Diagnosis as Self-Understanding & Self-Alienation

What you need to know about your diagnosis

I have said before that almost everyone in the psy-disciplines (even psychiatry, yes) dislikes, disdains, disregards, or begrudgingly tolerates the DSM but they do so for wildly different reasons. This is understandable as different complaints exist in the context of different clinical, scientific, and social goals. One set of grievances that frequently comes up pertains to the allegedly pernicious influence of the DSM on how we relate to our own emotional lives. In particular, it is said to have alienated us from the nature of our psychological difficulties.

This line of thinking is expressed quite well by the psychoanalyst Nancy McWilliams in the article Diagnosis and Its Discontents: Reflections on Our Current Dilemma (2021):

“One interesting (and, to a therapist, somewhat disconcerting) side-effect of the 1980 change toward descriptive and categorical psychiatric diagnosis involves the ways people in Western cultures have begun talking about themselves since the DSM-III paradigm shift. It used to be that a socially avoidant woman would come for therapy saying something like, “I’m a painfully shy person, and I need help learning how to deal better with people in social situations.” Now a person with that concern is likely to tell me that she “has” social phobia – as if an alien affliction has invaded her otherwise problem-free subjective life. People talk about themselves in acronyms oddly dissociated from their lived experience: “my OCD,” “my eating disorder,” “my bipolar.” There is an odd estrangement from one’s sense of an agentic self, including one’s own behavior, body, emotional and spiritual life, and felt suffering, and consequently one’s possibilities for solving a problem. There is a passive quality in many individuals currently seeking therapy, as if they feel that the prototype for making an internal psychological change is to describe their symptoms to an expert and wait to be told what medicine to take, what exercises to do, or what self-help manual to read.

Mental health problems are listed in the DSM and similar classifications as if there is no narrative that holds together the kinds of difficulties a person reports. Experienced therapists tend to see connections between someone’s “having,” simultaneously, a personality disorder, a depression, an addiction, a post-traumatic symptom, and a self-harming behavior. Since we know from clinical experience and research on self-reflective function (e.g., Fonagy et al., 1991; Gabbard, 2005; Jurist & Slade, 2008; Müller et al., 2006) that the development of a personal narrative about the connections between one’s unique life experiences and one’s idiosyncratic psychology is a key element of mental health – so evident in its absence from the shattered mental life of many survivors of trauma – it is not hard to view our current psychiatric nomenclature as contributing to self-fragmentation rather than providing a means to heal it.”

I do think the phenomenon is real — this collective sense of estrangement, passivity, and hyponarrativity in the face of psychological afflictions. It would be, however, simplistic to lay the entire blame on the diagnostic manuals, tempting as it may be (not that McWilliams offers such a simplistic explanation). So what is going on here?

The DSM was never designed nor intended to provide a framework for self-understanding of psychopathology. It is also, in my opinion, quite unsuited for this task. It is a diagnostic manual for use by professionals that assumes a certain degree of professional training. It is not a manual for patients or the general public. The deceptive simplicity of the manual, however, facilitates and encourages its use by non-professionals. This noted by the psychiatrist John Sadler in his book Values and Psychiatric Diagnosis (page 418):

“Perhaps the DSM would be better served, and more fairly portrayed, if its intentions and audience were focused more sharply towards professionals. It may be telling that the ICD is rarely lampooned in the manner the DSMs are; a casual perusal of the full International Classification of Diseases makes it quite clear that this hefty document assumes training and expertise. The ICD is a professional’s document, and a ho-hum one at that. While the DSM values of ‘user-friendliness’ and ordinary language usage have much to commend them, the unfortunate downside is that plain language create the (false) appearance that the DSM categories and descriptions are conceptually transparent and usable by anyone, suggesting a mental health encyclopedia rather than a technical manual for professionals. The DSM’s simple language and current status as a cultural icon have nudged it into the domain of pop psychology and pop culture. Perhaps a more virtuous DSM would be more stodgy, dull, and technical.”

The point above is also obvious from emerging diagnostic competitors, such as the Hierarchical Taxonomy of Psychopathology (HiTOP). No one taking a look at HiTOP would assume it to be a classification usable by someone without relevant training and expertise.

Here is how I make sense of the social situation (this is by now a fairly standard narrative):

• The DSM-III in 1980 privileged descriptive classification, and a group of psychiatrists used it to challenge the dominance of psychoanalytic thinking in the profession.

• The dethronement of psychoanalysis and the reliance on descriptive categories created an explanatory vacuum.

• This vacuum was rapidly filled by ‘biological psychiatrists’ who favored explanations of mental illnesses in terms of brain dysfunctions and biogenetic etiological mechanisms. Such thinking became mainstream during the “decade of the brain.”

• Anti-stigma campaigns seeking to establish parity between physical and mental health inadvertently promoted medical essentialism by emphasizing, without much qualification, that mental illnesses are diseases “just like diabetes” and psychiatric medications work in the same way as insulin does for diabetes mellitus.

• Psychotherapies increasingly became more manualized and diagnosis oriented — leaving less room for exploration of diagnostic “looping effects” and the impact of diagnosis on self-understanding

• Pharma companies aggressively used the “chemical imbalance” trope in direct-to-consumer advertising, also promoted by pharma-sponsored “key opinion leaders,” and once the idea became culturally ubiquitous it was adopted by clinicians as a way of legitimizing the medical status of psychiatric disorders and supporting the prescription of psychotropics.

• DSM diagnostic categories were adopted for the purposes of public communication and psychoeducation, and virtually all social and journalistic discussion around mental illness was centered around them. For the public, however, these were not merely descriptive categories, but represented well-defined disease entities. The value-laden and pragmatic nature of DSM constructs was not obvious to most non-professionals (and even to many professionals).

The situation now is that most people who see a clinician for mental health problems leave with their folk understanding of psychiatric distress intact (or reinforced) because all the implicit assumptions around psychiatric diagnoses are almost never examined and corrected. This “folk understanding” these days is very much a “biomedical” one.

What can be done differently? Lessons for public communication

Unlike some radical critics who wish to abandon psychiatric diagnoses entirely, I do not consider diagnostic categories to be the fundamental problem in this regard and see the abandonment of diagnoses — whether DSM/ICD-based or other scientific alternatives such as HiTOP — as naïve and harmful. The problem is how the diagnostic categories have been understood and interpreted. Most of the developments outlined above have been external to the DSM and don’t determine how diagnostic manuals are to be best understood.

I have emphasized negative influences on self-understanding, but we should not discount “the relief that comes from giving a name to nameless fears” (Abraham Nussbaum, The Pocket Guide to the DSM 5 Diagnostic Exam), the recognition conferred that the problem is a clinical one and deserves care from healthcare professionals, the ability of diagnostic categories to serve as bases for advocacy and activism, and the ability to access clinical and scientific research pertinent to one’s problems.

It is not sufficient now, and never was, to merely highlight the status of mental health problems as clinical or medical; we cannot leave unsaid conceptual and scientific aspects that are important to highlight to the public. These aspects include:

• Scientific research so far suggests that most psychiatric symptoms are continuous and dimensional in nature. There is no natural point at which everyday misery ends and clinical symptoms begin. The boundaries we draw are pragmatic, based on considerations of distress, impairment, maladaptivity, and harm.

• Screening instruments like PHQ-9 and GAD-7, common in primary care settings, are over-inclusive by design and not adequate at differentiating milder and situational forms of anxiety and depression that may resolve on their own without professional help. They should be used only as the starting point of a comprehensive evaluation. (This is often true even of DSM defined thresholds)

• Mental health problems are heterogeneous: people differ in how they present, in what factors are involved in their symptoms and impairments, what they need from professionals, and how they respond to treatment.

• The “medical” is not at odds with the “psychological.” Psychiatric disorders involve bodily changes and have a detrimental impact on overall health, but they are not meaningless quirks of brain chemistry. It is not enough to say that psychotherapy is an effective treatment. It has to be emphasized that psychiatric symptoms are meaningful and subject to psychological understanding in a way that symptoms in general medicine typically are not.

• The term “disorder” is interpreted in philosophical and scientific literature in a wide variety of ways. The way it is used for mental disorders in DSM and ICD, it does not refer to “disease entities,” but rather to symptomatic states that depart from our commonsensical norms of what is typical, ordinary, rational, or expectable, and that are associated with distress, disability, and harm. These norms are value-laden and socio-culturally influenced.

• Mental health problems exist in a particular context of temperament, development, life story, and social circumstance, and cannot be divorced from this context. It doesn’t change their status as “disorders,” but it changes how we conceptualize and approach them.

• Low mood and anxiety — like pain and cough — are inherently adaptive. They exist to signal the existence of and respond to a variety of problems and threats that we encounter in our day to day life. Low mood, for instance, may be adaptive in fostering disengagement from commitments to unreachable goals. Depressive and anxiety disorders represent instances when low mood and anxiety have become maladaptive, disabling, or arise in a manner that has is disconnected from their adaptive functions (See Good Reasons for Bad Feelings by Randolph M. Nesse). Given the dimensional nature of psychiatric symptoms and the broad nature of diagnostic categories, the adaptive functions and maladaptive roles can be difficult to distinguish, especially at the milder end of the spectrum. Examining the adaptive and maladaptive nature of psychiatric symptoms offers another way of challenging the perception of mental health problems as meaningless quirks of brain chemistry.

• Mental health problems and psychiatric disorders are conditions that span the physiological, the psychological, and the social. They are complex and multi-level phenomena, and cannot be reduced to any particular dimension or level of explanation.

• The treatment of mental illnesses cannot be divorced from a eudaimonic approach to flourishing that emphasizes family, work, education, and community as sources of meaning and fulfillment. (See Margaret Chisolm’s accessible book From Survive to Thrive: Living Your Best Life with Mental Illness)

• Classifications such as DSM and ICD do capture features of reality — they are not purely arbitrary or socially constructed — but they capture these features in limited and imperfect ways, and do not take away the necessity of approaching these problems from other perspectives. (“Our classifications are not objective enough to be considered inevitable but are more objective than being made up.” Peter Zachar)

• Mental health is political. Mental health is connected to social health, and social dysfunction breeds individual dysfunction. Our mental well-being requires sociopolitical action to address social determinants of health and to utilize a public health approach.

Many professionals in psychiatry and psychology are well-aware of these considerations and may take them for granted but they are not obvious to patients and the public. What “medical illness” or “mental disorder” means to them is different from what it means to philosophically-informed professionals. Our inability to say such things clearly and publicly has had detrimental consequences.

If we are to counter the alienating effects of psychiatric diagnosis on self-understanding, it is imperative for us to do a better job in what we convey to the public and to our patients.