Overdiagnosis and Diagnostic Chaos
Responses to ‘The “Overdiagnosis” Confusion’ and additional comments
My earlier post on overdiagnosis prompted numerous people to reach out to me via email, comments, Substack Notes, and other social media platforms. I am highlighting a selection of these responses that I found valuable and informative, along with some additional relevant items (unrelated to my post) that came to my attention.
Dost Öngür
Chief of Psychotic Disorders Division, McLean Hospital; William P. and Henry B. Test Professor of Psychiatry, Harvard Medical School; Editor in Chief of JAMA Psychiatry
I read your piece on overdiagnosis and it anticipated my thinking step by step, from overdiagnosis, to overtreatment, to the meaning of diagnosis for large swaths of the population. However, I arrive at a somewhat different assessment of the issue. The problem, as I see it, isn’t that psychiatrists are luring unsuspecting civilians into their offices and convincing them that they have a mental illness. Nor is it simply that pharmacotherapy doesn’t work for everyone, although the point about needing an NNT of 1 to avoid overtreatment is well taken. I also don’t believe that people with mild mental illnesses should be told that there’s nothing wrong with them in some misguided effort to erase suffering.
What I do see is a confluence of developments in the post-DSM-IV era that, taken together, are harming many people, and that concern is expressed through the language of overdiagnosis. Many people come to psychiatrists with genuine distress and dysfunction. They’re given an oversimplified theory of the nature of the problem, offered a partially effective treatment, and presented with few or no other options. One could say this is not overtreatment but mistreatment, but I think it’s both, and dwelling on the distinction doesn’t particularly help us. The dominant understanding of mental disorders offered by the profession and accepted by large swaths of the population today is overinclusive. That has consequences. It emphasizes a narrow range of interventions and often steers people away from more appropriate forms of help.
Consider how we treat chronic back pain, once serious medical causes like spinal cord compression have been excluded. People come to their doctors desperate for relief. They may believe they need surgery or opioid painkillers, and they may insist on them. But instead, they’re told by their physicians: yes, you’re suffering, your back pain is genuine, but your condition isn’t dangerous, and surgery or opioids won’t help you and may make things worse for you in the long term. The treatment approach then focuses on physical therapy and learning how to live with the condition. This approach doesn’t deny the pain, nor does it withhold diagnosis—it sets realistic expectations and points patients towards an appropriate treatment plan that leads to better outcomes for them, even if that is not the plan the patient initially wanted.
Psychiatry could do something similar. I don’t think this would discourage people from seeking help. If anything, the public would respect the field a lot more. A psychiatry that knows its strengths and communicates clearly about the limits of its tools is in a much better position to address the sociological dimensions of illness.
(Communication via email)
Ronald W. Pies
Professor Emeritus of Psychiatry at SUNY Upstate Medical Center and Clinical Professor of Psychiatry at Tufts University School of Medicine; Editor-in-Chief Emeritus (2007-2010) of Psychiatric Times.
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 (2020). 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.
(Posted as a comment on the substack post)
Aftab: For the benefit of readers and in the interest of transparency, here’s an excerpt from Fabiano & Haslam (2020) where they talk about the specific conditions for which there is evidence of diagnostic inflation:
Attention Deficit Disorder (ADD: from DSM-IV onward re-named ADHD) inflated from DSM-III to DSM-III-R, the RR estimate (1.18) indicating an 18% increase in diagnostic rate based solely on its diagnostic criteria becoming less stringent. Further inflation of the disorder, albeit nonsignificant in both cases, was apparent from DSM-III-R to DSM-IV (33%) and from DSM-IV to DSM-5 (17%). Rates of Autism also inflated 50% from DSM-III to DSM-III-R – albeit based on a single study – but deflated 15% from DSM-IV to DSM-5. Criteria for four personality disorders tightened between DSM-III and DSM-IV. Generalized Anxiety Disorder (GAD) inflated by 66% from DSM-IV to DSM-5, having seen a nonsignificant 17% inflation from DSM-III-R to DSM-IV. Substantial shifts occurred from DSM-IV to DSM-5 in the eating disorder domain, with Anorexia Nervosa and Bulimia Nervosa both showing significant inflation and Binge Eating Disorder (only recognized in Appendix B within DSM-IV) showing a 169% inflation that narrowly failed to reach statistical significance. In contrast to this expansionary trend, Eating Disorder Not Otherwise Specified (EDNOS) significantly deflated. These shifts represent intended consequences of diagnostic revisions designed to reduce high rates of EDNOS in DSM-IV, in part by relaxing criteria for Anorexia Nervosa (e.g., removing the amenorrhea criterion) and Bulimia Nervosa (e.g., reducing the required frequency of binge-eating).
Alejandra Morris
Psychoanalytic psychotherapist in private practice in the Pacific Northwest
Another category in the “overdiagnosis” conversation is overrepresentation of certain diagnoses in particular population groups. Examples of this dynamic include foster children or adoptees who are commonly diagnosed with any combination of ADHD, Borderline Personality Disorder (BPD), Nonverbal Learning Disorder (NVLD), Oppositional Defiant Disorder (ODD), or Reactive Attachment Disorder (RAD); overrepresentation of schizophrenia diagnoses in the Black community; or BPD in the queer and trans community, among others. Often this use of diagnosis is the result of stigma or stereotypes. In the examples above, children in foster care or adoptees (whether from birth or from foster care-to-adopt situations) may exhibit a wide range of behavioral, emotional, or relational challenges as a result of the trauma inherent to being separated from one’s original family. Each of the above diagnoses gets at a piece of the puzzle—but none of them fully capture the relational/developmental trauma and its reverberations at play. Systemic racism fuels the overdiagnosis of schizophrenia in the Black community, especially Black men. Similarly, homophobia and transphobia within the psychiatric and mental health fields lend themselves toward overdiagnosis of BPD among queer and trans people. Arguably, what’s actually being named in this category is “misdiagnosis” or “inappropriate diagnosis,” but it is an over-reliance on certain diagnoses in particular populations that affects many people; thus, “overdiagnosis” functions as shorthand.
(Communication via Bluesky and email)
Ron Sterling
Retired psychiatrist and author of The Adult ADD Factbook (2013)
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 from 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.
(Excerpt from a comment on the post; see full comment here)
Stephanie Nelson (aka )
Pediatric neuropsychologist
Dr. Aftab, I deeply admire your ability to hold complexity and navigate the dynamic tensions of our field with such clarity and thoughtfulness. This piece, too, brings welcome nuance to a complicated topic. That said, I find this to be one of the areas where your typically expansive generosity toward opposing viewpoints feels a bit compressed. When the only reasons you offer for why some might be concerned over overdiagnosis are confusion, lack of “patient-friendly” thinking, or discomfort with visible mental illness, perhaps you have ‘othered’ those you disagree with on this emotional topic, rather than tried to truly understand why there might be a wider conversation to be had.
To take the heat out of the issue, I wonder if it would be helpful to consider an analogy. In his lovely book “Paved Paradise: How Parking Explains the World”, Henry Grabar explored what happened in some cities where disabled parking permits become more available, not just to those they were designed for, but to many others, who sought them for a wide range of reasons: some valid, some misdirected, some opportunistic. The explosion in permits (from 30,000 to 300,000 in one city) had wide-ranging consequences. Disabled drivers couldn’t find parking spots. Public trust in the permit-granting system eroded. The "looser" system served the privileged, rather than helping the truly needy, the overlooked, or the edge cases. Structural problems with urban design were obscured by the focus on individual access.
Even well-intended permits sometimes hurt those who used them, reinforcing unhelpful narratives, skewing priorities (e.g., distorting the discomfort that helps us make difficult decisions), and distracting from better long-term solutions. That is, some people who obtained permits—even if they were in genuine pain—were likely solving the wrong problem. Sedentary people who were tired after long walks may have become even more deconditioned. Overwhelmed or over-scheduled people who needed slack in their day may now have squeezed in more obligations, in their constant quest for optimization and time-saving ‘hacks’. People wearing stylish but uncomfortable shoes could avoid confronting that trade-off, and continued making choices that increased their discomfort. Others may have sought affirmation, nurturance, or status, yet found themselves in a complicated psychological bind, where vulnerability was rebranded as a kind of superiority. In many cases, a solution that initially felt empowering may have left people more fragile, more isolated, or more disconnected from the broader changes that might have helped all of us: walkable cities, better infrastructure, collective problem-solving.
It’s not a perfect analogy, of course. But it illuminates a generous interpretation of the “overdiagnosis” concern: That many people are indeed in pain, and also that by giving every individual a label and interventions or accommodations, we may be offering the wrong solutions, in the wrong frame, in a way that unintentionally reinforces the very suffering we hope to alleviate.
Of course, it’s a delicate and often uncomfortable task to name this tension out loud. It's difficult to weave this gossamer thread between affirming people’s lived experience and gently wondering whether the story they’ve attached to it is the most helpful one, and we often get the balance wrong. But this is the heart of our clinical work. For those of us wrestling with questions of “overdiagnosis,” it's not about denying care or invalidating distress. It’s about keeping alive the possibility that some forms of suffering might be better addressed—individually and collectively—through more pluralistic frames and less pathologizing responses.
Grateful as always for your writing and the conversation it provokes.
(Posted as a comment on the substack post)
Sofia Jeppsson
Associate professor of philosophy at Umeå University
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 (obviously 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.
(Posted as a comment on the substack post)
(@replaceablehead)
… the issue isn't so much over diagnosis or under diagnosis or even misdiagnosis. I’d say it’s more diagnostic chaos. It’s like the right number of socks have been handed out but some people are wearing odd socks, others three or four and still others are wearing no socks at all.
I’m very weary of the way the issue is discussed. This isn’t something that requires high minded scientific proofs. It’s a painfully obvious truth that forces itself upon anyone actually working at the coal face. It’s a reality that insists upon itself.
(Edited excerpt from a comment on the post; see full comment here)
Aspiring writer and researcher who studies expertise in creative writing.
I found this piece to be excellent (and still do, for the most part), but I have some conflicted feelings about these sentences:
… however people may feel about seemingly functional, nerdy, socially awkward individuals using the term “autism” to refer to themselves, it is not an instance of clinical overdiagnosis. It is an instance of people reclaiming a clinical concept and extending it beyond the clinical sphere because of its epistemic value, because it allows them to make better sense of who they are.
I agree that self-diagnoses isn’t an instance of clinical over-diagnosis, and I agree that these kinds of conceptual extensions (a.k.a. instances of “concept creep”) help some people to make better sense of who they are. But personally I know some people who have self-diagnosed in an attempt to make sense of their psychological distress or social difficulties, and most of the people that I know who have done this seem to me to be either (1) inaccurately describing themselves—thus, making it harder for them to make sense of themselves, or (2) using their self-diagnosis as a way to criticize themselves for traits and tastes that are, as far as I’m concerned, very normal, very mundane, positive in some circumstances, and, at the very least, very tolerable and un-problematic.
… I don’t know; I just assume, until evidence proves me wrong, that the psychological effects of self-diagnosis are more disparate and varying than these sentences suggest. 🤷♂️
“I’ve observed and met more than a few individuals who self-diagnosed and absolutely use it as a way to conceptualize themselves as clinically ill, disabled, etc. etc. and then expect treatment and accommodations as though they carried a clinical diagnosis.”
I agree that many people who self-diagnose see themselves as ill or disabled, but the crucial part is whether they are
actually symptomatic and impaired (and would be recognized as such if they saw a clinician), or
asymptomatic or minimally impaired but erroneously think of themselves as ill, or
pretending to be ill for some external gain while knowing they are not (e.g. for college accommodations).
Self-diagnosis involves some distinctive considerations and I didn’t want to go into that too much in the original post. There is also very little empirical data on this, so it’s difficult to say much with confidence. For clinical treatment at least, they need buy-in from a clinician and an official diagnosis. For accommodations, things vary quite a bit, depending on the educational or work setting. I’d like to think that most people with self-diagnosis who see themselves as ill are indeed genuinely impaired, but I don’t know.
Also, see comment on Notes by
In October 2024, fellow psychiatry blogger
had published a post analyzing increasing rates of mental health diagnoses and treatments through an economic perspective: Reduced Prices, Induced Crisis. It’s a great post, and it had a substantial impact on how I think about these issues when I first read it. I strongly recommend it.Whether or not there is greater need in the medical sense, people are definitely “consuming” more mental health care - psychiatric medications, counseling, and diagnoses - in an economic sense. There are many causes of rising consumption, from greater supply to price regulation to marketing-driven demand to low-cost substitutes. Each of these has occurred in recent years. In short, people now use more mental health care because it got cheaper, more desirable, and easier to obtain.
Allen Frances wrote an Opinion piece in the New York Times (June 23, 2025) arguing that the rapid increase in autism rates is because of changes in the way that autism is defined and assessed. So far, so good. But Frances also talks about “overdiagnosis” of autism, including mislabeling of socially awkward behavior as autistic, and seems to hold the DSM responsible for it, which is where I respectfully disagree. Frances writes:
Our intentions were good, but we [the DSM-IV task force] underestimated the enormous unintended consequences of adding the new diagnosis. The resulting explosion in cases included many instances of overdiagnosis — children were labeled with a serious condition for challenges that would better be viewed as a variation of normal.
In 2013, the next edition of the diagnostic and statistical manual, the D.S.M.-V, eliminated Asperger’s disorder as a stand-alone diagnosis and folded it into the newly introduced concept of autism spectrum disorder. This change further increased the rate of autism by obscuring the already fuzzy boundary between autism and social awkwardness.
Frances acknowledges that there are indeed some benefits to expanded criteria and greater awareness…
Still, we should be concerned about the increasing tendency to mislabel socially awkward behavior as autistic.
But why is the increasing tendency to mislabel socially awkward behavior as autistic, to the extent that this happens, DSM’s fault? For a diagnosis of autism, DSM-5 requires a) persistent deficits in social communication and social interaction (that must manifest as deficits across multiple contexts in all three: social-emotional reciprocity, nonverbal communicative behaviors, and interpersonal relationships), and b) restricted, repetitive patterns of behavior, interests, or activities, and c) symptoms must be present in the early developmental period, and d) symptoms must cause clinically significant impairment in social, occupational, or other important areas of current functioning.
How can a person genuinely meeting these criteria be considered a socially awkward but otherwise normal person who is being ‘mislabeled’ or ‘overdiagnosed’? Should we refuse to give a clinical name to people who have persistent deficits in social communication, have restricted, repetitive patterns of behavior, and are impaired?
And if the issue is that the criteria are not being followed and people are being given a diagnosis without regard for criteria, how is that the DSM’s fault?
One could argue that “autism” as a category shouldn’t encompass such a wide range of impairment. I don’t necessarily agree with that, but fine. Even if we didn’t use the label “autism” for the mildly and moderately impaired, we’d still need some other clinical diagnosis to capture those people who come to clinical attention; otherwise, we’d have a diagnostic classification with holes in it.
A troubling symptom of modern times is that, if you mention anything about your kids, somebody will chime in to diagnosis. “Oh, they’re stubborn about putting rain boots on? That sounds like autism.” No wonder we have an over-diagnosis problem.
I guess this is a good illustration of the kind of experience that leads many in the public to complain about overdiagnosis as a phenomenon. As would be apparent, this has nothing to do with DSM criteria, nor with the medicalization of suffering, nor with clinical help-seeking; this represents a cultural eagerness to over-apply and over-extend clinical labels in a casual manner to situations where they are not warranted. It renders those who do have genuine difficulties invisible and trivializes their impairment. This societal trend deserves to be criticized and discouraged. At the same time, we should not assume that our contemporary cavalier social attitude towards diagnostic labels provides evidence on its own that we have an epidemic of clinicians giving diagnoses to unimpaired individuals or that our official diagnostic criteria are unduly lax, even if diagnostic chaos in practice is a “painfully obvious truth.”
I find all these comments valuable, thank you for posting them. Putting aside the fact that may people don't have access to needed diagnosis and treatment, for my purposes, in my practice, I feel like the power dynamic in the diagnostic process has shifted, for better or worse. In a sort of Promethean way, we have made the diagnostic apparatus available to the public, and people now "present" with diagnoses they feel fit them. Not everyone, of course, but diagnosis is more co-created than it used to be. And like fire, diagnosis can serve people or endanger them, at least in spiritual or developmental terms. But this is on us; we invented the system.