Has psychiatric diagnosis labelled rather than enabled patients?

The future of people with mental illness depends upon how psychiatry copes with diagnosis in the environment of advancing technology, so does the future of psychiatry.1

Psychiatric diagnoses are able to broadly direct treatment e.g. antidepressant medication and psychotherapy addressing negative cognitions and depression maintaining behaviours for diagnosed depression; antipsychotics for schizophrenia and trauma psychotherapy for PTSD. People with mental illness often yearn for self-discovery and cannot be empowered without an accurate understanding of their condition. Just welfare systems and protective legal frameworks can facilitate empowerment on a big scale and need endless pursuit, but they will not always fit the individual and their unstable and biased definitions are written by the authoritative voices of the time.

Diagnoses need enhancement rather than abandonment. Hopefully, by the standards of the future, the current DSM and ICD are primitive. An individual’s DSM or ICD diagnosis could gain validity and reliability with results integrated from genetic, receptor and head scan tests; more so as technology improves and cost lowers. The contemporary level of “this is already happening,” is insufficient. The lack of clear cut histopathology and biological understanding in psychiatry needs to be addressed optimistically in an age where the biopsychosocial model can be upgraded to accept that the psychosocial components always have biological correlates, which ironically can support the use of psychosocial interventions.

I agree with Callard and Bracken that diagnoses can maintain people as patients, but improved understanding of aetiology and effects of treatments such as mindfulness and medication on the brain provides the opportunity to empower the person to escape the suffering and labelling of being a patient. The integration of laboratory science into everyday psychiatric diagnoses and treatments is needed to avert the related crises of adherence to outdated diagnostic criteria and difficulty in recruiting good doctors as psychiatrists. It is needed to enable psychiatry to develop beyond infancy and to be a true medical discipline which puts the patient- person first by allowing her access to twenty first century technology and beyond that of interim and overlapping phenotypic descriptors.

1. BMJ 2013;347:f4312

What seems to happening here is what so often happens when misunderstandings arise. Two groups of people, or two schools of thought are using the same language in different ways. The critical word appears to be “diagnosis”. In medical circles it is commonly used, interchangeably, with “classification”. However, “diagnosis” is also used in many other contexts such as engineering, computer science and organisational studies to refer to the process of discerning the causes of problems, and routes to their mitigation and solution. When the question “What is the diagnosis?” is asked in lay or administrative circles, it generally means “How has the doctor classified the problem?”. When the same question is asked in professional medical circles, it generally means “How do we understand what is wrong with this patient?”. The two are distinct. Even when the diagnostic label immediately conveys an accurate and effective understanding of what has gone wrong as in “Myocardial Infarction” or “Fractured Neck of Femur”, the labels in themselves fail to convey the individual detail a treating physician or surgeon will need. They don’t tell us, for instance which coronary artery has been occluded, to what extent and with what consequences the myocardium had been compromised, or exactly where and in what way the femoral neck has been fractured.

David and Sartorius emphasise the need for an administrative scheme that classifies mental difficulties, and it is difficult to deny that need. Bracken and Callard argue that a diagnostic label based entirely upon the fact that a patient’s difficulties fulfil certain diagnostic criteria does not and cannot provide any useful information about the reasons behind them or how they might be mitigated. Both arguments hold, and they are only in conflict because they are using the term “diagnosis” in different ways.

Unlike the American Diagnostic and Statistical Manual, WHO’s International Classification of Diseases avoids the term “diagnosis”, and singularly also avoids the term “disease” in relation to mental disorders. Although other substantive chapters refer to groups of diseases, Chapter V refers to the classification of “Mental and Behavioural Disorders”. Confusion between a scheme that provides classification for administrative purposes, and the impression that application of such a classification reflects constructive insight into the underlying processes and experiences that make up the patient’s difficulties might be avoided by respecting this.

Debate over the rights and wrongs of psychiatric diagnosis is likely to continue and will remain fruitless and sterile unless a little more goes into understanding underlying misunderstandings. DSM and ICD are not diagnostic schemes in the sense of providing insight into the causes of mental health problems or what might mitigate them. They can and do fulfil necessary administrative tasks but the unfortunate use of the term “Diagnostic” in DSM suggests a capability they do not have. There might well be a need to classify mental disorders as DSM and ICD do so well, but perhaps it is time to move on, and accept that in itself, such a classification provides little or no insight into what is actually happening in relation to particular individuals.

The title of the Debate is irrational and can only produce the confusions we see in the arguments. That a diagnosis is called by the metaphor a 'label' is an example of the stigmatisation of both patients and psychiatrists by that widespread and often overwhelming prejudice against those suffering from psychiatric diseases. (This is not helped by the use of the pun 'enabled'.) This debate is really about the consequences of this stigmatisation, not about diagnosis. The Debate is one aspect of the internicine conflict within a stigmatised group rather than psychiatry, patient and doctor, combating prejudice and stigmatisation.

Psychiatry is that branch of medicine in which the prime symptoms are changes in behaviour - the way we think feel and act. Because the brain is such a complicated organ our understanding of its structure and processes is rudimentary. Lack of knowledge is universal in all of medicine e.g. cancers. It is stigmatising and suggests a professional self-depreciation to suggest that the DSM5 psychiatric classification is a sign of psychiatry's infancy as a science.

Diseases are defined by
1. A causal agent or its absence.
2. The lesion, the focus of damage and its consequences; the science of pathology.
3. The syndrome/s; collections of symptoms and signs that form recognisable entities.
For most 'psychiatric' diseases we have, as yet, only syndrome/s defined by symptoms alone rather than also with signs. Our basic classification is therefore syndromic: Hence DSM5. It is difficult if not at times impossible to distinguish between psychiatric diseases and confounding conditions. For example, depression as a disease arising de novo and as a non-pathological response to life's events such as bereavment. We may well treat some psychiatric diseases as confounding conditions and vice versa. The psychiatrist should be well versed in both psychiatric diseases and other forms of human suffering and then hopefully to be in an unique position to distinguish between them.

A psychiatrist is a medical practitioner who follows that well beaten path of diagnosis and prognosis that then validate the prescription of treatment.

That psychiatric diagnosis is at fault because it leads to stigmatisation of the patient is like criticising the diagnosis of plague because sufferers were sealed up in their residences to die or that sufferers diagnosed with leprosy were sent to a leper colony.

The protagonists in this debate should have been raging about the real issue: the stigmatisiation of psychiatric patients by that universal and corrupting prejudice we should call "psychiatrism". It is the failure to confront this grave universal prejudice against psychiatric patients and their physicians that should have been the moral and practical focus of this Debate, not these confused and irrelevant discussions about diagnosis and classification.

Can diagnoses harm? Of course they can, and not just in psychiatry, as is testified by the current concern over overmedicalisation. Any intervention we engage in, including labelling, can have a negative impact. Given this, Callard and Braken’s lines of argument are puzzling.

They lead with ‘diagnostic overshadowing’ and ‘poor psychiatric diagnosis’ leading to a deprivation of legal capacity in some parts of Europe. However, this is more reflective of institutional bias, prejudice, and bad practice, rather than a property of diagnosis per se. Indeed, the new Scottish Mental Health Act, seen by many as an exemplar of human rights in action, does not reject diagnosis per se.

Further, the pivotal statement that mental illnesses ‘are problems of persons, not of the brain (ie organ), is equally applicable to any branch of medicine. A myocardial infarction of equal size and site in two different individuals will probably have differing functional impacts. Despite this, no cardiologist (or patient) would abandon diagnosis. Finally, to purport that psychiatry is unique because it is ‘relational and value laden’ does not acknowledge the same factors in all other medical specialties.

That is not to say that the current ‘diagnostic’ classification systems are correct. However, there is clear acknowledgement of their shortcomings and their weaknesses. They do not purport to be an immutable truth, but rather a work in progress that may have utility for a period of time.

Fundamentally, diagnoses are pattern recognition of things that are different from normality. The mind according to Descartes, does not obey ‘the rules of physics’ and therefore has no norms - it is also a philosophical concept. If one believes that psychiatry is to do with ‘disorders of the mind’, diagnoses cannot exist, as there are no norms. The only logical conclusion from this is that medical science has no relevance in helping those with ‘disorders of the mind’, and that psychiatry should not be part of medicine.

Now that would indeed be a head to head!