Imagine that you get upset. Is it very remarkable that I can “diagnose” that you are upset? After all, you are clearly upset. What expert thing did I pull off by noticing that you were upset?
Or imagine that you are angry. Is it very remarkable that I can “diagnose” that you are angry? After all, you are clearly angry. Have I added anything meaningful by saying “I diagnose that you are angry” instead of “You seem angry”?
“You look upset” is the simple, truthful thing to say and “I diagnose that you look upset” is a piece of self-serving chicanery. By adopting that circumlocution I’ve tried to turn an ordinary observation into a pseudo-scientific marvel.
By contrast, let’s say that you explain to your physician that you’ve been having hallucinations. You describe the look of your hallucination and you also describe your recent history, other physical symptoms, and so on. Taking that information together, your doctor might have a strong hunch that you’re suffering from early Parkinson’s. He would then run tests to confirm or disconfirm his hypothesis and perhaps learn that it is indeed Parkinson’s. He didn’t “diagnose” your hallucination—that was a phenomenon and, in this case, a symptom of something. Rather, he diagnosed your Parkinson’s, that is, he diagnosed the underlying cause of your hallucinations.
People such as parents who do not spend any time thinking about these matters naturally have a lot of trouble understanding this difference between “diagnosing a symptom” and “diagnosing a cause.” The second is what medicine legitimately does. The first is what the mental health establishment illegitimately does. It is not real diagnosis for me to “diagnose you with an anxiety disorder” because you told me you were anxious. That isn’t genuine diagnosis. You don’t diagnose symptoms; rather you diagnose causes.
To diagnose a symptom is only to say, “Yes, I agree, you have a rash.” Everyone who looks at you knows that you have a rash. What we want to know is what sort of rash is it? What’s causing it? You observe the tumor but you diagnose the cancer. You observe the fever but you diagnose the influenza. You don’t observe the anxiety and then diagnose the anxiety. That isn’t diagnosis.
You observe a symptom, you interpret a symptom, and you make use of a symptom as part of your efforts at diagnosis. But the symptom isn’t the diagnosis. For example, it isn’t okay to turn a report of anxiety into “an anxiety disorder” just by saying so. Yet this is what is done all the time nowadays. Here, for example, are some of the questions whose positive answer will get you an “anxiety disorder” diagnosis:
+ “Are you feeling keyed up or on edge?” That is, are you feeling anxious?
+ “Do you have feelings of panic, fear, or uneasiness?” That is, are you feeling anxious?
+ “Are you constantly worrying about small or large concerns?” That is, are you feeling anxious?
+ “Are you constantly tense?” That is, are you feeling anxious?
+ “Does your anxiety interfere with your work, school, or family responsibilities?” That is, are you feeling anxious?
+ “Are you plagued by fears that you know are irrational, but can’t shake?” That is, are you feeling anxious?
+ “Do you avoid everyday situations or activities because they cause you anxiety?” That is, are you feeling anxious?
+ “Do you watch for signs of danger?” That is, are you feeling anxious?
If you answer yes to these questions, you are acknowledging in these different-but-same ways that you are feeling anxious. But what you get from the mental health establishment is not, “Yes, you are clearly feeling anxious. Let’s see if we can figure out why.” What you get is a “diagnosis” of an “anxiety disorder.” In our current system, you appear to have “eight symptoms” of an “anxiety disorder.” You come in looking anxious, acting anxious, and saying that you are anxious. What sort of diagnostic acumen does it take for me to say, “You’re anxious”? And isn’t it a bit of chutzpah on my part to continue by saying to you, “I have diagnosed you with an anxiety disorder”?
It should be clear that “diagnosing the symptom” (“You’ve got anxiety!”) and then “treating the symptom” (“Here’s a pill!”) is simply the path of least resistance. We can see why it is so tempting to engage in this shortcut and this illegitimate process, since it appears well nigh impossible to know exactly why an anxious person is anxious. Rather than admit that he doesn’t know what is causing the anxiety, probably can’t know, and doesn’t really care one way or the other, a chemical-oriented psychiatrist simply proceeds to “diagnose and treat the symptom.” We understand the temptation. But that doesn’t make it proper.
The simple question to ask someone diagnosing your child with a mental disorder is, “What are you diagnosing as the cause of the disorder?” Just wait for an answer. If you get one, see if it sounds reasonable to you. If it doesn’t, maintain a healthy skepticism that something genuinely medical has transpired. If you say, “My child is defiant,” and the provider says, “Oh, that a defiance disorder,” if you say, “My child is sad,” and the provider says, “Oh, that’s depression,” if you say, “My child is anxious,” and the provider says, “Oh, that’s an anxiety disorder,” be very alert to the fact that all that has happened is that the symptom you announced instantly got a disorder name. Just like that. See if that makes good sense to you.
Download this resource: Diagnosing Causes or “Diagnosing Symptoms”?
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.