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Psychiatry
The Debate Over Psychiatric Diagnosis
What’s in a name?
Posted October 17, 2022 Reviewed by Devon Frye
Key points
- Diagnoses like “major depressive disorder” or “bipolar disorder” can have unintended negative effects on people.
- Some mental health advocates have explored alternatives to diagnosis.
- Mental health providers should be more transparent with clients about the nature of diagnostic categories.
An online festival held in September called "A Disorder for Everyone!" featured academics, mental health professionals, mental health service users, and others who contest the primacy of psychiatric diagnoses. They think terms like “major depressive disorder,” “bipolar disorder” and “schizophrenia,” can have powerful and harmful side effects, and that there are better alternatives to healing.
The festival is associated with a group of mental health professionals and service users who criticize the dominant biomedical approach to mental disorders. In their view, this approach has foundational problems that need radical solutions.
Some of these critics include Joanna Moncrieff (whose recent article on the serotonin hypothesis of depression made global headlines), Sandra Steingard, and Sami Timimi; psychologists like Lucy Johnstone, James Davies, and John Read; and survivor campaigners like Jacqui Dillon and Eleanor Longden.
Diagnoses and Diseases
What could be the problem with diagnoses?
If I’m suffering from depression, going to a doctor and receiving a diagnosis could help me understand why I’m having these distressing thoughts and feelings. It puts me on track to treatment. A diagnosis might even be needed for benefits like unemployment compensation.
The problem, psychiatry’s critics urge, is that a diagnosis can create the misleading impression that my feelings are caused by an inner pathology, such as a known chemical imbalance. That could limit the treatment options it makes sense to explore and contribute to stigma. For example, it could lead us to overlook the possibility that one’s low mood is an understandable response to the problems of life, rather than a medical disease.
A False Equivalence
It seems to me that diagnosis has a core social meaning that comes from the everyday encounters that many of us have with doctors.
When a doctor diagnoses you with, say, emphysema, they’re not just saying that you have a bunch of symptoms like shortness of breath, wheezing, and mucus-rich coughing. Instead, they’re trying to explain your symptoms. They’re saying that the air sacs that line your lungs are damaged, and that the damage is causing your symptoms.
Even when we’re not quite sure what that cause is—as in the case of migraines—we can infer something inside of you isn’t working the way it’s supposed to. A diagnosis paves the way for an eventual explanation.
By and large, diagnoses in psychiatry have a different nature. We still don’t know what inner mechanisms cause depression. A diagnosis of major depressive disorder just means that I have a certain number of symptoms that may include low mood, excessive feelings of guilt or worthlessness, fatigue, and sleep problems.
A diagnosis can create the false impression that one’s low mood is caused by an inner pathology, akin to diabetes or emphysema. This could lead us to overlook other options.
For example, many mental health professionals think depression, far from being a disease or pathology, is the brain’s attempt to show us that something in our lives needs to change, and to motivate us to make those changes.
If I misconstrue depression as a disease, I might miss what it’s trying to say.
Alternatives to Diagnosis
What would be the alternative to giving a diagnosis?
Here’s one alternative: One might state what the client’s problem is, the circumstances in which it occurred, family and personal history, likely causes, and recommendations. “I understand that you’re feeling low, and that you’re having trouble sleeping. I also understand that you’ve recently moved to a new city and have concerns about your ability to fit in. Here are some recommendations…”
This practice is sometimes called “psychological formulation.” It is often used by clinical psychologists in the U.K. as an alternative to diagnosis, though other psychologists use it alongside diagnosis.
One approach, which promotes narrative-based understandings instead of diagnosis, is the Power Threat Meaning Framework (PTMF), developed by senior psychologists of the British Psychological Society and service users.
What if psychiatric diagnoses are needed to receive certain benefits, such as unemployment compensation or useful psychotropic medications? Ideally, if a mental health provider and the client still chose to use a diagnosis, they would do so only after discussing the pros and cons of using them.
A Step Too Far?
Many psychiatrists think there’s nothing particularly harmful about psychiatric diagnosis, even if they don’t explain symptoms. Diagnoses like “bipolar disorder” perform many valuable functions such as summarizing symptoms, improving communication between specialists, and guiding treatment.
A problem is that there may be a gap between the way psychiatrists often think about diagnosis, and the way the general public understands it. Sociologists have shown that lay people often think psychiatric diagnoses are meant to explain symptoms—not just summarize them.
For example, some people who receive an ADHD diagnosis feel relieved that they finally have an explanation for how they think. One study participant described being elated by the discovery that “there’s an actual reason why I acted like that.”
At the very least, doctors who choose to use psychiatric diagnoses ought to be clearer with clients about what these labels do and don’t imply, lest they mislead them about the nature of their problems.
Whatever you think about the value of psychiatric diagnoses, groups like A Disorder for Everyone! are drawing attention to a serious problem. It behooves all of us to listen.
