dou·ble·think. noun. Deliberate, perverse, or unconscious acceptance or promulgation of conflicting facts, principles, etc. “Doublethink… is a vast system of mental cheating” (George Orwell).
During my first week as a psychiatry department faculty member, a fourth-year psychiatry resident—I will call her Gabrielle—staffed a case with me. She gave me some demographic information about her patient (38, White, female) and then proceeded to list the medications she was prescribing. The rest of our conversation went something like this:
“What are we treating her for?”
“How do you understand her anxiety?”
Gabrielle cocked her head to the side with a blank, non-comprehending look, as though I had spoken a foreign language. I rephrased the question.
“What do you think is making your patient anxious?”
She cocked her head to the other side. I rephrased again.
“What is causing her anxiety?"
Gabrielle thought for a moment and then brightened. “She has generalized anxiety disorder.”
“Generalized anxiety disorder is not the cause of her anxiety,” I said. “That is the term we use to describe her anxiety. I am asking you to think about what is making your patient anxious.”
She cocked her head again.
“What is going on psychologically?”
There was a pause while Gabrielle processed the question. Finally she said, “I don’t think it’s psychological, I think it’s biological.”
“Okay, that’s a start,” I said. “Tell me why you think her anxiety is biological and not psychological.”
“Her mother was anxious.”
“And this means your patient’s anxiety is biological?”
It was my turn to cock my head.
“Let’s try a thought experiment. Imagine that your patient was adopted at birth and has no biological relation to the mother who raised her. Do you think that being raised by an anxious mother, who is constantly communicating that the world is unsafe, might make a child anxious?”
“I never thought about it that way,” Gabrielle said.
I fantasized briefly about banging my head against the cinderblock wall, then signed Gabrielle’s “treatment plan” and hoped I had planted a seed of curiosity.
In fairness, Gabrielle’s concreteness was not representative of her residency cohort. Still, she was a fourth year psychiatry resident, just months away from being a board certified psychiatrist.
It should be clear that a DSM diagnostic category cannot be the “cause” of anything. A DSM diagnosis is a consensually agreed upon term—a form of shorthand—that we use to refer to a group of symptoms. If a colleague says a patient has generalized anxiety disorder, we know the patient has been excessively worried or anxious for six months or longer and it is severe enough to cause problems. That is basically all we know. Saying that anxiety is “caused” by generalized anxiety disorder makes no more sense than saying “anxiety is caused by anxiety.” A label is not a cause.
The same applies to “major depression” and most other DSM diagnoses. If a patient is diagnosed with major depression, we know his mood has been depressed nearly every day for at least two weeks, or he has had no interest or pleasure in activities for at least two weeks, and he has at least three or four other symptoms that often accompany depressed mood. That is all we know. “Major depression” does not cause the symptoms of major depression, it is the name we give those symptoms.
In other areas of medicine, diagnosis often points to etiology—to underlying biological causes. That is why “chest pain” is not a diagnosis (it is a symptom, not a disease), but atherosclerosis, myocarditis, pericarditis, and pneumonia are diagnoses. These terms refer to underlying biological conditions that can cause chest pain. DSM diagnosis is categorically different because it is merely descriptive, not explanatory. Pretending that “generalized anxiety disorder” or “major depressive disorder” is equivalent to a medical diagnosis like pneumonia is what logicians call a category error—ascribing a property to something that does not and cannot have that property.
The introductions to all editions of DSM published since 1980 emphasize that DSM’s purpose is to provide a nomenclature—a shared vocabulary or system for naming things. They emphasize that DSM diagnosis implies nothing about the cause of any mental health condition or how to treat it. The American Psychiatric Association's website also makes this point: “Diagnostic criteria provide a common language for clinical communication... Patients sharing the same diagnostic label do not necessarily have disturbances that share the same etiology nor would they necessarily respond to the same treatment.”
Official public statements by DSM developers echo this. When the National Institute of Mental Health issued a policy statement saying that DSM cannot help us understand the causes of mental suffering and cannot be a foundation for mental health research, DSM developers made no objection. Instead, the DSM-5 Task Force chair issued a press release reiterating that DSM’s purpose is nomenclature: “DSM, at its core… is a guidebook to help clinicians describe… It provides clinicians with a common language.”
How could my resident Gabrielle have misunderstood something so fundamental? How did she come to think and speak of “generalized anxiety disorder” as if it were a disease entity that could cause the symptoms listed in DSM? One of the most helpful things about our struggling students is that in their moments of concreteness, they hold up a mirror to hypocrisies in our field. They reflect prevailing attitudes and assumptions simply and directly, without artifice.
Our field is guilty of pervasive doublethink. On the one hand, there is the introduction to DSM and the carefully phrased official statements of its developers. On the other hand, there are the messages professionals communicate to one another in word and action, day in and day out. Those are the messages Gabrielle heard, assimilated, and accurately reflected.
The text of DSM and the public statements of its developers may say DSM is not a guide to etiology or treatment. Psychotherapy researchers say it is, when they tell us to use treatment manuals based on DSM diagnoses. Professional organizations say it is, when they issue practice guidelines based on DSM diagnoses. Health insurers say it is, when they ask clinicians to follow algorithms and decision trees based on DSM diagnoses. Pharmaceutical companies say it is, when they run ads saying that a particular DSM diagnosis is “a distinct medical condition… it causes intense mood and physical symptoms” (the words come from a television commercial for a common antidepressant). A lot of constituencies seem to have a stake in doublethink.
At least the developer and publisher of DSM, the American Psychiatric Association, is not guilty of promoting the doublethink. Or so I thought. This week I came across a self-exam distributed by the American Psychiatric Association to educate clinicians in using DSM-5. The exam is from a forthcoming DSM-5 study guide with a cover design identical to DSM-5, to make clear it is a companion volume. Its format is case vignettes followed by multiple choice selections of possible diagnoses. I read a case vignette and there it was. The vignette described a patient with a fear of flying, followed by the following question: “Which of the following disorders is the most likely cause of his anxiety?” (emphasis added)
If I took the exam, the only answer I could give would be a write-in: “None of the above, because DSM diagnoses cannot cause anything. It says so in the introduction.” The correct answer, according to the study guide, was “c) Specific phobia–situational type.”
I would have failed the exam. My psychiatric resident, Gabrielle, would have aced it.
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Jonathan Shedler, PhD is a Clinical Associate Professor at the University of Colorado School of Medicine. He lectures to professional audiences nationally and internationally and provides online clinical consultation and supervision by to mental health professionals worldwide.