Thank you, Awais, for your careful anatomizing of the nebulous term, "overdiagnosis." You rightly point out the many senses in which this dubious charge is leveled against psychiatry and psychiatric diagnosis. I would like to comment specifically on your category #8 (expanding or loosening of diagnostic criteria), since this question has been studied systematically by Fabiano & Haslam [https://doi.org/10.1016/j.cpr.2020.101889] Their meta-analysis concluded that:
* Criteria for diagnosing mental disorders did not loosen from DSM-III to DSM-5.
* No post-DSM-III revision produced significant diagnostic inflation or deflation.
* Certain mental disorders have substantially inflated or deflated.
* Some critiques of diagnostic expansion in the DSM have been over-stated.
Specifically, they found "no overall change in diagnostic stringency from DSM-III to DSM-5" and concluded that "Although serious concerns have been raised about diagnostic inflation or “concept creep” in the DSM, these concerns may have been overstated."
I would also like to make a broader point, more in the nature of philosophy than statistics. In your article, I found four instances of the phrase, “distress and impairment.” I count at least 7 additional instances in which you use the term, “impairment.” As you know, I have been banging on about “suffering and incapacity” for at least the past 45 years, as the most clinically important feature of disease—not constituting an “essential definition” of disease, but the aspects of disease of greatest concern to both patients and clinicians.
If I am correct in this assertion, it seems that the most clinically relevant question to ask of our diagnostic categories is this: how well do they identify clinical conditions characterized by marked “distress and impairment”; or, as I would phrase it, marked suffering and incapacity. The DSMs usually invoke the phrase “distress or impairment.” I would prefer the tighter phrase, “distress and impairment.” Either way, I do not believe critics of psychiatric diagnosis have shown that psychiatrists using DSM-5 criteria are “overdiagnosing” substantial distress and/or impairment in the emotional, cognitive and behavioral realm. If anything, in my view, many people in our society are struggling with high degrees of suffering and incapacity and, alas, are not receiving professional evaluation or treatment.
“A lot of public criticism of “overdiagnosis” does not strike me as very patient-centered.” Yes - it breaks my heart when a patient confesses they were reluctant to tell me about their struggles with focus/emotional regulation/pain because they were worried I would roll my eyes and ask them if they have been watching too much tik tok. And the whole ‘what happened to watchful waiting’ pearl clutching? That went out the window when waiting lists blew out to 6 months+ for an initial assessment.
I would agree a bit with Dr. Pies below when he discusses the issue of the "expanding or loosening of diagnostic criteria" and points to the Fabiano 2020 report. The problem is criteria has always been "too loose." To me, that looseness is nothing new. It has been there since the very beginning. It would be difficult to "get looser than loose."
There are huge problems in nosology in the psychiatric and psychological realm that contribute to a subjective bias and negotiated use. Huge individual practitioner variation based on factors outside of science, as in the purpose of the diagnosis – utilitarian, conforming, non-conforming, negotiated bottom line with variables like financial, personal, and client needs and building alliances. The balancing act any practitioner is required to do in the realm of diagnosis is incredibly complicated and thus, highly variable. You can't discuss over-diagnosis unless you can rely on the diagnoses being made, which, again is a complex set of decisions related to factors that are not "scientific."
Most recent discussions of over-diagnosis have come from a population that does not trust the "medical establishment" (lack of a better term). Without a clear credibility based on consistent results of a large number of diagnosticians, the discussion of over-diagnosing is fraught with conjectures based on impressions. We think, but we don't know.
Toxic commerce in health care with toxic pressures for "efficiency" (read profiteering) and conformity to recipes (evidence based?), among other things, makes for an additional force for the facilitation of believing and using the term "over-diagnosing. Over-diagnosing is easy to believe when trust in health care has been destroyed. It is clearly another way to say, "I don't trust these professionals." Until you get money out of healthcare, profiteering will stain it to no end. Given the current level of distrust, who would not think that profit induces over-diagnosis.
I bet that if you did a survey on the prevalence of folks who believe there is too easy or too frequent diagnoses of certain "disorders," you would find a high level of general distrust. A historical curve chart comparing frequency of distrust to frequency of "over-diagnosing" would likely show parallel lines.
In addition, as long as we keep calling these "conditions" diseases or disorders, we promote distrust. When you use words that are proven to be questionable, you set up an expectation mismatch. When folks discover how loose the criteria actually is for diseases or disorders, distrust is automatic. Using a term that actually fits -- "conditions" -- allows for an appreciation rather than just a thing to fear. The "looseness" problem is no longer facilitating distrust. It is recognizing variability and dimensions.
Robert Chapman made really good points in their book Empire of Normality. Changing demands in society, in regular school and in commonly available jobs, result in a higher number of people actually experiencing significant difficulties. It's pointless to look for some objectively valid line between "healthy" and "disability" or "disorder" that stays the same regardless of society's demands, because there's no such line drawn in nature: Criteria WILL shift as society shifts.
We could argue that there's something wrong with a society in which a huge number of people fits psychiatric diagnostic criteria, and that politicians and other powerful people should set long-term goals to reduce the number of people who struggle like this (obvs that's never gonna be zero, but it can still be higher or lower). But that's actually quite different (though I'm not sure that everyone understands that it's quite different) from saying there's an over-diagnosis.
Like, we could have a long-term goal to reduce the number of people with cardiovascular problems in society, because we know that environmental factors play a big part. We could have a long-term goal to reduce certain types of cancer, etc. But this is different from saying there's an over-diagnosis.
How do you explain all the clinical messes though? I don't do clinical work but I see the charts, the laundry lists and I speak to the parents. It sure feels like we've got a diagnostic crisis. Not necessarily one of under or over or miss, but certainly a big fat mess. This seems to be the reality on the front lines regardless of what epidemiology suggests.
Nordgaard J, Nielsen KM, Rasmussen AR, Henriksen MG. 2023. Psychiatric comorbidity: a concept in need of a theory. Psychological Medicine. 53:5902-5908.
criticizes how changes in diagnostic systems have lead to people getting loads of diagnoses instead of just the one.
Some clinicians and researchers defend this change. They say that with just one diagnosis, there's a risk that some of the patient's very real problems get overlooked, even though these problems are supposed to fit inside the one diagnosis they have. A higher number of diagnoses for each person might improve their chances of getting help with everything they need help with.
But the authors of the paper believe that the change is mostly negative - a long list of diagnoses can make clinicians and patients alike more pessimistic about the latter's prospects, plus it often leads to detrimental polypharmacy.
HOWEVER, Awais writes about the very lively and very public debate about whether too many people are getting diagnosed in the first place. It seems to me that the debate about whether it's mostly good or bad that, e.g., schizophrenia patients these days don't only get "schizophrenia" but rather "schizophrenia, autism, ADHD, bipolar, depressive disorder, anxiety disorder" is much more confined to researchers, hasn't similarly made its way into popular media and the general public.
Thank you, Awais, for your careful anatomizing of the nebulous term, "overdiagnosis." You rightly point out the many senses in which this dubious charge is leveled against psychiatry and psychiatric diagnosis. I would like to comment specifically on your category #8 (expanding or loosening of diagnostic criteria), since this question has been studied systematically by Fabiano & Haslam [https://doi.org/10.1016/j.cpr.2020.101889] Their meta-analysis concluded that:
* Criteria for diagnosing mental disorders did not loosen from DSM-III to DSM-5.
* No post-DSM-III revision produced significant diagnostic inflation or deflation.
* Certain mental disorders have substantially inflated or deflated.
* Some critiques of diagnostic expansion in the DSM have been over-stated.
Specifically, they found "no overall change in diagnostic stringency from DSM-III to DSM-5" and concluded that "Although serious concerns have been raised about diagnostic inflation or “concept creep” in the DSM, these concerns may have been overstated."
I would also like to make a broader point, more in the nature of philosophy than statistics. In your article, I found four instances of the phrase, “distress and impairment.” I count at least 7 additional instances in which you use the term, “impairment.” As you know, I have been banging on about “suffering and incapacity” for at least the past 45 years, as the most clinically important feature of disease—not constituting an “essential definition” of disease, but the aspects of disease of greatest concern to both patients and clinicians.
If I am correct in this assertion, it seems that the most clinically relevant question to ask of our diagnostic categories is this: how well do they identify clinical conditions characterized by marked “distress and impairment”; or, as I would phrase it, marked suffering and incapacity. The DSMs usually invoke the phrase “distress or impairment.” I would prefer the tighter phrase, “distress and impairment.” Either way, I do not believe critics of psychiatric diagnosis have shown that psychiatrists using DSM-5 criteria are “overdiagnosing” substantial distress and/or impairment in the emotional, cognitive and behavioral realm. If anything, in my view, many people in our society are struggling with high degrees of suffering and incapacity and, alas, are not receiving professional evaluation or treatment.
Ronald W. Pies, MD
“A lot of public criticism of “overdiagnosis” does not strike me as very patient-centered.” Yes - it breaks my heart when a patient confesses they were reluctant to tell me about their struggles with focus/emotional regulation/pain because they were worried I would roll my eyes and ask them if they have been watching too much tik tok. And the whole ‘what happened to watchful waiting’ pearl clutching? That went out the window when waiting lists blew out to 6 months+ for an initial assessment.
I would agree a bit with Dr. Pies below when he discusses the issue of the "expanding or loosening of diagnostic criteria" and points to the Fabiano 2020 report. The problem is criteria has always been "too loose." To me, that looseness is nothing new. It has been there since the very beginning. It would be difficult to "get looser than loose."
There are huge problems in nosology in the psychiatric and psychological realm that contribute to a subjective bias and negotiated use. Huge individual practitioner variation based on factors outside of science, as in the purpose of the diagnosis – utilitarian, conforming, non-conforming, negotiated bottom line with variables like financial, personal, and client needs and building alliances. The balancing act any practitioner is required to do in the realm of diagnosis is incredibly complicated and thus, highly variable. You can't discuss over-diagnosis unless you can rely on the diagnoses being made, which, again is a complex set of decisions related to factors that are not "scientific."
Most recent discussions of over-diagnosis have come from a population that does not trust the "medical establishment" (lack of a better term). Without a clear credibility based on consistent results of a large number of diagnosticians, the discussion of over-diagnosing is fraught with conjectures based on impressions. We think, but we don't know.
Toxic commerce in health care with toxic pressures for "efficiency" (read profiteering) and conformity to recipes (evidence based?), among other things, makes for an additional force for the facilitation of believing and using the term "over-diagnosing. Over-diagnosing is easy to believe when trust in health care has been destroyed. It is clearly another way to say, "I don't trust these professionals." Until you get money out of healthcare, profiteering will stain it to no end. Given the current level of distrust, who would not think that profit induces over-diagnosis.
I bet that if you did a survey on the prevalence of folks who believe there is too easy or too frequent diagnoses of certain "disorders," you would find a high level of general distrust. A historical curve chart comparing frequency of distrust to frequency of "over-diagnosing" would likely show parallel lines.
In addition, as long as we keep calling these "conditions" diseases or disorders, we promote distrust. When you use words that are proven to be questionable, you set up an expectation mismatch. When folks discover how loose the criteria actually is for diseases or disorders, distrust is automatic. Using a term that actually fits -- "conditions" -- allows for an appreciation rather than just a thing to fear. The "looseness" problem is no longer facilitating distrust. It is recognizing variability and dimensions.
Robert Chapman made really good points in their book Empire of Normality. Changing demands in society, in regular school and in commonly available jobs, result in a higher number of people actually experiencing significant difficulties. It's pointless to look for some objectively valid line between "healthy" and "disability" or "disorder" that stays the same regardless of society's demands, because there's no such line drawn in nature: Criteria WILL shift as society shifts.
We could argue that there's something wrong with a society in which a huge number of people fits psychiatric diagnostic criteria, and that politicians and other powerful people should set long-term goals to reduce the number of people who struggle like this (obvs that's never gonna be zero, but it can still be higher or lower). But that's actually quite different (though I'm not sure that everyone understands that it's quite different) from saying there's an over-diagnosis.
Like, we could have a long-term goal to reduce the number of people with cardiovascular problems in society, because we know that environmental factors play a big part. We could have a long-term goal to reduce certain types of cancer, etc. But this is different from saying there's an over-diagnosis.
I blogged about the book here https://jeppssonphilosopherauthor.blogspot.com/2023/12/review-robert-chapmans-empire-of.html
How do you explain all the clinical messes though? I don't do clinical work but I see the charts, the laundry lists and I speak to the parents. It sure feels like we've got a diagnostic crisis. Not necessarily one of under or over or miss, but certainly a big fat mess. This seems to be the reality on the front lines regardless of what epidemiology suggests.
This paper
Nordgaard J, Nielsen KM, Rasmussen AR, Henriksen MG. 2023. Psychiatric comorbidity: a concept in need of a theory. Psychological Medicine. 53:5902-5908.
criticizes how changes in diagnostic systems have lead to people getting loads of diagnoses instead of just the one.
Some clinicians and researchers defend this change. They say that with just one diagnosis, there's a risk that some of the patient's very real problems get overlooked, even though these problems are supposed to fit inside the one diagnosis they have. A higher number of diagnoses for each person might improve their chances of getting help with everything they need help with.
But the authors of the paper believe that the change is mostly negative - a long list of diagnoses can make clinicians and patients alike more pessimistic about the latter's prospects, plus it often leads to detrimental polypharmacy.
HOWEVER, Awais writes about the very lively and very public debate about whether too many people are getting diagnosed in the first place. It seems to me that the debate about whether it's mostly good or bad that, e.g., schizophrenia patients these days don't only get "schizophrenia" but rather "schizophrenia, autism, ADHD, bipolar, depressive disorder, anxiety disorder" is much more confined to researchers, hasn't similarly made its way into popular media and the general public.