5.21.2009

Pros and Cons of Psychiatric Diagnosis

I happen to think that the use of psychiatric diagnosis does more harm than good. I'll tell you why. Please tell me what you think I've missed.

Pros
  • Psychiatric diagnosis provides a framework within which to understand mental illness.
  • By noticing which symptoms seem to show up together, then noticing which cluster of symptoms a particular patient seems to fall into, treatment decisions can be informed by what has or has not worked for other patients with similar clusters of symptoms.
  • Diagnoses can serve as a sort of cognitive shortcut. Rather than list all of a patient's symptoms individually, professionals can name the cluster and understand the patient more quickly, speeding communication.
  • When patients are given diagnoses, it can validate their experiences by letting them know that others have had similar experiences.
Cons
  • When the incomplete and tentative nature of the framework for understanding provided by psychiatric diagnosis is not acknowledged or is forgotten, it is used rigidly and inappropriately. I think this is probably a good part of the cause of the other problems diagnosis can cause.
  • Experience with patients having those clusters of symptoms, known as diagnoses, can appropriately be used to inform treatment, however, this tends to be used to dictate treatment.
  • As a cognitive shortcut, diagnosis would be useful only if people were mindful of the fact that they are using it as a cognitive shortcut. When people lose that mindfulness, diagnosis becomes a stereotype.
  • When diagnoses are overused, this harms those patients who validly fit the diagnosis. Services are taken up by people who don't need them as badly. The people who are inappropriately diagnosed give the diagnosis, and those who are appropriately diagnosed, a bad name and additional stigma in the eyes of the public (i.e. "depressives are just whiners.").
  • The rampant co-morbidity of diagnoses makes the framework lose its usefulness as a tool for simplifying and may even make mental illness seem much more complex.

I think that psychiatric diagnosis has some potential to be useful and beneficial. However, I think that the way they are presently used negates and actively prevents the potential usefulness they have. I also don't think the potential benefits are worth all the energy that goes into creating and maintaining this framework of diagnoses, nor do I think that the benefits are worth even the risk of them being used as inappropriately as they are.

I would rather see symptom-based treatment. Symptoms could be used to identify what needs treatment for each patient rather than diagnoses. Patients would list the symptoms that bother them and receive treatment for those and their underlying causes. There would be no misdiagnosis. No one would be treated for symptoms they don't have, because there would be no reason to assume that a cluster of symptoms has to go together. Even when patients have symptoms that do tend to go together, but one doesn't bother them, professionals won't have to feel compelled to treat that irrelevant symptom in the interest of treating the "full illness".

I know insurance-wise this may create practical problems, but I see the GAF score as the only thing they really need to know in terms of approving benefits; anything else is just the insurance companies meddling. I have no problem with GAF scores; I think they do a much better job than diagnoses. I wish that GAF scores were given more attention than diagnoses.

8 comments:

  1. My doctor agrees with you (as do I) - e.g., that symptoms should be treated, not diseases. He thinks there's an artificial process of creating new diseases - driven by the fact that, in our system (American, probably yours too), drugs are only approved to treat diseases or conditions, not symptoms.

    Especially in mental health care, I think "treat the symptom" is a much more appropriate model. The whole idea with a "symptom" is something that's distressing to the patient. Solving the patient's distressing problem - alleviating a "symptom" - is much more respectful in a mental health context than treating a "full illness," which, as you point out, is often used to stereotype and dehumanize people. A symptom focus is, I think, a focus on a patient's wishes and desires.

    Also, the model is especially appropriate here because there's no, you know, cure for most mental illnesses. A disease model works well with something like a bacterial infection - not so much with an incurable but manageable condition.

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  2. I was just thinking, how could there ever even be a cure for a mental illness? With physical illnesses, we know what the problem is and we have concrete ways for checking for the presence of physical disease. But with mental illness, all we have are vaguely linked groups of symptoms. How would we ever know if we cured it? How would we ever know it hadn't gone dormant? I imagine this was a problem earlier on in the practice of medicine, that the symptoms would disappear with no way of knowing whether the illness was cured or simply gone dormant. I mean, it was probably a problem once people were able to not just die from the first round of active illness.

    As for it being an artificial process for determining what is and is not an illness: it most certainly is. Unlike most illnesses, mental illnesses are basically determined by debate. Of course when new physical illnesses are discovered/identified/understood, there is considerable debate. But the nature of the debate is different. For physical illness, it is more of "do we agree that the evidence is sufficient to prove this illness?" sometimes the popular conclusion is right, sometimes it is wrong. But for mental illness, it is more "do we want to call this an illness?" And when they go back and change things (homosexuality, drapetomania, etc.), it isn't so much of a "we were wrong," as "we've changed our minds".

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  3. "I would rather see symptom-based treatment. Symptoms could be used to identify what needs treatment for each patient rather than diagnoses. Patients would list the symptoms that bother them and receive treatment for those and their underlying causes."

    I actually talked about this idea with my group this week. I told them that they could have any number of diagnoses, but if they are feeling sad, unmotivated, and anxious, then they will probably get the same medication. because meds are for symptoms. i encouraged them not to worry so much about their DSM dx but rather to think about whether the meds were helping with their symptoms.

    i also explained to them how the doc has no choice but to give a dx, as reimbursement and practice standards require it. a good doc will see the person and the symptoms behind the label.

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  4. Thanks so much for that, Tammy. It is very gratifying to hear a professional tell me that I am making sense. I agree that a good doctor will look at the symptoms rather than a diagnosis. How common do you think those doctors are?

    It seems that most scientific studies, at least the ones I have read, categorize people by diagnosis rather than symptom, which is less helpful, I think. I have heard some professionals express a similar sentiment. They also said that basically everyone knows that diagnoses are really not all that useful but they go along and use them anyway. I understand that it might be easier for insurance companies to inderstand if they use diagnoses, but then why use it anywhere else? Why not just tell the insurance companies, "no, we just aren't even going to use diagnoses anymore?"

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  5. Jess, may I use some of this material for an article I'm writing for a mental health journal - and if so, how would you like to be quoted?

    Please do email me at laurie.penny@gmail.com and we can chat about this more :)

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  6. What was the form of therapy you were talking about that was like existentialism?

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  7. I have always wondered which are the Pros and Cons of Psychiatric Diagnosis . It is a mystery for me, so I would like to see a good movie about this issue.

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  8. I think it's great that you can see the positive in this!

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I have controversial views on a controversial topic. Things can get heated. You are welcome to disagree with me, but please be respectful about it.