There has been a lively discussion on this site revolving around the question of whether one believes in mental illness. As I understand the conversation, it is not so much about the question of the existence of altered mood or cognitive states but more about whether these states constitute an illness or a disease state. In these discussions, the concept of psychiatric diagnosis is often disparaged. I read these blogs and discussions with great interest and have tried to formulate my own response. As a physician, I live in the world of diagnosis. I am no fan, however, of the Diagnostic and Statistical Manual (DSM) and yet, for many reasons, I can not escape it. With apologies if this seems overly defensive, I decided that I would start with my conclusion in order to be clear about where this essay is heading.
What do I tell my patients about diagnosis? I try to explain what a diagnosis is and is not. It is a label that reflects that the person has reported certain symptoms. It is a label for the symptoms not for the person. It might indicate what treatments could be helpful since treatment recommendations are informed by studies that included people who had similar symptoms. It does not explain to me why the person has those symptoms. It does tell not me if the person can or can not get well. It does not tell me that there is some permanent defect in that person’s brain. It does not tell me about the person’s family or life experiences. It does not need to dehumanize the person unless we give it that power.
The modern version of the DSM is considered to be volume III which was published in 1981. By most accounts, this was as much a political document as a scientific one. I was just starting out as a psychiatrist when the DSM III was introduced. I knew then and I know today that this classification system was in many ways a construct that was somewhat arbitrary. Giving someone a diagnosis did not signify that I had obtained a deep understanding of what was wrong with the person. It offered the advantage of improved consistency in communication. When I used the label schizophrenia to characterize a patient’s symptoms, I had a better chance of matching the label a colleague would use with the same patient than I might have had with earlier versions of the manual. This is helpful when studying and comparing treatments be it vitamins, psychotherapy, or drugs. Anatomy of an Epidemic would have been a less powerful book if earlier researchers had not made good attempts at clarifying the diagnoses of the people they were treating.
Even diagnoses that appear to be connected to a clear etiology are limited. For instance, Post Traumatic Stress Disorder is a diagnosis based in part on a history of trauma. However, in my experience, I have met people who have experienced trauma who do not have the particular symptoms included in the category of PTSD. I know some people, for example, who hear voices after traumatic experiences. The label I might use is schizophrenia but I still believe the trauma has played a role in the development of those voices.
Another limitation to the DSM is that it considers diagnosis in a categorical manner; one has a condition or one does not. This does not fit my own experience nor does it fit the research. Peoples’ problems often do not fall into the diagnostic boxes of the DSM. On this website, there were recent postings about the presence of psychotic symptoms in the general population as well as in those diagnosed with depression or anxiety. In one study, for example, 27% of people diagnosed with anxiety or depression had one or more psychotic symptoms even though these are not considered to be symptoms of most depressive or anxiety disorders (1).
So what do I tell my patients? I try to explain what a diagnosis is and is not. It is a label that reflects that the person has reported certain symptoms. It is a label for the symptoms not for the person. It might indicate what treatments could be helpful since treatment recommendations are informed by studies that included people who had similar symptoms. It does not explain to me why the person has those symptoms. It does not tell me if the person can or can not get well. It does not tell me that there is some permanent defect in that person’s brain. It does not tell me about the person’s family or life experiences. It does not need to dehumanize the person unless we give it that power.
1. Wigman,JT, et al., “Evidence that Psychotic Symptoms Are Prevalent in Disorders of Anxiety and Depresion, Impacting on Illness Onset, Risk, and Severity – Implications ofr Diagnosos and Ultra-High Risk Research.” Schizophrenia Bull (012) 38 (2): 247-257.
Anatomy of a Psychiatrist: Dr. Steingard chronicles how she is integrating information from Anatomy of an Epidemic into her community mental health practice. She also discusses changes in Vermont’s mental health system and the influence of pharmaceutical advertising on clinical practice.