Saturday, 30 March 2013

Diagnostic Utility 2: Treatment

I promise this will be the last pro-diagnosis-sounding post I make for the time being. I have been cooking up a piece examining the debate from the other side, but for the sake of neatness I want to present this argument first.

In the last post I suggested that diagnosis had some rude utility as a measure of the risk someone poses for suicide. Certain DSM diagnoses indicate a higher risk than others, and even when there are better and more specific ways to assess for suicidality, it doesn't seem unreasonable to retain diagnostic information as a rough and ready measure for clinicians.

However, it is in the realm of psychological and psychiatric treatment that diagnosis is actually supposed to be helpful. The theory is that if you know the nature of a person's problem you can better offer them appropriate help.*

It is true that therapy is not particularly diagnosis specific (a wide range of different "disorders" are amenable to similar therapeutic approaches, i.e. CBT), but if even only a few existing diagnoses can sensibly pick out types of problem with specific treatment indications, the practice still might have a useful role.

Here are two examples of categories where this seems to apply:

1. So called "Borderline Personality Disorder" (a phrase that is deeply unpleasant, for its implications that the sufferer is both somehow "fringe-y" and "disordered" at the very level of their personality):

For a long time, "BPD" was regarded as untreatable, and those so designated were locked away in seclusion and more or less given up on. The psychologist Marsha Linehan experienced this first hand (here's a New York Times article on her experience) and ultimately went on to develop a psychological treatment approach that dealt specifically with the problems she had encountered. That treatment, DBT, has gone on to be immensely successful, helping other people in a similar situation to Linehan, and the words "similar situation"  are an important part of the phrase. Doctors are constantly being confronted by people who are asking them for help and who would find in this treatment the help they are seeking. Unless those doctors are able to tell those people apart, to pick them out from others who would find shorter/easier treatments helpful, then they can't know what to offer. This where diagnosis comes in. We could change the name of the problem ("Abusive Relational Trauma Sequelae" might be appropriate) and we could adapt the criteria somewhat if we wanted (DSM's criteria don't really get at the person's experience and so miss an essential part of the picture), but as long as we are clustering people together according to shared characteristics and offering a kind of assistance based on the aetiology of the problem, then what we are doing is diagnosis.

2. Psychosis (note, this is too broad to be a DSM category, but it has never been the project of this blog to examine DSM per se, but rather diagnosis more broadly-which can be done using multiple alternative classification systems):

Psychosis is a very distinctive part of the human experiential repertoire. There remains enormous contention around who is and who isn't psychotic, how long it is likely to last and what might be the best way to help them. We do know that some people, some of the time, find the neuroleptic medications to be helpful in dealing with the intense and overwhelming disruption in their experience of reality. This is pretty sketchy detail as far as diagnosis goes, but it still seems there is some useful information contained in the distinction "Psychosis" vs "No-Psychosis". I would argue that the most important information is not:

(i) "Those designated as experiencing psychosis may benefit from neuroleptics"

but rather:

(ii) "Those not designated as experiencing psychosis certainly won't benefit from neuroleptics"

Given the toxicity of so called "anti-psychotic" medications (and "anti-psychotic" is extremely over-optimistic given what these drugs actually do) it seems extremely important to rule out their use in anyone for whom it can definitely be said they won't be of any benefit.

These two examples generalise to some extent, but some diagnoses are more useful than others. DSM gets ever fuller with needlessly specific "disorders", and as Lucy Johnstone has pointed out, many of them are merely descriptions rather than diagnoses proper. What I am exploring here is not whether we should keep the DSM or not (I'm all for its abolition), but whether it should be replaced with an alternative form of diagnosis or an alternative to diagnosis.

*Some readers' answer to this will be that psychiatrists/psychologists aren't able to help anyone anyway. I am extremely sympathetic to anyone whose encounters with the "professionals" have left them feeling this way. The self disclosure in my Bio will alert you to the fact that I have a greater degree of optimism on this question. I have found therapy very helpful in the past, and I have spoken to a few others who claim to have found it transformative. Many people may be better served by non-medical/non-psychological interventions. 

Wednesday, 27 March 2013

Diagnostic Utility 1: Suicide.

For many practitioners today, mental health diagnoses are largely invalid categories so we are better off without them. This is a position I completely agreed with for a while, after all it was Richard Bentall's magnificent "Madness Explained", a comprehensive deconstruction of post-Kraeplinian psychiatry, that persuaded me I wanted to be a clinical psychologist. However, I noticed that even once I started working alongside people who disavowed the use of psychiatric diagnosis, they still seemed to need to benefit from the use of a language for describing the different sorts of problems experienced by those they were working with (distinguishing psychosis from depression for example). This is a contradiction that I think largely goes ignored, but this paper by Kendall and Jablensky provides one solution. They distinguish between the Validity (largely non-existent) and the Utility (more debatable) of psychiatric diagnosis and conclude that the latter does not require the former. They seem to be advocating a fast and loose approach whereby mental health professionals accept the limitations of diagnosis but nonetheless use them as heuristics for as long as they can be helpful.

Of course this raises a further question, can they be helpful? Do the pros of thinking "diagnostically" outweigh the cons?* In this post I want to flag up one answer given by Paul Meehl in his long and ill tempered paper "Why I Do Not Attend Case Conferences",which I think every aspiring and trainee clinical psychologist should read. Below is a dialogue Meehl includes in his paper to emphasise the value of giving at least some minimal consideration to diagnosis. It serves as an amusing demonstration of how Meehl himself could be rather pompous and self-satisfied but it also, I think, shows vividly how diagnosis can be helpful in the rough and ready context of mental health. Anyone who sees only the bad in "labels" should consider the point Meehl is making here:

MEEHL: “You look kind of low today.”
STUDENT: “Well, I should be—one of my therapy cases blew his brains out over the weekend.”
MEEHL: “Oh, I’m sorry to hear that—that is a bad experience for any helper. Do you want to talk about it?”
STUDENT: “Yes. I have been thinking over whether I did wrong, and trying to figure out what happened. I have been his therapist and I thought we were making quite a bit of progress; we had a good
relationship. But then he went home on a weekend pass and shot himself.”
MEEHL: “Had the patient talked to you about suicide before?”
STUDENT: “Oh, yes, quite a number of times. He had even tried to do it once before, although that was before I began to see him.”
MEEHL: “What was the diagnosis?”
STUDENT: “I don’t know.”
MEEHL: “You mean you didn’t read the chart to see what the formal diagnosis was on this man?”
STUDENT: “Well, maybe I read it, but it doesn’t come to my mind right now. Do you think diagnosis is all that important?”
MEEHL: “Well, I would be curious to know what it says in the chart.”
STUDENT: “I am not sure there is an actual diagnosis in the chart.”
MEEHL: “There has to be a formal diagnosis in the chart, by the regulations of any hospital or medical clinic, in conformity with the statistical standards of the World Health Organization, for insurance purposes, and so on. Even somebody who doesn’t believe in diagnosis and wouldn’t bother to put it in a staff note must record a formal diagnosis on the face sheet somewhere. He has to put something that is codeable in terms of the WHO Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death.”
STUDENT: “Oh, really? I never knew that.”
MEEHL: “Did you see this man when he first came into the hospital?”
STUDENT: “Yes, I saw him within the first week after he was admitted.”
MEEHL: “How depressed did he look then?”
STUDENT: “Oh, he was pretty depressed all right. He was very depressed at that time.”
MEEHL: “Well, was he psychotically depressed?”
STUDENT: “I don’t know how depressed ‘psychotically depressed’ is. How do you tell a psychotic depression?”
MEEHL: “Hasn’t anybody ever given you a list of differential diagnostic signs for psychotic depression?”
MEEHL: “Tell me some of the ways you thought he was ‘very depressed’ at the time he came into the hospital.”
STUDENT: “Well, he was mute, for one thing.”
MEEHL: “Mute?”
STUDENT: “Yes, he was mute.”
MEEHL: “You mean he was not very talkative, or do you mean that he wouldn’t talk at all?”
STUDENT: “I mean he wouldn’t talk at all—he was mute, literally mute.”
MEEHL: “And you don’t know whether that tells you the diagnosis—is that right?”
STUDENT: “No, but I suppose that means he was pretty depressed.”
MEEHL: “If he was literally mute, meaning that he wouldn’t answer simple questions like what his name is, or where he lives, or what he does for a living, then you have the diagnosis right away. If the man is not a catatonic schizophrenia, and if you know from all the available evidence that he is some kind of depression, you now know that he is a psychotic depression. There is no such thing as a neurotic depression with muteness.”
STUDENT: “I guess I didn’t know that.”
MEEHL: “Why was he sent out on pass?”
STUDENT: “Well, we felt that he had formed a good group relationship and that his depression was lifting considerably.”
MEEHL: “Did you say his depression was lifting?”
STUDENT: “Yes, I mean he was less depressed than when he came in-although he was still pretty depressed.”
MEEHL: “When does a patient with a psychotic depression have the greatest risk of suicide?”
STUDENT: “I don’t know.”
MEEHL: “Well, what do the textbooks of psychiatry and abnormal psychology say about the time of  greatest suicide risk for a patient with psychotic depression?”
STUDENT: “I don’t know.”
MEEHL: “You mean you have never read, or heard in a lecture, or been told by your supervisors, that the time when a psychotically depressed patient is most likely to kill himself is when his depression is ‘lifting’?”
STUDENT: “No,I never heard of that.”
MEEHL: “Well you have heard of it now. You better read a couple of old books, and maybe next time you will be able to save somebody’s life.”

As a sort of footnote to this, I want to point out that Meehl trained in a psychological tradition that has long since disappeared. As a psychodynamically inclined clinical psychologist  in the 1950s and 60s he would have been trained with DSM versions I and II. These are distinct from their "atheoretical" predecessors by dint of their grounding in psychodynamic thinking. Whatever the problems with this orientation, it is distinct from the "medical model" in that it incorporates the notion that psychology is a process rather than just a momentary state or illness. There is an excellent blog post here which outlines how this fact has created a theoretical minefield for DSM-III and IV's Bereavement Exclusion for Major Depressive Disorder, which is being dropped in DSM 5.

It would be interesting to know if the current opposition to psychiatric diagnosis is partly a product of the shift to DSM-III, which ditched the language of "processes" in favour of "illnesses" or "disorders". Distress is always (by definition) the result of distressing life events. For this reason many (most?) people find it insulting to suggest that what they are experiencing is simply an illness within them rather than the product of many complicated processes and interactions. Perhaps this is less of a problem when a diagnosis itself is viewed not as a discrete "illness" label but rather as a distilled description of the sort of process that has commonalities across multiple cases.

* I am working on a post about the cons of diagnosis at the moment

Sunday, 24 March 2013

Six Problematic Arguments Used Against Psychiatric Diagnosis (Part 2)

In my last post I addressed some of the arguments that get used by activists who wish to abolish psychiatric diagnosis. While I generally admire these people's stated ends, I have the feeling that diagnosis in mental health unfairly becomes a totem for all that is wrong with psychiatry. Here are three more arguments that I take issue with:

4. Diagnosis itself is the cause of stigma about mental health:
The troubling fact of stigma towards people with mental health problems is often cited as a reason to abandon diagnosis. If people stop being “medicalised” runs the argument, then they will stop being seen as different or separate from “healthy” people, and will no longer be treated in de-humanising ways by the intolerant or afraid.

There are two problems with this argument. The first is that it makes an unsubstantiated empirical claim, assuming that the fact of diagnosis is itself a cause of mental health stigma. In fact it is possible to construct a perfectly plausible causal social explanation of mental health stigma without recourse to this assumption. People who present to mental health services often display highly unusual, or even dangerous and frightening forms of behaviour. If they didn’t many of them would never receive any attention at all. It is the job of clinical psychology to care for people in this situation and aim to understand behaviours that others find baffling, with the hope of alleviating the underlying distress. However, individuals with no mental health training feel no such obligation and deal with their fear by discriminating against those they think of as “odd” or “dangerous” (Incidentally there is also a psychological label for these processes: “stereotyping”). It is a fact that mental health stigma often trades in the crass and offensive language of insult, but the commonly used terms “looney” “nutter” and “psycho” derive not from the euphemistic language of any modern psychiatric system, but from cruel and simplistic vernacular.

The second problem is that validated and clinically useful non-psychiatric medical labels can just as easily be used in hateful ways, leading to their replacement as terms, not as categories. When I was at school it was common to hear people described as “spastic”, but the ugly misuse of this once medical word doesn’t mean that the category “cerebral palsy” doesn’t have a role in describing a valid medical condition. The solution in the latter case was to discard the now-offensive word and replace it with a label that described a condition rather than a person. The stigma attached to the term “personality disorder” is a fact which has long been recognised by researchers (here is a classic paper on the subject), but the presence of this problem suggests a need for a different label or categorisation rather than the abandoning of diagnosis itself.

5. Diagnosis itself, rather than the treatments it leads to, causes harm to people:

Lucy Johnstone  makes this point directly here when she says that “‘Diagnosing’ someone with a devastating label such as ‘schizophrenia’ or ‘personality disorder’ is one of the most damaging things one human being can do to another.” To say this is to equate a routine medical practice as on an ethical par with killing, mutilating or raping them, the sort of extreme rhetoric which risks alienating anti-nosologists from other mental health professionals.

Being told that you have “Schizophrenia” or “Personality Disorder” (for example) is problematic because these terms seem to contain two sources of information, one true and one untrue:

1.       The person faces extremely difficult but understandable life circumstances (true)


2.       The person has a purely biological disease/personality defect with a pessimistic prognosis (not true).

The second of sort of information is presumably where we can locate the damage referred to by Johnstone. In the case of “Schizophrenia”, this often means a lifetime of neuroleptic medications which can cause serious health problems . In the case of “Personality Disorder” it has meant that individuals are considered “untreatable” and regarded with mistrust by health professionals.

However, information of the first sort can be validating, conveying the sense that for the first time a person’s behaviour or feelings make sense to them and that they are in the company of a professional who can understand how to help.  If the only consequences of receiving these diagnoses (or similar ones) were that people received care that was appropriate and helpful, then the harm in receiving them would evaporate. It is the way that people think of mental health diagnoses (i.e. as illnesses which are more or less permanent and respond to only one form of intervention) that causes so many problems.

6. Discarding Classification altogether would represent progress:

There are many aspects of the medical approach to illness which have been extremely damaging, and hearing the stories of people who feel misunderstood and discarded by a callous medical machine can give one the sense that progress lies elsewhere than with medical psychiatry. However, it does not follow that the complete disavowal of everything concerned with the “medical model” would represent progress. For almost a century it was believed that fire burned because of a mysterious substance in combustible objects called phlogiston. Progress in our thinking about this came not when the entire idea of an atmospheric substance was discarded, but when the clumping theoretical entity phlogiston was replaced by the idea of Oxygen. Whatever is wrong with the DSM, it is a mistake to think that the only progressive alternative is a complete rejection of classification.

Classifications can have value even where they do not map neatly onto nature. Fields such as Epidemiology and Sociology frequently divide people up by traits which are dimensional (i.e. socioeconomic status, lifestyle) and still yield useful information. The fact that it is bizarre and offensive to speak about these categories as though they implied something essential about their members (poverty, for example, being a set of conditions, not a characteristic of humans) does not mean that there is not predictive information contained in them. Psychiatry and Psychology have yielded numerous categorical systems, not all of which overlap. Although it's easy to fall readily into condemning them for their over-zealous "medicalisation" of people, it is worth remembering that they also help us to avoid inappropriate treatments too. Drug treatments are severe, invasive and controversial, but the fact remains that some people (and there's a good example here) find them positively life-altering and helpful. A benefit of diagnosis is that it not only includes some people in groups considered "medication appropriate", it also excludes others. Thus a person with strong obsessive rituals that sound bizarre and magical to the person assessing them may be considered to be experiencing OCD rather than psychosis and spared the resort of powerful and unpleasant medications. 

Diagnosis remains an imperfect process, and the various competing diagnostic systems are grounded in different aspects of the human experience. I think they are best judged by the extent to which they manage to help rather than harm people, especially as an ultimate "true" system of classification seems highly unlikely. In future posts I want to explore further the extent to which diagnosis is helpful, and also to look at some of the alternative systems to DSM. 

Wednesday, 20 March 2013

Six Problematic Arguments Used Against Psychiatric Diagnosis (Part 1)

Diagnosis in mental health is extremely unpopular at the moment, and perhaps with good reason. Service user movements in the UK and the US have led to a rise in articulate accounts of the misery of first being “labelled” and of feeling misunderstood by a medical establishment which then fails anyway to administer the sort of help that would know, help.

However, it sometimes looks as though the complex problems of mental health care are too easily explained away by a crusade against diagnosis, which runs the risk of diverting people’s reasonable anger to a part of psychiatry which oughtn't to be taking all the blame.

Across two blog posts I will be highlighting six of what I think are some of the non-starter arguments that get used by those who hold what the psychologist Paul Meehl would have called “Antinosological bias”

1. Because Mental Health Problems aren't Diseases, they are not recognisable entities:

In her marvellous book “Schizophrenia, A Scientific Delusion", Mary Boyle argues that Schizophrenia is not a unified disease concept, a position which is then frequently extended to the whole system of classifying mental health problems. I can’t argue with her position (in fact I’m not sure how many people do). However, the fact that this term doesn't refer to an entity that shows both signs and symptoms (Boyle’s chosen definition of a disease), doesn't lead inexorably to the fact that there is no phenomenon (i.e. psychosis) worthy of understanding or treatment.

Moods are not diseases, but they are (roughly) classifiable. We recognise, feel and talk about them. They have the potential to be problematic, even devastating. 

Diagnosis is not just a process of placing something in the category “disease”, it is a process of classifying. To be useful to clinicians, Diagnosis needs to mark out a distinct phenomenon (rather than a person) as worthy of recognition, study, and indicate specific treatment approaches.

2. Because some diagnoses are useless or absurd, so too is the entire system (i.e. Diagnosis=DSM):

It is common in arguments against diagnosis to bolster one’s case by citing the most absurd sounding examples from the forthcoming DSM. This rhetorical sleight of hand is supposed to achieve the effect of extending to the whole edifice of psychiatric diagnosis an air of the ridiculous. This is precisely what clinical psychologist and academic Peter Kinderman does here in an article published by the BBC. Kinderman makes the case that a “new diagnosis of ‘disruptive mood dysregulation disorder’ will turn childhood temper tantrums into symptoms of a mental illness”. If doctors believe that something as trivial sounding as “temper tantrums” could be an illness, he implicitly suggests, then all of their other psychiatric “illnesses” must be flawed as well.

While it can be readily agreed that the over-medicalisation of “temper tantrums” could have pernicious effects (who wants to over-medicate kids?), it is a mistake to infer from this that the act of labelling a cluster of behaviours is itself inherently unwarranted or ridiculous. Consider the use of the phrase “temper tantrum” itself, which connotes a phenomenon that can be recognised instantly, without recourse to a complex description of behaviours or imputed emotions. We immediately that it refers to a welling up of anger that is too much for the child to bear, and which will manifest itself in crying, screaming, shouting, and possibly stiffening of the limbs and kicking or hitting. We can also recognise that it refers to a common situation in which the entire behavioural sequence is likely to be self limiting, that the child will eventually tire and wear itself out. This shared sense of a phrase is a kind of natural language diagnosis, and it resembles what clinicians are doing when they label psychiatric disorders that they recognise in the people who come to them for help.  

3. Diagnoses preclude the possibility of thinking sensitively about people’s problems and developmentally about their causes:

The fact that diagnosis is a short verbal label is often taken as meaning that it can never do justice to the complexities of our human suffering. This line of argument is fallacious for two reasons. First, labels have more meaning than we give them credit for. A diagnosis of a blood infection doesn't say how the infection was acquired, how upsetting it is to have it, or how likely it is to happen again. However, it does describe a particular form of problem and suggests measures which will be helpful in its management. It contains information. I am not suggesting that mental health issues are anything like as simple or straightforwardly treatable as blood disorders, but to suggest their categorisation contains no meaning about a person’s predicament  is to overlook the possibility that clinicians could have a shared and sympathetic sense of what it might mean to talk of “depression” or “anorexia”. More information is always necessary, but that doesn’t mean that there isn’t value in grouping together types of problems to improve our knowledge of how to solve them.

A second point here is that the use of a label does not preclude the parallel use of efforts to achieve detailed understanding of a person’s history and problems. However much it has historically been the case that people are simplistically treated as though they were “just a diagnosis” and allocated impoverished services, there is no reason why the activity of diagnosing should make this so.