentina)
    Escola de Clínica Psicoanalítica amb Nens i Adolescents. ECPNA. (Barcelona)
    Escuela de Clínica Psicoanalítica con Niños y Adolescentes de Madrid.
    Escuela de Psicoanálisis de los Foros del Campo Lacaniano – F7 (España)
    Escuela de Psicoanálisis de los Foros del Campo lacaniano: Foro Tucumán/Salta de Argentina
    Espacio Psicoanalitico. Asociación para la extensión del psicoánalisis en la Comunidad de Madrid.
    Espai Clínic Psicoanalític de Barcelona
    Federación de Psicólogos de la República Argentina. FePRA.
    Freuds Agorá – Skole for psykoanalysen. København (Danmark)
    Fundació Congrès Català de Salut Mental. FCCSM. (Barcelona)
    Fundación C. G. Jung. España
    Fundación Europea para el Psicoanálisis. (España).
    Fundación INTRAS (España)
    Fundación Psicoanalítica / Madrid 1987.
    Fundación Psicooncológica de Buenos Aires. Argentina
    Fundación RedesLife. España
    Fédération Francophone Belge de Psychothérapie Psychanalytique. Bruxelles
    Fédération Nationale Agréée des Psychologues Praticiens d’Orientation Psychanalytique de Belgique (APPPsy) Bruxelles, Belgique
    Fédération professionnelle des psychologues cliniciens et des psychologues psychothérapeutes (Belgique).
    Fòrum Psicoanalític de Barcelona
    Fòrum Psicoanalític Tarragona
    Gradiva, Associació d’Estudis Psicoanalítics, Barcelona
    Institut de Formation à l’Intervention en Santé Mentale. Belgique
    Institut de Psicologia Analítica Carl Gustav Jung (ICGJ) Barcelona
    Instituto Terapia de Reencuentro. Valencia – España
    Instituto Valenciano de Psicología y Psicoterapia Analítica (IVaPA)
    iPsi, Centre d’Atenció en Salut Mental – iPsi, Formació psicoanalítica (Barcelona)
    Kairós Associació per l’estudi, recerca i divulgació de la psicoanàlisi. (Barcelona)
    La Otra Psiquiatría (Valladolid)
    La Trama Psi. Servicio de Acompañamiento Terapéutico e Integración Socioeducativa. (Córdoba -Argentina-)
    Logos Clínica Psicoanalítica (Barcelona)
    Los Naranjos Comunidad Terapéutica. San Pedro – Prov. Buenos Aires- Argentina.
    Metàfora, centre d’estudis d’artteràpia. (Barcelona)
    Mi Encuentro, Asociación civil -Escuela especial, Centro de día- (Muñiz, Buenos Aires)
    MP – Consultora y Asesora en Psicologìa y Educaciòn – Buenos Aires (Argentina)
    Núcleo de Pesquisa e Extensão em Psicanálise da Universidade Federal de São João del Rei (Brasil)
    ONG Casa de la Mujer. Rosario (Argentina)
    Patologías actuales en la Infancia (Buenos Aires)
    Phoenix Espai Terapèutic. Barcelona
    Plataforma NOGRACIAS (España)
    Plataforma Psicoanálisis Siglo XXI. (Barcelona)
    Profesionales Latinoamericanos/as contra el Abuso de Poder. (Buenos Aires / Montevideo)  
    Programa “Cuidar-Cuidando”. Buenos Aires (Argentina)
    Projeto de Investigação e Intervenção na Clínica das Anorexias e Bulimias (Departamento de Psicanálise/ Instituto Sedes Sapientiae), Sao Paulo – Brasil.
    Projeto Transversões – Projeto Integrado de pesquisa Saúde Mental, Desinstitucionalização e Abordagens psicossociais Escola de Serviço Social da UFRJ (Rio de Janeiro -Brasil-)
    Psycorps (Ecole Belge de Psychothérapie Psychanalytique à Médiations) (Belgique)
    Quidem, Escuela Aragonesa de Psicoanálisis Aplicado. (Zaragoza)
    Red de psicoanalistas. Rosario (Argentina)
    RED-CAPS. Red de mujeres profesionales de la salud. (España)
    Seminaires psychanalytiques de Paris (France)
    Seminari de Psicoanàlisi de Tarragona
    Sociedad Española de Medicina Psicosomática y Psicología Médica. Madrid.
    Sociedad Española de Psicología Analítica (SEPA)
    Sociedad Española de Psiquiatría y Psicoterapia del Niño y del Adolescente. SEPYPNA (Madrid)
    Sociedad Paraguaya de Logoterapia (Asunción -Paraguay-)
    Societat Catalana de Rorschach i Mètodes Projectius (Barcelona)
    Triciclo: Clínica Psicanalítica+Centro de Estudos. (Brasilia -Brasil-)
    UMBRAL, Red de asistencia “psi” (Barcelona)
    Union Syndicale de la Psychiatrie. USP (France)
    http://www.lenguajeaprendizaje.com.ar (Rep. Argentina)

    MANIFEST FOR A CLINICAL NON-STATISTICAL
    PSYCHOPATHOLOGY

    By this manifest, the undersigned professionals and institutions, want to declare ourselves in favor of clinical diagnostic criteria, and therefore against the imposition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, as the sole criterion in the clinic of psychological symptoms. We would like to share, discuss and agree on the clinical knowledge -logy- on mental pathos, understood as symptomatic suffering, and not a disease. We wish to question the existence of mental health, statistical or normative, as well as the clinical and intellectual imposture of the notion of mental disorder or mental illness. We also want to denounce the imposition of one sole therapy treatment for typified disorders. These being formatted to the detriment and contempt of other theories and treatment strategies, as well as the contempt of the patients’ right to choose. At present, we witness how clinical practice is becoming less dialogist and more indifferent to the manifestations of mental sufferings, clinging to the protocols and palliative treatments, which only address the consequences, but not their causes.

    As stated by G. Berrios (2010) “We are facing a paradoxical situation in which clinicians are asked to accept a radical change in the way of developing their work, (ie leave the advice of your own experience and follow the dictates of statistical and impersonal data) when in fact, currently, the basis that are used for evidence are no different than what the statistics, theorists, managers, companies (such as the Cochrane Institute) and capitalist investors say, being these who precisely say where you put the money.” We thus want to uphold a health model, where the speech is a value to promote and where each patient is considered in its particularity.
    The defense of the subjective dimension entails to value and consider what each one brings into play to address what remains unbearable, stranger to oneself, but yet familiar. We express our rejection to the welfare policies which prioritize security at the expense of freedom and human rights. Policies that, under the guise of good intentions and the search for the good of the patient, reduce the patient to a performance calculation, a risk factor or a vulnerability index which ought to be removed, nearly by force.
    For any discipline, the approach to the reality is done through a theory. But this limited knowledge should not be confused with The Truth. This would act as an ideology or religion, where any thought, event, or even the used language would serve to promote the re-ligarebetween knowledge and truth. Any clinician with a true scientific spirit knows that his theory is what Aristotle called an Organon, that is a tool to approach a reality, which becomes always more plural and changeable, and whose categories are only an expression of its diversity, making it become wider from both a theoretical and practical perspective.
    This conception is opposed to the idea of ​​a canon, in the sense of what necessarily things are and that they must perform in a certain way. We all know the consequences of this kind of position that goes from being indicative to set a rule and become prescriptive, and ultimately coercive. This is where knowledge becomes the exercise of a power that sanctions as per what obeys or disobeys this canon. It also means the subordination of subjectivity to the management of social order, as per what markets demand. Everything is for the patient but without taking the patient into consideration. We know that any knowledge dismissing the subject constitutes an act of power on this subject. J. Peteiro calls it “scientific authoritarianism”. For all this, we want to express our opposition to the existence of a Sole, Compulsory and Universal Diagnosis Code.

    Furthermore, the a-theoretical model that the DSM boats about, claiming to guarantee any objectivity, only talks about his epistemological failure. Suffice is to recall its inability to define what a mental disorder and mental health are. The contents of this psychiatric taxonomy respond more to political reasons and agreements than to clinical observations, leading to a very serious epistemological problem.
    Regarding the classification method applied at the DSM, we find that even though many things can be sorted, stacked or grouped, there is no nosographic entity that can be established in a given field. Finally, and in the same line as above, the statistics used in the DSM have a weak point of origin: the ambiguity of the object on which it operates, that is, the concept of mental disorder. Statistics are presented as a technique, a tool that can be used for multiple causes, of any kind. Items and basic values ​​of the statistical curve are handled by persons, and they are responsible to quantify and interpret the data.

    In this context of poverty and confusion, the forthcoming DSM-V constitutes a clear threat: no one is sheltered from what is fixed as illness. There is no room for health in terms of change, mobility, complexity and multiplicity of forms. All of us are patients and we all suffer from a disorder. Any manifestation of discomfort will be quickly transformed into symptoms of an illness that needs to be medicalized for life. This is the big leap that has been done without any epistemological net: from prevention to the prediction. Frances Allen, head of Task Force of the DSM IV, warn us in his article “Opening Pandora’s box” about lower diagnostic thresholds for many existing or newly diagnosed disorders that could be extremely common in the general population. He also lists some of the new conditions that are to be included within the DSM-V: the risk of psychosis syndrome (“It is certainly the most disturbing suggestios. The false positive rate would be alarming, going from 70 to 75%”). The mixed depressive anxiety disorder. Minor cognitive disorder (“is defined by specific symptoms … the threshold has been arranged to include a massive 13.5% of the population”.) Binge eating disorder. Dysfunctional disorder character with dysphoria. Paraphilic coercive disorder. Hypersexuality disorder, etc.As a result, it does not only increase the number of disorders but also the semantic field of many of them, as it is in the case of the ADHD. The DSM-V promotes a diagnosis based on the sole presence of symptoms, and doesn’t entail any disability. Furthermore, it reduces to the half the number of symptoms required for adults. The diagnosis of ADHD is also provided in the presence of autism, which would involve creating two false epidemics and would foster an increased use of stimulants in a particularly vulnerable population.
    If we combine these statistics with the heterogeneity thematic working groups that have proliferated, ranging from gender identity, through the adaptation of the pulse, hyper-sexuality, mood swings etc., we cannot ignore the pursuit of a full autonomy with respect to any theoretical framework and any epistemic rigor control by the international classifications. We, nevertheless, do not believe that the classifications and treatments can be neutral with respect to etiology theories, as it is intended. They can neither be neutral with respect to the ideology of social control, and other extra-clinical interests.
    Paul Feyerabend, in “The Myth of Sscience and its Role in society”, writes: “Basically, there is hardly any difference between the process leading to the formulation of a new scientific law and the process that precedes a new law in society ” It seems, continues this author in “Farewell to Reason” that: “The world we live in is too complex to be understood by theories that obey to epistemological (general) principles. And scientists, politicians, -anyone trying to understand and / or influence the world and, taking into account this situation,- are violating universal rules, abusing of developed concepts, distorting the knowledge already obtained and constantly thwarting attempts to impose a science, in the sense used by our epistemologists. ”

    Finally, we would like to draw attention to the danger it involves to the treatment of psychological symptoms the fact that new clinicians are deliberately educated in the ignorance of classical psychopathology. Clinical psychopathology responds to the dialectic between theory and clinical practice, between knowledge and reality, but it is no longer taught at our universities. And yet, they are instructed in the paradigm of a pharmacologic approach that has become universally prescriptive for everybody and for any condition. It is not much different from a label vending machine, which restocks medication. What we denounce is the complete ignorance of the foundations of psychopathology, a fundamental tool when exploring patients and, consequently, a considerable constraint when making a diagnosis.

    Since knowledge may the most ethical way for approaching our plural reality, the coexistence of different theories about the complexity of human beings should be respected.

    Therefore, we propose to take actions in order to stop the increasing spread and growth of international classifications, and alternatively work with classification criteria which are based on psychopathology fundamentals and exclusively stem from the clinical practice.

    http://stopdsm.blogspot.com

    Barcelona, April 14th 2011

    MANIFESTE POUR UNE PSYCHOPATHOLOGIE CLINIQUE NON STATISTIQUE

    Par le présent texte, les professionnels et organisations signataires, se prononcent en faveur de critères cliniques de diagnostic, et par conséquent à l’encontre de ce qui est imposé par le “Diagnostic and Statistical Manual of Mental Disorders” ou DSM IV par l’Association de Psychiatrie américaine comme grille de critères unique pour la clinique de la symptomatologie psychiatrique.

    Nous souhaitons partager, débattre et nous mettre d’accord sur les connaissances cliniques concernant les pathologies psychiques – souffrances symptomatiques et non pas maladies – afin de mettre en question une santé psychique qui serait statistique ou normative, ainsi que l’imposture clinique et intellectuelle du “désordre”, du “trouble”, de la “maladie” mentale. Nous voulons aussi dénoncer que soit imposé un traitement unique – thérapies codifiées pour troubles formatés – au mépris des différentes théories et stratégies thérapeutiques et de la liberté de choix du patient.

    En ce moment nous assistons à la naissance d’une clinique qui fait chaque fois moins de place au dialogue, qui est de plus en plus indifférente aux manifestations de souffrance psychique, qui est cramponnée aux protocoles et aux traitements exclusivement palliatifs des conséquences, et non des causes. Comme le disait G. Berrios (2010) : “Nous sommes confrontés à une situation paradoxale dans laquelle il est demandé aux cliniciens d’accepter un changement radical dans la façon de concevoir leur travail (exemple: abandonner les conseils de l’expérience au profit des dictats fournis par des données statistiques impersonnelles) quand, en réalité, les fondements actuels de la certitude ne sont autres que ce que disent les statistiques, les théoriciens, les gestionnaires, les entreprises (comme l’Institut Cochrane) et les investisseurs capitalistes qui sont précisément ceux qui disent où se trouve l’argent.

    Par conséquent, nous défendons un modèle de santé où la parole serait une valeur à promouvoir et où chaque patient serait considéré dans sa singularité. La défense de la dimension subjective implique la confiance dans ce que chacun met en jeu pour traiter quelque-chose en soi qui se révèle insupportable, étranger à soi, et cependant familier. Nous manifestons notre répulsion à l’égard des politiques d’assistance qui recherchent la sécurité au détriment des libertés et des droits. A l’égard des politiques qui, sous couvert de bonnes intentions et de la recherche du bien du patient, le réduisent à un calcul de rendement, à un facteur de risque ou à un indice de vulnérabilité qui doit être éliminé, à peine moins violemment que par la force.

    Quelle que soit la discipline, l’approche de la réalité de son objet se fait au travers d’une théorie. Ce savoir limité ne saurait se confondre avec La Vérité, car cela supposerait de faire comme une idéologie ou une religion, où toute pensée ou évènement, et y compris le langage utilisé, servent à forcer à faire un lien (re-ligare) entre savoir et vérité. Tout clinicien qui a un certain esprit scientifique sait que sa théorie est ce qu’Aristote appelait un Organon, c’est à dire un outil pour approcher une réalité qui est toujours plus multiple et changeante, et dont les classifications doivent laisser de la place à la manifestation de cette diversité, permettant ainsi le progrès théorique aussi bien que pratique.

    Cette conception s’oppose à l’idée de règle au sens où nécessairement, obligatoirement et inéluctablement les choses sont et doivent fonctionner d’une manière déterminée. Nous savons tous quelles sont les conséquences de cette position qui va de l’orientation vers la norme, à la prescription, pour finir par devenir contrainte. C’est ici que le savoir se transforme en exercice du pouvoir : quand il sanctionne, au sens large, ce qui obéit ou n’obéit pas à cette règle. Ordonnancement de la subjectivité à l’Ordre Social que réclament les marchés. Tout pour le patient sans le patient. Un savoir sans sujet est un pouvoir sur le sujet. C’est ce que J. Peteiro a appelé l’autoritarisme scientifique.

    C’est pour tout cela que nous voulons manifester notre opposition à l’existence d’un Code Diagnostic Unique Obligatoire et Universel.

    Par ailleurs, le modèle a-théorique dont se pare le DSM, et qu’on a voulu confondre avec de l’objectivité, nous parle de ses failles épistémologiques. Il n’est que d’évoquer son manque de définition concernant ce que nous pouvons comprendre par “trouble mental” ou “santé psychique”. Le contenu de cette taxonomie psychiatrique relève plus d’ententes politiques que d’observations cliniques, ce qui engendre un problème épistémologique très grave.

    Quant à la méthode de classification du DSM, on constate qu’on peut classer, entasser ou regrouper beaucoup de choses, mais que ce n’est pas établir une entité nosographique dans un champ déterminé.

    Enfin, dans la même veine que ce qui précède, les statistiques utilisées ont un point de départ faible: l’ambiguïté de l’objet auquel elles sont appliquées, c’est à dire le concept de “trouble mental”. Les statistiques se présentent comme une technique, un outil qui peut être mis au service de questions multiples et en tous genres. Ce sont les mêmes personnes qui définissent les items et les valeurs de base de la courbe statistique, qui décident aussi de l’inclinaison plus ou moins éloignée de la marge de ce qui va être quantifié et interprété ultérieurement.

    Dans ce contexte de pauvreté et de confusion conceptuelle, la prochaine publication du DSM-V suppose une menace évidente: personne ne sera à l’abris de quelque-chose qui le stoppe, qui en fasse un malade. Il ne restera pas d’endroit pour la santé, en termes de changement, de mouvance, de complexité ou de multiplicité des façons d’être. Tout le monde malade, tout le monde victime de “trouble mental”. Toute manifestation de mal-être sera rapidement convertie en symptôme de “trouble mental” qui nécessitera une médicalisation à vie. C’est le grand saut qui a été fait sans aucun appui épistémologique: de la prévention à la prédiction.

    Des seuils diagnostics plus bas pour beaucoup de “désordres” existants ou de nouveaux diagnostics qui pourraient être extrêmement courants dans la population générale, voilà de quoi nous prévient Allen Frances, chef de groupe de travail du DSM-IV, dans son écrit “Ouvrant la boîte de Pandore”.Faisant référence aux nouveaux “troubles” que comprendra le DSM-V, cet auteur cite quelques-uns des nouveaux diagnostics problématiques:
    - le syndrome de risque de psychose (“c’est certainement la plus préoccupante des suggestions. Le taux de faux-positifs serait alarmant, de l’ordre de 70 à 75 %”).
    - Le “trouble” mixte d’anxiété dépressive [ce qui s’appelait jadis la dépression névrotique ? ].
    - Le “trouble” cognitif mineur (“il a été défini pour des symptômes non spécifiques (…) le seuil a été fixé pour (…) comprendre un énorme 13 % de la population”)[Il avait été question jadis de MBD ; minor brain dysfunctions, troubles de soft, Touwen, in : Wallon : La Vie mentale, p. 66].
    - Le “trouble” de l’excessivité
    - Le “trouble” dysfonctionnel du caractère avec dysphorie
    - Le “trouble” de la déviation sexuelle [Dans le DSM IV, il y a des pédophiles, mais plus d’homosexuels]
    - Le “trouble” de l’hypersexualité
    - etc.
    [Contradiction massive : tout le monde est jugé potentiellement malade, en même temps que convoqué au « travailler plus », autrement dit au « surtravail » (Ueberarbeit)]

    Par conséquent, il y a augmentation du nombre de “troubles” et augmentation aussi du champ sémantique de nombre d’entre eux, comme le fameux TDAH, [Trouble de déficit de l'attention / hyperactivité], qui non seulement se permet un diagnostic basé seulement sur la présence de symptômes, et ne requérant pas l’incapacité, mais encore est réduit pour les adultes à la moitié du nombre des symptômes requis. Le diagnostic TDHA se rencontre aussi dans l’autisme, ce qui impliquerait la création de deux fausses épidémies et engendrerait une augmentation de l’utilisation de stimulants dans une population particulièrement vulnérable.

    Si on relie ce traitement statistique avec l’hétérogénéité thématique des groupes de travail, qui se multiplient et vont de l’identité en passant par l’adaptation des pulsions, l’hypersexualité, les changements d’humeur, etc., force est de constater que les classifications internationales prétendent être totalement autonomes par rapport à une quelconque empreinte théorique et, par conséquent, libres de tout type de contrôle sur le plan de la rigueur épistémologique. Cependant, nous ne croyons pas que les classifications et traitements puissent être neutres par rapport aux théories étiologiques, comme on le prétend, et dans le même temps être neutres par rapport à l’idéologie du Contrôle Social, et à des intérêts autres que la clinique.

    Paul Feyerabend, dans Le mythe de la science et sa mission dans la société, nous dit: « A la base, c’est à peine s’il y a une différence entre le processus qui conduit à l’énonciation d’une nouvelle loi scientifique et le processus qui précède un nouvelle loi dans la société ». Il semble, poursuit cet auteur dans Adieu la Raison, que : »Le monde dans lequel nous vivons est trop complexe pour être compris par les théories qui obéissent aux principes (généraux) de l’épistémologie. Et les scientifiques, les politiques – toute personne qui veut comprendre et/ou avoir une influence dans le monde -, prenant en compte cette situation, violent les règles universelles, abusent des concepts, déforment les connaissances déjà acquises et empêchent constamment les tentatives pour imposer une science au sens de nos épistémologues. »

    Enfin, nous voulons attirer l’attention sur le danger que représente pour la clinique des symptômes psychiatriques le fait que les nouveaux cliniciens sont formatés, délibérément, dans l’ignorance de la psychopathologie classique, puisque cela entre dans la dialectique entre théorie et clinique, entre savoir et réalité. La psychopathologie clinique qui déjà n’est pas enseignée dans nos facultés non plus que dans nos programmes de formation (…).Cependant, ils sont instruits du modèle d’indication… pharmacologique: universalisation de la prescription pour tous et pour tout, et qui ne se différencie en rien d’un distributeur automatique d’étiquettes psy et de réponses médicamenteuses. Ce que nous dénonçons est une méconnaissance des fondements de la psychopathologie, un obscurcissement de taille au moment d’examiner les patients et, par conséquent, une limite plus que considérable au moment d’établir un diagnostic.

    Dans la mesure où la connaissance est la forme la plus éthique que nous ayons de nous approcher de notre réalité plurielle, la coexistence de différents savoirs sur la complexité de l’être humain n’est pas un problème.

    C’est pour tout cela que nous proposons de mettre en oeuvre des actions qui auraient pour objectif de poser des limites à tout ce processus croissant des classifications internationales, et de travailler avec des critères de classification qui auraient une base solide en psychopathologie et qui, par conséquent, proviendraient exclusivement de la clinique.

    Barcelone, le 14 Avril 2011

    Pour signer le manifeste, cliquer là: http://stopdsm.blogspot.com/

    Nous serons reconnaissants de la diffusion maximum de ce premier manifeste (suivi d’autres, de pays différents)

    Les éléments recueillis seront traités de façon confidentielle (ils ne seront publiés qu’au moment de présenter les adhésions à un organisme officiel)

    Les groupes et organisations qui souhaitent adhérer à la campagne peuvent envoyer un courrier à stopdsm@gmail.com

    Information et contact: stopdsm@gmail.com

    MANIFESTO A FAVORE DI UNA PSICOPATOLOGIA CLINICA CHE NON SIA SOLO STATISTICA.

    Attraverso questo scritto, i professionisti e le istituzioni che sottoscrivono
    questo documento, si dichiarano a favore di criteri diagnostici clinici e
    pertanto contro l’imposizione del Manuale Diagnostico e Statistico dei Disturbi
    Mentali dell’Associazione Psichiatrica Americana come unico criterio delle
    sintomatologie psichiche.

    Vogliamo condividere la conoscenza clinico “logica” sul pathos psichico sulla
    “sofferenza sintomatica” e non sulla malattia.Vogliamo mettere in discussione
    l’esistenza di una salute psichica, statistica o normativa. Inoltre vogliamo
    denunciare l’imposizione di un trattamento unico,di “terapie classificate per
    disturbi catalogati” per il disprezzo che presenta verso le varie teorie e
    strategie terapeutiche e della libertà di scelta dei pazienti.

    Attualmente assistiamo ad una clinica sempre meno dialogante, più indifferente
    alle manifestazioni della sofferenza psichica, aggrappata ai protocolli e alle
    cure meramente palliative, preoccupata più delle conseguenze che non delle sue
    cause. Come dice G. Berrios (2010) “Siamo di fronte ad una situazione
    paradossale in cui si chiede ai clinici di accettare un cambiamento radicale
    nel modo di sviluppare il loro lavoro (es.: abbandonare i dettami della propria
    esperienza per seguire quelli meramente statistici quindi impersonali) quando
    in realtà, l’attuale base delle evidenze non sono altro che quello che dicono
    gli statistici, i teorici, i dirigenti, le aziende (come l’Istituto Cochrane)
    ed i finanziatori capitalisti che sono precisamente quelli che dicono dove si
    “investe il denaro” .

    Di conseguenza, esprimiamo il nostro sostegno a un modello sanitario, dove la
    parola sia un valore da promuovere e dove ogni paziente sia considerato nella
    sua particolarità. La difesa della dimensione soggettiva implica una fiducia in
    ciò che ognuno mette in gioco per affrontare ciò che a lui stesso si rivela
    insopportabile, estraneo a se stesso, ma tuttavia familiare. Esprimiamo il
    nostro rifiuto delle politiche assistenzialiste che inseguono la sicurezza a
    scapito della libertà e dei diritti. Una politica che, sotto la maschera delle
    buone intenzioni e cercando il bene del paziente, lo riduce a un calcolo delle
    sue prestazioni, a un fattore di rischio o a un indice di vulnerabilità che
    deve essere eliminato, più o meno in maniera forzata.

    Per qualsiasi disciplina, l’approccio alla realtà del suo campo avviene
    attraverso una teoria. Questa conoscenza limitata non dovrebbe confondersi con
    La Verità, dato che agirebbe come ideologia o religione, dove qualsiasi
    pensiero, un evento o persino il linguaggio utilizzato, si trova al servizio
    della forzata unione tra conoscenza e verità. Ogni clinico con un certo spirito
    scientifico sa che la sua teoria è quello che Aristotele chiama un Organon,
    vale a dire, uno strumento per avvicinarsi a una realtà sempre più plurale e
    mutevole e dove le categorie riscontrate lasciano spazio alla manifestazione di
    quella diversità, permettendo un allargamento tanto teorico come pratico.
    Questa concezione si oppone all’idea di Canon nella quale: necessariamente,
    obbligatoriamente e in maniera prescrittiva le cose sono (o esistono) e devono
    essere svolte in un certo modo. Sappiamo tutti le conseguenze di questa
    posizione che va dall’orientamento normativo, al prescrittivo per poi
    finalmente diventare coercitivo. Ed è qui, in senso lato, dove il sapere
    diventa l’azione di un potere in qualità di sanzione, quello che obbedisce e
    disobbedisce questo canone. Ordinare la soggettività all’Ordine Sociale
    richiesto dai mercati. Tutto per il paziente senza paziente. Conoscenza senza
    soggetto è già un potere sul soggetto. J. Peteiro lo chiama autoritarismo
    scientifico. Per tutto questo esprimiamo la nostra opposizione alla esistenza
    di un Codice Diagnostico Unico, Obbligatorio e Universale.

    Inoltre, il modello a-teorico che vanta il DSM e che ha voluto essere confuso
    con l’obiettività, ci parla della sua falla epistemologica. Basti ricordare la
    sua indefinitezza su quello che chiama “disturbo mentale”, “salute
    psicologica”. Il contenuto di questa tassonomia psichiatrica risponde molto di
    più a patti politici che a osservazioni cliniche, producendo un grave problema
    epistemologico.

    Per quanto riguarda il metodo di classificazione DSM, sappiamo che è possibile
    classificare, ammucchiare o raggruppare molte cose, ma questo non vuol dire
    stabilire un’entità nosografica in un determinato campo. Infine, sulla stessa
    linea di cui sopra, i dati statistici utilizzati nel DSM hanno un punto di
    partenza debole: l’ambiguità dell’oggetto su cui si opera, vale a dire, il
    concetto di disturbo mentale. La statistica si presenta come una tecnica, uno
    strumento che può essere messo al servizio di molteplici cause e di ogni
    genere. Sono le persone che gestiscono gli item e i valori di base della curva
    statistica e che decidono sullo spostamento, più o meno verso i margini di ciò
    che si andrà a quantificare e interpretare più tardi.

    In questo contesto di povertà e confusione concettuale, la prossima
    pubblicazione del DSM-V è una chiara minaccia: nessuno rimarrà fuori dalla
    malattia. Non rimarrà spazio per la salute, in termini di cambiamento, di
    mobilità, di complessità o di molteplicità delle forme. Tutti malati, tutti
    disturbati Qualsiasi manifestazione di disagio sarà presto trasformata in
    sintomo di un disturbo che necessita di essere medicalizzato a vita. Questo è
    il grande salto che si fa senza nessuna rete epistemologica: dalla prevenzione
    alla previsione.

    Soglie diagnostiche più basse per molti disturbi esistenti e nuovi strumenti
    diagnostici che potrebbero essere estremamente comuni nella popolazione
    generale, di questo ci avverte Frances Allen, capo del gruppo di lavoro del DSM
    IV, nel suo scritto “Aprendo la scatola di Pandora”. Riferendosi ai nuovi
    disturbi che includerà il DSM-V, l’autore cita alcuni dei nuovi strumenti
    diagnostici problematici: la sindrome di rischio da psicosi (“è certamente il
    più inquietanti dei suggerimenti. Il tasso di falsi positivi sarebbe allarmante
    dal 70 al 75%”). Il disturbo misto d’ansia depressiva. Il disturbo cognitivo
    lieve (“è definito da sintomi non specificati … la soglia è stata predisposta
    per includere un massiccio 13,5% della popolazione.”) Mangiatori compulsivi. Il
    disturbo disfunzionale di personalità con disforia.

    Il disturbo coercitivo parafilico?. Il disturbo di ipersessualità, ecc.
    Aumenta, pertanto, il numero di disturbi e aumenta anche il campo semantico di
    molti di questi, tra cui il famoso ADHD (deficit di attenzione ed
    iperattività), in quanto la diagnosi si basa solo sulla presenza di sintomi,
    senza richiedere una disabilità e inoltre, si riduce alla metà il numero di
    sintomi necessari per gli adulti. La diagnosi di ADHD è contemplata anche in
    presenza di autismo, pertanto implicherebbe la creazione di due false sindromi
    e favorirebbe un maggiore utilizzo di stimolanti in una popolazione
    particolarmente vulnerabile.

    Se mettiamo insieme questa gestione statistica con l’eterogeneità dei gruppi
    di lavoro tematici, che si moltiplicano e che vanno dall’identità di genere,
    attraversando l’adattamento degli impulsi, ipersessualità, sbalzi di umore,
    ecc., Non possiamo ignorare che le classifiche internazionali pretendono una
    totale autonomia rispetto a qualsiasi quadro teorico, e si presentano prive di
    qualsiasi tipo di controllo e di rigore epistemico. Tuttavia, non crediamo che
    le classificazioni ed i trattamenti possano essere neutrali rispetto alle
    teorie eziologiche, come si pretende e allo stesso tempo essere neutrali
    rispetto alla ideologia del controllo sociale e agli interessi extra clinici.

    Paul Feyerabend, nel libro “Il mito della scienza e del suo ruolo nella
    società”, ci dice: “Fondamentalmente, non vi è quasi alcuna differenza tra il
    processo che porta alla formulazione di una nuova legge scientifica e il
    processo che precede una nuova legge nella società “. A quanto pare, dice
    l’autore nel libro Addio alla ragione, che “il mondo in cui viviamo è troppo
    complesso per essere compreso sia da teorie che obbediscono a principi
    (generali) epistemologici. Gli scienziati, i politici, e chiunque cerchi di
    capire e / o influenzare il mondo, tenendo conto di questa situazione, viola
    regole universali, abusa di concetti elaborati, distorce la conoscenza già
    ottenuta e contrasta costantemente il tentativo di imporre una scienza basata
    sulle teorie dei nostri epistemologi”

    Infine, vorremo attirare l’attenzione sul pericolo che rappresenta per la
    clinica della sintomatologia psicologica che i nuovi clinici siano formati
    deliberatamente nell’ignoranza della psicopatologia classica, dato che questa
    risponde alla dialettica tra teoria e clinica, tra sapere e realtà. La
    Psicopatologia Clinica non è più insegnata nelle nostre scuole o in corsi di
    formazione . Tuttavia, sono istruiti nel paradigma delle prescrizioni
    farmacologiche, una specie di prescrizione universale per tutti e per tutto che
    non si differenzia in nessun modo da un distributore automatico di etichette o
    da una scansia di farmaci. Il risultato che denunciamo è l’ignoranza delle
    fondamenta della psicopatologia, uno scotoma importante al momento di esaminare
    i pazienti e di conseguenza, una limitazione più che considerevole al momento
    di fare una diagnosi.

    In quanto la conoscenza è la forma più etica che abbiamo di avvicinarci alla
    nostra realtà plurale, non deve essere un problema la coesistenza di diverse
    conoscenze sulla complessità degli esseri umani.

    Proponiamo pertanto di portare a termine azioni con l’obiettivo di porre
    limite all’incremento delle classificazioni statistiche internazionali e di
    lavorare con criteri di classificazione che abbiano una solida base
    psicopatologica e, pertanto, provenienti esclusivamente dalla clinica.

    Barcellona, 14 aprile 2011

    stopdsm@gmail.com
    http://stopdsm.blogspot.com

    MANIFIESTO POR UNA PSICOPATOLOGÍA CLÍNICA, QUE NO ESTADÍSTICA.

    Mediante el presente escrito, los profesionales e instituciones abajo firmantes, nos manifestamos a favor de criterios clínicos de diagnosis, y por lo tanto en contra de la imposición del Manual Diagnóstico y Estadístico de los Desórdenes Mentales de la American Psychiatric Association como criterio único en la clínica de las sintomatologías psíquicas.

    Queremos compartir, debatir y consensuar el conocimiento clínico -logía- sobre el pathos psíquico -padecimiento sintomático, que no enfermedad- a fin de cuestionar la existencia de una salud psíquica, estadística o normativa, así como la impostura clínica e intelectual del desorden, trastorno, enfermedad mental. También queremos denunciar la imposición del tratamiento único -terapias tipificadas para trastornos formateados- por el menosprecio que supone a las diferentes teorías y estrategias terapéuticas, y a la libertad de elección de los pacientes. En el momento actual, asistimos al devenir de una clínica cada vez menos dialogante, más indiferente a las manifestaciones del padecimiento psíquico, aferrada a los protocolos y a tratamientos exclusivamente paliativos para las consecuencias, y no para sus causas. Tal y como dice G. Berrios (2010) «Nos enfrentamos a una situación paradójica en la que se les pide a los clínicos que acepten un cambio radical en la forma de desarrollar su labor, (ej. abandonar los consejos de su propia experiencia y seguir los dictados de datos estadísticos impersonales) cuando en realidad, las bases actuales de la evidencia no son otras que lo que dicen los estadísticos, los teóricos, los gestores, las empresas (como el Instituto Cochrane) y los inversores capitalistas que son precisamente aquellos que dicen donde se pone el dinero». En consecuencia, manifestamos nuestra defensa de un modelo sanitario,donde la palabra sea un valor a promover y donde cada paciente sea considerado en su particularidad. La defensa de la dimensión subjetiva implica una confianza en lo que cada uno pone en juego para tratar aquello que en él mismo se revela como insoportable, extraño a sí mismo, pero sin embargo familiar. Manifestamos nuestra repulsa a las políticas asistenciales que persiguen la seguridad en detrimento de las libertades y los derechos. A las políticas que, con el pretexto de las buenas intenciones y de la búsqueda del bien del paciente, lo reducen a un cálculo de su rendimiento, a un factor de riesgo o a un índice de vulnerabilidad que debe ser eliminado, poco menos que a la fuerza.

    Para cualquier disciplina, la aproximación a la realidad de su campo se hace a través de una teoría. Este saber limitado no tendría que confundirse con La Verdad, pues, supondría actuar como una ideología o religión, donde cualquier pensamiento, acontecimiento o incluso el lenguaje utilizado, está al servicio de forzar el re-ligare entre saber y verdad. Todo clínico con un cierto espíritu científico sabe que su teoría es lo que Aristóteles llamaría un Organon, es decir, una herramienta de acercamiento a una realidad siempre más plural y cambiante, y donde las categorías encontradas han de dejar espacio a la manifestación de esa diversidad, permitiendo así una ampliación tanto teórica como práctica. Esta concepción se opone a la idea de un canon, en el sentido de lo que necesariamente, obligatoriamente y prescriptivamente las cosas son y han de funcionar de determinada manera. Todos sabemos las consecuencias de esta posición que va de lo orientativo a lo normativo, prescriptivo para, finalmente, convertirse en coercitivo. Es ahí donde el saber se convierte en el ejercicio de un poder en tanto sancionador, en un sentido amplio, de lo que obedece o desobedece a ese canon. Ordenación de la subjetividad al Orden Social que reclaman los mercados. Todo para el paciente sin el paciente. Un saber sin sujeto ya es un poder sobre el sujeto. Autoritarismo científico, lo llama J. Peteiro. Por todo esto queremos manifestar nuestra oposición a la existencia de un Código de Diagnostico Único Obligatorio y Universal.

    Por otra parte, el modelo a-teórico del que hace gala el DSM, y que se ha querido confundir con objetividad, nos habla de su falla epistemológica. Baste recordar su indefinición sobre qué podemos entender como trastorno mental, así como por salud psíquica. Los contenidos de esta taxonomía psiquiátrica responden mucho más a pactos políticos que a observaciones clínicas, lo que da lugar a un problema epistemológico muy grave.

    En cuanto al método clasificatorio del DSM, constatamos que se puede clasificar, amontonar o agrupar muchas cosas, pero eso no es establecer una entidad nosográfica en un campo determinado. Por último, y en la misma línea que lo anterior, la estadística empleada en el DSM tiene un punto de partida débil: la ambigüedad del objeto sobre el que se opera, es decir, el concepto de trastorno mental. La estadística se presenta como una técnica, un utensilio que puede ser puesto al servicio de múltiples causas y de todo tipo. Son las personas quienes manejan los ítems y valores de base de la curva estadística, pero también quienes deciden el deslizamiento, más o menos hacia los márgenes de lo que se va a cuantificar e interpretar posteriormente.
    En este contexto de pobreza y confusión conceptual, la próxima publicación del DSM-V supone una clara amenaza: nadie quedará fuera de aquello que se detiene, de lo que enferma. No quedará espacio para la salud, en términos de cambio, de movilidad, de complejidad o de multiplicidad de las formas. Todos enfermos, todos trastornados. Cualquier manifestación de malestar será rápidamente transformada en síntoma de un trastorno que necesita ser medicalizado de por vida. Éste es el gran salto que se realiza sin red epistemológica alguna: de la prevención a la predicción.
    Umbrales diagnósticos más bajos para muchos desórdenes existentes o nuevos diagnósticos que podrían ser extremadamente comunes en la población general, de esto nos advierte Allen Frances, jefe de grupo de tareas del DSM IV, en su escrito Abriendo la caja de Pandora. Refiriéndose a los nuevos trastornos que incluirá el DSM-V, este autor cita algunos de los nuevos diagnósticos problemáticos: el síndrome de riesgo de psicosis, («es ciertamente la más preocupante de las sugerencias. La tasa de falsos positivos sería alarmante del 70 al 75%»). El trastorno mixto de ansiedad depresiva. El trastorno cognitivo menor, («está definido por síntomas inespecíficos… el umbral ha sido dispuesto para incluir un enorme 13.5% de la población».) Trastorno de atracones. El trastorno disfuncional del carácter con disforia. El trastorno coercitivo parafílico. El trastorno de hipersexualidad, etc. Aumenta, por tanto, el número de trastornos y aumenta también el campo semántico de muchos de ellos, como el famoso TDAH, ya que se permite el diagnóstico basado sólo en la presencia de síntomas, no requiriendo discapacidad y, además, se reduce a la mitad el número de síntomas requeridos para adultos. El diagnóstico de TDAH también se contempla en presencia de autismo, lo cual implicaría la creación de dos falsas epidemias e impulsaría el uso aumentado de estimulantes en una población especialmente vulnerable.
    Si juntamos este manejo estadístico con la heterogeneidad temática de los grupos de trabajo, que se multiplican y que van desde la identidad de género, pasando por la adaptación de los impulsos, hipersexualidad, cambios de humor etc., no podemos obviar que las clasificaciones internacionales pretenden una autonomía total respecto de cualquier marco teórico, y por ende, libre de cualquier tipo de control de rigor epistémico. Sin embargo, no creemos que las clasificaciones y tratamientos puedan ser neutrales respecto a las teorías etiológicas, como se pretende, y al mismo tiempo ser neutrales respecto de la ideología del Control Social, e intereses extra clínicos.

    Paul Feyerabend, en El mito de la ciencia y su papel en la sociedad, nos dice: «Básicamente, apenas si hay diferencia alguna entre el proceso que conduce a la enunciación de una nueva ley científica y el proceso que precede a una nueva ley en la sociedad». Parece ser, sigue diciendo este autor en Adiós a la razón, que: «El mundo en que vivimos es demasiado complejo para ser comprendido por teorías que obedecen a principios (generales) epistemológicos. Y los científicos, los políticos -cualquiera que intente comprender y/o influir en el mundo-, teniendo en cuenta esta situación, violan reglas universales, abusan de los conceptos elaborados, distorsionan el conocimiento ya obtenido y desbaratan constantemente el intento de imponer una ciencia en el sentido de nuestros epistemólogos».

    Finalmente, queremos llamar la atención del peligro que supone para la clínica de las sintomatologías psíquicas, que los nuevos clínicos estén formateados, deliberadamente, en la ignorancia de la psicopatología clásica, pues, ésta responde a la dialéctica entre teoría y clínica, entre saber y realidad. Psicopatología clínica que ya no se enseña en nuestras facultades ni en los programas de formación de los MIR y PIR. Y sin embargo, se les alecciona en el paradigma de la indicación… farmacológica: universalización prescriptiva para todos y para todo, y que en nada se diferencia de una máquina expendedora de etiquetas y reponedora de medicación. El resultado que denunciamos es un desconocimiento de los fundamentos de la psicopatología, un escotoma importante a la hora de explorar a los pacientes y, en consecuencia, una limitación más que considerable a la hora de diagnosticar.

    En tanto que el conocimiento es la forma más ética que tenemos de acercarnos a nuestra plural realidad, no ha de ser un problema la coexistencia de diferentes saberes sobre la complejidad del ser humano.

    Por todo ello proponemos llevar a cabo acciones con el objetivo de poner límite a todo este proceso incrementalista de las clasificaciones internacionales, y trabajar con criterios de clasificación que tengan una sólida base psicopatológica y, por tanto, que provengan exclusivamente de la clínica.

    Barcelona, a 14 de Abril de 2011

    PARA FIRMAR EL MANIFIESTO PULSAR AQUÍ.

    AGRADECEREMOS LA MÁXIMA DIFUSIÓN DE ESTE PRIMER MANIFIESTO (al que seguirán otros de diferentes países).

    Información y contacto: stopdsm@gmail.com

    Los Grupos e Instituciones que deseen adherirse a la campaña, pueden enviar un correo a stopdsm@gmail.com

  10. STOP DSM
    November 1st, 2011 @ 5:58 pm

    MANIFEST FOR A CLINICAL NON-STATISTICAL
    PSYCHOPATHOLOGY

    By this manifest, the undersigned professionals and institutions, want to declare ourselves in favor of clinical diagnostic criteria, and therefore against the imposition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, as the sole criterion in the clinic of psychological symptoms. We would like to share, discuss and agree on the clinical knowledge -logy- on mental pathos, understood as symptomatic suffering, and not a disease. We wish to question the existence of mental health, statistical or normative, as well as the clinical and intellectual imposture of the notion of mental disorder or mental illness. We also want to denounce the imposition of one sole therapy treatment for typified disorders. These being formatted to the detriment and contempt of other theories and treatment strategies, as well as the contempt of the patients’ right to choose. At present, we witness how clinical practice is becoming less dialogist and more indifferent to the manifestations of mental sufferings, clinging to the protocols and palliative treatments, which only address the consequences, but not their causes.

    As stated by G. Berrios (2010) “We are facing a paradoxical situation in which clinicians are asked to accept a radical change in the way of developing their work, (ie leave the advice of your own experience and follow the dictates of statistical and impersonal data) when in fact, currently, the basis that are used for evidence are no different than what the statistics, theorists, managers, companies (such as the Cochrane Institute) and capitalist investors say, being these who precisely say where you put the money.” We thus want to uphold a health model, where the speech is a value to promote and where each patient is considered in its particularity.
    The defense of the subjective dimension entails to value and consider what each one brings into play to address what remains unbearable, stranger to oneself, but yet familiar. We express our rejection to the welfare policies which prioritize security at the expense of freedom and human rights. Policies that, under the guise of good intentions and the search for the good of the patient, reduce the patient to a performance calculation, a risk factor or a vulnerability index which ought to be removed, nearly by force.
    For any discipline, the approach to the reality is done through a theory. But this limited knowledge should not be confused with The Truth. This would act as an ideology or religion, where any thought, event, or even the used language would serve to promote the re-ligarebetween knowledge and truth. Any clinician with a true scientific spirit knows that his theory is what Aristotle called an Organon, that is a tool to approach a reality, which becomes always more plural and changeable, and whose categories are only an expression of its diversity, making it become wider from both a theoretical and practical perspective.
    This conception is opposed to the idea of ​​a canon, in the sense of what necessarily things are and that they must perform in a certain way. We all know the consequences of this kind of position that goes from being indicative to set a rule and become prescriptive, and ultimately coercive. This is where knowledge becomes the exercise of a power that sanctions as per what obeys or disobeys this canon. It also means the subordination of subjectivity to the management of social order, as per what markets demand. Everything is for the patient but without taking the patient into consideration. We know that any knowledge dismissing the subject constitutes an act of power on this subject. J. Peteiro calls it “scientific authoritarianism”. For all this, we want to express our opposition to the existence of a Sole, Compulsory and Universal Diagnosis Code.

    Furthermore, the a-theoretical model that the DSM boats about, claiming to guarantee any objectivity, only talks about his epistemological failure. Suffice is to recall its inability to define what a mental disorder and mental health are. The contents of this psychiatric taxonomy respond more to political reasons and agreements than to clinical observations, leading to a very serious epistemological problem.
    Regarding the classification method applied at the DSM, we find that even though many things can be sorted, stacked or grouped, there is no nosographic entity that can be established in a given field. Finally, and in the same line as above, the statistics used in the DSM have a weak point of origin: the ambiguity of the object on which it operates, that is, the concept of mental disorder. Statistics are presented as a technique, a tool that can be used for multiple causes, of any kind. Items and basic values ​​of the statistical curve are handled by persons, and they are responsible to quantify and interpret the data.

    In this context of poverty and confusion, the forthcoming DSM-V constitutes a clear threat: no one is sheltered from what is fixed as illness. There is no room for health in terms of change, mobility, complexity and multiplicity of forms. All of us are patients and we all suffer from a disorder. Any manifestation of discomfort will be quickly transformed into symptoms of an illness that needs to be medicalized for life. This is the big leap that has been done without any epistemological net: from prevention to the prediction. Frances Allen, head of Task Force of the DSM IV, warn us in his article “Opening Pandora’s box” about lower diagnostic thresholds for many existing or newly diagnosed disorders that could be extremely common in the general population. He also lists some of the new conditions that are to be included within the DSM-V: the risk of psychosis syndrome (“It is certainly the most disturbing suggestios. The false positive rate would be alarming, going from 70 to 75%”). The mixed depressive anxiety disorder. Minor cognitive disorder (“is defined by specific symptoms … the threshold has been arranged to include a massive 13.5% of the population”.) Binge eating disorder. Dysfunctional disorder character with dysphoria. Paraphilic coercive disorder. Hypersexuality disorder, etc.As a result, it does not only increase the number of disorders but also the semantic field of many of them, as it is in the case of the ADHD. The DSM-V promotes a diagnosis based on the sole presence of symptoms, and doesn’t entail any disability. Furthermore, it reduces to the half the number of symptoms required for adults. The diagnosis of ADHD is also provided in the presence of autism, which would involve creating two false epidemics and would foster an increased use of stimulants in a particularly vulnerable population.
    If we combine these statistics with the heterogeneity thematic working groups that have proliferated, ranging from gender identity, through the adaptation of the pulse, hyper-sexuality, mood swings etc., we cannot ignore the pursuit of a full autonomy with respect to any theoretical framework and any epistemic rigor control by the international classifications. We, nevertheless, do not believe that the classifications and treatments can be neutral with respect to etiology theories, as it is intended. They can neither be neutral with respect to the ideology of social control, and other extra-clinical interests.
    Paul Feyerabend, in “The Myth of Sscience and its Role in society”, writes: “Basically, there is hardly any difference between the process leading to the formulation of a new scientific law and the process that precedes a new law in society ” It seems, continues this author in “Farewell to Reason” that: “The world we live in is too complex to be understood by theories that obey to epistemological (general) principles. And scientists, politicians, -anyone trying to understand and / or influence the world and, taking into account this situation,- are violating universal rules, abusing of developed concepts, distorting the knowledge already obtained and constantly thwarting attempts to impose a science, in the sense used by our epistemologists. ”

    Finally, we would like to draw attention to the danger it involves to the treatment of psychological symptoms the fact that new clinicians are deliberately educated in the ignorance of classical psychopathology. Clinical psychopathology responds to the dialectic between theory and clinical practice, between knowledge and reality, but it is no longer taught at our universities. And yet, they are instructed in the paradigm of a pharmacologic approach that has become universally prescriptive for everybody and for any condition. It is not much different from a label vending machine, which restocks medication. What we denounce is the complete ignorance of the foundations of psychopathology, a fundamental tool when exploring patients and, consequently, a considerable constraint when making a diagnosis.

    Since knowledge may the most ethical way for approaching our plural reality, the coexistence of different theories about the complexity of human beings should be respected.

    Therefore, we propose to take actions in order to stop the increasing spread and growth of international classifications, and alternatively work with classification criteria which are based on psychopathology fundamentals and exclusively stem from the clinical practice.

    http://stopdsm.blogspot.com

    Barcelona, April 14th 2011

  11. Mary Huhn, LISW
    November 17th, 2011 @ 8:57 pm

    I believe that we treat emotional illness and learned dysfunctional behavior as life long mental illness. Instead of seeing it as something that can be changed by the client and that the client can recover from, we get them hooked on drugs which often decrease the client’s ability to think clearly, decrease his/her motivational energy and actually create zombies out of them. We then label them over and over as mentally ill and we give them excuses to act that way.

  12. Still More on DSM-5 – Lois Holzman
    January 18th, 2012 @ 3:14 am

    [...] Health Service in Lincolnshire, UK. He told me about a campaign he launched a few months ago—“No More Psychiatric Labels.” It’s an interesting read, especially refreshing coming from a psychiatrist. Here’s the [...]

  13. No More Psychiatric Labels | Mad In America
    January 28th, 2012 @ 10:16 pm

    [...] models for organizing effective mental health care are available. You can read the full article at http://www.criticalpsychiatry.net/?p=527 you can add your name to the cause [...]

  14. Donna
    February 13th, 2012 @ 6:00 am

    Though I applaud this author for his appeal to eliminate bogus DSM stigmas and their drug company inspired fad fraud epidemics like the current bipolar fraud that has destroyed countless lives, I disagree with him that psychiatry has all kinds of good modern, helpful treatments with much biological and other evidence behind them. Robert Whitaker’s book and countless others including many whistleblowers in psychiatry, neurology, psychology and other fields including mainstream biolgical psychiatry itself have exposed that there is not a shred of scientific, medical, biological, genetic, chemical imbalance or any other evidence that proves anyone has a so called mental illness or bogus DSM disorder. Moreover, there is not one medical test like x-rays, blood tests, or discovery of lesions or real disease/illness to prove that anyone has any of these bogus disorders in the DSM. In short, these fraudulent labels were invented in bed with BIG PHARMA to push each new toxic poison psych drug always proven to do far more harm than good. See, Dr. Peter Breggin, TOXIC PSYCHIATRY, YOUR DRUG MAY BE YOUR PROBLEM, 2nd. ed., Dr. Johanna Montcrieff, THE MYTH OF THE CHEMCIAL CURE, Dr. Grace Jackson, RETHINKING PSYCHIATRIC DRUGS, Dr. Timothy Scott, AMERICA FOOLED, Dr. David Healy, MANIA: A SHORT HISTORY OF BIPOLAR DISORDER, Dr. Joseph Glenmuller, PROZAC BACKLASH, Dr. Fred Baughman, ADHD FRAUD, Dr. Marcia Angell, THE TRUTH ABOUT THE DRUG COMPANIES and many others.

    Again, the whole evil, bogus multibillion dollary pathocracy of corrupt psychiatrists, BIG PHARMA and government hacks needs to be abolished to save our world from this latest horrific holocaust against the entire human race.

    The so called treatments of the mental death profession are far worse than any original problem anyone could ever have.

    Robert Whitaker talks of increased disability, but as this article discusses, the stigma of bipolar alone is enough to destroy one’s career, marriage, family, financial security, relationships and life in general. I hope the mental death profession has its own Nuremburg Trials some day!

  15. Chris Parker
    March 19th, 2012 @ 6:46 pm

    It is great to see a challenge to the dominant structure in psychiatric services. We do not need labels to see the struggles people have in their lives. We need to support people in their struggles or to help them survive the powerful pressures to normalise behaviour.

    So many young people that I see or support could easily have several labels but not one of them would help them to live their life.

    Chris Parker
    Consultant Child and Adolescent Psychotherapist
    CAMHS
    Nottinghamshire

  16. Aidan
    April 13th, 2012 @ 10:50 pm

    The mental health act in itself is a human rights abuse. Power tends to corrupt. Absolute power corrupts absolutely and mental health have absolute power. It should be made illegal to force mind altering…and the rest…drugs on to any person living in a so called ‘free’ world.

    They don’t have to label you to drug you.

  17. Anne-Laure Donskoy
    April 15th, 2012 @ 12:04 pm

    Most if not all mental health laws around the globe function hand in hand with and rely on psychiatric labels/diagnoses to justify the human rights violations they perform daily on individuals, including involuntary treatments in hospitals, institutions and in the community, at the request of the psychiatric order, of families, of state officials etc. That’s a fact.
    Removing psychiatric labels is a start but must not be replaced by another labelling system controlled by psychiatry or should I say, mental health. Persons who live with the experience must be in control and must be allowed to describe for themselves their experience.

    Furthermore, nowhere did I see in the text nor in any of the posts a reference to the United Nations Convention on the Rights of Persons with Disabilities, ratified in 2008 and now signed and ratified by over a 110 countries around the world. The Convention brings a radical change of paradigm, moving from a medical model of psychosocial distress, “mental illness”, to a social model, whereby a person must be treated on an equal basis with others. There again most if not all mental health laws around the globe flout the Convention and are illegal. Let it be known…

    Anne-Laure Donskoy
    User Researcher and Activist
    UK and France

  18. Coalition Against the Borderline Label (CABL)
    April 26th, 2012 @ 1:02 pm

    This is a brilliant initiative. Sami is highly regarded by both users/refusers/survivors and his peers.
    It is vitally important to remember that the debate surrounding the bio medical model of distress should not be the sole focus of rejecting the pathologising of human distress. Too often we fail to sufficiently critique and challenge equally dominant and pernicious trends in psychology and psychoanalysis which have strong bearing on the pathologising and labelling of personality and behaviour.
    In applying ‘personality disorder’ labels for example, particularly to women, minorities and survivors of trauma, untold damage can be done to the person. The harm caused by such labelling can be far more pernicious and traumatic than the ‘major mental illness’ tags.

    Much of the language used, often unknowingly by well intentioned mental health workers lacks insight into the fact that ‘formulation’ and ‘analysis’ of the ‘subject’ and their ‘problems’ is highly problematic. The right to define one’s own narrative and have control over any interpretation and formulation about one’s distress is as important as the right to refuse medication, seclusion, restraint, ECT or any other unwanted ‘treatment’.

    There are some very good people working for change from within psychiatry. Sami Timimi and indeed Phil Thomas and Pat Bracken are making vital contributions in demanding change. Well done.

  19. “The psychiatric oligarchs who medicalise normality.” « ISEPP Blog
    May 14th, 2012 @ 2:02 pm

    [...] read the full evidence based arguments view the ‘No More Psychiatric Labels’ paper at http://www.criticalpsychiatry.net/?p=527 or view the petition [...]

  20. English context of Autism in relation to medical and other political formulations « Lacanian Works
    July 5th, 2012 @ 11:26 am

    [...] To read the full evidence based arguments view the ‘No More Psychiatric Labels’ paper here [...]

  21. Sami Timimi, M.D., Author at Mad In America
    April 9th, 2013 @ 7:26 pm

    [...] He is founder member of the International Critical Psychiatry Network and recently launched the No More Psychiatric Labels campaign to abolish formal psychiatric diagnostic [...]

  22. No more psychiatric labels. Campaign to abolish psychiatric diagnostic systems such as DSM and ICD | Recovery Wirral
    April 16th, 2013 @ 9:02 am

    [...] http://www.criticalpsychiatry.net/?p=527 [...]

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