I have been exploring what, if anything, makes professional judgments of personality different from non-professional judgments (background here).

This week, I turn to the diagnosis of mental disorders -- a bright and shining line --  because making a diagnosis of a person is a line that, when crossed, plainly labels a person.

Commentators in the media make widespread, and sometimes quasi-professional use of psychiatric terms. The term "narcissism," for example, is not an official diagnosis, but surely it is evocative of "Narcissistic Personality Disorder." I would guess that the "narcissism" label has been applied to public figures many times in the past year. In just a few minutes, I found three instances where the term was applied: to a boxer on the 15rounds site (here), a Hollywood actor in the New York Times (here), and a golfer on NBC sports (here).  No doubt there are more.

Media commentators, although typically not mental health professionals, are nonetheless sophisticated. That said, a diagnosis of a mental disorder made by a psychiatrist or psychologist is different from one indicated by a commentator with a background in journalism. The mental health professional's use of a label involves a specific use of occuaptional influence: that of a person with an advanced degree in the area, the backing of scientific research, and whose opinion in the area has legal relevance. 

Concerning the legal aspects of diagnosis, there are two key psychiatric diagnostic systems available in the world today that are closely related.  The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), and the Diagnostic and Statistical Manual of the American Psychological Association, IVth Edition, with Text Revision (DSM-IV-TR). (There also is the Psychodynamic Diagnostic Manual, a newer contribution to a group of such manuals). 

The US Federal Government recognizes the ICD as the official diagnostic system in use in the United States. Since 1980, the Centers for Medicare and Medicaid Services (CMS) have allowed clinicians to use the DSM-IV (and DSM-IV-TR) to assign diagnostic codes as well -- sometimes called the "Crosswalk Option." ICD/DSM codes are also employed by insurance companies. These and similar usages in the clinical community gives the DSM and those who employ it professionally legal standing as regards the diagnosis of mental disorders. 

Such diagnoses are essential to the accurate identification and treatment of disease.  They allow mental health professionals to study, communicate about, and treat people. Public discussions of diagnostic categories in the realm of mental health potentially help people to understand certain mental disorders, so that they can be informed of issues related to those disorders, just as similar discussions help the public understand other medical disorders such as heart disease and diabetes and their symptoms.

More problematically, people respond to those who have been given a psychiatric label differently than they might respond if no label were involved.  In David Rosenhan's classic 1973 study, "Sane in insane places," the researcher convinced several non-patients to enter mental hospitals complaining of hearing voices that said "empty," "hollow," and "thud." After admittance, they were all instructed to behave normally and to try to be released as soon as possible. All of them were diagnosed as having schizophrenia, and one was not released until the 52nd day of hospitalization. Critics of the study complained that requesting hospitalization due to hearing voices is a biasing event itself, and that, given such subterfuge, it was no wonder that the diagnoses were incorrect. That said, the study raised some important concerns about how labels can influence people's perceptions of others. Moreover, contemporary surveys indicate that despite improvements in the ICD/DSM, even today, many patients diagnosed as schizophrenic may have their diagnosis changed to something else over the course of a decade or less and those not initially diagnosed as schizophrenic may be so labeled later.

Research on the impact of labeling bears out the potentially negative impact of a psychiatric diagnosis. Link and Phelan concluded in a 2001 review that diagnosing a person as suffering from a mental disorder potentially brings about a number of effects: It connects a stereotype of mental illness to the person being labeled, and can result in a person's loss of status. The professional who makes the diagnosis typically does not want this to occur, of course.  He or she hopes that in most cases any negative consequences will be mitigated by the patient finally finding some clarity in the diagnosis and obtaining treatment for the ailment.

The stigma of a label is relative. Returning to the case of diagnosing a public figure, if an individual is diagnosed with, for example, "Caffeine Intoxication Disorder (305.90)" -- being jittery because of too much caffeine -- and that became public, I am not sure the person so-judged would mind very much. If a person were suffering from a Schizophrenic Disorder (e.g., Disorganized Type, 295.10), on the other hand, the stigma would be considerable.

The DSM openly sets out criteria for each mental disorder, which raises the question of whether the public ought to regard diagnoses of public figures (e.g., Narcissistic Personality Disorder) made by journalists (or economists, or sociologists, etc.), or quasi-diagnostic labeling (e.g., "narcissism"), as roughly equivalent to that made by a psychiatrist or psychologist. After all, the DSM is made up of behavioral checklists. Although media commentators may be trained in other fields, they are typically educated, very bright, and have access to the DSM manual.  They also can check with a friend, spouse, or neighbor who is in the mental health field as to their hunch about a person. I don't know of an empirical study that compares the diagnostic skills of mental health professionals with that of reputable media commentators for public figures assessed "at a distance" (i.e., through media reports) but my guess is that, given equivalent information, their diagnostic performance might be closely equivalent.  That said, such labeling represents an educated guess under the best of circumstances.

One difference I can see is that when a columnist writes that someone is narcissistic, a reader may be inclined to consider it a partly moral judgment based on the public individual's overall personality style. When a mental health professional enters "Narcissistic Personality Disorder" on an insurance form (or argues that a public figure might have that disorder), it is a psychiatric diagnosis. We don't know which stigma might be greater -- a moral criticism made by a columnist or a psychiatric label applied by a mental health professional.  In private life, a diagnosis is often kept confidential.  In the public sphere, a diagnostic judgment may be mitigated because, although it may be potentially stigmatizing, its public nature invites other commentators to explain that it could be wrong, and why. 


My claim that there are often revisions of the diagnostic assessment of patients with and without schizophrenia is based, in part, on Chen, Y.R., Swann, A. C., & Burt, D. B. (1996). Stability of diagnosis in schizophrenia. American Journal of Psychiatry, 153, 682-686, and similar works.

Cooper, J. E. (2003). Prospects for Chapter V of ICD-11 and DSM-V. British Journal of Psychiatry, 183, 379-381.

The "Crosswalk Option" is found in Hausman, K. (2003, November 21). Govt. decides to continue DSM-IC Crosswalk Option. Psychiatric News, 38, 21.

Information on the ICD-DSM relationship, and relation of the coding systems to legal categories is also found on p. xxvii, and p. 1 of the American Psychiatric Associaiton (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association.

For this post, I also drew on: Link, B. G., & Phelan, J. C. (2001) Conceptualizing Stigma. Annual Review of Sociology, 27, 363-85.

Copy edits: Light copy edits were made +48 hours after posting

Copyright © 2010 John D. Mayer

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