The Psychiatric Diagnostic Evaluation: Medical Expertise or Smoke And Mirrors?

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Psychiatrists used to not put much effort into diagnosing. Instead, they focused on getting to and working on the issues in their clients’ lives that were upsetting them. But all that changed when the 1980 DSM came out. Since then, diagnosing mental disorders has been one of their main focuses (prescribing medicine being the other). People pay huge sums of money for psychiatrists’ expert opinions, and their diagnostic evaluations carry great weight in court, school, the workplace, and disability determinations. But is this truly warranted? Is a doctor really needed to make a psychiatric diagnosis, or can anyone do it?

Here are three points which support the idea that anyone can make a psychiatric diagnosis:

1. All the diagnostic criteria that psychiatrists learn in their training can be easily found on various websites. Therefore anyone can look up the criteria for diagnosing any mental illness and then conduct a do-it-yourself diagnostic evaluation.

2. It’s true that only trained doctors can perform physical exams and order lab tests, x-rays/scans, biopsies, etc.. And it’s true that only doctors are qualified to interpret their results. But these medical workups are only ever done to verify physical illness diagnoses, like cancer or diabetes. They are never done to diagnose mental illnesses. If a medical workup is ever done during a mental illness evaluation, it’s only to rule out a real (physical) illness.

3. If one examines the criteria for all the mental illness diagnoses, it becomes clear that identifying them doesn’t require any medical background or skill. For example, here are some criteria for diagnosing depression: diminished interest/pleasure in activities, indecisiveness, and feelings of worthlessness. First of all, these are not terms/concepts that only doctors are privy to. Secondly, they’re vague, subjective perceptions rather than objective, scientific facts. They’re in the eye of the beholder. Thus, any human could offer an opinion as to whether or not someone is experiencing them. Who’s to say which is the “right” opinion?

These are all excellent points.

But if a regular human such as you dares to take it upon yourself to perform a psychiatric diagnostic evaluation, you’ll be laughed at for your brazenness. You need a doctor’s official stamp of approval to make the diagnosis appear legitimate and valid. Doctors are greatly revered and trusted. Only if you tell others that a learned doctor diagnosed you with your mental illness, will it be viewed as a proven fact rather than a mere opinion. So even though psychiatrists don’t use any medical knowledge when making diagnoses, they do have MD degrees, and that’s enough.

Furthermore, for centuries psychiatrists have been designated by society to be the supreme authorities over several key areas: They decide who is insane and should be involuntarily committed and forcibly sedated. They also determine who is mentally unfit and should lose their right to manage their own lives. Perhaps these longstanding power roles have culturally imbued psychiatrists with an aura of superhuman capabilities which makes all their opinions far more important than a regular person’s. The common belief that psychiatrists have the intimidating ability to read and manipulate people’s minds may enhance this aura. Without necessarily being consciously aware of the aura, people may sense it, fear it, and be awed by it. They may thus be particularly likely to unquestioningly, submissively accept whatever their omniscient psychiatrist diagnoses and commands.

Psychiatry’s aura of superiority may be what enabled it to convince people that mental illnesses are real physical illnesses, even though they’re opposites: First psychiatry constructed a fantasy about emotional distress being a medically-treatable disease caused by a chemical imbalance or brain anomaly.Then it turned it into a reality just by proclaiming it to be true. It didn’t matter that 50 years of intensive research never found any chemical imbalances or brain anomalies. Nor did it matter that antidepressants were proven to be mere placebos(1). When psychiatry says something is true, that makes it true, no matter how illogical. And this isn’t the first time this was done: The diagnosis of hysteria was taken seriously for many centuries. It was another example of emotional distress being unfoundedly declared to be a medical condition. This time it was said to be caused by a wandering uterus, and the treatment was to coax it back into place(2).

Psychiatry would lose its power over people if its aura was removed, because nothing would be left but smoke and mirrors. People would lose faith in it (just as happened to the Wizard of Oz when his curtain was removed, revealing that he wasn’t a higher being but just a regular human). Psychiatry’s customers would then realize that they’re not defective and helpless as their doctor oppressively insists. They’d see that they’re actually capable of thinking for themselves in order to devise adaptive ways to solve their own problems. (The tin man, scarecrow, and lion made the same realization after their wizard was shown to be a fraud.) If this ever happens, then people will no longer feel compelled to follow the yellow brick road to a doctor’s office to have their painful feelings medicalized.

1. Kirsch, I. “The Emperor’s New Drugs: Exploding The Antidepressant Myth”, Basic Books, New York, 2010.

2. Wellesley, M “A Load Of Ballokis” London Review of Books, 23 April 2018.

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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.

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30 COMMENTS

  1. Actually it is more complicated than that. This editorial is reminiscent of the view that all psychiatric diagnosis is the same , everyone has one , nobody gets better and all treatments are the same.
    It also ignores the problems with self diagnosis and what brain neurophysiological knowledge tells us, what validity and reliability about diagnosis tell us and the importance of population studies , genetics, and environmental effects on DNA on brain function.
    Self diagnosis is possible for any medical symptom , but that does not mean people should be treating themselves.
    Finally the article has not addressed how diagnoses are made today with cultural, and other factors are involved.
    You could give a person an instruction book on how to make any diagnosis of anything from a broken dishwasher to flying an airplane. That does not create competence .
    This article would have been more accurate if written before the Victorian era

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    • Please, share your knowledge with us, because this sounds like boilerplate psychiatric gobbledygook:

      “what brain neurophysiological knowledge tells us, what validity and reliability about diagnosis tell us and the importance of population studies , genetics, and environmental effects on DNA on brain function.”

      What does “brain neurophysiological knowledge” tell us? Why has Thomas Insel repeatedly stated that despite 20 billion spent on research into “brain neurophysiology”, the people at NIMH learned nothing?

      Looking forward to your response!

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    • “Finally the article has not addressed how diagnoses are made today with cultural, and other factors are involved.”

      What does this mean? Cultural “and other” (social? economic?) factors are excluded from the DSM entirely and always have been. If a person’s problems are culturally, socially, or economically based, why should they have any diagnosis? Why should they be labeled “mentally ill”? You seem to argue against any DSM diagnosis, since none of them take “cultural and other factors” into account.

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  2. This article is really not accurate. Many psych and neurologic illnesses are caused by physical conditions and can be found using labs and scans. Additionally there are objective assessments to identify various psych conditions. This article is really misinformation and artificially delineating medical vs psych in a way that doesn’t hold up.

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    • Would you mind specifying the “many” psychiatric “illnesses” caused by physical conditions and that are supposedly found by using “labs and scans?” And precisely what are the “objective” assessments for identifying various psychiatric conditions? Without adducing solid, evidence-based, and verifiable data to back these sweeping assertions, they contribute absolutely nothing to this particular issue and in no way invalidate the author’s conclusions.

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      • Agreed! Brain disorders may be detected in a scan or lab test. But mental illnesses are mental and therefore subjective. Of course depression could be caused by a physical illness elsewhere in the body. But there are no known objective test for a purely mental illness. Behaviour is always open to interpretation by the doctor.

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    • If people have conditions that can be found using lab tests, they have physical conditions. Possibly those physical conditions have psychological symptoms, but they are still physical conditions and those physical conditions will not be helped by prescribing of psych drugs.

      For example, a person with severe iron deficiency anemia will likely experience fatigue, lethargy and hopeless thoughts. This is a physical condition that needs to be addressed by medical doctors (iron infusions) or by iron rich diet/supplements. A medical doctor can and should order tests to try to determine the cause of the iron deficiency.

      My psychiatrists ignored my blood work that showed serious iron deficiency anemia for years while they ordered ECT, prescribed more drugs including antipsychotics, and took away my hope along with my money and sense of safety by blaming my worsening condition on a severe personality disorder.

      It would be helpful if supporters of psychiatry took classes in logic so that they would stop putting forth nonsensical arguments. But I guess these arguments are part and parcel of the smoke and mirrors that keeps psychiatry thriving while people continue to suffer.

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    • What are the objective assessments? If they’re done by a person, they are by definition subjective. If they’re done using the DSM, which has been deemed invalid even by those who compiled it, they are subjective assessments.

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  3. Having had serious mental health issues in my family (schizophrenia, depression, etc.) I can attest that medication does work in many instances, whatever the underlying mechanism. So does ECT. It also doesn’t always work. They also do not work as seen on shows such as Law and Order, etc. I have worked one on one with many schizophrenics that are definitely better off on medication than without and most would attest to the effect. To state that all psychiatric medications are not helpful is doing a disservice to many individuals. It is discounting all scientific double blind studies. They are not however a panacea and should be used judicially.

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    • What exactly does it mean when the claim is made that psychiatric “medications” (i.e. neurotoxins) supposedly “work?” Yes, they can have a numbing and suppressive effect, but that’s achieved through disturbance of normal brain functions (see Dr. Peter Breggin’s excellent coverage of this subject in “Toxic Psychiatry” and “Brain-Disabling Treatments in Psychiatry,” as well as journalist Robert Whitaker’s many articles on this website and in his book “Anatomy of an Epidemic”).
      It amazes me to see how the fallacious, self-serving myths served up by Big Pharma and its enablers in the media, academia, and venal medical community continue to delude people for decade after decade despite the efforts of honest, courageous researchers like Joanna Moncrieff and Dr. Peter Gotzsche.

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    • “I can attest that [psychiatric] medication does work in many instances, whatever the underlying mechanism.”

      Just WHAT do you mean by “work”???

      So-called psychiatric medications “work” like insecticides: they’re toxic compounds that kill the bugs (so-called “symptoms”) and also harm the environment, (the human brain and body).

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    • I think ECT and other medications do have a dampening down effect. If that is preferable to the patient than the experience of a mental illness in full flow I guess that it is their choice. And of course it doesn’t last unless the treatment is reapplied. The long term brain damage is a risk but drug trials should be questioned. Are they really double blind? The patients receiving the active drug can work out it out by the unusual side effects they are experiencing where’s the inert substance will not produce any unusual effect.

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      • Unfortunately, in many cases, it’s not the patient’s choice. So many people now are under some kind of conservatorship, guardianship, and are put on antipsychotic injections under court ordered treatment. This is happening to young people, old people, disabled people…in very high numbers across the board. When I used to read the antipsychiatry sub on Reddit, I was blown away by how many young people wrote about being under some kind of treatment order. Often it resulted either from them having a single psychotic or suicidal episode and/or from a parent or other family member convincing someone working in the system that the person “is crazy” and “needs to be medicated”.

        Another issue is the disabling affect of ECT and many psych drugs. For people who support psychiatry forcibly or coercively administering treatments, I wonder if they also blame those people when they become disabled and therefore need to rely on social security or other forms of government assistance to pay for basic needs. My sense is that people are being forced to undergo disabling treatments and are then being blamed for not having full time employment or for relying on assistance.

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    • Is it DOCTOR Sangesland?
      NA Sangesland, PA Sangesland, MSW Sangesland, R.N. Sangesland, ‘counselor’ Sangesland, volunteer Sangesland, receptionist Sangesland….?

      Your “attest(ing)” SOUNDS very ‘evidence-based’…but without the evidence. That sure resembles a psych M.D. or a ‘wanna-be’….in my expert experience of 11 years as a former, targeted client.
      My gift to you is the fact I forced their Lifetime Bipolar diagnosis to be capitulated…in writing.
      The psych industry is a yawning sink-hole of marketing BS.
      Do yourself a favor, watch the documentary, “Medicating Normal”. Pay close attention to the ‘history’ of & relationship with Pharma.

      They’re fallible, compromised, & desperate to retain their legitimacy/revenue stream by sedating a vulnerable, trusting population. Short & long-term prognosis resulting from ‘Treatment Plans’ (drugs) are not a concern, simply the ‘price’ of stability. (!)

      Psych nearly killed me several (documented) times (9 years)…a common story, especially among Commenters here. I was lucky, only 2.5 additional years to withdraw, w/a doctor’s guidance. Only 3 more years of 19 seizures…and THEN a (still) challenging re-entry to Life.
      I am the lucky one. ONE.

      It explains the rage and outrage in these Comments. Justified & appropriate.

      You’re an example of a guy who MET a combat veteran-now lecturing other veterans what COMBAT is all about.

      My advice…as a veteran of the psych wars…Sshhhh.

      What’s “…not helpful…& doing a disservice…” is anecdotal evidence based on personal observation…..stating opinions as facts…to people who know better & have the scars to prove it.

      Learn from the industry you enthusiastically hand Hall-Passes to….start littering your vocabulary-on this topic-with the “should, possibly, might, perhaps, may, often, sometimes”, & other qualifiers used to dilute liability,…the blurred, semantic ‘confidence’ of a dangerous poser/predator.

      Regarding the drugs…
      “They are not however a panacea and should be used judicially.”

      You raised the awkward, awful question yourself….if you believe that, why ARE they used as a panacea…and prescribed ‘for life’?

      Your remarks illustrate insight & humility are nowhere in sight. You lack credibility on this topic, regardless of your family members, one on one (sic) engagements, & “scientific, double blind studies” you don’t cite.

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  6. A difficult topic, to be sure. Your approach is a little simplistic, throwing the baby out with the bathwater. Just because the current system is not perfect, is sometimes primitive and applied in a punitive fashion, and so much of our knowledge of these things is still in its infancy doesn’t mean there is no value in having someone with education and experience involved in diagnosis. Plus the obvious: if you are experiencing emotional lability, psychosis, paranoia, homicidal urges, etc., it is probably not the best of circumstances under which to self-diagnose.

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    • I think you are missing the larger point, Donna. You say our “knowledge” of these things is in its infancy. But the “diagnoses” themselves are not explanatory of anything, regardless of the education and experience of the person involved. How is saying, “Joe feels really hopeless and sees no point in his life” any different than saying “Joe has major depression?” Is there some way to distinguish Joe’s “Major Depression” from Mary’s “Anxiety disorder with depressive features?” They are simply descriptions of what is observed, and clinicians will make a lot of noise about “clinical depression” vs. “reactive depression” but look in the DSM, there is simply NOTHING there to make a distinction. You meet 5 out of 8 criteria, you “have major depression.” Only meet 4, you don’t. Nothing about cause, nothing about ongoing stressors, nothing about culture – just a description. That’s not a “knowledge in its infancy.” That’s just making stuff up, plain and simple. There is no way any “knowledge” can advance from that kind of basis. The DSM is not knowledge. It’s a fantasy that makes people believe “knowledge” is behind it.

      Not sure what the answer is, but calling people names based on arbitrary checklists isn’t it.

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      • Excellent rejoinder, Steve.
        The DSM does not constitute a body of knowledge obtained through meticulous experimentation and verifiable empirical data, but rather a compilation of arbitrary categories of “symptoms” agreed upon by a panel of so-called mental health professionals who not infrequently have an incestuous relationship with the pharmaceutical industry whose medications (neurotoxins) they foist upon their patients (unwary victims).
        I’ve asked this elsewhere but have yet to receive a reasoned reply: If what I have said about the DSM as a work of fiction is true (and even Dr. Alan Francis, who helped to compile it, himself acknowledged as much), what gives not only psychiatrists but also psychologists, social workers, counselors, and other would-be experts legitimate authority to claim superior insight into the complexities of human behavior?

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    • I’m astonished whenever I hear someone claim that psychiatry is in its infancy. First of all, it isn’t, not by a long shot. Secondly, if you really believe that, are you admitting, then, that psychiatry doesn’t know anything (like an infant?). How long should we let the infant prescribe neurotoxins and take away people’s free will? How many deaths and ruined lives is enough before you start holding this profession accountable for the grievous harm it continues to cause? What you’re really saying, when you argue that “psychiatry is in it’s infancy” is: let them keep practicing on people, regardless of the dire consequences. Maybe someday they’ll figure it out.

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  8. I think in terms of rights of a medical patient this plays out with a wide range wisdom approach. There used to be studies on noncompliance and it is an issue and an old doc once said to me we know that and expect and not surprised.
    Everyone who seeks any type of treatment and or medical should be first given a through assessment then a thorough explanation and the truth is I am not sure or my best guess is and We can try this or that and the Practioner of any type should see themselves part of a team or a dance choreography. And m ost folks if able should try to have at least one person who they trust to be a second pair of eyes and ears.
    Some chemicals are addictive and tbostshoukd be front and center and sometimes one might choose them and hopefully a plan in place for short term and a plan for withdrawal there.
    Or if side effects cause possible issues then low dose and again plan for withdrawal.
    Treatment has been in human civilization for a very long time. The fact that we find ourselves in the IS with mumtiple issues that are overtly and covertly associated with so many social personal and community issues I find appalling. There are uses in other countries but our plethora of so call healthcare and community health shattering are is beyond tragic.
    So it can be implemented but that implementation must cross all medical schools, the governments local regional and federal and create a safety net by the corporate entities that currently have cut the safety nets and are using the absence of safety as a profit making walled barrier for the few.
    I really don’t understand how medical school presidents and health business CEPs or CFOs either with medical supplies or pharma or high tech offerings can really sleep at night and the lobbyists who get paid big money to pull and hand the chains of politicians that seem to be like Jacob Marley unfelt but still there. My best guess is they have to be escaping reality many various means and in various ways. I would love to have them visited by a ghost and have them see the children of Dickens creation called Ignorance and Want.

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