Diagnostic alphabet soup

Earlier this year a reader asked me:

“I would be very interested to hear your thoughts on patients becoming too focused on diagnoses. […] While I was in an RTC as a teenager, and recently in the hospital as an adult, I have found that people almost treat their diagnoses as a competition. I was calling it the alphabet olympics. I also have a friend who will rattle off a bunch of abbreviations for his diagnoses. There is always something new popping up too. Sometimes I wonder if over diagnosing is a mistake some psychiatrists make.”

I’ve seen this too.  Here’s my take on the alphabet soup of diagnosis, and whether it’s good for patients to focus on it.  First, a little history…

Prior to 1980, before the revolutionary 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry tended to lump disorders into a few broad categories.  Schizophrenia covered a wide range of presentations, from relatively minor symptoms to devastatingly severe ones.  Depression could be brief, prolonged, triggered by obvious stressors or losses, or appear out of nowhere.  Neurosis referred to any presumed unconscious conflicts that interfered with life.

DSM-III changed all that.  (An excellent historical review article, in pdf format, is available here.)  This was the first effort by the American Psychiatric Association (APA) to publish an atheoretical, phenomenological psychiatric nosology.  What do these $10 words mean?  The idea was to create diagnoses that could be used regardless of one’s school of thought or theory.  For example, some psychiatrists thought depression was biological, others considered it psychological.  Either way, if a patient had a low mood for two weeks, along with poor sleep, appetite, concentration, and libido, he or she had Major Depressive Disorder according to DSM-III.  It didn’t matter why.

This scheme encouraged multiple diagnoses.  A given patient could fulfill criteria for Major Depressive Disorder, an Anxiety Disorder, a Personality Disorder, and other disorders, all at the same time.  This reflects a drawback of atheoretical diagnosis.  An underlying theory, such as Freudian psychoanalytic theory, or a systematic biological or learning theory, can pull together apparently disparate symptoms into a coherent diagnostic formulation.  Without such a theory to guide diagnosis, each set of symptoms stands on its own.  While some DSM diagnoses had exclusion criteria — they could not be listed in the presence of other diagnoses — this still left plenty of opportunity to list multiple disorders in the same person.

Each edition of the DSM grows in size.  One reason is that scientists can’t stand to leave a good category alone — if it can be turned into two good categories.  Thus, anorexia and bulimia, which used to be one disorder, are now divided.  Depression is divided into major depression, dysthymia, seasonal affective disorder, adjustment disorder with depressed mood, and so forth.  Bipolar disorder comes in Type I and Type II, as well as lesser versions.  I am not against making these distinctions when there is good reason to do so, and there often is.  But one consequence is diagnostic alphabet soup: a growing set of arcane labels usually shortened to three- or four-letter abbreviations.  And the nature of atheoretical diagnosis means that any given patient may qualify for several.

Many psychiatrists feel they “understand” a patient better if they can establish one or more DSM diagnoses — although, being atheoretical,  such diagnoses don’t actually explain anything.  They do, however, point reassuringly to recommended treatments, usually pharmaceutical.  Moreover, medications are FDA-approved for each of these indications separately.  This has marketing advantages for drug manufacturers.  Shyness doesn’t sound like a psychiatric problem to be treated with medication, but “Social Anxiety Disorder,” essentially a synonym for shyness, does.  Dividing anxiety into Generalized Anxiety Disorder, Social Anxiety Disorder, and many other types created markets for various medications.  In a parallel fashion, health insurers demanded more specific diagnoses in order to pay for psychiatric treatments.  There is money, and therefore politics, behind dividing human misery in these particular ways.

Perhaps the most interesting part of my reader’s question is why some patients are attracted to these labels.  Her experience with teens and young adults may, in part, reflect embracing these labels in an ironic or mocking way:  “Now I have MDD, OCD, and PTSD.  Isn’t that a kick?”  Probably more relevant is the concrete way a diagnosis seems to account for one’s frightening instability.  Better to be “ADHD” than merely a scattered teen who can’t study.  The former confers scientific legitimacy, promises specific treatments, and even justifies entitlements such as extra testing time in school.  These labels can also ease personal responsibility and humiliation, as when outrageous social behavior can later be attributed to Bipolar Affective Disorder or some other “chemical imbalance.”  Despite the persistent stigma of psychiatric diagnosis, these labels have enough psychological and practical advantages that some patients wear them proudly.

The downside to all of this is that individuals can become known, even to themselves, by impersonal diagnostic labels.  Knowing oneself as PTSD, ADHD, and/or OCD can dehumanize.  It can prematurely close off inquiry and self-reflection.  And DSM diagnoses do not actually explain anything; they are better conceptualized as statistical categories.  Such diagnoses are useful tools, but like all tools they can be misused.