Well, the day had to come when we would deeply disagree. I would say that sometimes emotional discomfort and distress is important and necessary. Sometimes guilt and even shame are the result of actions that should produce guilt and shame in someone who aspires to be a good person. One of my greatest dissatisfactions with psychiatry is that it feels untethered to character and morality. I think that's why Alcoholics Anonymous appeals to so many people: it recognizes that alcoholism hurts other people, and regardless of whether people are blameworthy for becoming alcoholics, they should try to make amends. i have seen diagnoses become an all-purpose explanation for not turning in classwork on time, or at all; for abusive mistreatment of others; for failure to keep promises; for neglect of children or worse. The diagnosis is not only an explanation, but an absolution. People with psychiatric disabilities are just like everyone else: some are generous and kind, some are selfish and deceitful. Parsing out where the disability drives the behavior, and whether it can be treated and ameliorated, is crucially important work. But I have noticed that people never attribute virtuous behavior to diagnoses, only behavior that would otherwise be subject to social condemnation. I am not saying at all that there is some kind of character/pathology binary distinction. I am saying questions of morality and character are no longer even raised in the context of psychiatry and that over-diagnosing, to me, is a question of rewriting the narrative of behavior to erase those questions.
With the breakdown of the nuclear family I have no doubt the average person is quite a bit more disturbed today than in the 1960s.
But in my opinion as any diagnosis can introduce iatrogenic harm, diagnostic threshold should not be objective across all generations… but should be in direct proportion to our ability to fix deep-seated problems. To diagnose is to involve yourself in treatment, otherwise it may cause harm, and although for example borderline traits are more common today, and psychiatrists as public health practitioners should comment on it, nevertheless, as people have gotten sicker a case can be made to pull back from diagnosis.
A diagnosis is like a Freudian interpretation: it is a stressor and may destabilize someone.
I haven't read the article yet. But I think you are on target. I was amused thinking about a lecture Nassir Ghaemi gave at the LAST APA convention in NYC, in which he "showed" statistically that we UNDERdiagnose bipolar disorder, not OVERdiagnose it. There is a similar argument we UNDERdiagnose ADHD not OVERdiagnose it, too. I realized both these arguments are no more than sophistry.
The fundemental problem with these discussions relates to the variable definition of "diagnosis" and even "normal", and unless these are defined at the start, assessing the overdiagnosis "problem" is hopeless. That is the heuristic problem. The clinical problem more relates to motivations of patients. When patients seek enlightenment and recommendations or treatment, "diagnosis" means one thing. When they actually come to the doctor with an agenda explicit or unspoken (like "stimulants"), "diagnosis" means something else.
In my clinical experience (and I am open-minded to other experiences), patients adopt or repeat or encourage certain diagnoses because it labels an anxiety they have and this makes them feel better (ie "autism"). In contrast, the patients who come to me seeking stimulants are less intent on being diagnosed with "ADHD" than obtaining their desired drug. I think that we document "ADHD" in various locations to address OUR anxiety about prescribing the stimulant. I personally don't care, I don't have this anxiety. But there are numerous places "ADHD" is populated or has to be written to finish the prescription process, and I write "ADHD" as a telegraphic way of describing why the person gets stimulants, to differentiate it from "narcolepsy" (for example) or "OSAHS", maybe my compulsion to write that is subconciously addressing my anxiety so that I don't appear to be giving uppers "because I feel like it".
Remember, precise diagnoses are rarely needed to provide psychiatric services or get paid. I might have to document a relatively precise diagnosis like "obstructive sleep apnea", but this is rare. I might have to endorse specific psychiatric diagnoses, say, twice per year in my practice, it is that rare, most commonly in pre-authorizations. And I don't take it seriously or concern myself with truthfulness in those instances either, I am just trying to finish the damn pre-auth and get the drug approved. But this is truly rare.
I personally don't have an "overdiagnosis" problem. Now patients bandy various labels sure, but that is just one more aspect of getting a history. Truthfully the problem isn't their throwing around jargon, it is their refusal to provide records, which has been a gradual trend in psychiatry such that most patients are now shocked when I request their records.
If we psychiatrists are "overdiagnosing" something, that comes from disagreement over what the diagnosis means, which I consider a problem of operationalization (a serious problem in psychiatric nomenclature). Examples are biopolar disorder or ADHD. I don't think there is a solid consensus in the profession or in society about what these mean. Compare the diagnosis of "Lewy Body Dementia". It is in the DSM, we all know what it means. No one would say it is over-used. I PERSONALLY think that "major depressive disorder" is very easy to operationalize, others might disagree, to give an example of something without a clear physiologic basis or pathology.
So I think that "overdiagnosis" is a problem only if you say it is.
Lumping ADHD and bipolar disorder together in this way makes it seem like all psychiatric diagnosis is inaccurate or pointless. There absolutely is a baseline consensus of what bipolar disorder is: an episodic mood disorder consisting mostly of depressive episodes, sometimes with hypomanic or manic episodes, though probably most often with mixed episodes, and with periods of remission in between.
ADHD is somewhat looser/broader and more socially constructed as a diagnosis than bipolar disorder which has been well-described for over a century. Then on the much less objective end of the diagnostic spectrum we have things like prolonged grief disorder.
But some psychiatric diagnoses are real and observable, and we should not let the muddy waters of certain diagnoses spill over into all the others.
I think psychiatry faces the paradoxical problem of both underdiagnosis and overdiagnosis. Depression and bipolar disorder can still go unrecognized, despite being conditions for which we have some of the most established treatments. At the same time, we see potential overdiagnosis of Neurodevelopmental conditions or Personality disorders where treatment is often not straight forward.
Suffering is real, and the medical mandate to help has had positive intention and impact. The problem is that emotion is not a sickness, and never has been. We must normalize and understand emotional distress as a basic primal instinct that needs to be regulated, not a sickness that needs to diagnosed. You’re not sick when you’re emotional, you’re “on animal” —and it’s not your fault: it’s a function of being a living creature in need of surviving. Emotional states are a human condition, and how intense and frequently one has them depends on the degree to which validation and reassurance about having these states was achieved when developing. Emotional states are not complicated: they are the psychological extensions of our instinctive need to fundamentally protect ourselves, but since we are not typically in real need of physically protection, they are always exaggerated. Simplifying the human state of suffering as overreactive instinct, that needs validating but not pathologizing is the much needed direction for metal health.
I wonder whether the label "overdiagnosis" is standing in for a different issue, one that comes up often but links less obviously to nosology: the medicalization of distress. Mental distress, and increasingly various forms of psychosomatic and psychosocial distress, can be framed in many ways. What people perceive as overdiagnosis may reflect the current dominance of the medical framing. On this view, the distress is real, and it coexists with overdiagnosis understood as the framing of human suffering as medical dysfunction. The discussion, then, is less about overdiagnosis as such than about the wider reframing of human suffering in medical and psychiatric terms, of which overdiagnosis is a symptom.
This, of course, links to the disappearance of other frames: socioeconomic, political, religious, moral etc.
Also intensity and aspiration to "feeling happy". Distress is thus real -- tho what LEVEL of distress is acceptable, normal, put-able with is also culturally determined (WHO redefinition of health can work as Exhibit 1 in this) -- but both individualised and medicalised framing is, excuse the term, "socially constructed".
Guess I’m not sure how we are converging when the categories themselves are so mushy. It feels at risk of begging the question. I guess ‘adverse outcomes’ may be quantifiable in a real way, but psychiatric burden probably isn’t really. The ‘burden’ is subject to both conditions and cultural norms. What does it mean if “depression” is higher when considerable economic uncertainty is present? This doesn’t mean this depression shouldn’t be treated but I’d question if we are then converging on something fundamental, normative, or ‘real world,’ or instead something more circumstantial.
And culture defines a lot of this. Both expectations of how people will behave and what we should expect from our intrapsychic experiences are culturally defined. This doesn’t necessarily challenge all of your argument - we could be converging on cultural expectations and thereby benefiting the society - but it doesn’t seem like that’s what you’re arguing. I’m not sure from the post who legitimized distress, or maybe more precisely help-seeking, but the thirst for labels at present that is almost certainly culturally defined. Over half of the population of the UK is now ‘neurodivergent.’ I’m not sure if I understand what that means anymore. And this isn’t novel. There was significant prescription of amphetamines in the 1940s and 50s, not because we were concerned about attention issues, but because of a cultural norm around ‘pep.’ I’m sure this was scientifically dignified in various ways, but in the end the trend was cultural.
Well, the day had to come when we would deeply disagree. I would say that sometimes emotional discomfort and distress is important and necessary. Sometimes guilt and even shame are the result of actions that should produce guilt and shame in someone who aspires to be a good person. One of my greatest dissatisfactions with psychiatry is that it feels untethered to character and morality. I think that's why Alcoholics Anonymous appeals to so many people: it recognizes that alcoholism hurts other people, and regardless of whether people are blameworthy for becoming alcoholics, they should try to make amends. i have seen diagnoses become an all-purpose explanation for not turning in classwork on time, or at all; for abusive mistreatment of others; for failure to keep promises; for neglect of children or worse. The diagnosis is not only an explanation, but an absolution. People with psychiatric disabilities are just like everyone else: some are generous and kind, some are selfish and deceitful. Parsing out where the disability drives the behavior, and whether it can be treated and ameliorated, is crucially important work. But I have noticed that people never attribute virtuous behavior to diagnoses, only behavior that would otherwise be subject to social condemnation. I am not saying at all that there is some kind of character/pathology binary distinction. I am saying questions of morality and character are no longer even raised in the context of psychiatry and that over-diagnosing, to me, is a question of rewriting the narrative of behavior to erase those questions.
With the breakdown of the nuclear family I have no doubt the average person is quite a bit more disturbed today than in the 1960s.
But in my opinion as any diagnosis can introduce iatrogenic harm, diagnostic threshold should not be objective across all generations… but should be in direct proportion to our ability to fix deep-seated problems. To diagnose is to involve yourself in treatment, otherwise it may cause harm, and although for example borderline traits are more common today, and psychiatrists as public health practitioners should comment on it, nevertheless, as people have gotten sicker a case can be made to pull back from diagnosis.
A diagnosis is like a Freudian interpretation: it is a stressor and may destabilize someone.
I spend a lot of time undiagnosing.
I haven't read the article yet. But I think you are on target. I was amused thinking about a lecture Nassir Ghaemi gave at the LAST APA convention in NYC, in which he "showed" statistically that we UNDERdiagnose bipolar disorder, not OVERdiagnose it. There is a similar argument we UNDERdiagnose ADHD not OVERdiagnose it, too. I realized both these arguments are no more than sophistry.
The fundemental problem with these discussions relates to the variable definition of "diagnosis" and even "normal", and unless these are defined at the start, assessing the overdiagnosis "problem" is hopeless. That is the heuristic problem. The clinical problem more relates to motivations of patients. When patients seek enlightenment and recommendations or treatment, "diagnosis" means one thing. When they actually come to the doctor with an agenda explicit or unspoken (like "stimulants"), "diagnosis" means something else.
In my clinical experience (and I am open-minded to other experiences), patients adopt or repeat or encourage certain diagnoses because it labels an anxiety they have and this makes them feel better (ie "autism"). In contrast, the patients who come to me seeking stimulants are less intent on being diagnosed with "ADHD" than obtaining their desired drug. I think that we document "ADHD" in various locations to address OUR anxiety about prescribing the stimulant. I personally don't care, I don't have this anxiety. But there are numerous places "ADHD" is populated or has to be written to finish the prescription process, and I write "ADHD" as a telegraphic way of describing why the person gets stimulants, to differentiate it from "narcolepsy" (for example) or "OSAHS", maybe my compulsion to write that is subconciously addressing my anxiety so that I don't appear to be giving uppers "because I feel like it".
Remember, precise diagnoses are rarely needed to provide psychiatric services or get paid. I might have to document a relatively precise diagnosis like "obstructive sleep apnea", but this is rare. I might have to endorse specific psychiatric diagnoses, say, twice per year in my practice, it is that rare, most commonly in pre-authorizations. And I don't take it seriously or concern myself with truthfulness in those instances either, I am just trying to finish the damn pre-auth and get the drug approved. But this is truly rare.
I personally don't have an "overdiagnosis" problem. Now patients bandy various labels sure, but that is just one more aspect of getting a history. Truthfully the problem isn't their throwing around jargon, it is their refusal to provide records, which has been a gradual trend in psychiatry such that most patients are now shocked when I request their records.
If we psychiatrists are "overdiagnosing" something, that comes from disagreement over what the diagnosis means, which I consider a problem of operationalization (a serious problem in psychiatric nomenclature). Examples are biopolar disorder or ADHD. I don't think there is a solid consensus in the profession or in society about what these mean. Compare the diagnosis of "Lewy Body Dementia". It is in the DSM, we all know what it means. No one would say it is over-used. I PERSONALLY think that "major depressive disorder" is very easy to operationalize, others might disagree, to give an example of something without a clear physiologic basis or pathology.
So I think that "overdiagnosis" is a problem only if you say it is.
Lumping ADHD and bipolar disorder together in this way makes it seem like all psychiatric diagnosis is inaccurate or pointless. There absolutely is a baseline consensus of what bipolar disorder is: an episodic mood disorder consisting mostly of depressive episodes, sometimes with hypomanic or manic episodes, though probably most often with mixed episodes, and with periods of remission in between.
ADHD is somewhat looser/broader and more socially constructed as a diagnosis than bipolar disorder which has been well-described for over a century. Then on the much less objective end of the diagnostic spectrum we have things like prolonged grief disorder.
But some psychiatric diagnoses are real and observable, and we should not let the muddy waters of certain diagnoses spill over into all the others.
I think psychiatry faces the paradoxical problem of both underdiagnosis and overdiagnosis. Depression and bipolar disorder can still go unrecognized, despite being conditions for which we have some of the most established treatments. At the same time, we see potential overdiagnosis of Neurodevelopmental conditions or Personality disorders where treatment is often not straight forward.
Suffering is real, and the medical mandate to help has had positive intention and impact. The problem is that emotion is not a sickness, and never has been. We must normalize and understand emotional distress as a basic primal instinct that needs to be regulated, not a sickness that needs to diagnosed. You’re not sick when you’re emotional, you’re “on animal” —and it’s not your fault: it’s a function of being a living creature in need of surviving. Emotional states are a human condition, and how intense and frequently one has them depends on the degree to which validation and reassurance about having these states was achieved when developing. Emotional states are not complicated: they are the psychological extensions of our instinctive need to fundamentally protect ourselves, but since we are not typically in real need of physically protection, they are always exaggerated. Simplifying the human state of suffering as overreactive instinct, that needs validating but not pathologizing is the much needed direction for metal health.
I wonder whether the label "overdiagnosis" is standing in for a different issue, one that comes up often but links less obviously to nosology: the medicalization of distress. Mental distress, and increasingly various forms of psychosomatic and psychosocial distress, can be framed in many ways. What people perceive as overdiagnosis may reflect the current dominance of the medical framing. On this view, the distress is real, and it coexists with overdiagnosis understood as the framing of human suffering as medical dysfunction. The discussion, then, is less about overdiagnosis as such than about the wider reframing of human suffering in medical and psychiatric terms, of which overdiagnosis is a symptom.
This, of course, links to the disappearance of other frames: socioeconomic, political, religious, moral etc.
Also intensity and aspiration to "feeling happy". Distress is thus real -- tho what LEVEL of distress is acceptable, normal, put-able with is also culturally determined (WHO redefinition of health can work as Exhibit 1 in this) -- but both individualised and medicalised framing is, excuse the term, "socially constructed".
Any discussion on how psychiatric disorders have "expanded" should include an honest look at the influence of the pharma industry.
Guess I’m not sure how we are converging when the categories themselves are so mushy. It feels at risk of begging the question. I guess ‘adverse outcomes’ may be quantifiable in a real way, but psychiatric burden probably isn’t really. The ‘burden’ is subject to both conditions and cultural norms. What does it mean if “depression” is higher when considerable economic uncertainty is present? This doesn’t mean this depression shouldn’t be treated but I’d question if we are then converging on something fundamental, normative, or ‘real world,’ or instead something more circumstantial.
And culture defines a lot of this. Both expectations of how people will behave and what we should expect from our intrapsychic experiences are culturally defined. This doesn’t necessarily challenge all of your argument - we could be converging on cultural expectations and thereby benefiting the society - but it doesn’t seem like that’s what you’re arguing. I’m not sure from the post who legitimized distress, or maybe more precisely help-seeking, but the thirst for labels at present that is almost certainly culturally defined. Over half of the population of the UK is now ‘neurodivergent.’ I’m not sure if I understand what that means anymore. And this isn’t novel. There was significant prescription of amphetamines in the 1940s and 50s, not because we were concerned about attention issues, but because of a cultural norm around ‘pep.’ I’m sure this was scientifically dignified in various ways, but in the end the trend was cultural.