Debating DSM-5:diagnosis and the sociology of critique

The development of the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders—the DSM-5—has reenergised and driven further forward critical discourse about the place and role of diagnosis in mental health. The DSM-5 has attracted considerable criticism, not least about its role in processes of medicalisation. This paper suggests the need for a sociology of psychiatric critique. Sociological analysis can help map fields of contention, and cast fresh light on the assumptions and nuances of debate around the DSM-5; it underscores the importance of diagnosis to the governance of social and clinical life, as well as the wider discourses critical commentaries connect with and are activated by. More normatively, a sociology of critique can indicate which interests and values are structuring the dialogues being articulated, and just how diverse clinical opinion regarding the DSM can actually be. This has implications for the considerations of health services and policy decision-makers who might look to such debates for guidance

The science of clinical practice: disease diagnosis or patient prognosis? Evidence about "what is likely to happen" should shape clinical practice.

BACKGROUND: Diagnosis is the traditional basis for decision-making in clinical practice. Evidence is often lacking about future benefits and harms of these decisions for patients diagnosed with and without disease. We propose that a model of clinical practice focused on patient prognosis and predicting the likelihood of future outcomes may be more useful. DISCUSSION: Disease diagnosis can provide crucial information for clinical decisions that influence outcome in serious acute illness. However, the central role of diagnosis in clinical practice is challenged by evidence that it does not always benefit patients and that factors other than disease are important in determining patient outcome. The concept of disease as a dichotomous 'yes' or 'no' is challenged by the frequent use of diagnostic indicators with continuous distributions, such as blood sugar, which are better understood as contributing information about the probability of a patient's future outcome. Moreover, many illnesses, such as chronic fatigue, cannot usefully be labelled from a disease-diagnosis perspective. In such cases, a prognostic model provides an alternative framework for clinical practice that extends beyond disease and diagnosis and incorporates a wide range of information to predict future patient outcomes and to guide decisions to improve them. Such information embraces non-disease factors and genetic and other biomarkers which influence outcome. SUMMARY: Patient prognosis can provide the framework for modern clinical practice to integrate information from the expanding biological, social, and clinical database for more effective and efficient care

Known Allergen Structures Predict Schistosoma mansoni IgE-Binding Antigens in Human Infection

This is the final published paper. The article was originally published in Frontiers in Immunology 6:26, 03 February 2015, doi: 10.3389/fimmu.2015.00026The IgE response has been associated with both allergic reactions and immunity to metazoan\ud parasites. Recently, we hypothesized that all environmental allergens bear structural\ud homology to IgE-binding antigens from metazoan parasites and that this homology defines\ud the relatively small number of protein families containing allergenic targets. In this study,\ud known allergen structures (Pfam domains) from major environmental allergen families were\ud used to predict allergen-like (SmProfilin, SmVAL-6, SmLipocalin, SmHSP20, Sm triosephosphate\ud isomerase, SmThioredoxin, Sm superoxide dismutase, SmCyclophilin, and Sm phosphoglycerate\ud kinase) and non-allergen-like [Sm dynein light chain (SmDLC), SmAldolase\ud SmAK, SmUbiquitin, and Sm14-3-3] proteins in Schistosoma mansoni. Recombinant antigens\ud were produced in Escherichia coli and IgG1, IgG4, and IgE responses against them\ud measured in a cohort of people (n = 222) infected with S. mansoni. All allergen-like antigens\ud were targeted by IgE responses in infected subjects, whilst IgE responses to the nonallergen-like\ud antigens, SmAK, SmUbiquitin, and Sm14-3-3 were essentially absent being of\ud both low prevalence and magnitude.Two new IgE-binding Pfam domain families, not previously\ud described in allergen family databases, were also found, with prevalent IgE responses\ud against SmDLC (PF01221) and SmAldolase (PF00274). Finally, it was demonstrated that\ud immunoregulatory serological processes typically associated with allergens also occurred\ud in responses to allergen-like proteins in S. mansoni infections, including the production of\ud IgG4 in people responding with IgE and the down-regulation of IgE in response to increased\ud antigen exposure from S. mansoni eggs. This study establishes that structures of known\ud allergens can be used to predict IgE responses against homologous parasite allergen-like\ud molecules (parallergens) and that serological responses with IgE/IgG4 to parallergens mirror\ud those seen against allergens, supporting our hypothesis that allergenicity is rooted in\ud expression of certain protein domain families in metazoan parasites.We would like to thank the people of Namoni Village for their\ud time and co-operation in the study as well as the field workers\ud of the Ugandan Virus Research Institute and the Kenyan Medical\ud Research Institute. Thanks go also to Shona Wilson, Joseph\ud Mwatha, and Timothy Kamau, for their knowledge and skill in\ud collecting and preparing samples for the study. We would also\ud like to thank Maureen Laidlaw of the Schistosomiasis Research\ud Group (University of Cambridge) for her expert technical assistance;\ud Undergraduate students Aws Sadik, Matthew J Murray,\ud Emma Robbins, and Emily Day for their hard work during final\ud year projects in the Schistosomiasis Research Group; and Prof.\ud Dame Janet Thornton at the European Bioinformatics Institute\ud for her continued help and support. This work was supported by\ud the Wellcome Trust via program WT 083931/Z/07/Z and project\ud WT 094317/Z/10/Z grants and by the European Commission via\ud FP7-CP-IP-SICA scheme grant 242107

Allergen manufacturing and quality aspects for allergen immunotherapy in Europe and the United States:An analysis from the EAACI AIT Guidelines Project

Adequate quality is essential for any medicinal product to be eligible for marketing. Quality includes verification of the identity, content and purity of a medicinal product in combination with a specified production process and its control. Allergen products derived from natural sources require particular considerations to ensure adequate quality. Here, we describe key aspects of the documentation on manufacturing and quality aspects for allergen immunotherapy products in the European Union and the United States. In some key parts, requirements in these areas are harmonized while other fields are regulated separately between both regions. Essential differences are found in the use of Reference Preparations, or the requirement to apply standardized assays for potency determination. Since the types of products available are different in specific regions, regulatory guidance for such products may also be available in one specific region only, such as for allergoids in the European Union. Region-specific issues and priorities are a result of this. As allergen products derived from natural sources are inherently variable in their qualitative and quantitative composition, these products present special challenges to balance the variability and ensuring batch-to-batch consistency. Advancements in scientific knowledge on specific allergens and their role in allergic disease will consequentially find representation in future regulatory guidelines

Children and ADHD: seeking control within the constraints of diagnosis

The views of children diagnosed with ADHD have, until recently, largely been neglected in research, policy and practice. This article focuses on qualitative research which explored children's lived experience, drawing attention to the ways that they actively 'take' responsibility for managing their physical, psychological and emotional well‐being within the constraints of a medical diagnosis. The neglect of a tradition which asks children about their own experiences of ADHD is crucially bound up with children's low social and political status in UK society and notions of competency and responsibility in relation to ADHD

Mast Cells in Allergic Asthma and Beyond

Mast cells have been regarded for a long time as effector cells in IgE mediated type I reactions and in host defence against parasites. However, they are resident in all environmental exposed tissues and express a wide variety of receptors, suggesting that these cells can also function as sentinels in innate immune responses. Indeed, studies have demonstrated an important role of mast cells during the induction of life-saving antibacterial responses. Furthermore, recent findings have shown that mast cells promote and modulate the development of adaptive immune responses, making them an important hinge of innate and acquired immunity. In addition, mast cells and several mast cell-produced mediators have been shown to be important during the development of allergic airway diseases. In the present review, we will summarize findings on the role of mast cells during the development of adaptive immune responses and highlight their function, especially during the development of allergic asthma

What is psychiatry? Co-producing complexity in mental health

What is psychiatry? Such a question is increasingly important to engage with in light of the development of new diagnostic frameworks that have wide-ranging and international clinical and societal implications. I suggest in this reflective essay that ‘psychiatry' is not a singular entity that enjoins consistent forms of critique along familiar axes; rather, it is a heterogeneous assemblage of interacting material and symbolic elements (some of which endure, and some of which are subject to innovation). In underscoring the diversity of psychiatry, I seek to move towards further sociological purchase on what remains a contested and influential set of discourses and practices. This approach foregrounds the relationships between scientific knowledge, biomedical institutions, social action and subjective experience; these articulations co-produce both psychiatry and each other. One corollary of this emphasis on multiplicity and incoherence within psychiatric theory, research and practice, is that critiques which elide this complexity are rendered problematic. Engagements with psychiatry are, I argue, best furthered by recognising its multifaceted nature

Challenges in the implementation of EAACI guidelines on allergen immunotherapy:A global perspective on the regulation of allergen products

Regulatory approaches for allergen immunotherapy (AIT) products and the availability of high quality AIT products are inherently linked to each other. While allergen products are available in many countries across the globe, their regulation is very heterogeneous. First, we describe the regulatory systems applicable for AIT products in the European Union (EU) and in the United States (US). For Europe, a depiction of the different types of relevant procedures, as well as the committees involved is provided and the fundamental role of national agencies of the EU member states in this complex and unique network is highlighted. Furthermore, the regulatory agencies from Australia, Canada, Japan, Russia, and Switzerland provided information on the system implemented in their countries for the regulation of allergen products. While AIT products are commonly classified as biological medicinal products, they are made available by varying types of procedures, most commonly by either obtaining a marketing authorisation or by being distributed as named patient products. Exemptions from marketing authorisations in exceptional cases, as well as import of allergen products from other countries, are additional tools applied by countries to ensure availability of needed AIT products. Several challenges for AIT products are apparent from this analysis and will require further consideration

Fighting to be heard: contested diagnoses

This chapter explores how diagnoses can become sites of contest, rather than of agreement. Conflict can arise when illness refuses to yield the level of proof that epidemiology, clinical medicine, and toxicology require, or its existence is doubted within mainstream medicine. Other forms of contest take place when doctor and patient disagree on the symptoms of an illness, its exact etiology, or its treatment. This chapter explores core features of contested diagnoses and provides case studies to demonstrate the social dynamics that can occur when diagnostic processes create conflicts and disagreements. We begin by examining the often-fraught diagnostic processes that surround unexplained physical symptoms, providing a case study that illustrates the difficulties medical experts face when confronted with unexplained symptoms and the disagreements that can ensue. This chapter then traces patient experiences of, and responses to, a contested diagnosis, as well as the psychological effects that the absence of an illness label produces. We examine two major domains of diagnostic contest. First, we chart the contests surrounding environmental illnesses, demonstrating the challenges they pose to medical notions of proof. Such illness claims also expose how social factors such as class, gender, and ethnicity curtail access to diagnostic processes and the medical information crucial to crafting a diagnosis. A case study of nuclear bomb test veterans illustrates how structures of power and social practices can limit patients' abilities to seek an accurate diagnosis and gain recognition. We also detail the rising influence of environmental health movements that challenge conventional medical explanations of environmental illness. We show how activists shape the labeling of disease and political responses to risk, and reveal the tensions and dialogues between expert authority and patient experience. Next we examine attempts to medicalize and demedicalize certain mental illnesses, taking attention deficit hyperactivity disorder (ADHD) as an extended case study. Finally, while outlining some of the problems with the category "contested diagnosis," we demonstrate the importance of understanding the social, cultural, and political factors that shape conflicts within the diagnostic process