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Mental health diagnoses: Help or hindrance?

It has become quite usual to turn to our GPs for help if we are feeling down,
fearful, tearful, panicky, distressed, stressed by work, having difficulties with our
children’s moods and behaviour, having problems sleeping, experiencing extreme
moods or thoughts, grieving over the loss of a loved one – and a whole range of
other personal matters.  We assume the doctors can and will help us. We are
reassured when they explain that our emotional troubles are actually specific
disorders that are caused by chemical imbalances in the brain that can be
rectified by medicines - the doctor finally tells us the diagnosis and writes a
prescription. Unfortunately these neat and reassuringly simple explanations are
not based on sound science and fail to respect the complexity of human
experiences; the intricacy and mystery of our brains; and the limits of our
understanding of all these. 

Notice what happens here – it happens so quick we can miss it.  We go to the
doctor with our personal concerns and experiences - we then leave the surgery
with a diagnosis and a prescription. What happened to our concerns and
experiences? The doctor has become the expert and interpreter of our troubles,
and these are now perceived as medical conditions and (invariably) drugs are
assumed to be the answer.  However, as Professor Ghaemi points out, the
decision that medications are the most appropriate treatment is often made by
doctors “without scientific reasons to do so”.1  This is not a criticism of doctors;
rather we are questioning the way we as a society view and treat emotional and
mental distress.
The diagram below draws attention to the possibility that a more rigidly applied
medical approach (to mental and emotional concerns) could lead to some people
becoming over-reliant on mental health professionals and psychiatric
medications. By way of contrast, a more contextual understanding of their
experiences might prove more beneficial for some people and lead to greater
autonomy. I am not suggesting that these contrasting approaches are
necessarily mutually exclusive.

Diagram of doiagnosis

   
Doctor consultation
 
     
  There are no objective
medical tests by which to
diagnose any psychiatric
condition. The subjectivity
of psychiatric diagnosis
makes them vulnerable to
commercial exploitation
 
  Dr Joseph Glenmullen,
Harvard Medical School
   
         
  Psychiatric drugs cannot
solve problems. The most
they can do is suppress
symptoms…
 
Dr Marc Rufer (psychiatrist)
   
  In contrast to most medical
conditions like diabetes,
tuberculosis and heart
disease, no psychiatric
condition can be traced to
a specific dysfunctional
bodily process, excepting
dementia, and the
occasional neurological
conditions that present to
psychiatrists. In other
words, there is no agreed
physical aetiology for
psychiatric disorders,
although there are
numerous and ongoing
speculations about
physical processes that
might be involved.
 

Dr Joanna Moncrieff, 5

Consultant Psychiatrist, UCL

 
       
 

I think diagnostic labels (like bipolar disorder, or ADHD, for example) wrongly give the
impression that a person has an incurable illness and can shatter dreams, aspiration and any
hope of recovery. Surely what really matters is how we each experience and try to make sense
of our lives as we discover our personal way forwards.

Mental health concerns are not akin to physical illnesses

The idea that our mental health concerns are akin to physical illnesses - as “mental illnesses” - is often assumed; on the other hand, there are doctors who contest this: “There is no established specific physical basis to psychiatric disorders”4 writes the psychiatrist Dr Joanna Moncrieff. A statement to the House of Commons Select Committee for Health by a group of UK psychiatrists was more specific: “the great majority of common psychiatric conditions (such as depression or psychosis) are unlike other medical disorders in that there is no evidence to support the view that these conditions are caused by underlying disturbances in brain function…Biological explanations of mental disorder dominate contemporary psychiatry despite the absence of convincing evidence that conditions such as depression and schizophrenia have a biological basis”.2

Categories of convenience

On this matter, Dr Terry Lynch has a strong word for fellow doctors: “No doctor has ever, ever established a biochemical deficiency in any so-called ‘psychiatric patient’s’ biochemistry…therefore, regarding all forms of so-called ‘mental illness’, doctors must cease telling people that medication will correct their biochemical abnormality.”3

Clearly, some doctors like to interpret their patient’s more extreme moods, emotions and thinking as illnesses to be treated; however, to date, there isn’t the evidence to support this practice.  And according to Dr Moncrieff 4, neither is there evidence to show that psychiatric drugs are specific treatments to cure these 'illnesses'.

It is important that we bear in mind that the diagnostic categories that are so familiar (bipolar disorder, schizophrenia, ADHD etc) are convenient labels used by doctors. That’s all they are. It’s simply one way of trying to view and make sense of personal suffering. If a person is given a diagnosis for lung cancer, for an infection, or a broken arm, for example, we know that the diagnosis is based on an objective blood test, scan or x-ray. This is not the same with mental health. Most of the diagnostic categories are based on the American Psychiatric Association’s Diagnostic & Statistic Manual (DSM) classifications. These diagnoses are decided on by committee votes, and not on the basis of objective science. That said, there are those who argue that mental health diagnoses still have a practical use even though "most contemporary psychiatric disorders, even those such as schizophrenia that have a pedigree stretching back to the 19th century, cannot yet be described as valid disease categories." 6

As Professor Insel (Director of the National Institute of Mental Health) points out: "Terms like “depression” or “schizophrenia” or “autism” have achieved a reality that far outstrips their scientific value. Each refers to a cluster of symptoms, similar to “fever” or “headache.” But beyond symptoms that cluster together, there should be no presumption that these are singular disorders, each with a single cause and a common treatment." (Article here).

Terms like “depression” or “schizophrenia” or “autism” have achieved a reality that far outstrips
their scientific value. Each refers to a cluster of symptoms, similar to “fever” or “headache.” But
beyond symptoms that cluster together, there should be no presumption that these are singular
disorders, each with a single cause and a common treatment. Prof Insel

Furthermore, diagnostic categories come and go. A history of psychiatry shows that with each new edition of the DSM new disorders are formed (not discovered). New ones planned with the release of DSM-5 includes Disruptive Mood Dysregulation Disorder, which will mean that childhood temper tantrums are much more likely to be diagnosed as a mental disorder. In reality, "Disruptive Mood Dysregulation Disorder doesn’t describe a unitary group with some unifying cause or even a unique syndrome [see here]" As the psychiatrist (and Chair of the DSM-IV Committee) rightly concludes: "The history of psychiatry is littered with fad diagnoses that in retrospect did far more harm than good." These "fad diagnoses" do inevitably lead to the unnecessary prescribing of drugs.

The fact that some people find diagnostic categories convenient does not mean that each person has to think in these terms. Perhaps a more personal understanding is more helpful. You may like to read a blog I wrote on mental health labelling here. I am not in any way suggesting that a person's suffering is not real or at times devastating. But an illness model is not only on weak grounds from a scientific perspective, but it so easily closes down other options that people might like to consider.

With reference to diagnosis in psychiatry, psychiatrist Dr Daniel Carlat writes that there is "far too much emphasis on the diagnosis, which predicts the treatment, when in fact a diagnosis does not necessarily reflect biological reality but rather a “best guess.”" (You can read his blog here).  As he rightly suggests, there is always a danger of making the patients fit the diagnosis.

It seems to me that Western society is far too set on wanting to change (sometimes by coercive means) those who appear not to conform or who are not easily understood or accepted. Labelling people with mental health diagnoses such as so-called “schizophrenia” gives the misleading impression that doctors are able to make sense in medical terms of apparent differences. I think this is not just misleading but dishonest. It also means that patients and their families place confidence and trust (initially at least) in the treatments then offered on the basis of this assumed medical authority.

We [psychiatrists] have lost the ability to accurately recognize our patientsí signs and symptoms;
hence, we routinely misdiagnose, then we mistreat. And throughout the process, we have little clue
that we might be wrong. Prof S. N. Ghaemi (Source)

The stigma of diagnosis

Aside from the fact that mental health diagnoses are not really medical entities, there's one major problem that we have not addressed: stigma. True enough, some people rather like to be identified as having a so-called mental health diagnosis as for them it seems to describe and account for their troubles. I respect that.

But what about the mother of a young person diagnosed as "schizophrenic", for example? Can she really dismiss the contrived and distorted media image associated with this diagnosis? And what about the person him or herself - with the shame, stigma, sense of helplessness, and hopelessness - that a diagnosis can bring. I recognise that some parents push health professionals for their child to be recognised as having a particular mental disorder (hoping perhaps for more support at school, for example); however, in my work with children and families I help them to gain a sense of who they are without these diagnostic labels. This also helps the youngsters take responsibility for their behaviour too rather than attributing it to some disorder or other.

Preliminary findings by the independent Inquiry into the ‘Schizophrenia’ Label (ISL) in 2012 reveal widespead opposition to the label "schizophrenia". "The majority of respondents feel that a diagnosis of ‘schizophrenia’ is damaging: Over 80% of the respondents said that the diagnosis of ‘schizophrenia’ makes life more difficult for people diagnosed;  88% think that ‘schizophrenia’ is associated in the minds of the public with violence against others despite evidence to the contrary." You can read more here.

As diagnostic categories are widely assumed to be medically/scientifically validated entities there are other repercussions. Paula Caplan (who served as advisor to two DSM-IV committees before resigning due to the blatant disrespect for scientific evidence) points out in a press report that "Getting a psychiatric diagnosis can often create more problems than it solves, including difficulties with obtaining health insurance, loss of employment, loss of child custody, the overlooking of physical illnesses and the loss of the right to make decisions about one's medical and legal affairs."

By narrowing down a person’s concerns to a diagnostic label or category we run the risk of failing to give time and consideration to any precipitating concerns the person has – the very matters that provoke the distress that has been labelled as some "mental illness".  In this regard, labelling can not only bring stigma but limit a person’s horizon on life too. Dr Peter Gordon, himself a psychiatrist, writes: “I am convinced the diagnostic lens is a stigmatiser in itself. In such a view the doctor (and the wider world) ceases to see the whole person, and can too easily be distracted from what else is going on outside any label. This, in itself, limits understanding.”

There are also human and civil rights issues too in that a doctor can decide a person has a particular mental disorder when this is essentially a subjective decision without adequate supporting scientific/medical evidence. And even though this decison by the doctor is speculative, it takes priority over a person's own understanding of their situation and troubles.

Without doubt a psychiatric diagnosis can have a detrimental effect on a person's self perception, confidence and aspirations too. What really matters is who we really are. And who we are is not fixed but ever-evolving and should not be constrained by the mythical boundaries of psychiatric diagnosis.

And finally. Now doctors, if you favour a medical perspective, it's OK to say to patients that you find that way of viewing emotional and mental distress helpful - it is after all, just an opinion, isn't it? Isn't it?

References - Bibliography - Further reading

1 Ghaemi, N. Nosologomania: DSM & Karl Jaspers' Critique of Kraepelin. Philosophy, Ethics, and Humanities in Medicine. 2009:
4:10

2 Appendix 11, Memorandum by Critical Psychiatry Network (P1 31) House of Commons Select Committee on Health http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/42we13.htm

3 Double, D. Ed. (2006) Critical Psychiatry: The Limits of Madness: UK: Palgrave Macmillan, p.112-113, Dr Terry Lynch

4 Moncrieff, J. (2008) The Myth of the Chemical Cure. UK: Palgrave MacMillan

5 Moncrieff, J. (2010) Psychiatric diagnosis as a political device. Social Theory & Health (2010) 8, 370–382. doi:10.1057/sth.2009.11. Full PDF available here

6 Kendell, R. & Jablensky, A. (2003) Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of
Psychiatry
; 160:4–12. Available here.

 

Further reading

By Prof Mary Boyle. (2007) The Problem With Diagnosis. The Psychologist Vol 20 No 5. Full article here.