The British Psychological Society Condemns DSM-5

The British Psychological Society (BPS) is a highly esteemed organization representing 50,000 members. Recently, it released an open letter to the American Psychiatric Association offering a harshly critical view of DSM-5. Most of the BPS criticisms are right on target, accurately pointing out the dangerous excesses of DSM-5. But some are so overly broad that the cogent points get lost in the shuffle, allowing the DSM-5 leadership to be archly dismissive of the entire letter. This is unfortunate because the BPS warning deserves serious consideration as we approach the endgame of DSM-5 decision making.

The BPS is at its best when exposing those DSM-5 proposals that medicalize normal variability. It vigorously and convincingly opposes the DSM-5 tendency to turn the expectable reactions to life's difficulties (eg, grief) into psychiatric illness. The letter rightly expresses particular concern about suggestions to include in DSM-5 the risk syndromes (eg, psychosis risk) or the attenuated, milder forms of existing psychiatric disorders (eg, mixed anxiety depression, mild neurocognitive, binge eating).

This portion of the BPS critique is crisply telling and completely true and goes to the heart of what is most wrong and most dangerous in DSM-5. Medicalizing normal experience stigmatizes and cheapens the human condition and promotes overtreatment with unnecessary and potentially harmful drugs. But the BPS critique goes too far and wide in denying the value of all psychiatric diagnosis.

The most striking example is its seemingly blanket disdain applied equally for both schizophrenia and for "psychotic risk syndrome" (lately in a name changing game aka "attenuated psychotic symptoms"). The letter implies that these are more or less equally flawed and undeserving constructs. Most decidedly they are not. The BPS willingness to throw the valuable baby of schizophrenia out with the problematic bathwater of "psychosis risk" reduces the force of its otherwise persuasive argument against the risky bathwater.

Schizophrenia is admittedly a flawed construct with limited descriptive and explanatory power. It is a wildly heterogeneous with dozens of different presentations and probably hundreds of different causes (none of them known). This diverse group of schizophrenias contains within it a wide range of possible onsets, courses, severities, and treatment responses. There is no available biological test available for its diagnosis and none is on the horizon.

All that said, schizophrenia remains a valuable diagnosis that economically captures a great deal of information and serves as a useful (if imperfect) guide to clinical care and research. The literature on schizophrenia accumulated over the past century is extensive and suggests at least the outlines of what we don't yet know. The BPS criticizes schizophrenia as a construct, but offers no viable alternative.      

In contrast, "psychosis risk" is a relative newcomer whose properties remain quite unknown. We don't know how best to define it, can't diagnose it accurately, don't know how to treat it, don't know if treating it has any lasting value, and don't know the extent of its harmful unintended consequences if it were to be made official.

Most telling of all is the widespread opposition to including psychosis risk syndrome as an official diagnosis in  DSM-5--even among those who have devoted their careers to researching it. The tipping point was reached recently when two of the most prominent promoters of psychosis risk (Patrick McGorry and Alison Yung) withdrew their support for its inclusion in DSM-5 and asserted publicly that it will not be included in Australia's ambitious new mental health program that is targeted at treating early presentations of schizophrenia. 

It is now only the DSM-5 diehards who are still hanging fast to the "psychosis risk" bandwagon-- but unfortunately it is they who hold the final casting vote. The BPS is doing a great service in entering this fray and adding its strong voice to the diverse chorus trying to prevent this travesty. But BPS dilutes its valuable message when it simultaneously attempts a takedown of the venerable concept of schizophrenia (especially when there really is no currently available diagnostic alternative). 

Psychiatric diagnosis is admittedly imperfect, but also absolutely necessary; extremely easy to criticize, but so far impossible to replace. It gives comfort to the misguided DSM-5 workers (and protection for their worst ideas) if outside critiques can be dismissed by them as "antipsychiatry" broadsides. DSM-5 deserves and badly needs searching and sustained outside criticism, but this will be most effective if targeted to its numerous, egregious, and specific defects, not to the whole enterprise of psychiatric diagnosis.