The War on Psychiatric Diagnosis
The War on Psychiatric Diagnosis
One of the first psychotic patients I treated during my residency was a middle-aged man who was burrowing through the wall of his room. Yes, I mean “burrowing,” as in using his bleeding hands, fists, and fingernails to tear through the flimsy plaster and stucco wall of the clinic. Now, after reading the British Psychological Society (BPS) report on psychosis,1 one might conclude that the way to help such a patient is to sit down with the poor chap over lemon tea; guide him toward a mature understanding of his problem; and allow him to decide what, if any, treatment he wants. (Presumably, this chat occurs after the patient burrows through the wall of one’s office.)
Of course, I am caricaturing the BPS report—which, to its credit, does contain several useful recommendations, as I and others have acknowledged. Where the report fails is in conveying the fact that psychotic-level illnesses are often devastating and even life-threatening. Psychosis is not just an alternative lifestyle or manner of viewing the world. In addition to the excruciating suffering psychosis often engenders, it is also independently linked with increased risk of suicide attempts.2
The BPS report has been roundly and rightly criticized by several eminent psychiatrists—and a few psychologists—and I won’t repeat their arguments here.3-5 Suffice it to say that the BPS report radically misconceives the nature of psychosis by focusing on hearing “voices”—which is rarely the main source of dysfunction and incapacity in patients with, for example, schizophrenia. Schizophrenia is a global disorder of personhood itself, usually involving impaired cognition; difficulty in assessing risk; disturbed ego boundaries; interference with activities of daily living; and impaired ability to attain one’s “prudential interests,” as Dr Robert Daly6 has argued.
But there is a larger issue raised in the BPS report that goes to the very heart of psychiatric diagnosis, which the report tries to discredit with the following argument:
We normally expect medical diagnoses to tell us something about what has caused a certain problem, what the person can expect in future (“prognosis”) and what is likely to help. However, this is not the case with mental health “diagnoses,” which rather than being explanations are just ways of categorizing experiences based on what people tell clinicians. . . . For example, someone who says that they are hearing voices might be given a diagnosis of schizophrenia. Since this says nothing about cause, it makes little sense to say that the person hears the voices “because of” the schizophrenia.1
Actually, it makes a good deal of sense, in precisely the same way it makes sense to say, “Mr Jones has severe facial pain because he has tic douloureux;” or “Smith has severe left-sided head pain and nausea because he has migraines.” We still do not know the precise causes of these conditions; moreover, the diagnosis of tic douloureux (literally, “painful tic”) or migraine headache (etymologically, headache “in half the cranium”) is made almost entirely on the basis of “what people tell clinicians”—not on the basis of an abnormal laboratory value, x-ray film, or anatomical finding. (Of course, certain tests, such as a CT scan of the head, can help rule out other diagnostic possibilities, such as a brain tumor.)
Indeed, the history of medicine is replete with well-established diagnoses which, on their initial description, were of unknown etiology; eg, James Parkinson’s description of the disease that now bears his name provided no conclusions as to its etiology: he merely characterized in rich detail what he called the “shaking palsy.” And recently, the Institute of Medicine identified chronic fatigue syndrome as a bona fide disease (re-christened, “Systemic Exertion Intolerance Disease”) without identifying its precise cause or causes.7
To be clear: I am not singing the praises of DSM-5 or its (mostly) categorical approach to diagnosis. Like many psychiatrists, I have expressed criticism and reservations regarding both the categorical model and specific DSM-5 categories.8 My point is that the BPS report’s argument against descriptive diagnosis in medicine is historically ill-informed and medically naive.