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DSM-5 online

11 Feb, 10 | by Steven Reid, Evidence-Based Mental Health

Following a year of bitter exchanges about secrecy with accusations flying of vested interests and industry ties the American Psychiatric Association (APA) has posted the new, fifth edition of the Diagnostic and Statistical Manual of Mental Disorders online. Often called the psychiatrist’s bible but perhaps more aptly thought of as the psychiatrist’s cookery book the next update of the Manual is not due for release until May 2013 but the taskforce is looking for comments from clinicians, researchers and the general public (submissions welcome until April 20, 2010).

At first glance the most notable change is, of course, the decision to use an Arabic rather than Roman numeral in the title. Other changes include the likely introduction of Psychosis Risk Syndrome which will certainly prove controversial given the limited evidence for such a diagnosis having much predictive value. It looks like Compulsive shopping disorder and Internet addiction disorder are not going to make it in, but the currently topical Hypersexual disorder is. More to follow, but comments will be welcome here as well as at the APA site.

The End of Kraepelin’s Dichotomy

23 Jan, 09 | by Steven Reid, Evidence-Based Mental Health

No, don’t worry; this isn’t a blog about metaphysics. It was over 100 years ago that Emil Kraepelin, widely considered the father of contemporary psychiatry, divided psychosis into two discrete disorders: dementia praecox (schizophrenia) and manic-depressive insanity (bipolar disorder). Hence the dichotomy, which remains a hallmark of the classification of mental illness.


This categorical approach to diagnosis has plenty of critics but the divide remains firmly in place. Why? Partly because making a psychiatric diagnosis is often an uncertain business. It’s inherently appealing to have just two options to choose from when trying to make sense of a complex clinical picture. Plus the textbooks tell you it’s straightforward: schizophrenia means an enduring illness, with a flat, unreactive mood, and inevitably a poor outcome, in contrast to bipolar illness which is episodic with dramatic changes in mood, and of course that flair for creativity. Well life’s not actually like that. In clinical practice it’s often difficult to discriminate between the two. Take a look at the casenotes of a person with schizophrenia and at some point it’s likely someone will have made a diagnosis of bipolar disorder, and vice versa. In fact we’ve even had to invent a new diagnosis – schizoaffective disorder – for those cases when you just can’t make up your mind. So there has been disquiet about Kraepelin’s dichotomy for some time and now we have a behemoth of a study which may well prove to be the final nail in its coffin.


Published in the Lancet this is a population-based study including over nine million Swedes, that teases apart the genetic and environmental contributions to both schizophrenia and bipolar disorder. Previous genetic studies have been nowhere near as big so the findings are compelling. We know that genes are important in both schizophrenia and bipolar disorder but here it’s demonstrated that they share a common genetic cause. First-degree relatives of people with bipolar illness had an increased risk for schizophrenia, including adopted children to biological parents with bipolar disorder. Similarly, relatives of those with schizophrenia were at increased risk of bipolar disorder.


So what next? Out with the old diagnostic criteria? Perhaps…it certainly gives the committees debating the next version of the psychiatrists’ diagnostic manual (DSM-V) plenty to think about. Maybe it’s time we moved toward a psychosis-spectrum disorder with a renewed emphasis on symptoms. After all, it’s the symptoms that predict response to a specific treatment, not the diagnosis. And what of Kraepelin, would he approve? Well he was having doubts about his own dichotomy back in 1920, “No experienced psychiatrist will deny that there is an alarmingly large number of cases in which it seems impossible, in spite of the most careful observation, to make a firm diagnosis…. It is becoming increasingly clear that we cannot distinguish satisfactorily between these two illnesses and this brings home the suspicion that our formulation of the problem may be incorrect”.

I’m a Psychiatrist… Get Me out of Here!

16 Nov, 08 | by Steven Reid, Evidence-Based Mental Health

“Take ten volunteers, half have psychiatric disorders, the other half don’t – but who is who? Follow this two-part social experiment to see if you can tell which of the people have a mental health diagnosis”

Reality TV meets mental illness in ‘How Mad are You?’, the first part of which was broadcast last week (in the UK you can still watch it on the BBC iPlayer). The film was made for Horizon, a BBC science programme, but there was little science in evidence here. Ostensibly an exploration of the fuzzy border between mental illness and normality, the producers have rejected the considered investigation that the subject merits and instead invite viewers to indulge in a ‘Spot the Screwball’ contest.

The setup derives from the controversial Rosenhan experiment. This study from the 1970s involved a group of people with no mental health problems attempting to gain admission to a psychiatric hospital by reporting vague psychotic symptoms. The pseudopatients were all admitted, given diagnoses of schizophrenia or manic–depression, and none were identified as imposters by staff. Rosenhan described the experiment in his paper ‘On Being Sane In Insane Places’, a forceful critique of the validity of psychiatric diagnosis, and an insight into the demeaning experiences of psychiatric inpatients. A repeat of Rosenhan’s study, I suspect, is what the Horizon team were looking for but this crass Big Brother escapade falls some way short.

The volunteers have been taken to a picturesque castle in the Kent countryside where they undergo a series of tests that will supposedly reveal symptoms of the six disorders:  social anxiety, OCD, anorexia, depression, schizophrenia, and bipolar disorder. In the first episode they all have a turn at stand-up comedy. Someone with social anxiety should be filled with dread at the prospect, although given that they have already agreed to self-exposure on television is telling a few jokes in a pub likely to lead to panic? The next stunt, or challenge, involved cleaning out a cowshed. No prizes for guessing who they were hoping to flush out with that one. I wonder what they have planned for next week – a banquet perhaps?

Competing with the viewers, hidden away in a darkened room watching proceedings, are the three wise men: a psychiatrist, a psychologist and a psychiatric nurse. The psychologist, Richard Bentall, is a vehement critic of psychiatric classification and diagnosis so his willingness to take part comes as a surprise. These experts don’t have much to go on – video clips and a few brief interviews – so they are reduced to making banal and often risible observations, the sort that would make even a daytime TV sofa-shrink squirm.  So the ‘thin one’ must have anorexia, the ‘risk-taker’ must have bipolar disorder and every time anyone makes an insightful comment it’s an obvious sign of treatment with cognitive behavioural therapy. At the end of the episode the three select one person who they think has a psychiatric disorder, and one who doesn’t. They correctly spot the man with OCD, catching him out as he says that he is planning to throw his boots away after the mucking-out. The programme’s best moment comes when we see the happiness of one of the volunteers after the experts get it wrong, confidently telling her that it’s clear she has no psychiatric history.

Mental health all too rarely gets a fair deal on our TV screens and I think Horizon gets it wrong here, veering toward exploitation for the sake of entertainment. This programme risks trivializing mental illness. Social anxiety means you don’t fancy being a comic, sticking your hands in dung will be difficult with OCD, and depressed people tend to be rather gloomy. In addition, we’re treated to annoyingly repetitive pan shots of the volunteers standing on a lawn looking perplexed, clumsy expressionist lighting presumably signifying the unknowable interiors of the human psyche, interspersed with some irrelevant neuropsychological tests in an effort to ratchet up the science quotient.

As the first episode drew to a close the narrator intoned, “No one knows what the outcome of this challenge will be…” I can’t say that I particularly care either, but if you do the second episode will be shown on Tuesday 18th November. An 0800 number appeared after the credits, but not for viewers to call in and vote to eject a contestant. It was a support-line for those distressed by what they had witnessed. I was sorely tempted.

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