A No-Nonsense Introduction to Psychiatric Diagnosis
My article in Psyche for patients and general readers
I wrote about psychiatric diagnosis for Psyche magazine — what it means and what it doesn’t mean. If you are looking for a general introduction to diagnosis in mental healthcare that is accessible but informed by scientific and philosophical work (or if you are grappling with your own diagnosis), this is the piece for you. Although not primarily aimed at clinicians, I think clinicians will find it of value as well. It’s a fairly simple piece, in a way, but I’ve realized with time and experience that a lot of effort hides behind such simplicity.
Psyche — What a psychiatric diagnosis means – and what it doesn’t mean
Due to word limit, I couldn’t cover all the points that I wanted to, so I am planning to post a part 2 on this Substack in the near future.
I am thankful to Matt Huston, the editor, for working with me on this piece.
An excerpt:
A diagnosis is a description
Most psychiatric diagnoses are descriptive in nature: they refer to observable and reportable patterns of experiences and behaviours that cause distress or impairment in a person’s life. For example, a diagnosis of generalised anxiety disorder is made when someone experiences excessive, uncontrollable anxiety and worry along with a certain number of other symptoms – such as restlessness, difficulties with concentration, muscle tension, sleep disturbance, and so on – for a specific period of time. At present, the diagnosis is not based on medical tests (other than to exclude relevant medical causes, such as hormonal disorders), nor does it pinpoint an underlying biological or psychological cause.
This descriptive approach reflects the current state of scientific knowledge in psychiatry and psychology. It’s a pragmatic way to group and treat presentations with similar symptoms, even though the relevant causes are not fully understood and are likely different in different people. (After making a diagnosis, a competent clinician will then go beyond descriptive features to further explore the patient’s personal experience and hypothesise about causes and contributing factors; this is called a clinical formulation. Mental health problems arise from the interaction of various factors – such as personality characteristics, genetic vulnerabilities, childhood development, social adversity, and patterns of brain circuitry – and the crisscrossing web of causes doesn’t respect the boundaries of clinical description.)
To diagnose patients, mental health professionals rely to varying degrees on the descriptions contained in official diagnostic manuals, including the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Here you can find categories such as obsessive-compulsive disorder, social anxiety disorder and anorexia nervosa, along with characteristic symptoms of each. Despite their widespread use, these manuals are imperfect tools. A proper diagnosis is based on more than a list of symptoms; it is the outcome of a thorough evaluation that takes various possibilities into account. Clinicians also frequently use names and labels (such as treatment-resistant schizophrenia) that are not in the manuals but are recognised and accepted by professionals in the field. When a diagnosis is uncertain or unclear, which happens quite often, clinicians rely on narrower clinical features, such as delusions, obsessions or mood instability, instead of a specific category to guide treatment.
It is often said that psychiatric diagnoses don’t explain anything, though this is not quite true. They do offer a limited form of explanation, namely that of pattern recognition and matching. When a diagnosis is made, the clinician is conveying to the patient that their presentation matches this well-recognised pattern of symptoms, and not these other patterns that could conceivably apply. Based on that, we can link the person’s presentation with existing medical knowledge and use treatments that have been studied for that pattern. This is why accurate diagnoses of conditions such as autism and ADHD can offer powerful explanations for patients and lead them to look at their lives in a new light, even though the causes and mechanisms remain unknown.
For clinicians and professionals looking for a more academic discussion, I will refer them to my article in Journal of Nervous and Mental Disease (with Konrad Banicki, Mark Ruffalo, and Allen Frances): Psychiatric Diagnosis: A Clinical Guide to Navigating Diagnostic Pluralism.
P.S.
My (brief) book review of “Categories We Live By: How We Classify Everyone and Everything” by Gregory L. Murphy was published in the British Journal of Psychiatry earlier this month. You can read it here.
Gregory L. Murphy's book, Categories We Live By, offers a thought-provoking exploration of the ubiquitous human practice of categorisation, and serves as a useful antidote to naivete about the nature of scientific categories. For psychiatrists, it is a powerful reminder that psychiatric categories are not unique in the conceptual and scientific difficulties encountered. The debate about the definition of a ‘planet’ in astronomy that led to Pluto's demotion is familiar to many, but such problems are common across the natural and social sciences. Even well-established scientific concepts can be ‘surprisingly fuzzy’. I chuckled at this amusing remark by the metallurgist Robert Pond: ‘There's a big group of people who don't know what a metal is. Do you know what we call them? Metallurgists!’
Murphy recounts his initial belief that biologists must have definitive definitions for each species, only to discover that not only is this not the case but biology lacks a universally accepted definition of ‘species’ to begin with. Psychiatrists will find such examples reassuring. In fact, the book includes a chapter devoted to psychodiagnostic categories, providing an informative overview of conceptual developments in this area. Murphy views psychiatric categories as a heterogeneous collection: some are extremes of variations on psychological dimensions (categorisable for practical purposes), others are fuzzy prototypes consisting of a cluster of related features that co-occur but lack a clear essence and some psychiatric categories (neuropsychiatric diseases) are defined by neurobiological essences, such as Huntington disease. Proposed alternatives such the Research Domain Criteria are also discussed, but Murphy correctly notes that even dimensional frameworks inevitably generate their own categories. Categories play a crucial and indispensable role in how we engage with the world, and in the psy-sciences, how we engage with psychiatric suffering.
Kudos for this lucid article, Awais! In my view, one of the most important sections is this excerpt:
"It is often said that psychiatric diagnoses don’t explain anything, though this is not quite true. They do offer a limited form of explanation, namely that of pattern recognition and matching. When a diagnosis is made, the clinician is conveying to the patient that their presentation matches this well-recognised pattern of symptoms, and not these other patterns that could conceivably apply. Based on that, we can link the person’s presentation with existing medical knowledge and use treatments that have been studied for that pattern. This is why accurate diagnoses of conditions such as autism and ADHD can offer powerful explanations for patients and lead them to look at their lives in a new light, even though the causes and mechanisms remain unknown."
This is precisely the point Dr. Mark Ruffalo have been making in our numerous debates with two Finnish colleagues, published in Psychiatric Times. For example, we wrote:
"...when we provide the patient with a psychiatric diagnosis, we are simply hypothesizing the existence of a condition that “best makes sense” of the patient’s presenting signs and symptoms. This is very close to what philosophers of science call “inference to the best explanation.” In so doing, we are not making any metaphysical claims, or reifying the condition by positing some essence, substance, or thing residing inside the patient—akin to, say, a burst appendix."
https://www.psychiatrictimes.com/view/no-psychiatric-diagnoses-do-not-reflect-circular-logic
Thanks again for your efforts in bringing these ideas to a wide, general audience.
Regards,
Ron
Ronald W. Pies MD
Also see: https://www.psychiatrictimes.com/view/our-closing-argument-in-defense-of-psychiatric-diagnosis
I encourage readers to read the entire article on Psyche. For reasons unclear to me, I got five times more out of the complete article than I got out of the extract.