There's no sense in revising the psychiatrist's bible

Forget the Diagnostic and Statistical Manual of Mental Disorders ? we need a new system based on brain physiology, says psychiatrist Nick Craddock

You don't believe we should update the Diagnostic and Statistical Manual (DSM) used to classify mental illness. Why not?
There are many reasons we should pause. The DSM checklist of symptoms is not fit for purpose: its categories don't map onto the emerging science of emotion and cognition, yet the DSM-5 rewriters plan to pull in more areas in the new categories and over-medicalise the situation further. Obviously the people rewriting DSM are not stupid, but the project is the wrong thing now. There are lots of great findings coming out of biology, neuroscience and psychology. We will need a new diagnostic system based on these.

How do you see a non-DSM system of classifying mental illness?
It should be based on brain physiology, and make sense in biological and psychological terms. People think mental health is very different from physical health but I think our understanding of it is similar to where we were 100 years ago with illnesses such as diabetes. Take schizophrenia - people vary so much, but the DSM definition doesn't capture that. In 20 years' time the condition will have a biological and psychological typology. Right now our approach is like a blunderbuss.

What changes in DSM-5 worry you?
Suppose you suffer from severe low mood, lack of energy and lack of self-esteem for two weeks continuously. As things stand, if this happens up to six months after a bereavement, it would be considered normal. For most of us that fits with common sense. DSM-5 drops that exclusion and classifies such an episode as depression. This seems unhelpful, to say the least.

What about the "temper tantrum" category?
DSM-5 plans to bring in "Disruptive mood dysregulation disorder" which refers to an onset of temper outbursts before age 10. The thinking is this may be a prelude to later bipolar disorder. However, I believe we need much more firm evidence for the benefits of doing this before labelling children with such a diagnosis.

Do you have any other concerns?
There's likely to be a move to include people with mild delusions, hallucinations or disorganised speech into the psychosis category as "an attenuated form with intact reality testing". This underlines the overwhelming criticism of DSM - we need more research to distinguish correctly between normal and abnormal states before it is clinically justified to add a new diagnosis like this.

DSM is American. Does it apply in Europe?
In Europe we look more to the World Health Organization's International Classification of Disease in our clinical work, but DSM does guide research here.

How strong is the opposition to DSM-5?
There is widespread scepticism globally because of the issues I have mentioned and the DSM's poor ability to translate outside the context of the US healthcare system. Over 11,000 people working in or concerned with mental health care have signed a petition calling for a rethink.

Profile

Nick Craddock is professor of psychiatry at the Institute of Psychological Medicine and Clinical Neurosciences at Cardiff University School of Medicine, and is the director of the Welsh National Centre for Mental Health

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