Mainstream medical paradigms
The prevailing medical paradigms in mental health and neurodiversity often revolve around the identification and categorisation of various conditions through standardised assessment tools and diagnostic criteria. These paradigms tend to use clusters of symptoms to assign diagnoses, aiming to classify and treat mental health conditions and neurodivergent traits within established frameworks.
The two key established frameworks in this area are the Diagnostic and Statistical Manual (DSM) and the International Classification of Diseases (ICD) (see Box 1), which both provide diagnostic criteria for mental health disorders and neurodevelopmental conditions based on symptom presentation. Assessment of symptoms may be supported by various psychological assessments, interviews, and questionnaires that are used to evaluate an individual's behavioural, emotional, and cognitive patterns. These assessments often contribute to forming diagnostic impressions and guiding treatment plans. In some cases, tools such as brain scanning and genetic testing may complement diagnostic processes, offering additional insights into brain functioning and potential genetic factors associated with certain conditions.
These approaches often emphasise biological factors, such as genetics, neurochemistry, and brain structure or function as primary contributors to mental health conditions and neurodiversity. Research in fields like neuroscience and genetics is used to identify biological markers and mechanisms underlying these conditions. The frontline biomedical treatments include medications such as antidepressants, anti-anxiolytics and anti-psychotics, all of which are aimed at alleviating symptoms or correcting perceived biochemical imbalances in the brain, and various forms of psychotherapies (“talking therapies” which aim to help people identify and change their thought processes. Somatic interventions such as electroconvulsive therapy are now much more rarely used than they once were due to concerns about effectiveness, long term effects and ethical considerations. Practical support such as skills training and various assistive technologies can also help people overcome specific barriers that they face.
Further important considerations in the context of this report are the link between mental health and addiction, and the connection with suicide. While “Disorders due to substance use or addictive behaviours” falls within the heading of “Mental, behavioural or neurodevelopmental disorders” under ICD-11, conventionally addictions are treated as being somewhat separate to other mental health problems, though it is recognised that many people who suffer as a result of addictions also have other mental health disorders – so-called “dual diagnosis”. Likewise, while many people who take their own lives do have a mental health diagnosis, many do not, and therefore suicide is not necessarily seen as a result of “mental illness”. Within the confines of the biomedical approach, this is entirely appropriate. However alternative approaches can help bring greater coherence to these perceived relationships, as described further below.
Critique of biomedical paradigms
Critiques of this biomedical paradigm have existed for many years. Biomedical approaches to mental health, particularly those reliant on traditional psychiatric diagnoses, have faced growing scrutiny regarding their validity and potential arbitrariness. Several critiques challenge the objectivity and scientific grounding of these diagnostic categories, highlighting the following key points:
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Lack of objective biomarkers: While poor mental health can undoubtedly manifest through physiological symptoms, traditional psychiatric diagnoses often lack clear, objective biological markers. Unlike many other medical conditions with identifiable physical indicators, mental health and learning disability diagnoses rely heavily on reported symptoms and subjective assessments. The absence of reliable biomarkers raises questions about the objectivity and scientific validity of psychiatric diagnoses. It underscores the challenge of establishing a clear biological basis for many mental health conditions.
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Arbitrary diagnostic boundaries: Diagnostic criteria for mental health and learning disorders are often defined by a set number of symptoms or behaviours, leading to diagnostic thresholds that may seem arbitrary and even circular (for example: hearing voices – auditory hallucinations – leads to a diagnosis of schizophrenia, which is then given as an explanation for the hallucinations). The shifting nature of diagnostic criteria over time adds to the perception that these boundaries lack a solid scientific foundation.
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Overlap and comorbidity: Many individuals receive multiple diagnoses simultaneously, indicating a high degree of overlap and comorbidity among different disorders. The co-occurrence of various diagnoses suggests that the discrete categories may not accurately capture the complexity and interconnectedness of mental health conditions. This challenges the idea of clear and distinct disorder.
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Reliability issues in diagnosis: Studies reveal inconsistencies in psychiatric diagnoses, with different clinicians sometimes providing different diagnoses for the same individual. The lack of consistent reliability in diagnoses raises concerns about the robustness of psychiatric categories, including the potential conflation between the presentation of neurodiversity and complex trauma. The subjective nature of diagnostic assessments and potential clinician bias contribute to the variability observed in practice.
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Heterogeneity within diagnoses: Many psychiatric diagnoses encompass a wide range of symptoms and presentations, leading to considerable heterogeneity within diagnostic categories. Critics argue that this heterogeneity challenges the validity of overarching diagnostic labels, as individuals within the same category may exhibit vastly different symptom profiles and trajectories.
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Cultural and contextual bias: Psychiatric diagnoses may reflect cultural biases and be influenced by prevailing societal attitudes. Perhaps most notoriously, homosexuality was included as a mental disorder in the Diagnostic and Statistical Manual of the American Psychiatric Association until 1974, and even then it was still referenced in the DSM until 1987; more broadly, it has been argued that many diagnostic definitions have been developed by a profession that has historically been predominantly white and male, who clearly bring a certain perspective to interpreting others’ experiences. The cultural specificity of certain diagnoses and the potential for pathologising normal variations in behaviour highlight the influence of societal factors on diagnostic frameworks.
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Reductionist approach with limited emphasis on social and environmental factors: The biomedical model can be inclined to focus on biochemical and neurological differences without always considering the impact of social and environmental factors on the experiences of individuals. A more comprehensive understanding should account for the complex interplay between biology, environment, and individual experiences, challenging the reductionist view of solely biological causation.
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Pathologisation of neurodivergent traits: Traditional psychiatric diagnoses may pathologise neurodivergent traits, such as those associated with autism, ADHD, or dyslexia, by framing them as disorders rather than natural variations in cognitive functioning. Neurodiversity advocates argue that many traits classified as disorders are part of the natural spectrum of human diversity, challenging the appropriateness of medicalising these differences, and recognising that efforts to “mask” these traits can in fact create additional challenges for people.
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Overemphasis on deficits: Biomedical models often focus on deficits associated with neurodivergent conditions rather than recognising the diverse skills and capabilities neurodivergent individuals may possess. Critics argue that framing neurodivergence primarily in terms of deficits perpetuates a deficit-based model, neglecting the positive aspects of neurodivergent thinking and potentially hindering opportunities for neurodiverse people.
- Pharmaceutical industry influence: The influence of the pharmaceutical industry on psychiatric research and practice has raised concerns about the potential over-reliance on medication-based interventions. Critics argue that the close relationship between pharmaceutical companies and psychiatric research may contribute to a medicalisation of normal human experiences, with an emphasis on pharmacological solutions.
In conclusion, the critique of biomedical approaches to mental health and learning disability centres on the arbitrary nature of traditional diagnoses and the failure to recognise the validity of the breadth of human experience. The lack of clear biological markers, overlap between diagnoses, reliability issues, and cultural biases all contribute to questions about the scientific validity and objectivity of the current diagnostic framework.
Alternative perspectives
While mainstream medical paradigms try to offer systematic approaches to mental health and neurodiversity, a critical lens suggests that a significant portion of diagnoses may be adaptations to adversity or represent variations within the broad scope of normal human experiences. This perspective urges a re-evaluation of diagnostic frameworks to encompass the nuances of adversity responses and the diversity of human cognition and behaviour.
As Peter Kinderman puts it in his recent book A Manifesto for Mental Health: “We are born as natural learning engines, with highly complex but very receptive brains, ready to understand and then engage with the world. As a consequence of the events we experience in life, we develop mental models of the world, including the social world. We then use these mental models to guide our thoughts, emotions and behaviours. Our social circumstances, and our biology, influence our emotions, thoughts and behaviours – our mental health – through their effects on how we have learned to make sense of, and respond to, the world...Seeing our mental health as the consequence of normal, understandable, psychological processes, rather than ill-defined and elusive “illnesses”, offers an opportunity radically to re-conceptualise mental health services.”
Such a re-conceptualisation would need to take significant account of two key factors. First, the impact of trauma and adversity. A growing body of research suggests that numerous mental health conditions may stem from experiences of trauma or adversity, which includes inadequate attachment in childhood. These factors can significantly affect an individual's mental and emotional well-being, potentially leading to symptoms that align with various diagnoses. Their effects might manifest as symptoms resembling traditional mental health conditions such as anxiety, depression, or dissociation. These manifestations often represent adaptive responses to overwhelming experiences rather than inherent disorders. And second, diversity of experience. Many traits and behaviours encompassed within diagnostic criteria exist on a continuum within the normal spectrum of human experiences. Varied cognitive styles, emotional responses, and personality traits may not inherently signify pathology but rather reflect diverse ways individuals engage with the world. There is therefore a risk of over-pathologising common variations in human behaviour, where certain traits or reactions that deviate slightly from societal norms are labelled as disorders or deviations from the norm.
Within this broader approach, both addictions and suicide can clearly be seen as responses to or outcomes of mental distress brought on by a range of psychosocial factors rather than as separate phenomena. Addiction in particular is clearly not a choice, and nor is it helpfully seen as a disease; as the American psychiatrist Gabor Maté puts it, “Addictions represent, in their onset, the defenses of an organism against suffering it does not know how to endure. In other words, we are looking at a natural response to unnatural circumstances, an attempt to soothe the pain of injuries incurred in childhood and stresses sustained in adulthood.” The same could be said of many experiences currently defined as mental disorders.