Why Psychiatric Diagnosis Matters
Part 2: Despite claims, diagnosis in psychiatry is scientifically meaningful.
Posted Aug 10, 2019
This is Part 2 of a two-part article. To view Part 1, click here.
Claim #6: Diagnosis per se may worsen the patient's distress.
The authors argue that, "...labeling distress as abnormal may in itself create further distress. For example, flashbacks in the context of trauma are distressing in themselves, but the diagnosis has the potential to make the experience more distressing because the flashbacks are regarded as abnormal" (Allsopp et al., 2019, pp. 20-21).
The authors cite no evidence for the claim that the diagnosis—presumably of PTSD—is, by itself, likely to make the patient's experience "more distressing." Furthermore, the authors misunderstand the way psychiatrists and other skilled clinicians present symptoms like flashbacks in the context of trauma. No experienced therapist would say to the patient, "Your flashbacks are abnormal." Rather, any well-trained clinician would say something like, "Flashbacks are quite common in PTSD. Many people who have been through what you have been through will have these experiences." That is, the therapist recognizes PTSD as a genuine disorder, but tries to "normalize" the patient's experience within the context of the diagnosis.
Claim #7: "Although diagnostic labels create the illusion of an explanation, they are scientifically meaningless and can create stigma and prejudice." [K. Allsopp, quoted in the Science Daily interview]
- First, the DSM framework is not, and never has been, aimed at providing a comprehensive "explanation" of the patient's signs and symptoms, with only a few exceptions; e.g., in the section on "Substance-induced disorders," the presumption is that the disorder is causally related to "...the recent ingestion of a substance," such as alcohol or cocaine. Again, the Manual makes it very clear that "...a diagnosis does not carry any necessary implications regarding the etiology of causes of the individual's mental disorder..." (APA, 2013, p. 25). Charging the DSM system with "creating the illusion of an explanation" mistakenly imposes a burden on the Manual that its developers never intended.
- Dr. Allsopp goes on to characterize the categories of the DSM as "scientifically meaningless." Leaving aside the vast philosophical controversies regarding the meaning of "scientific," it is transparently false to assert that the DSM's categories are "meaningless." When something is said to be "meaningless," it is, by definition, without consequence or "lacking any significance" (see Meaningless, 2019). Thus, the claim that psychiatric diagnoses are "scientifically meaningless" implies that diagnosis in psychiatry lacks predictive validity, i.e., the ability to predict the course or prognosis of an individual's disease. However—as noted earlier—multiple studies tell us, for example, that a DSM-III-R defined diagnosis of schizophrenia shows high predictive validity (Mason et al., 1997). Similarly, a diagnosis of bipolar I disorder in childhood has shown good predictive validity for the presence of adult bipolar disorder (Geller, Tillman, Bolhofner, & Zimerman, 2008). This is not to say that all the DSM-5 categories have high predictive validity, but if some do, it is wrong to dismiss the entirety of categorical diagnosis as "scientifically meaningless." Furthermore, as Dr. Jordan W. Smoller (2019) recently pointed out, "All major psychiatric disorders have a familial and heritable component," with the latter reaching levels of 75% or more for autism spectrum disorder, schizophrenia, and bipolar disorder. It is impossible to reconcile such high correlations with the claim that psychiatric diagnosis is "scientifically meaningless."
- Dr. Allsopp's third error, in our view, lies in supposing that "stigma and prejudice" toward people with mental illness arise from receiving a (categorical) psychiatric diagnosis. Dr. Allsopp cites no empirical evidence for this claim. We would argue that stigma and prejudice arise from ignorance and fear, and from the de facto segregation of those with mental illnesses. Eliminating categorical diagnoses will not eliminate stigma and prejudice. As Dr. Allen Frances (2019) has written, stigma will be diminished when "the entire community embrace[s] mentally ill persons as useful citizens integrated into every aspect of work and play and valued for their contributions to the society." Furthermore, as Prof. Kelso Cratsley (2019) observes, there is little if any evidence that non-categorical approaches to psychiatric diagnosis result in less "stigma," and may actually produce stigma of another sort: He states, "...anti-stigma programs may prefer an approach based on the notion that mental disorder is relatively normal or common, an 'ordinary' response to stressful experiences similar to what everyone goes through now and again. But this may also lead to a different kind of stigma driven by questions about why any one individual responds to stress in such an extreme way. This potentially opens the door to value judgments regarding moral weakness or flaws of character."
Claim #8: The DSM-5 represents a "biomedical diagnostic approach" and "wrongly assumes that all distress results from disorder."
Prof. Kinderman claims, in the Science Daily interview, "This study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose.... The diagnostic system wrongly assumes that all distress results from disorder, and relies heavily on subjective judgments about what is normal."
This is a serious mischaracterization of the DSM-5, and of psychiatric diagnosis in general. First, there is very little in the DSM-5 that could be characterized as "biomedical," other than some of the descriptions of the neurocognitive disorders, such as Alzheimer's Disease. For the vast majority of diagnoses, no "biomedical" model is invoked and no diagnostic criteria are dependent on biomedical findings. Second, nothing in the DSM-5 asserts or implies that "all distress results from disorder." Moreover, the DSM-5 is keenly aware of the difficulties in distinguishing "normal" from "abnormal." The Introduction to DSM-5 states that "Clinical training and experience are needed to use DSM for determining a diagnosis. The diagnostic criteria identify symptoms, behaviors, [and] cognitive functions...that require clinical expertise to differentiate from normal life variation and transient responses to stress" (p. 5.) Furthermore, the Manual notes that "...the boundaries between normality and pathology vary across cultures...the judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms..." (p. 14). Indeed, in the section of DSM-5 titled, Glossary of Cultural Concepts of Distress, this statement is made regarding the condition called "Nervios": "Nervios refers to a general state of vulnerability to stressful life experiences and to difficult life circumstances...[and] is a broad idiom of distress that spans the range of severity from cases with no mental disorder to presentations resembling adjustment, anxiety, [or other]...disorders" (p. 835). Thus, Prof. Kinderman's claim (the DSM assumes that "all distress results from disorder") is simply wrong.
So, too, with the "V codes" in DSM-5. These are explicitly identified as "not mental disorders," yet they may indeed be associated with "distress." For example, in "Other problems related to primary support group" (V61.10), "relationship distress" is noted, which may be associated with "impaired functioning in behavioral, cognitive, or affective domains" (p. 716). But these problems are not attributed to mental disorder, much less explained in "biomedical" terms.
Our term "diagnosis" (Gk. dia, across or between; gnosis, knowledge) means literally, "knowing the difference between." Whether one adopts a categorical or a dimensional approach to diagnosis, it is still critical to "know the difference between" conditions that may present with similar symptoms. The implications for treatment are clear when, for example, we consider the symptom of psychosis. In the context of schizophrenia, psychotic symptoms are unlikely to respond adequately to lithium alone. However, in the context of bipolar I disorder, lithium is a specific and effective treatment, and psychosis during mania is associated with a good response to lithium prophylaxis (Rosenthal et al., 1979).
Diagnosis may literally be a matter of life and death when, for example, a patient presents with the syndrome of catatonia. The condition known as malignant (or lethal) catatonia—which is potentially fatal—responds well to benzodiazepines and electroconvulsive therapy, and may be worsened with use of antipsychotic agents (Sienaert, Dhossche, Vancampfort, De Hert, & Gazdag, 2014). On the other hand, some reports suggest a role for clozapine in schizophrenia patients with recurrent catatonia (Hung, Yang, & Huang, 2006).
Even if one is opposed to the DSM's categorical diagnoses, it remains true that practitioners of various theoretical persuasions utilize diagnosis as a form of understanding and guide for treatment. Even psychoanalysts—those mental health professionals who explicitly focus on the effects of past experiences on mental suffering—have their own diagnostic manual called the Psychodynamic Diagnostic Manual (PDM) (Lingiardi & McWilliams, 2015). Many psychoanalysts, of course, also utilize the DSM. Indeed, the PDM "…in focusing on the full range of mental functioning...aspired to complement DSM and ICD efforts to catalogue symptoms and syndromes" (Lingiardi & McWilliams, 2015, p. 237).
In conclusion, we respectfully but adamantly disagree with Allsopp et al.'s claims regarding the "meaninglessness" of psychiatric diagnosis. Such views conflict starkly with the scientific and clinical reality, and they potentially pose harm to patients who may interpret these claims as discounting the reality of their illness. As we have shown above, many of the claims are easily refuted by a careful reading of the DSM itself. While we acknowledge that there is much room for improvement in psychiatric nosology, diagnosis itself remains a vital, meaningful, and scientifically supported practice.
This article is co-authored by Ronald W. Pies, M.D., clinical professor of psychiatry at Tufts University Medical School and professor emeritus of psychiatry at the State University of New York Upstate Medical University; and Mark L. Ruffalo, D.Psa., psychoanalyst and instructor of medical education (psychiatry) at the University of Central Florida College of Medicine.
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