Mind Tapas

Small Plates of Healing and Ideas

Pathology Be Damned!

Is diagnosis-making the new bullying?

Yesterday's New York Times featured a personal Op-Ed by Benjamin Nugent, a young man inappropriately diagnosed with Asperger's Disorder by his psychologist mother, who cast her son in the starring role of her widely distributed educational videos on the disorder.

Only years later did it become obvious to him that he was misdiagnosed and that the Diagnostic and Statistical Manual IV criteria for this high functioning autism spectrum disorder are far too broad and overinclusive to be fair to children like him. As a "withdrawn, bookish" kid, he suffered doubly--by an overreaching set of rules for diagnosis making and by an overzealous diagnostician mother whose pathology-oriented attention to her son hit a little too close to home, her home.

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Although he describes having made peace with his mother after so many years of agonizing soul-searching, this case prompts us to better consider what it is exactly we do when we give someone a psychiatric diagnosis.

As a psychiatrist in clinical practice for greater than a decade, I rely on the DSM-IV diagnostic criteria to help me conceptualize overarching mental disorders. In principle and in practice not to do so would be at best imprudent, at worst malpractice. However, to employ anything but the utmost caution in using this guide, known to be an imperfect and increasingly changeable set of diagnoses and rules, risks the very mental health we hope so badly to improve.

Thoughtful clinicians do understand the potential for harm that internalizing labels can wreak on the most vulnerable as they learn, in a sense, to become their disorder. To help others even more, I now think it makes better sense to still use diagnoses best appearing to fit specific symptoms and then to do something radical--decide to put it aside for the moment. This way, that same disorder-addled person becomes liberated to cultivate the most creative, expressive self that they could ever hope for, diagnosis be damned.

Our current model begs for us psychiatrists, psychologists, and masters-level therapists to take our words and our labels even more seriously than most of us already believe we do, and choose them very thoughtfully, lest we create impenetrable cognitive walls within the minds of those that seek our help. If we are incautious we could be guilty of plaguing others with falsely applied pessimism, can't-do attitudes, and needless over-pathologizing--souring a framework by which they will indefinitely assess their own lives. Indeed, there is such need and ravenous hunger for optimism in the face of even the most statistically reliable diagnoses. We have no reason not to become tireless bearers of this sorely-needed optimism.

Fortunately, the forthcoming DSM-V criteria for autism will be considerably more narrow in scope, leaving people like Benjamin Nugent was as a child to being just quirky and as he says, "nerdy," so they can grow up as quirky and nerdy, unburdened by the critical eye of pathologizing-gone-wrong.

 

Jeremy Spiegel, M.D. is a psychiatrist and medical director of Casco Bay Medical, with offices in Greater Boston, Massachusetts and Portland, Maine.

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