A Call for Obligatory Diagnostic Reporting and Appeals Mechanisms

Ciarán Crummey, BSc, PhD
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“The large print giveth, and the small print taketh away.”Tom Waits, from the song “Step Right Up”

A psychiatric diagnosis means many things to many people. In some fashionable circles in California a few years ago, bipolar disorder was a desirable label to possess. It may still be the case today. Within these groups, it was seen as something they might have in common with high-profile public celebrities they admired. It was cool. If they wanted it badly enough, and had the money, it might not have been difficult to get. This would be a somewhat twisted version of what used to be known as malingering. A simpler example would be someone who might be able to use a psychiatric diagnosis to avoid the consequences of some calamitous event in their lives, such as bankruptcy, or a criminal prosecution of some kind. It happens.

At the other end of the scale there are those who feel they have been condemned to the dustbin of humanity when a psychiatric label is attached to them — especially the more serious ones such as schizophrenia, or one of the personality disorders. To be labelled with one of these titles is seen by many as a grievous assault on one’s personhood.

There are usually two grounds for being detained: perceived risk to oneself or others, or the catch all ‘need for treatment’ one. An existing diagnosis might be all that is needed to invoke the latter. A psychiatric diagnosis, therefore, can have very profound implications for those who receive one.

And they exist, for better or for worse, until death. Unlike marriage partners though, divorce from most psychiatric diagnosis is impossible. They may, and often do, exist in numbers greater than one, and they often change over time if the opinions of the psychiatrists who see you change. When we get married we choose to do so. But we can be psychiatrically labelled without having any choice or control over the process. Some of these diagnoses can be more life-changing than marriage.

Whether or not you consider a diagnosis either empowering (many probably do) or disempowering is a matter of choice too. If health is moving towards the idea of adapting and implementing one’s own control, in light of the challenges of life, then at the very least we should be able to have some control over the psychiatric labels that may be forced onto us.

Most non-psychiatric clinicians who have been around as long as I have have seen shoddy and slapstick psychiatric diagnostic practices. Some clinicians are trigger happy when it comes to applying them. Some have their pet diagnoses that they like to use. Uniquely in psychiatry, patients are afraid to challenge these decisions, as to do so runs the risk of being taken as further evidence that the diagnosis was correct. This is a dreadful situation for anyone to be in. Within a system that is focused on observing and recording deficits, and that operates in an increasingly risk averse culture, the direction of misdiagnosis bias in psychiatry is likely to be in favour of creating false positives (i.e., receiving ones that you don’t have), rather than in the opposite direction. And of course, all of this operates without oversight of any kind.

We should be entitled to a formal diagnostic report every time we receive a diagnosis. This report should clearly indicate how each symptom we are deemed to have was arrived at. If third party information was used, it should be noted too. This information, since it is provided in ordinary language, should also be recorded in ordinary language. This would act as the beginning of what would hopefully be, for many, a demystifying process. This would be using the small print to understand and question the jargon used in the big — the labels themselves. It would also make clinicians think twice before using diagnoses. Failure to write such reports should be grounds for professional misconduct.

Why should psychiatry be singled out in medicine for such a thing? The answer to this question is simple. Almost all psychiatric diagnoses are not based on empirical data, they are ballooning in scope and in numbers, many have dramatic and life-changing consequences, reliability levels are poor, co-morbidity levels are high, and the validity of many are doubtful. Despite all of this, they have escaped any kind of regulation. Whatever misdiagnosis rates are in the rest of medicine, they must be considerably higher in psychiatry. Is this not a case of naming an elephant that has been sitting quietly in the room for a long time?

Despite all of the well-known political and unscientific ways that the DSM has been influenced, despite its enormous power, despite the explosion in disability rates associated with psychiatric labeling, and the corruption of its treatment evidence base, their diagnostic system has to date escaped oversight or external regulation of any kind. While they must write prescriptions for the drugs they inevitably want their patients to take, they can diagnose away to their hearts content.

Things start to get complicated when another major difference between psychiatry and the rest of medicine is understood. In most of medicine, diagnosis and treatment are well correlated. In psychiatry this is not the case. Psychiatric diagnoses are poor indicators of treatment, and also of outcomes. Establishing the need for formal diagnostic reports as outlined in this article could eventually contribute in a major way with the process of improving this. This would be a very big improvement for all service users, and for psychiatry.

There is growing criticism of the current diagnostic system. The DSM project seems to have lost control of itself. It could collapse if these ideas were implemented. But if so it would need to be replaced by another, and it too would need to be scrutinized.

Someone I know was deemed to be manic based on an unfounded allegation made by a third party that he had blown the equivalent of over $30,000 in a week. This important error was used to diagnose him with bipolar disorder. Afterwards, the fact that he was able to show, with bank statements, that he had moved the money from one account to another, and not spent it, came too late. He’d been labelled, and there was nothing he could do about it. When errors like this can be shown to have occurred, it should be possible to appeal the diagnosis and, if successful, to have it removed. This would make clinicians even more careful before they diagnose.

The implementation of this new mental health reform initiative is both practical and concrete. It could also have profound implications for how psychiatry operates. If you agree with it, you are invited to sign my petition on change.org:

“Making psychiatric diagnostic reports obligatory and allowing them to be appealed.”

This petition will be delivered to the College of Psychiatrists of Ireland, and to the chair of the Oireachtas Committee on the Future of Mental Health Care. But hopefully it will set in motion a change that will come to every country. It’s desperately needed.

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24 COMMENTS

  1. One thing I’ve heard “mental health” workers complain about is paper work. As far as I can make out this “diagnostic report” would just mean additional paper work. I have doubt that it would affect the process that much. We’re dealing with bureaucracy here, after all, and bureaucracy is paper work.

    As “mental illness” diagnosis (nobody diagnoses “mental health”) is baloney, I don’t see much coming of these reports then except as a loss to the file cabinet, or network database. More paperwork. The only real reason for the diagnoses in the first reason is to give the insurance company a tangible to pay for. No diagnosis = no insurance money for “treatment”, and as anybody who has been “treated” against their will, and then charged for that “treatment”, can tell you, “treatment” is expensive (and that’s only the financial end of it.)

    Regarding this guy you know who received the “manic” diagnosis, I’ve seen people get out of “treatment” for BAD, and thus a diagnosis. What helps is more support and advocacy. When there are, no, not “treatment” advocates, but human rights advocates, protecting people from rash decisions on the part of psychiatrists becomes more plausible. When there isn’t such support the likelihood of being thrown to the “treatment” wolves is way up there at approaching the 100 % mark.

    “Mental health” “treatment” is a “consumer” product, and this makes all “consumers” “customers”. People aren’t healed by the use of “consumer” products, this would mean ceasing to “consume”, they “consume” them. Diagnosis is the gateway into “consuming” this “consumer” product, “treatment”. As I mentioned, psychiatrists are trained in diagnosing “mental illness”, not “mental health”. “Mental health” “belongs” to people who don’t “consume” “treatment”. The “consumer” product is not “health”, the “consumer” product is “treatment”. Given this circumstance, it can hardy be a wonder that so few people “recover”.

    This brings us back to the word that you began with, malinger. I would suggest that the term malinger is not so archaic as you would suggest, and that, in fact, the “mental health” “treatment” industry is an industry that produces malingerers. Of course, the industry doesn’t call them malingerers, that would be bad for business, it calls them “consumers” instead.

    As yet, I would have to see more reason for these diagnostic reports that you are proposing than I have been given. If you could show me, for instance, how they could help someone like your friend who received the “manic” diagnosis, there you go. This proposal would comprise another “regulation” surely, but then, what was I saying? Bureaucracy again, it’s all about “regulating”, and the paper work that comes of it. Give additional support to the victim, and you dispense with the need for extra paper work on the part of workers in their eagerness to come up with another example of throw away humanity.

  2. Debating which psychiatric “diagnosis” is appropriate would be like debating whether Santa Claus, the Easter Bunny, The Great Pumpkin, or other human-imagined concepts are valid. Considering such a debate suggests that there may be some psychiatric “diagnoses” that are actually real entities, when they are just arbitrarily conjured-up ways to make sure insurance companies can always be successfully billed, since they were conjured up in a way that intentionally made sure that everyone meets “criteria” for nearly every one of them. So lets not perpetuate the public’s mistaken belief that these are real things when they aren’t by suggesting that some are legitimate in some cases while others aren’t. They are all illegitimate.

      • What psychiatrists, DSM and psychiatric labelling do really well is rob the truth of people’s lives away from them.

        You label people with 2 labels, it will look like they have 2 “illnesses”. You label them with 5 labels, it will look like they have 5 “illnesses”.

        When the consequences of said labelling have to be faced by the person labelled with this junk, the cowardly bastards (the psychiatrists) are nowhere to be found. In fact, sometimes they will blame you, the screwed over person, for the consequences of their own disgusting methods.

        The truth about a person is always descriptive. Causes and effects. Causal factors and effects.

        People tell you junk like “labels guide ‘treatment'”, which is utter bullshit. If anything, they make everything worse, because you are basing your conclusions on false knowledge. It’s like labelling people with “fever disorder” and “headache disorder”. The worst part is, once a person is labelled, they put everyone who is biologically related to them at risk, because they will then become their “family history”. DSM labels are not family histories. An actual history when it comes to a person’s life is descriptive.

        Imagine the number of kids with attention problems or anxiety/depression (for whatever reasons) who have been prescribed Ritalin and SSRIs, who have gone on to experience manic episodes due to those drugs, and now they are labelled with “co-morbid conditions” like ” ‘ADHD’+ ‘Bipolar Disorder’ ” or ” ‘OCD’+ ‘Bipolar Disorder’ “. Disgusting.

        If you are physically assaulted, you can even go to the police. What can you do if psychiatry and psychiatric terminology is being used to harass, defame and gaslight you? You can’t even get justice. This has been happening to me for years, and I have been able to do nothing about it.

        Day by day, I am losing hope. I can understand why someone like Matt Stevenson killed himself (not that I want to die).

        DSM labelling is defamation and libel. That is it.

          • A person I know, recently had seizures. There’s no history of epilepsy in the person’s family. We were all a bit perturbed as to how it happened.

            After tests, we found out that eggs of a worm formed cysts inside the person’s brain. They call it “neurocystic sarcosis”.

            Imagine the doctors labelled this person with “seizure disorder” and only gave him/her anti-convulsants. He/she would be dead.

            This is what psychiatry is doing. They are defaming and ruining people’s lives.

  3. “Psychiatric diagnoses are poor indicators of treatment, and also of outcomes.”

    What use is a “diagnosis” that doesn’t correlate to either effective treatment or case prognosis? Answer: no use whatsoever! Might as well call someone a “dunce” or a “spoiled brat,” as these labels have equally poor relationship to any concrete intervention or outcome. The DSM is just a rarefied way of name calling those whose behavior we don’t like and/or don’t understand. While I think it would be BETTER if we required diagnostic reports, it still would give credence to these nonsense labels, which as Lawrence points out are actually no more or less than a list of insurance billing codes. The best approach would be to call the psychiatric profession out and demand the DSM no longer be used as a diagnostic manual at all. If they want to put down little numbers for the insurance company, I guess that’s their problem, but these labels have next to nothing to do with helping clients, whether the clients like the labels or not. After all, we don’t decide someone has cancer or doesn’t based on whether they like their label or not. It’s idiocy and it needs to be abolished!!!

  4. If a Psychiatrist or Psychotherapist is practicing upon a minor and that minor is not already being represented in court by an attorney, then said Psychiatrist or Psychotherapist is a hired professional accomplice abuser.

    Said Psychiatrist or Psychotherapist should be handcuffed and taken away to jail.

  5. Maybe they could call what they are treating for by its cause, such as lingering effects of childhood abuse, or latent effects of childhood emotional neglect, or emotional injury from abusive spouse. They don’t need to say anything about disorder, or to say that a person has something. When they use the word disorder, it implies something wrong with the functioning of the mind. But people’s minds can be functioning fine, it’s just that they are working on really awful data.

    • “Maybe they could call what they are treating for by its cause, such as lingering effects of childhood abuse, or latent effects of childhood emotional neglect, or emotional injury from abusive spouse”

      That would still be preying upon survivors. That still comes back to the survivor, making them the culpable party for not having “gotten over it” sooner.

      People need to stand up to the Mental Health and Recovery System, recognizing it as the lethal threat which it is.

      Of course no one in their right mind would ever go to any doctor or therapist who is going to report.

      But we also need to let people see how any type of psychotherapy is absolutely poisonous.

  6. “Someone I know was deemed to be manic based on an unfounded allegation made by a third party that he had blown the equivalent of over $30,000 in a week.” I was misdiagnosed as “bipolar,” in part, because some third parties (some pedophiles, who’d abused my child), unbeknownst to me, made an allegation to my therapist that I donated $400 to a children’s charity. My father was a bank owner, so a $400 donation to a charity was well within my means.

    As to how to get a “bipolar” diagnosis off one’s medical records, tell a decent and ethical doctor that you are allergic to drugs that cause anticholinergic toxidrome, like the antidepressants and/or antipsychotics.

    https://en.wikipedia.org/wiki/Toxidrome

    This basically embarrasses all the doctors, who were taught about anticholinergic toxidrome in med school, by pointing out that today’s DSM “bipolar” treatment recommendations are already medically known to make people “psychotic,” via anticholinergic toxidrome. And you can remind the doctor that claiming a person who does not suffer from mania and depression, which are the symptoms of “bipolar,” as “bipolar,” is defamation of character. And defamation of character is illegal, at least it is in the US, I presume it is also in Ireland.

    This may work for someone defamed as “schizophrenic,” as well. Since the “gold standard schizophrenia treatments,” the antipsychotics/neuroleptics, all by themselves can also create both the negative and positive symptoms of “schizophrenia.” The negative symptoms are created via neuroleptic induced deficit syndrome.

    https://en.wikipedia.org/wiki/Neuroleptic-Induced_Deficit_Syndrome

    I do agree, all “mental health professionals,” and I believe all mainstream doctors as well, should be legally required to hand over all their diagnosis, at the time of diagnosis. That way a person would know immediately if they were defamed with a blatant misdiagnosis, or many blatant misdiagnoses as I was, and they could quickly find new doctors who hopefully would not be unethical.

    Although since there is a “white wall of silence,” that is harder than one who is unaware of such an unethical thing to get away from. The bottom line is you must remember the mainstream medical community has been utilizing the scientifically invalid “mental health professionals” to cover up their easily recognized iatrogenesis for decades, so the mainstream doctors are not a trustworthy group either.

    • I once gave some stranger a $300 worth of gift. When I give, I give generously beyond my means because I give from the bottom of my heart. Later this person collaborated with some other people who were spreading bad rumors about me.( because I called out a 70 something gentleman poaching a 30 something married woman from a financially struggling husband unethical — because face it the man was using the woman for sex and the woman was using the man for money. Ask anyone with a common sense they will say so. If this rich elderly man was in the mood of generosity he should just give money to this couple which was my view. )

      Now I am called bipolar or psychotic for being kind-hearted and displaying human warmth not materialistic and calculating like “normal” people.

  7. After my second hospitalization I was informed I had a mental illness that I’d be sick the rest of my life and I should think about relocating to a big city and living in residential living facility.

    Later when I was let out my dad took me to Perkins. What’s wrong pal he asked? I said ya know dad the old Perkins doesn’t seem the same after being in psych ward.

    I said how about dynasty buffet. An autobiography I had just completed said Chinese eatery was the only place a man and his mother who was suffering mentally could go without being hassled.

    As a young man of 17 I thought to myself it’s just as the book described it to be. I ate some at the dynasty but when I got home I fixed a tuna sandwich on wheat.

    My first day at the new public high school I went to didn’t run so smooth. First period swimming and I asked coach for a bigger swimsuit please. In turn he gave one big hoot on his whistle. Now on to showers where I was pelted by dial like soap bars repeatedly by dudes quite a bit taller than me. At this day in age they didn’t use hand soap dispensers.

    Ahh third period math and falling asleep at my desk. Only to wake up with a laughing audience and a few friends along with it. An invitation to smoke a little dope and go golfing tomorrow. Just like that I’m the new kid with friends and for something like this. It’s indispensible I thought to be weird in this place.

    I began to think its was going good until the end of the day. Walking home and along the way a dude asks me if I’m east side or west side. Not sure I thought but thought for a few seconds and answered both. This was preceded by staring back and forth for about a minute at least until he eventually walked away.

    So there was me at seventeen and first day of new semester.

    • If you were fishing for a response, you’re not the only one who has been there.

      “I was informed I had a mental illness that I’d be sick the rest of my life…”

      This is why it is important to, as you might have heard when you were going to grade school, think for yourself. If you were to let a shrink do your thinking for you, you’d be a lost cause. They don’t know, and what they do know comes from drugging the daylights out of people.

      I remember a book from when I was little. It was called, The Little Engine That Could. The little engine that could had this mantra: ‘I think I can, I think I can, I think I can’. This mantra got the little engine that could from one place to another. More specifically, it got him over a steep hill he had to climb.

      The little engine that could was fortunate enough not to be handed over to a shrink. Had the little engine that could been seeing a shrink he might have been singing a different tune.

      There was a reason why the book was not titled The Little Engine That Couldn’t. Maybe you can figure out what that reason was.

    • I too was told I was incurably insane. For 20 years I acted on that premise.

      Tapered off the drugs and have my mind back. Relocated to where no one knows the shame they pinned on me.

      Some people do get their labels removed; Dr. Crummey is wrong about that. Even if it is harder to obtain than a divorce.

      I will try my hardest to get my stigma removed. If I fail I’ll move to Mexico where they don’t have a massive psych system run amuck.

  8. The purpose of book was to teach the value of hard work. Doesn’t matter what type of work but that you do it with integrity.

    No need that I share more. I like to actually communicate with people in reality as opposed to a screen in my underwear eating Rice Krispies.