A few weeks ago I went to a lecture on anxiety disorders (yes, students do turn up to their lectures sometimes). As part of the wider topic of the session, the lecturer talked about problems with the current system of diagnosing mental disorders. Maybe it comes with my personal tendencies to ignore the bigger picture (i.e. anxiety disorders) because I got distracted by one tiny facet that I found interesting, but that got me thinking.
Quick disclaimer: in case anyone needs reminding, I’m not a qualified psychologist or doctor. The rest of this post comprises mostly my own opinion interspersed with the occasional nugget of information I found from lectures and the Internet (and therefore must be true, right?). Take it with a pinch of salt and we should all be fine!
The problems with diagnosis
To diagnose mental disorders, quite a lot of healthcare professionals (especially in the USA) use the Diagnostic and Statistical Manual of Mental Disorders. It’s a mouthful, so most people fondly nicknamed it the DSM. It basically lists every single mental disorder thought to exist and sets out the criteria which someone has to meet to be diagnosed with a specific mental disorder.
From what I understand, psychologists got three editions into the DSM and then realised that when they actually looked at healthcare professionals diagnosing people, they weren’t hugely reliable in who they diagnosed with what. (E.g. the chances of Hypothetical Jim being consistently diagnosed with schizophrenia by 10 different healthcare professionals weren’t that great). When they brought out the DSM-IV, their huge focus was on reliability (e.g. Hypothetical Jim should be able to walk up to 10 different healthcare professionals and be diagnosed with schizophrenia each time). Today, the DSM-V boasts reliability as its strength. Which is awesome.
Hypothetical Jim can be happy in the knowledge that it doesn’t matter which doctor he goes to, he should be diagnosed with schizophrenia. The issue lies in the fact that essentially a load of experts come to a consensus (failing that, they vote) on whether or not some facet of behaviour should be defined as ‘schizophrenia’ and, perhaps indirectly, whether or not Jim has a mental disorder.
To compare, a non-psychiatric condition like diabetes is diagnosed based on objective signs (like stupidly high blood sugar) linked to symptoms (like peeing loads). You can objectively test whether someone has diabetes (like stabbing them in the finger and seeing how much sugar is in their blood). Psychiatric conditions, however, will inherently have some sort of cultural influence on the way it’s diagnosed because, expert or not, people have their own biases and (especially in this day and age) voting on whether or not some facet of behaviour is abnormal is simply not good enough.
In 2001, a researcher called Noyes found that some stupid high percentage of people with major depression (like over 60%) will have generalised anxiety disorder at some point in their life. It’s so high they might as well be the same disorder. In fact, looking at the DSM criteria for GAD and depression, some of the things in the criteria are basically identical. (Restlessness? Fatigue? Impaired concentration? Irritability? Difficulty sleeping? Sounds vaguely familiar. OH WAIT, they’re the criteria for depression too). Instances such as this make me start to question the validity of the criteria for some mental disorders.
There are good reasons why this is the current psychological practice (e.g. less money is spent on psychology compared to medicine and therefore progress in scientific knowledge is generally slower). However, there are problems with this way of doing things. Even though Hypothetical Jim should be diagnosed with schizophrenia whichever doctor he goes go, Jim (or his doctors, for that matter) can’t be sure whether the criteria used to diagnose Jim correctly measures whether someone has schizophrenia at all. Which is less awesome.
Like it or not, stigma around mental disorders persist in society today. Labelling Hypothetical Jim with schizophrenia comes with its own hazards. His friends might be frightened because they don’t understand the condition. Jim might fear or even be subject to discrimination from his employers. I question the benefits over risk of categorising psychiatric disorders, especially with the debate going on about the current validity of diagnosis.
“Patients with an illness” or “people with a problem”?
Going right back to the anxiety disorders lecture I was supposed to be concentrating on, the lecturer mentioned that there is a move in thinking about the people that come into contact with services as less of “patients with an illness” and more of “people with a problem”.
I am in no way diminishing the effect of mental disorders on someone’s life. In fact, I realise from experience that mental disorders can completely screw you (and others in vicinity) over. But perhaps, given the current way of diagnosing mental disorders, we can enhance the quality of life of someone with mental disorders without labelling them as “patients with an illness”. Hypothetical Jim may be plagued with hallucinations. Even though Jim ticks some other boxes to diagnose him with schizophrenia, do we need to label him as such? Can we not just consider the fact that the hallucinations cause him distress and give him antipsychotic medicine and therapy?
There are merits in diagnosing people. As a wannabe doctor, I do realise that it’s quite central to my future career. However, when it comes to mental disorders, I don’t think our evidence base is strong enough to diagnose patients with great certainty. With stigmatisation of mental illnesses on top of that, perhaps the risk of labelling people with diagnoses outweighs the benefits. Perhaps right now it’s more helpful, instead of categorising patients into illness boxes, to consider them as people with a problem.
What do you think? Perhaps you feel validated with the diagnosis of a mental disorder. Perhaps it brought relief as you can finally start to make sense of the chaos. Perhaps you don’t like having the label of a mental illness. I’d love to hear from you in the comments.