Every year about this time I review my template file for new client notes. It has blank sections for name, presenting concern, history, plan, and a number of other categories.
This year I found myself staring at it, considering whether a revision was in order. And the category that leapt out at me was “Diagnosis.” The truth is, I seldom use it any more.
Once, that part of the template was more elaborate. I had space for all 5 diagnostic axes of DSM-IV, and sometimes convinced myself that by filling them in I was doing something useful. That didn’t last long – at least not for the majority of people I see.
I dropped the detail years ago, leaving only that “Diagnosis” heading. When DSM-5 came out it seemed that I had been prescient. The axes were gone. The new Bible revealing the truth of immutable human nature had been revealed, and the axes were not a part of it. The nature of disease had, once more, changed overnight.
Maybe new copies of the DSM should come with an “Orwell pill” that erases memories of previous editions. This might help older clinicians like me forget that things were ever different, and we would more readily leap onboard with a fervent belief in the new revelation.
It’s hard for a psychologist not to diagnose. In many jurisdictions, diagnosis is one of the few controlled acts that distinguish our profession from other counselors: We’re allowed to do it, they are not. In reality, of course, they do it all the time. We say “This individual suffers from panic disorder.” They say “This individual reports symptoms that appear to meet criteria for panic disorder.”
Nevertheless, it’s an important distinction. Somehow. If it’s your one Special Power, it’s hard not to use it.
What’s Diagnosis For?
Definitions vary, but the core of diagnosis is the identification of the character and etiology of (in this context) a disorder. (Quibble if you wish.) The essential point of diagnosis is to guide action. By knowing what you are faced with, you may know what to do about it.
Diagnosis is enormously useful in most of medicine. A patient might present with a host of symptoms – perhaps including fever. Diagnosis might attempt to determine whether the person suffers from a viral or bacterial infection. If bacterial, an antibiotic might be effective. If viral, the antibiotic will be a waste of time. Diagnosis takes a host of symptoms and creates a knife-edge dichotomy: yes or no, this or that. If done correctly, the side of the line on which one falls can make a huge difference in the treatment used and the outcome expected.
Diagnosis becomes more difficult when problems are continuous rather than dichotomous. Instead of “Does she have mumps or does she not?” the question is “Are the symptoms severe enough to merit a diagnosis of depression?” In the first case, we are making an inference about the underlying reality of the disorder. In the second case, we are drawing an artificial line, much like the lines defining different time zones. We could move the line a few kilometers to the west or east, and it would be meaningless for someone to argue that we had done it incorrectly.
In striving to emulate the rest of medicine, psychiatry and the other mental health professions saw diagnosis as essential. In many ways this was true.
- In order for a study on the effective treatment of OCD in Baltimore to be relevant to the treatment of patients in Edinburgh, we had to know we were talking about the same thing.
- In order to apportion scarce mental health resources, we had to have a systematic way of admitting patients to treatment – it isn’t fair for the primary determinant of whether one gains access to a mental health center to be which side of Oak Street one lives on.
- And indeed, there are a few conditions – very few – that seem genuinely and sharply distinct from others. An example from the 20th century was tertiary syphilis – a condition that might, to the untrained eye, resemble other conditions but had an entirely distinct cause.
There may be others. Currently a great deal of work is looking at the genetic markers for disorders like schizophrenia. Although for the most part these seem only to be hints of the level of risk for a disorder, it is conceivable that distinct causes will be discovered.
As well, in some cases we may not have sliced the pie thinly enough. Many people suspect, for example, that one problem with Major Depression is that we are looking at a cluster of disorders rather than a single entity. If we could identify distinct types we might be able to select treatments and predict outcomes better than we can now.
In clinical settings, however, the main point of diagnosis is utility. If we take all the complexity of the human life sitting before us and boil it down to a nice clear label, this will tell us what to do.
The trouble is, it almost never does this.
I frequently get referrals of clients who already have a diagnosis. Setting aside the fact that the diagnosis is often incorrect (not surprisingly, having usually been made in the context of a five-minute consultation), this tells me little. In order to decide what course treatment should take, I need to take all the detail back out of the box to see the complexity again. What’s going on in the person’s life? When did it all start? Which of the symptoms of that disorder does the client actually have? What thoughts are they having as they exhibit those symptoms? What do they think is going on?
We are indoctrinated in the church of diagnosis so firmly, that it took an inordinately long time for me to begin questioning what I was doing. I would see the client, pull up my intake template, pull out my DSM, turn to the disorder that seemed to describe the person most closely, and puzzle through whether they had the requisite “5 of 9,” or “6 of 11,” or “A, B, and 3 of the 5 symptoms for C” to meet criteria. I’d put down the answer and that would be the last time I looked at it.
As a tool for guiding treatment, diagnosis was the ultimate null entity. A placebo, if you like.
True believers are infuriated by this. Take even a simple case, they say. Your client is too afraid to get on a plane. What are they afraid of? If it’s that the plane will crash, they have 300.29, Specific Phobia. If it’s that they will have a panic attack, and these occur in other settings as well, then it’s 300.01, Panic Disorder. This makes a difference! In the one case you’ll look at the overprediction of catastrophe; in the other you’ll do panic treatment. A classic knife-edge diagnostic distinction.
Well, yes. But it’s not the diagnosis that tells you this. It’s your assessment. Take away the assigning of the number, and you still have all the information on which your diagnosis was based. In fact you have more, because the whole point of diagnosis is to shave away the detail to leave you with a nice clear label. In order to treat the client you have to reclaim all the shavings and flesh out your understanding.
So you spend all that time packing things into a box, only to open up the box and take everything back out in order to decide what to do. The diagnosis provides you with almost no guidance.
What about that cutoff line? In addition to asking “this disorder or that disorder,” diagnosis attempts to declare “disorder or no disorder.” In my work, the cutoff is virtually irrelevant. If someone has OCD-ish symptoms and meets criteria, I’ll look at the details and work with them on the OCD – maybe with exposure and response prevention (ERP). If they have OCD-ish symptoms but fall short of the full diagnostic criteria I’ll do exactly the same thing. No one has ever shown that the diagnostic line has magical qualities: people who fall on one side respond to ERP; people on the other do not. In both cases I’ll point out that therapy requires a lot of work, and that it is up to them whether they wish to invest the effort in it.
Some people argue that my stance comes from having a psychotherapy practice. Medications, it is sometimes argued, have specific neurochemical effects and so identifying the underlying pathology via diagnosis is critical. (I am setting up a bit of a straw man, here, admittedly – given the last 10 years of psychopharmacology almost no one argues that diagnosis reveals specific neurochemical underpinnings anymore.)
In practice, however, sharp diagnostic lines do not often dictate prescribing practice. Antipsychotics, once given almost exclusively to people with psychotic-spectrum disorders (hence the name), are now as ubiquitous as Jelly Tots. Antidepressants are routinely prescribed to patients who do not meet diagnostic criteria for major depression (or any psychiatric disorder), despite the lack of evidence of efficacy of these medications for subclinical symptoms. (The relatively poor evidence of efficacy for appropriately diagnosed mild-to-moderate depression is another concern.)
So what? Is there a downside to diagnosis?
One problem with diagnosis is that we spend scarce clinical time performing an act that often has little value in structuring treatment. But there are others.
Diagnosis can shape clients’ self-perceptions. Sometimes this can be positive. Certain clients learn that they have an identifiable disorder and sigh with relief. “So I’m not just weird – and there are other people like me.”
But diagnosis can have the reverse effect as well. It can draw a firm line dividing the person from the rest of humanity. “So I’m different from mentally healthy people. They have intact minds and I do not.” In my experience diagnosis more often has an alienating effect on clients than a soothing one.
If I sense that a client will feel better to know the name for their problem, I have no problem giving it. “Yes, these are all symptoms of depression.” But I make it clear that the dividing line is neither important nor indelible. “Just as many of us will have symptoms of a cold which then go away, we will work to bring your symptoms down to the point where you are not in a depression.” I attempt to intervene if I see the label becoming welded to the person’s sense of self – for example, if they begin referring to themselves as “a depressive.” The more they incorporate the symptoms into their vision of who they are, the more recovery will involve “killing” a part of the self or becoming a new and strange person.
This me-versus-them distinction might be inevitable if it was based on a clear reality: “Yes, you are infected with Hepatitis C and most people are not.” But again, most psychiatric diagnosis is defined by a consensus agreement of committee members around a boardroom table, not by a blood test. Most diagnosis involves the drawing of artificial and rather arbitrary lines. But it becomes a psychological reality in the mind of the person diagnosed. “The problem,” so a colleague once said to me, “is that people think these disorders are actually REAL.”
Well, the symptoms are real. The distress is real. In many cases the need for treatment is real. But the label itself takes on a reality that is often a barrier to improvement rather than an aid.
Furthermore, diagnoses find their way into the clinical record. Once a label is down on paper it can influence the outcome of court cases, career aspirations, and the quality and nature of medical care. Many have noted the chill that a diagnosis of “Borderline Personality Disorder” can give to subsequent providers, whether or not it is accurate. Similar unintended effects can happen with depression, anxiety disorders, or other problems. This can be entirely appropriate: if an airline pilot is in the throes of major depression we want to know this. Capriciously given, however, or assigned as a routine part of a clinical consultation, a diagnosis can have long-lasting and damaging effects that outweigh any beneficial elements of the encounter.
Clients themselves are often unaware of the potential long-term difficulties associated with receiving a diagnosis. It is not uncommon for a university student to petition me for a diagnosis of ADD or anxiety disorder to be provided to examination staff. Except in extreme circumstances I have become very resistant to these requests. It is a service provided readily by many practitioners, but is not one I am obliged to offer as part of my work – and I have seen too many unintended negative consequences of casual diagnosis.
Some people have said to me, “Isn’t there an ethical requirement to assign a formal diagnosis prior to conducting therapy?” Actually, there isn’t. There is a requirement to conduct a proper assessment to see what’s going on. But the assigning of a label is optional.
First, do no harm. If I am doing something that runs a significant risk of causing harm to a client, I had better know that the likely benefits of such an act outweigh those risks. In the case of diagnosis the benefits have become steadily less apparent to me, and the downside steadily more visible.
Partly I have become less enthusiastic about diagnosis because I fail to see its usefulness in most circumstances. Partly it’s because I see it as a potential ethical failing.
Maybe we should be trying to understand our clients more, and oversimplify them less. Just a thought.
This is a great article, very honest and revealing for those of us who wonder what is going through the heads of real people who make these diagnoses.
I could write a response as long as your article, but what I’d like to focus on is that many studies such as John Read’s work have emphasized how diagnoses tend to promote a biological, innate, essentialist view of someone as “having a (usually) lifelong illness”. This viewpoint gets internalized as you said and it then leads to more pessimism, more distancing, and probably to poorer outcomes. I think this is one of the most damaging things in our society’s approach to serious emotional suffering -that young people are told that rather than suffering understandable responses to overwhelming stress (including psychosis), that their delusions, fears, depression, hallucinations, confusion etc. represent something wrong with them, a brain illness that must be managed with drugs rather than understood. What a horrible lie that is! And what a damaging one. Also, what a drag on the economy, causing millions of young people to be less likely to work and contribute to GDP over the long term.
It is important to tell people that DSM diagnoses are not valid and reliable, and that psychiatrists who formulate treatment plans based on one particular diagnoses may have no idea what they are really doing and may cause serious harm.
I have my own model of “diagnosis”, not that I really use that word, but that I use to think about different degrees of emotional suffering; here’s an image of it:
Almost all the DSM diagnoses could be thought of as mislabeled off-shoots or correlates emotional developmental problems, which results when some combination of trauma, stress, abuse, neglect, relational deficit, etc lead to a person having problems in how they interface with the environment in important relationships and work functioning. Understanding fusion (prevalent in psychosis), splitting (prevalent in personality disorders), and integration of all-good and all-bad perceptions (i.e. less severe neurotic problems) is to my mind a much more useful guide to understanding what is happening between a person and their environment than a DSM label. Much more useful than saying “they have schizophrenia” as if that explains or means anything. There is a good book along these lines by Nancy McWilliams called Psychoanalytic Developmental Diagnosis.
Very thoughtful and clear article about an important topic, thank you.
I think one of the of the many harms of DSM diagnoses is how they have infiltrated popular culture as ways of putting down people (stigma). I hear people all the time saying things like “they must be borderline” or “what a narcissist” or “you’re being manic,” etc., without even knowing whatsoever what they are saying.
Usually, people who project these ‘diagnoses’ onto others as ways to insult or demean someone during a disagreement or what have you are not even matching up what that means even according to the DSM, they’re just generic put-downs–which I interpret as purely name-calling, of the schoolyard variety type. (They may as well be saying, “You’re mental!”).
I’m afraid, at least in the USA, this has infested the fabric of our society. Everyday people are using these terms to insult others, with no foundation whatsoever, other than they are angry, fearful, insecure, or cut-throat competitive.
In addition–aside from the harms done by these specious DSM diagnoses, I do believe that a diagnostic criteria can be used safely and with the intention of bringing healing, as is what occurs from healing perspectives.
For example, when I sit with a client whom the psychology framework would call ‘manic,’ when I see this, I would call it ‘ungrounded,’ which is remediable in the most natural way, and with the practice of disciplined focus. Grounding solves many issues at once, in the way of bringing balance, clarity, and relief. Anyone who applies themselves with intention can accomplish grounding after long periods of being ungrounded–which is what leads to things such as ‘psychosis,’ rash actions, chronic fear and agitation, etc.
A ‘diagnosis’ should be used as a way of identifying an imbalance for which there should be a concrete treatment plan. The course of someone’s healing is hardly predictable because everyone is different, and we learn from each others’ processes if we are can observe others without judgment. More often than not, however, this is not the case.
But knowing what is causing chronic pain or discomfort (either emotionally or physically) for the purpose of healing it at the root cause would require some sort of diagnostic identification. I just think it’s more sound and effective in a healing way to apply neutral and universal diagnostic criteria that does not malign one’s character, by implication. Most unfortunately, this is what the DSM has become, to a large extent–merely a book of insults, division, and marginalization.
One last thing about DSM diagnoses that I wanted to mention for the time being–
For the majority of these diagnoses, my feeling is that, in spirit at least, it’s pretty much saying that one is ‘too sensitive’ or ‘too thin-skinned’ to deal with life and its many challenges, which is why one would require “medication” (or some other form of lifetime dependence) to compensate for this.
Whereas I feel the reality is that we’re all sensitive beings in an evolutionary process, for the purpose of knowing how to feel so we know when we feel relaxed and at peace, as opposed to conflicted or depressed or in some kind of mental chaos from high stress and trauma.
Regardless what one calls it, I think that simply the idea of going from feeling bad to feeling better would be the goal, however that is best accomplished. Otherwise, we’re just spinning our wheels in costly academic and political exercises which do nothing whatsoever t0 serve the public in any way shape or form.
I have been in practice for 40 years, through all the changes in the DSM. Truthfully for me and most therapists in private practice, diagnosis really has nothing to do with treatment and everything to do with getting reimbursed. Trained in the days when we decried the medical model, I have never bought into the hocus pic us of the DSM.
Add to this that once assigned a diagnosis and it becomes part of the person’so medical record, it is there forever, unlike diagnoses for physical illnesses like pneumonia. And that has consequences when it becomes reason to deny diability insurance, for example.
Truly, defaming a person with a so called “lifelong, incurable genetic mental illness” takes away hope, thus is an inately evil practice. Especially since none of the DSM disorders have any actual scientific “genetic” validity nor reliability. And given the reality that the psychiatrists seemingly know absolutely nothing about the adverse effects of their drugs, while fraudulently claiming they “know everything about the meds.” And the psychiatrists harbor “odd delusions” their toxic “torture” drugs are “wonder drugs.”
Case in point, it’s quite appalling that today’s current “gold standard” treatment recommendations for “bipolar,” combining the antidepressants and antipsychotic drugs, are known to cause “psychosis,” via anticholinergic toxidrome. Why would an industry recommend drug cocktails known to create “psychosis” in the “bipolar” stigmatized, if their true goal was not to make their patients sick for their entire life?
Defamation, and subsequent torture and murder, with scientifically invalid “mental disorders” is exactly what the Nazi psychiatrists did. I had no idea there was an entire industry that did not learn from the Haulocaust that such behavior was unacceptable human behavior.
I do so hope the psychiatric industry will learn that defaming others, and iatrogenically creating “psychosis” in people for profit, is not an appropriate way for any human being to behave. I’m glad you’re seeing the impropriety of stigmatizing, and then torturing, other human beings.
Regarding “Currently a great deal of work is looking at the genetic markers for disorders like schizophrenia. Although for the most part these seem only to be hints of the level of risk for a disorder, it is conceivable that distinct causes will be discovered.”
You are wrong. The word “schizophrenia” is as meaningless as a diagnosis of “witchcraft”.
If anything is wrong in the male “schizophrenic”, it’s that they are not having sexual relations. Sexual relations controlled by society, totally UN-natural.
The sexophobic can’t contemplate the idea of humans being just like all the other animals who respond to natures compulsion to mate (from hormones).
Human Testosterone graph.http://www.mhhe.com/socscience/sex/common/ibank/ibank/0088.jpg
Rate of incidence of schizophrenia versus age. http://d34jb20qqe27k2.cloudfront.net/content/bjprcpsych/202/s54/s5/F1.medium.gif
Testosterone production and “schizophrenia” match on the graphs.
Can you control dogs, cats or any other animal in “heat”? Not very easily.
It’s not hormones though. No, No. It’s schizophrenia. We humans are not animals to be controlled by nature. We don’t eat, breath and sh*t like all the other animals.
And don’t forget all the boy children turning into girls from medicinal treatment. http://blogs.wsj.com/pharmalot/2015/02/24/johnson-johnson-loses-trial-over-risperdal-and-male-breasts/
Thanks Randy for this insightful post. Squishing people into these invalid boxes is such a disservice. The toxic impact on how they see themselves, on how others see them is substantial. We spend so much time talking about reducing stigma – when it is being inflicted by the very people trying to help.
One quibble – ” As ubiqitous as Jelly Tots”?? (wish I had a clue what they were)
About a year ago there was an article in the Canadian Post(?) entitled “The shrinking field of psychiatry” that indicated that there is a decrease in enrolment to become psychiatrists. They spoke to the fact that psychiatrists were tired of redefining the DSMV diagnoses, finding medications to be overall not very effective and not having any breakthroughs in treatment. it is not surprising to me that this is true given the lack of progress in successful and sustained change witnessed in clients suffering with mental illness.
As Randy mentions in his article, diagnosis is not nearly as important as an understanding. An understanding of what the client is dealing with and an understanding of how to help the client are paramount to success. In my work as a mental health nurse for over thirty years, I have seen how mental health professionals have been trained and are knowledgeable about mental illness. What has been lacking is being trained and knowledgeable about Mental HEALTH. Most MH professionals understand Mental Health to be the absence of mental illness. I would like more to be aware of True Mental Health as explained as innate mental well being where common sense, wisdom, joy, love, peace, calm, relaxation, motivation, creativity, productivity, compassion, energy, self esteem, mindfulness, presence, resiliency etc live! This is our default setting as human beings when our mind settles and there is less thought on our minds. As human beings we have learned to think unproductively and excessively and find this healthy state of mind to be more elusive.
There is nothing that gives me more joy than waking my clients up to the fact that they create their reality moment to moment via their thinking. Once someone has an understanding about how their minds work, they become more aware of thought and are able to be less engaged with unproductive and poor thinking habits. They find themselves living in their well being more often. Someone once said that all diagnoses are really just thought recognition disorder. I believe that the field of psychology has been gifted with the cure for mental illness. The remarkable and sustained change in clients is proof. Whether it be in MH, education, prisons, communities, business etc, the results are amazing. Though not well known to the world in general, this “Inside Out” understanding has been changing lives for over 40 years! If you are interested in knowing more about this understanding that is changing the field of psychology, visit http://www.threeprinciplesmovies.com, http://www.threeprinciplesfoundation, Or http://www.3pgc.org for starters.
You may also enjoy a webinar “The Truth about Mental HEALTH” that is on my website. http://www.threeprinciplesnurse.com I would love to hear your responses!