The issues raised by the Diagnostic Statistical Manual (DSM) are complex and require careful and studied consideration. There are many aspects that concern the Critical Psychiatry Network about the way the debates around the publication of the new DSM-5 have been represented in the media. In particular, we are concerned about the portrayal of the controversy as a guild dispute, and the polarisation of the debate as one of nurture versus nature.

1.


Portrayal of the controversy as a guild dispute

A number of


reports have described the storm of criticism around DSM-5 as a guild dispute driven by professional rivalries between psychologists and psychiatrists. However, many psychiatrists are deeply concerned about the limitations and failings of diagnosis in psychiatry and equally, many psychologists take an uncritical view of diagnostic based approaches. Psychiatrists’ concerns about the role of diagnosis were expressed in a recent special article co-authored by 29 Members and Fellows of the Royal College of Psychiatrists and published in the British Journal of Psychiatry in December 2012. The article concludes that there is little evidence to support the use of diagnosis as an organizing paradigm for the delivery of mental healthcare.

2.

Epistemological polarisation

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We are also concerned about the way that some commentators question the importance of environmental factors in understanding mental illness. Any attempt to open up the full complexity of serious mental health problems by drawing attention to the importance of a wide range of environmental factors, including childhood adversity such as trauma and abuse, has been met with accusations of ‘witch-hunts’ that seek to blame families for the misfortunes of their children. Yet, psychiatry has always prided itself on being an eclectic profession, one that recognises the importance of holistic approaches to understanding and responding to people who use mental health services. Of course biological, neureodevelopmental and genetic factors are important in helping us to understand the biological basis of mental illness, and in developing better forms of help and support for those who suffer from them, but personal experiences of adversity, especially childhood adversity, play a central role in understanding how people cope with, and recover from, mental distress. To deny the importance of these factors is to deny the importance of finding meaning in suffering. We believe that serious debate that can help us develop a more comprehensive bio-psycho-social model of understanding needs to fully engage with the evidence base pointing toward the role of adverse experiences and with the diverse understandings that service users and carers have of their experiences.

Conclusions

Most psychiatrists recognise the importance of a balanced understanding of mental distress. Psychiatrists, psychologists, and mental health professionals from across the disciplines support non-diagnostic and social perspectives that reject bio-determinism. The differences of opinion do not cast a divide that separates the disciplines, rather the divide, where it exists, is between those who support the importance of diagnostic based practice and those who do not, regardless of their professional background. There are many voices engaged in the debate over the future of psychiatric diagnosis. The Hearing Voices Network has expressed serious reservations about DSM-5, and rightly drawn attention to the importance of service user perspectives in this debate. Mental Health Europe, a non-governmental organisation that represents a diverse range of perspectives, including service users, carers and professionals from a range of disciplines has also expressed deep concern about DSM-5 and the future direction of psychiatric diagnosis. Many psychiatrists will continue to contribute to an informed public debate about the limitations and failings of psychiatric diagnosis including those inherent in the DSM-5. The view of the Critical Psychiatry Network is that a DSM diagnosis is incapable of capturing the full range of experiences of distress in the way that a more comprehensive formulation can.