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Responses to DSM-5
PAPER
When psychiatric diagnosis becomes an overworked tool George Szmukler Correspondence to Professor George Szmukler, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK; [email protected] Received 13 August 2013 Revised 24 September 2013 Accepted 26 October 2013 Published Online First 15 November 2013
ABSTRACT A psychiatric diagnosis today is asked to serve many functions—clinical, research, medicolegal, delimiting insurance coverage, service planning, defining eligibility for state benefits (eg, for unemployment or disability), as well as providing rallying points for pressure groups and charities. These contexts require different notions of diagnosis to tackle the particular problem such a designation is meant to solve. In a number of instances, a ‘status’ definition (ie, a diagnostic label or category) is employed to tackle what is more appropriately seen as requiring a ‘functional’ approach (ie, how well the person is able to meet the demands of a test of performance requiring certain capabilities, aptitudes or skills). In these instances, a diagnosis may play only a subsidiary role. Some examples are discussed: the criteria for involuntary treatment; the determination of criminal responsibility; and, assessing entitlements to state benefits. I suggest that the distinction between ‘status’ versus ‘function’ has not been given sufficient weight in discussions of diagnosis. It is in the functional domain that some of the problematic relationships between clinical psychiatry and the social institutions with which it rubs shoulders are played out. A status, signified by a diagnosis, has often been encumbered with demands for which it is poorly equipped. It is a reductive way of solving problems of management, allocation or disposal for which a functional approach should be given greater weight.
INTRODUCTION
▸ http://dx.doi.org/10.1136/ medethics-2013-101468 ▸ http://dx.doi.org/10.1136/ medethics-2013-101661 ▸ http://dx.doi.org/10.1136/ medethics-2013-101762 ▸ http://dx.doi.org/10.1136/ medethics-2013-101763 ▸ http://dx.doi.org/10.1136/ medethics-2013-101933
To cite: Szmukler G. J Med Ethics 2014;40:517–520.
The storm of controversy surrounding the publication of Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 offers a good time to examine the place of psychiatric diagnoses. Such a diagnosis may be asked to serve many functions. It may be used clinically, of course, but also for research, for medicolegal purposes, insurance, service planning and commissioning, eligibility for state benefits such as for unemployment and disability, as well as providing rallying points for pressure groups and charities. I shall argue that these contexts require different notions of diagnosis to resolve the particular problem in which such a designation is asked to play a role. Indeed, in some cases, as in determining when a person should be detained in hospital involuntarily, a diagnosis of a ‘mental disorder’ may perform a subsidiary role or virtually none at all; indeed it may be deemed discriminatory. Sometimes, using a diagnosis represents a reductive or lazy way of solving a complex social problem.
Szmukler G. J Med Ethics 2014;40:517–520. doi:10.1136/medethics-2013-101761
How well suited DSM-5 will prove for any of the roles I shall discuss is not the primary concern of this paper. What is being attempted is to put psychiatric diagnosis in a social context. For the argument, it is helpful to draw a distinction between ‘status’ and ‘function’. By ‘status’ is meant the assignment of a person to a category of some kind, such as is given by a diagnosis like schizophrenia. From this assignment, important consequences may follow, for example, having a decision held not to be legally valid. By ‘function’ is meant the ability to meet the demands of a test of performance that requires certain capabilities, aptitudes or skills. A good historical example of the difference concerns the requirements for the making of a will. In the mid 19th century English courts, in the words of Judge Denzil Lush, Senior Judge of the Court of Protection1: allowed themselves to be seduced and blinded by science. They espoused a fashionable doctrine called the ‘doctrine of the unity and indivisibility of the mind’…a doctrine, according to which any degree of mental unsoundness, however slight, and however unconnected with the testamentary disposition in question, must be held fatal to the capacity of the testator.
This ‘status’ notion was rejected in a celebrated case, operative to this day, Banks v Goodfellow (1870) which held that whether the testator, Banks, harboured paranoid delusions did not have significance if, at the time, he understood the nature of the act and its effects, and the extent of the property he was disposing; and he appreciated the claims to which he ought to give effect. A delusion would only be relevant if “it shall influence his will in disposing of his property and bring about a disposal of it which, if the mind had been sound, would not have been made”. This is an example of a ‘functional’ test. It is salutary that the implications of an 1870 judgement relevant to mental disorder have not in other similar spheres been fully realised to this day.
CLINICAL AND RESEARCH DIAGNOSES Before considering a number of situations in which diagnosis is being asked to do too much work, some brief comments are necessary on two contexts where the role of diagnosis is more or less clear, and necessary—in the clinic and in the research enterprise. Diagnosis is an indicator, guide, map or hypothesis for the clinician as to the nature of the disorder that a patient may be presenting, and especially as a guide to treatment and prognosis. It thus has an essential role in clinical 517
Downloaded from http://jme.bmj.com/ on November 14, 2015 - Published by group.bmj.com
Responses to DSM-5 practice and is expected to evolve in the light of new, relevant knowledge. What kind of diagnostic scheme covering mental disorders would perform that task best is beyond the scope of this paper. The need for the task itself is relatively uncontroversial even though the extent to which a putative disorder represents a ‘natural kind’ as opposed to a social construction remains debatable.2 The role of ‘values’ is also noteworthy.3–6 Whether a 1000 page manual listing 300 or so disorders, impossible to memorise, and many of which have been argued to represent a medicalisation of common emotional and behavioural variants—especially when taken in context—can be a helpful guide is an important question. In its detail DSM-5 is more reminiscent of one of those voluminous guides to taxation law than a clinical manual. However, these are not questions to be considered here. The second context is in research. Ideally, research should provide a solid foundation for clinical diagnoses. As has been remarked by a number of notable reviewers, existing clinical diagnoses such as those in DSM-IV have not been vindicated through meeting criteria of validity independent of the diagnostic criteria themselves, whether using epidemiological, genetic or pathophysiological methods.7–9 It is appropriate that research diagnostic criteria, such as the Research Domain Criteria proposed by the National Institute of Mental Health, break free from what seems to be a clinical noose like DSM, and adopt forms that hold the greatest promise for the science, especially in relation to developing more effective interventions ideally founded on an understanding of aetiology and disturbed processes. By ‘research’ I do not mean only biological approaches, but include the entire range of methods—epidemiological, psychological, social and so on. Research funding will follow research classifications. One hopes that the research findings will eventually lead to the establishment of well-validated clinical diagnoses that will be informative about causes, treatments and prognoses.
SITUATIONS WHERE ‘FUNCTION’ MAY OUTWEIGH ‘STATUS’ How may the purposes and roles of diagnosis vary? Three situations in which diagnosis commonly plays a part in solving a social problem will be considered.
Involuntary treatment The first concerns the law governing involuntary detention and treatment of people in psychiatric hospitals, and more recently involuntary treatment in the community. It is here that a highly significant difference emerges in the use of a ‘status’ versus ‘functional’ approach. In nearly all countries with welldeveloped legal regimes, mental health legislation authorises involuntary detention based on two criteria: first, the presence of a ‘mental disorder’, in some places loosely defined, in others restricted to certain diagnostic groups; and second, the presence of a significant risk to the health or safety of the person or to other people. The requirement for a diagnosis of a mental disorder makes this a ‘status’ based approach. This contrasts with involuntary treatment in medicine in general where it is usually only legally permitted if the patient lacks ‘decision-making capacity’ (DMC) and the treatment is in the patient’s ‘best interests’. Some aspects of how DMC should be assessed and of the precise meaning of ‘best interests’ are the subject of some controversy, but neither is based on ‘status’. DMC generally refers to something along the lines of a person’s ability to understand and retain information relevant to a decision they need to make, their ability to appreciate that the information is relevant to 518
their predicament, the ability to reason with that information in the light of their values and life choices, and the ability to express a choice.10 ‘Best interests’ might refer to something like the best determination made by others of the decision the person would have made in the present circumstances if his or her DMC were retained. An advance directive would be to offer important evidence in this regard. Thus an entirely different set of rules governs involuntary detention (and usually treatment) of the patient with a psychiatric disorder versus the medical patient. Colleagues and I have argued that mental health legislation is unfairly discriminatory in not according the same level of respect to the patient’s ‘autonomy’, in the sense of the person’s right to decide about treatment, as in the rest of medicine.11 12 Such respect would require a ‘functional’ approach in mental health law, as in general medicine, and not one based on the ‘status’ of having a diagnosis of a ‘mental disorder’. The person with DMC can reject treatment even if it might appear imprudent to others, and indeed even highly risky. If this argument is accepted, it becomes apparent that a separate mental health law is not required. A single law can govern the non-consensual treatment of all persons who lack DMC, regardless of the cause of their impairment of DMC, that is, regardless of diagnosis (whether it be an intellectual disability, dementia, stroke, head injury, epilepsy, schizophrenia, postoperative confusion, overwhelming emotional distress and so on).11 ‘Function’—the ability to make a decision, not ‘status’—being assigned to a diagnostic category, does the main work. Diagnosis may still play a role, but nevertheless it is a secondary one. There may be a statement like that in the Mental Capacity Act 200513 that a person lacks capacity in relation to a matter if at the material time he or she is unable to make a decision for himself or herself in relation to the matter because of ‘an impairment of, or a disturbance in the functioning of, the mind or brain’. Some may regard this as a form of ‘diagnostic test’, but its breadth, as well as the impossibility of imagining someone lacking DMC who does not have some sort of disturbance in the functioning of the mind or brain makes this test more or less redundant. The assessment of DMC may well involve a testing of the person’s understanding of what they have been informed about a diagnosis and treatment, and, if DMC is impaired, a consideration of ‘best interests’ may well examine what treatment option, if any, the person would have chosen. However, the problem and interventions may not relate directly to a specific diagnosis or a medical treatment as, for example, in the case of a frail, elderly person with mildly impaired memory who on account of their inability to manage their home independently or with supports, may lead others to consider whether a placement in a nursing home might be appropriate, against the person’s currently expressed preferences. A functional test of DMC is a far cry from the state of affairs in many countries where a diagnosis of a ‘mental disorder’ may result in a status attribution entailing social exclusion and the loss of a host of rights—civil, cultural, economic and political. These may include, for example, the choice of where to live (sometimes involving indefinite placement in a ‘care home’), access to work, a right to marriage, a right to vote and a right to manage one’s financial affairs14 15). It is an attempt to prevent this kind of discrimination that inspired the UN Convention on the Rights of Persons with Disabilities.16 A range of mental disorders is clearly included under the rubric of ‘disability’. A number of authoritative interpretations of the UN Convention on the Rights of Persons with Disabilities state that the requirement of a diagnosis (status) Szmukler G. J Med Ethics 2014;40:517–520. doi:10.1136/medethics-2013-101761
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Responses to DSM-5 criterion in legislation authorising involuntary treatment (or ‘substitute decision-making’)—even if it is one of a number of criteria, including, for example, the risk of harm—is clearly discriminatory and that such legislation should be repealed.17
Mental disorder and criminal responsibility A second example where diagnosis as ‘status’ may be asked to play a role that is highly problematic is in criminal procedures involving a serious crime. The recent case of Anders Behring Breivik, the perpetrator of a bombing in Oslo followed by a mass-shooting at a youth camp in 2011 is an example. Under Norwegian law, a person who at the time of the crime was insane—that is, psychotic or with a severely impaired level of consciousness—is not legally accountable and cannot be punished.18 19 Whether Breivik was legally accountable depended on ‘status’, that is, being diagnosed as having a ‘psychosis’ at the time of the crime. A huge importance, generating a mass of public attention, thus became attached to whether Breivik should be given a diagnosis of schizophrenia. If he had a psychosis, he would be sent to a psychiatric hospital where he might be detained indefinitely; if not, the court could find him guilty and he would be sent to prison for up to 21 years. At first it was reported that he would then have to be released but it emerged that a special form of sentence could extend his detention indefinitely. A first forensic psychiatric examination concluded he was psychotic. Following a huge clamour from many quarters with criticisms of the leaked report, a second forensic psychiatric examination was ordered by the court. In contrast with the first report, the experts concluded that Breivik did not suffer from a psychosis. Although in other jurisdictions the approach to the relationship between a mental disorder and a criminal offence varies and can be rather unclear, it is usually a significantly ‘functional’ one, and turns on some notion of responsibility rather than diagnosis. In England, for example, assuming the definitional elements of the crime are proven, it is a defence such as ‘insanity’ or ‘diminished responsibility’ that brings psychiatry into the picture. Briefly, a person is ‘not guilty by reason of insanity’ if, at the material time, they were suffering from a defect of reason due to a disease of the mind. The defect of reason, specifically, is that the person did not know the nature and quality of their acts, or did not know they were wrong. For diminished responsibility (reducing an offence from murder to manslaughter), the person must have been suffering from an abnormality of mind at the material time that substantially impaired their mental responsibility. A diagnosis plays little role at this stage. A connection that is acceptable to the court between the mental element and the act is what is sought. A clinical diagnosis becomes important at the stage of disposal if this is to a psychiatric hospital.
Entitlement to state benefits The third area where function should arguably play a larger, defining role than diagnostic status concerns entitlements that persons with mental disorders may have to the receipt of certain ‘goods’, such as illness-related unemployment or disability benefits, or special housing or support provisions. Persons receiving a diagnosis of schizophrenia, for example, will vary greatly in their capabilities for independent living and participation in the community. A diagnosis alone, even if supplemented with a severity dimension, is not especially informative in this regard and offers a flimsy basis for allocating the kinds of ‘goods’ mentioned above. A ‘functional’ account, determining what kinds of assistance a person needs to manage their life as well as possible, Szmukler G. J Med Ethics 2014;40:517–520. doi:10.1136/medethics-2013-101761
provides a more appropriate basis for the receipt of benefits. A clinical diagnosis may play a secondary role by pointing to treatments or interventions that might significantly ameliorate impairments associated with the disorder. These impairments, in interaction with society’s institutional (and individual personal) responses to them, determine the kind and level of disability that a person may experience. ‘Disability’ refers here to the outcome of that interaction, so that the level of disability will be reduced as social accommodations are increased. There are cases where a person is apparently not able to perform functions that are generally regarded as illness-related and merit support, but where there may be doubts that a ‘real’ or ‘medically accredited’ disorder is present or responsible. Resolution may prove difficult, but retaining a focus on the ‘functional’ should assist clarification. Establishing a meaningful connection between the symptoms or impairments associated with the disorder and the conceptually distinct functional impairments for which benefits might be entertained would be important here, as would the overall coherence of the presentation and the ways in which social responses amplify or diminish disability. A manual offering more and more diagnostic categories and operational criteria might not be especially helpful. Research on defining more precisely the mechanisms leading to the relevant functional impairments would offer a more promising approach, as well as attention to the kinds of social and work accommodations that reduce disability despite illnessrelated impairments. Such research seems at present to be given a low priority. In some places a degree of attention may be given to ‘functional’ aspects, but it tends to be of a ‘tick-box’ nature or the functions selected are more pertinent to physical impairments (and required accommodations to them). (For an example that suffers such limitations but which may point in the right direction, see the assessment for Personal Independence Payments in England20). I recognise that this area is a difficult one, and that much work would need to be done to develop validated approaches that tackle the functional elements head-on. However, there is a good case that the subject merits further investigation.
CONCLUSIONS As people with ‘mental disorders’ have moved out of the asylum and into the community, the notions of what constitutes such disorders have changed, as well as the increasingly complex social situations where a diagnosis may be asked to play a role.21 These complex and varying situations involve a range of practices within psychiatry and in its interaction with a number of social institutions. Discussions about DSM and diagnosis have generally underplayed some of these complexities and what they might mean for the place of the diagnosis of a mental disorder. The difference between clinical and research diagnoses has been well articulated. Diagnosis is indispensible to clinical practice, and is informed and shaped by research into underlying causes and treatments, which may adopt for further investigation, promising new or modified ‘diagnoses’ suggested by emerging evidence. In other areas I suggest that the distinction between ‘status’ versus ‘function’ has not been given sufficient weight. It is in the functional domain that some of the problematic relationships between clinical psychiatry and the social institutions with which it rubs shoulders are played out. A ‘status’, signified by a diagnosis, has often been encumbered with demands for which it is poorly designed. Indeed, it may be a lazy way of solving problems of management, allocation or disposal for which a 519
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Responses to DSM-5 ‘functional’ approach is more suited. It is recognised that a ‘functional’ approach is also more demanding, since it is arguably more complex, requires considerable conceptual clarity about what constitutes the function at issue, and thus carries a greater degree of transparency in its realisation. Charles Rosenberg, a historian of contemporary medicine, while perhaps overemphasising a social constructionist view, has summarised today’s challenge well: “We have never been more aware of the arbitrary and constructed quality of psychiatric diagnoses, yet we have never been more dependent on them than now, in an era characterised by the increasingly bureaucratic management of healthcare and an increasingly pervasive reductionism in the explanation of normal, as well as pathological behavior”.22 The reductionism requires some redress. Acknowledgements The author gives special thanks to Nikolas Rose for his perceptive comments on an early version of this manuscript, and to Martyn Pickersgill and Felicity Callard for their comments on a later draft. Competing interests None. Provenance and peer review Commissioned; externally peer reviewed.
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Lush D. Address to Society of Trust and Estate Practitioners, December 2012. http://step.org/banks-v-goodfellow-1870 Phillips J, Frances A, Cerullo MA, et al. The six most essential questions in psychiatric diagnosis: a pluralogue. Part 4: general conclusion. Philos Ethics Humanit Med 2012;7:14. Wakefield JC. Disorder as harmful dysfunction: a conceptual critique of DSM-III-R’s definition of mental disorder. Psychol Rev 1992;99:232–47. Wakefield JC. The concept of mental disorder. On the boundary between biological facts and social values. Am Psychol 1992;47:373–88. Fulford KW. Moral theory and medical practice. Cambridge: Cambridge University Press, 1989.
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Bolton D. What is mental disorder? An essay in philosophy, science and values. Oxford: Oxford University Press, 2007. Hyman SE. A glimmer of light for neuropsychiatric disorders. Nature 2008;455:890–3. Regier DA, Narrow WE, Kuhl EA, et al. The conceptual development of DSM-V. Am J Psychiatry 2009;166:645–50. Insel T, Cuthbert B, Garvey M, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry 2010;167:748–51. Okai D, Owen G, McGuire H, et al. Mental capacity in psychiatric patients: systematic review. Br J Psychiatry 2007;191:291–7. Dawson J, Szmukler G. Fusion of mental health and incapacity legislation. Br J Psychiatry 2006;188:504–9. Szmukler G, Daw R, Dawson J. A Model Law fusing incapacity and Mental Health legislation & outline of the Model Law. J Mental Health Law 2010;Special Issue Ed 20:1101–26. HM Government. Mental capacity act 2005. London: The Stationery Office, 2005. Lewis O. Mental disability law in central and eastern Europe: paper, practice, promise. December 2002. J Mental Health Law 2002; December:293–303. Drew N, Funk M, Tang S, et al. Human rights violations of people with mental and psychosocial disabilities: an unresolved global crisis. Lancet 2011;378: 1664–75. United Nations. Convention on the Rights of Persons with Disabilities. 2006. Annual report of the High Commissioner for HumanRights to the General Assembly. A/HRC/10/49, presented 26 January 2009, para 48–9. http://www.ohchr. org/EN/UDHR/Documents/60UDHR/detention_infonote_4.pdf (accessed 12 Aug 2013). Maseide PH. The battle about Breivik’s mind. Lancet 2012;379:2413. Melle I. The Breivik case and what psychiatrists can learn from it. World Psychiatry 2013;12:16–21. Department for Work & Pensions (2013) PIP Assessment Guide. https://www.gov. uk/government/publications/personal-independence-payment-assessment-guidefor-assessment-providers (accessed 13 Aug 2013). Abi-Rached JM, Rose N. The birth of the neuromolecular gaze. Hist Human Sci 2010;23:11–36. Rosenberg CE. Contested boundaries—psychiatry, disease, and diagnosis. Perspect Biol Med 2006;49:407–24.
Szmukler G. J Med Ethics 2014;40:517–520. doi:10.1136/medethics-2013-101761
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When psychiatric diagnosis becomes an overworked tool George Szmukler J Med Ethics 2014 40: 517-520 originally published online November 15, 2013
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Responses to DSM-5
PAPER
When psychiatric diagnosis becomes an overworked tool George Szmukler Correspondence to Professor George Szmukler, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK; [email protected] Received 13 August 2013 Revised 24 September 2013 Accepted 26 October 2013 Published Online First 15 November 2013
ABSTRACT A psychiatric diagnosis today is asked to serve many functions—clinical, research, medicolegal, delimiting insurance coverage, service planning, defining eligibility for state benefits (eg, for unemployment or disability), as well as providing rallying points for pressure groups and charities. These contexts require different notions of diagnosis to tackle the particular problem such a designation is meant to solve. In a number of instances, a ‘status’ definition (ie, a diagnostic label or category) is employed to tackle what is more appropriately seen as requiring a ‘functional’ approach (ie, how well the person is able to meet the demands of a test of performance requiring certain capabilities, aptitudes or skills). In these instances, a diagnosis may play only a subsidiary role. Some examples are discussed: the criteria for involuntary treatment; the determination of criminal responsibility; and, assessing entitlements to state benefits. I suggest that the distinction between ‘status’ versus ‘function’ has not been given sufficient weight in discussions of diagnosis. It is in the functional domain that some of the problematic relationships between clinical psychiatry and the social institutions with which it rubs shoulders are played out. A status, signified by a diagnosis, has often been encumbered with demands for which it is poorly equipped. It is a reductive way of solving problems of management, allocation or disposal for which a functional approach should be given greater weight.
INTRODUCTION
▸ http://dx.doi.org/10.1136/ medethics-2013-101468 ▸ http://dx.doi.org/10.1136/ medethics-2013-101661 ▸ http://dx.doi.org/10.1136/ medethics-2013-101762 ▸ http://dx.doi.org/10.1136/ medethics-2013-101763 ▸ http://dx.doi.org/10.1136/ medethics-2013-101933
To cite: Szmukler G. J Med Ethics 2014;40:517–520.
The storm of controversy surrounding the publication of Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 offers a good time to examine the place of psychiatric diagnoses. Such a diagnosis may be asked to serve many functions. It may be used clinically, of course, but also for research, for medicolegal purposes, insurance, service planning and commissioning, eligibility for state benefits such as for unemployment and disability, as well as providing rallying points for pressure groups and charities. I shall argue that these contexts require different notions of diagnosis to resolve the particular problem in which such a designation is asked to play a role. Indeed, in some cases, as in determining when a person should be detained in hospital involuntarily, a diagnosis of a ‘mental disorder’ may perform a subsidiary role or virtually none at all; indeed it may be deemed discriminatory. Sometimes, using a diagnosis represents a reductive or lazy way of solving a complex social problem.
Szmukler G. J Med Ethics 2014;40:517–520. doi:10.1136/medethics-2013-101761
How well suited DSM-5 will prove for any of the roles I shall discuss is not the primary concern of this paper. What is being attempted is to put psychiatric diagnosis in a social context. For the argument, it is helpful to draw a distinction between ‘status’ and ‘function’. By ‘status’ is meant the assignment of a person to a category of some kind, such as is given by a diagnosis like schizophrenia. From this assignment, important consequences may follow, for example, having a decision held not to be legally valid. By ‘function’ is meant the ability to meet the demands of a test of performance that requires certain capabilities, aptitudes or skills. A good historical example of the difference concerns the requirements for the making of a will. In the mid 19th century English courts, in the words of Judge Denzil Lush, Senior Judge of the Court of Protection1: allowed themselves to be seduced and blinded by science. They espoused a fashionable doctrine called the ‘doctrine of the unity and indivisibility of the mind’…a doctrine, according to which any degree of mental unsoundness, however slight, and however unconnected with the testamentary disposition in question, must be held fatal to the capacity of the testator.
This ‘status’ notion was rejected in a celebrated case, operative to this day, Banks v Goodfellow (1870) which held that whether the testator, Banks, harboured paranoid delusions did not have significance if, at the time, he understood the nature of the act and its effects, and the extent of the property he was disposing; and he appreciated the claims to which he ought to give effect. A delusion would only be relevant if “it shall influence his will in disposing of his property and bring about a disposal of it which, if the mind had been sound, would not have been made”. This is an example of a ‘functional’ test. It is salutary that the implications of an 1870 judgement relevant to mental disorder have not in other similar spheres been fully realised to this day.
CLINICAL AND RESEARCH DIAGNOSES Before considering a number of situations in which diagnosis is being asked to do too much work, some brief comments are necessary on two contexts where the role of diagnosis is more or less clear, and necessary—in the clinic and in the research enterprise. Diagnosis is an indicator, guide, map or hypothesis for the clinician as to the nature of the disorder that a patient may be presenting, and especially as a guide to treatment and prognosis. It thus has an essential role in clinical 517
Downloaded from http://jme.bmj.com/ on November 14, 2015 - Published by group.bmj.com
Responses to DSM-5 practice and is expected to evolve in the light of new, relevant knowledge. What kind of diagnostic scheme covering mental disorders would perform that task best is beyond the scope of this paper. The need for the task itself is relatively uncontroversial even though the extent to which a putative disorder represents a ‘natural kind’ as opposed to a social construction remains debatable.2 The role of ‘values’ is also noteworthy.3–6 Whether a 1000 page manual listing 300 or so disorders, impossible to memorise, and many of which have been argued to represent a medicalisation of common emotional and behavioural variants—especially when taken in context—can be a helpful guide is an important question. In its detail DSM-5 is more reminiscent of one of those voluminous guides to taxation law than a clinical manual. However, these are not questions to be considered here. The second context is in research. Ideally, research should provide a solid foundation for clinical diagnoses. As has been remarked by a number of notable reviewers, existing clinical diagnoses such as those in DSM-IV have not been vindicated through meeting criteria of validity independent of the diagnostic criteria themselves, whether using epidemiological, genetic or pathophysiological methods.7–9 It is appropriate that research diagnostic criteria, such as the Research Domain Criteria proposed by the National Institute of Mental Health, break free from what seems to be a clinical noose like DSM, and adopt forms that hold the greatest promise for the science, especially in relation to developing more effective interventions ideally founded on an understanding of aetiology and disturbed processes. By ‘research’ I do not mean only biological approaches, but include the entire range of methods—epidemiological, psychological, social and so on. Research funding will follow research classifications. One hopes that the research findings will eventually lead to the establishment of well-validated clinical diagnoses that will be informative about causes, treatments and prognoses.
SITUATIONS WHERE ‘FUNCTION’ MAY OUTWEIGH ‘STATUS’ How may the purposes and roles of diagnosis vary? Three situations in which diagnosis commonly plays a part in solving a social problem will be considered.
Involuntary treatment The first concerns the law governing involuntary detention and treatment of people in psychiatric hospitals, and more recently involuntary treatment in the community. It is here that a highly significant difference emerges in the use of a ‘status’ versus ‘functional’ approach. In nearly all countries with welldeveloped legal regimes, mental health legislation authorises involuntary detention based on two criteria: first, the presence of a ‘mental disorder’, in some places loosely defined, in others restricted to certain diagnostic groups; and second, the presence of a significant risk to the health or safety of the person or to other people. The requirement for a diagnosis of a mental disorder makes this a ‘status’ based approach. This contrasts with involuntary treatment in medicine in general where it is usually only legally permitted if the patient lacks ‘decision-making capacity’ (DMC) and the treatment is in the patient’s ‘best interests’. Some aspects of how DMC should be assessed and of the precise meaning of ‘best interests’ are the subject of some controversy, but neither is based on ‘status’. DMC generally refers to something along the lines of a person’s ability to understand and retain information relevant to a decision they need to make, their ability to appreciate that the information is relevant to 518
their predicament, the ability to reason with that information in the light of their values and life choices, and the ability to express a choice.10 ‘Best interests’ might refer to something like the best determination made by others of the decision the person would have made in the present circumstances if his or her DMC were retained. An advance directive would be to offer important evidence in this regard. Thus an entirely different set of rules governs involuntary detention (and usually treatment) of the patient with a psychiatric disorder versus the medical patient. Colleagues and I have argued that mental health legislation is unfairly discriminatory in not according the same level of respect to the patient’s ‘autonomy’, in the sense of the person’s right to decide about treatment, as in the rest of medicine.11 12 Such respect would require a ‘functional’ approach in mental health law, as in general medicine, and not one based on the ‘status’ of having a diagnosis of a ‘mental disorder’. The person with DMC can reject treatment even if it might appear imprudent to others, and indeed even highly risky. If this argument is accepted, it becomes apparent that a separate mental health law is not required. A single law can govern the non-consensual treatment of all persons who lack DMC, regardless of the cause of their impairment of DMC, that is, regardless of diagnosis (whether it be an intellectual disability, dementia, stroke, head injury, epilepsy, schizophrenia, postoperative confusion, overwhelming emotional distress and so on).11 ‘Function’—the ability to make a decision, not ‘status’—being assigned to a diagnostic category, does the main work. Diagnosis may still play a role, but nevertheless it is a secondary one. There may be a statement like that in the Mental Capacity Act 200513 that a person lacks capacity in relation to a matter if at the material time he or she is unable to make a decision for himself or herself in relation to the matter because of ‘an impairment of, or a disturbance in the functioning of, the mind or brain’. Some may regard this as a form of ‘diagnostic test’, but its breadth, as well as the impossibility of imagining someone lacking DMC who does not have some sort of disturbance in the functioning of the mind or brain makes this test more or less redundant. The assessment of DMC may well involve a testing of the person’s understanding of what they have been informed about a diagnosis and treatment, and, if DMC is impaired, a consideration of ‘best interests’ may well examine what treatment option, if any, the person would have chosen. However, the problem and interventions may not relate directly to a specific diagnosis or a medical treatment as, for example, in the case of a frail, elderly person with mildly impaired memory who on account of their inability to manage their home independently or with supports, may lead others to consider whether a placement in a nursing home might be appropriate, against the person’s currently expressed preferences. A functional test of DMC is a far cry from the state of affairs in many countries where a diagnosis of a ‘mental disorder’ may result in a status attribution entailing social exclusion and the loss of a host of rights—civil, cultural, economic and political. These may include, for example, the choice of where to live (sometimes involving indefinite placement in a ‘care home’), access to work, a right to marriage, a right to vote and a right to manage one’s financial affairs14 15). It is an attempt to prevent this kind of discrimination that inspired the UN Convention on the Rights of Persons with Disabilities.16 A range of mental disorders is clearly included under the rubric of ‘disability’. A number of authoritative interpretations of the UN Convention on the Rights of Persons with Disabilities state that the requirement of a diagnosis (status) Szmukler G. J Med Ethics 2014;40:517–520. doi:10.1136/medethics-2013-101761
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Responses to DSM-5 criterion in legislation authorising involuntary treatment (or ‘substitute decision-making’)—even if it is one of a number of criteria, including, for example, the risk of harm—is clearly discriminatory and that such legislation should be repealed.17
Mental disorder and criminal responsibility A second example where diagnosis as ‘status’ may be asked to play a role that is highly problematic is in criminal procedures involving a serious crime. The recent case of Anders Behring Breivik, the perpetrator of a bombing in Oslo followed by a mass-shooting at a youth camp in 2011 is an example. Under Norwegian law, a person who at the time of the crime was insane—that is, psychotic or with a severely impaired level of consciousness—is not legally accountable and cannot be punished.18 19 Whether Breivik was legally accountable depended on ‘status’, that is, being diagnosed as having a ‘psychosis’ at the time of the crime. A huge importance, generating a mass of public attention, thus became attached to whether Breivik should be given a diagnosis of schizophrenia. If he had a psychosis, he would be sent to a psychiatric hospital where he might be detained indefinitely; if not, the court could find him guilty and he would be sent to prison for up to 21 years. At first it was reported that he would then have to be released but it emerged that a special form of sentence could extend his detention indefinitely. A first forensic psychiatric examination concluded he was psychotic. Following a huge clamour from many quarters with criticisms of the leaked report, a second forensic psychiatric examination was ordered by the court. In contrast with the first report, the experts concluded that Breivik did not suffer from a psychosis. Although in other jurisdictions the approach to the relationship between a mental disorder and a criminal offence varies and can be rather unclear, it is usually a significantly ‘functional’ one, and turns on some notion of responsibility rather than diagnosis. In England, for example, assuming the definitional elements of the crime are proven, it is a defence such as ‘insanity’ or ‘diminished responsibility’ that brings psychiatry into the picture. Briefly, a person is ‘not guilty by reason of insanity’ if, at the material time, they were suffering from a defect of reason due to a disease of the mind. The defect of reason, specifically, is that the person did not know the nature and quality of their acts, or did not know they were wrong. For diminished responsibility (reducing an offence from murder to manslaughter), the person must have been suffering from an abnormality of mind at the material time that substantially impaired their mental responsibility. A diagnosis plays little role at this stage. A connection that is acceptable to the court between the mental element and the act is what is sought. A clinical diagnosis becomes important at the stage of disposal if this is to a psychiatric hospital.
Entitlement to state benefits The third area where function should arguably play a larger, defining role than diagnostic status concerns entitlements that persons with mental disorders may have to the receipt of certain ‘goods’, such as illness-related unemployment or disability benefits, or special housing or support provisions. Persons receiving a diagnosis of schizophrenia, for example, will vary greatly in their capabilities for independent living and participation in the community. A diagnosis alone, even if supplemented with a severity dimension, is not especially informative in this regard and offers a flimsy basis for allocating the kinds of ‘goods’ mentioned above. A ‘functional’ account, determining what kinds of assistance a person needs to manage their life as well as possible, Szmukler G. J Med Ethics 2014;40:517–520. doi:10.1136/medethics-2013-101761
provides a more appropriate basis for the receipt of benefits. A clinical diagnosis may play a secondary role by pointing to treatments or interventions that might significantly ameliorate impairments associated with the disorder. These impairments, in interaction with society’s institutional (and individual personal) responses to them, determine the kind and level of disability that a person may experience. ‘Disability’ refers here to the outcome of that interaction, so that the level of disability will be reduced as social accommodations are increased. There are cases where a person is apparently not able to perform functions that are generally regarded as illness-related and merit support, but where there may be doubts that a ‘real’ or ‘medically accredited’ disorder is present or responsible. Resolution may prove difficult, but retaining a focus on the ‘functional’ should assist clarification. Establishing a meaningful connection between the symptoms or impairments associated with the disorder and the conceptually distinct functional impairments for which benefits might be entertained would be important here, as would the overall coherence of the presentation and the ways in which social responses amplify or diminish disability. A manual offering more and more diagnostic categories and operational criteria might not be especially helpful. Research on defining more precisely the mechanisms leading to the relevant functional impairments would offer a more promising approach, as well as attention to the kinds of social and work accommodations that reduce disability despite illnessrelated impairments. Such research seems at present to be given a low priority. In some places a degree of attention may be given to ‘functional’ aspects, but it tends to be of a ‘tick-box’ nature or the functions selected are more pertinent to physical impairments (and required accommodations to them). (For an example that suffers such limitations but which may point in the right direction, see the assessment for Personal Independence Payments in England20). I recognise that this area is a difficult one, and that much work would need to be done to develop validated approaches that tackle the functional elements head-on. However, there is a good case that the subject merits further investigation.
CONCLUSIONS As people with ‘mental disorders’ have moved out of the asylum and into the community, the notions of what constitutes such disorders have changed, as well as the increasingly complex social situations where a diagnosis may be asked to play a role.21 These complex and varying situations involve a range of practices within psychiatry and in its interaction with a number of social institutions. Discussions about DSM and diagnosis have generally underplayed some of these complexities and what they might mean for the place of the diagnosis of a mental disorder. The difference between clinical and research diagnoses has been well articulated. Diagnosis is indispensible to clinical practice, and is informed and shaped by research into underlying causes and treatments, which may adopt for further investigation, promising new or modified ‘diagnoses’ suggested by emerging evidence. In other areas I suggest that the distinction between ‘status’ versus ‘function’ has not been given sufficient weight. It is in the functional domain that some of the problematic relationships between clinical psychiatry and the social institutions with which it rubs shoulders are played out. A ‘status’, signified by a diagnosis, has often been encumbered with demands for which it is poorly designed. Indeed, it may be a lazy way of solving problems of management, allocation or disposal for which a 519
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Responses to DSM-5 ‘functional’ approach is more suited. It is recognised that a ‘functional’ approach is also more demanding, since it is arguably more complex, requires considerable conceptual clarity about what constitutes the function at issue, and thus carries a greater degree of transparency in its realisation. Charles Rosenberg, a historian of contemporary medicine, while perhaps overemphasising a social constructionist view, has summarised today’s challenge well: “We have never been more aware of the arbitrary and constructed quality of psychiatric diagnoses, yet we have never been more dependent on them than now, in an era characterised by the increasingly bureaucratic management of healthcare and an increasingly pervasive reductionism in the explanation of normal, as well as pathological behavior”.22 The reductionism requires some redress. Acknowledgements The author gives special thanks to Nikolas Rose for his perceptive comments on an early version of this manuscript, and to Martyn Pickersgill and Felicity Callard for their comments on a later draft. Competing interests None. Provenance and peer review Commissioned; externally peer reviewed.
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Szmukler G. J Med Ethics 2014;40:517–520. doi:10.1136/medethics-2013-101761
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When psychiatric diagnosis becomes an overworked tool George Szmukler J Med Ethics 2014 40: 517-520 originally published online November 15, 2013
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