In my first week as a psychiatry faculty member, an advanced psychiatry resident—I’ll call her Dr. G—staffed a case with me. That’s medical speak for discussing a patient with a teacher. Dr. G gave me some demographic information and then began listing medications she was prescribing.
“Hold on,” I said. “What are we treating her for?”
“How do you understand her anxiety?”
Dr. G cocked her head to the side with a blank, non-comprehending look. I rephrased. “What do you think is making your patient anxious?”
She cocked her head to the other side.
“What is causing her anxiety?"
Dr. G pondered, then brightened. “She has generalized anxiety disorder.”
“Generalized anxiety disorder is not the cause of anxiety,” I explained. “That is just the label we use to describe it.”
Another blank look. I tried a different tack. “What do you think is going on psychologically?”
“I don’t think it’s psychological, I think it’s biological.”
“Okay, that’s a start,” I said. “Tell me why you think that.”
“Her mother was anxious.”
“This means your patient’s anxiety is biological?”
It was my turn to cock my head.
“Let's try a thought experiment. Suppose your patient was adopted at birth and is not biologically related to the mother who raised her. Do you think an anxious mother, who is continually communicating that the world is unsafe, could make a child anxious?”
“I never thought about it that way.”
I suppressed a momentary urge to bang my head against the cinderblock wall. Then I signed Dr. G’s treatment plan and hoped I had planted at least a seed of curiosity.
Diagnoses listed in the DSM—the Diagnostic and Statistical Manual of Mental Disorders, the so-called bible of psychiatry—do not cause anything. They are not things. They are agreed-upon labels—a kind of shorthand—for describing symptoms. Generalized anxiety disorder means a person has been anxious or worried for six months or longer and it’s bad enough to cause problems—nothing else. The diagnosis is description, not explanation. Saying anxiety is caused by generalized anxiety disorder makes as much sense as saying anxiety is caused by anxiety.
The same is true for other common DSM diagnoses. Major depressive disorder means a person has had continually depressed mood, or lack of interest or pleasure in activities, for two weeks or longer, along with several other symptoms which often accompany that. Major depressive disorder does not cause these symptoms, it is the term we use to describe them.
Here is the circular logic: How do we know a patient has depression? Because they have certain symptoms. Why are they having these symptoms? Because they have depression.
Confusion arises because medical diagnoses often point to etiology—underlying biological causes. This is why “chest pain” is not a disease, it is a symptom. Atherosclerosis, myocarditis, and pneumonia are diseases. They describe underlying biological conditions that can cause chest pain.
Psychiatric diagnoses are categorically different because they are merely descriptive, never explanatory. It's not that we don't know their causes yet. It's that DSM diagnoses cannot speak to causes, now or ever. It is was not designed to address causes, only describe effects. Most thoughtful psychiatrists ascribe to a "biopsychosocial" model, which means they see the causes of mental health problems as biological, psychological, or social—or some interaction. The DSM is not organized by any of these factors, does not address them, and does not attempt to address them.
The ever-expanding list of entries in the DSM sound like medical diseases, especially with the ominously-appended term disorder, but they aren't. If we speak of generalized anxiety disorder or major depressive disorder as if they are equivalent to pneumonia or diabetes, we are committing a logical fallacy called a category error. A category error means ascribing a property to something that cannot possess it—like emotions to a rock.
The American Psychiatric Association also made this point. Until recently, its website included this crystal-clear caveat about the DSM: “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.”
When the National Institute of Mental Health concluded DSM diagnoses do not and cannot map underlying causes—and therefore cannot be a foundation for mental health research—the American Psychiatric Association agreed. “DSM, at its core… is a guidebook to help clinicians describe,” the chair of the DSM-5 Task Force wrote in response. “It provides clinicians with a common language.”
How could Dr. G misunderstand this? How did she come to think of generalized anxiety disorder as a disease that causes anxiety?
Our struggling students, in their moments of concreteness, hold up a mirror to hypocrisies in our field.
The American Psychiatric Association says patients with the same diagnosis do not necessarily have the same disturbances or respond to the same treatments. Then researchers develop treatment manuals for DSM diagnoses. Professional organizations publish practice guidelines for DSM diagnoses. Health insurers ask providers to follow treatment algorithms for DSM diagnoses. And pharmaceutical companies run television ads that say, “Depression is a distinct medical condition… It causes intense mood and physical symptoms.” Of course they do.
In other words: we say DSM diagnoses are constructs, not things. Then blithely go on to speak of them is if they were things. Doublethink, anyone?
Recently, I saw a self-exam in the American Psychiatric Association study guide for DSM-5. The format is case vignettes followed by multiple-choice diagnoses. One vignette described a patient with a fear of flying, followed by the question: “Which of the following disorders is the most likely cause of his anxiety?”
My write-in answer would have been: “None of the above, because DSM diagnoses are descriptive labels, not causes.”
The study guide answer was “c) Specific-phobia—situational type.” I would have failed that exam. My student, Dr. G, would have aced it.
Addendum: I appreciate the lively discussion that followed this post. I was surprised by some comments, apparently by psychiatrists, impugning my credentials to discuss diagnosis. Below is a Tweet by Allen Frances, Chair of the DSM-IV Task Force. I apologize for the educational deficiencies that prevent me from understanding the DSM. I can only take some small comfort in knowing its senior editor and I misunderstand it the same way.
"Mental disorders are constructs, not diseases. Descriptive, not explanatory.
Helpful in communication/treatment planning, but no claims re causality/homogeneity/clear boundaries.
We wrote this in DSM-IV Intro—no one read it." —Allen Francis, July 29