![\"\"](\"http:\/\/blog.stevenreidbordmd.com\/wp-content\/uploads\/2010\/11\/mossytree.jpg\" "\\"mossytree\\"")
Earlier this year a reader asked me:<\/p>\nEarlier this year a reader asked me:<\/p>\n
“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.”<\/p>\n
I’ve seen this too. \u00a0Here’s my take on the alphabet soup of diagnosis, and whether it’s good for patients to focus on it. \u00a0First, a little history…<\/p>\n
Prior to 1980, before the revolutionary 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders<\/a> (DSM-III), psychiatry tended to lump disorders into a few broad categories. \u00a0Schizophrenia covered a wide range of presentations, from relatively minor symptoms to devastatingly severe ones. \u00a0Depression could be brief, prolonged, triggered by obvious stressors or losses, or appear out of nowhere. \u00a0Neurosis referred to any presumed unconscious conflicts that interfered with life.<\/p>\n DSM-III changed all that. \u00a0(An excellent historical review article, in pdf format, is available here<\/a>.) \u00a0This was the first effort by the American Psychiatric Association (APA<\/a>) to publish an atheoretical, phenomenological psychiatric nosology. \u00a0What do these $10 words mean? \u00a0The idea was to create diagnoses that could be used regardless of one’s school of thought or theory. \u00a0For example, some psychiatrists thought depression was biological, others considered it psychological. \u00a0Either 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\u00a0according to DSM-III. \u00a0It didn’t matter why.<\/p>\n This scheme encouraged multiple diagnoses. \u00a0A given patient could fulfill criteria for Major Depressive Disorder, an Anxiety Disorder, a Personality Disorder, and other disorders, all at the same time. \u00a0This reflects a drawback of atheoretical diagnosis. \u00a0An 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. \u00a0Without such a theory to guide diagnosis, each set of symptoms stands on its own. \u00a0While some DSM diagnoses had exclusion criteria \u2014 they could not be listed in the presence of other diagnoses \u2014 this still left plenty of opportunity to list multiple disorders in the same person.<\/p>\n Each edition of the DSM grows in size. \u00a0One reason is that scientists can’t stand to leave a good category alone \u2014 if it can be turned into two<\/em> good categories. \u00a0Thus, anorexia and bulimia, which used to be one disorder, are now divided. \u00a0Depression is divided into major depression, dysthymia, seasonal affective disorder, adjustment disorder with depressed mood, and so forth. \u00a0Bipolar disorder comes in Type I and Type II, as well as lesser versions. \u00a0I am not against making these distinctions when there is good reason to do so, and there often is. \u00a0But one consequence is diagnostic alphabet soup: a growing set of arcane labels usually shortened to three- or four-letter abbreviations. \u00a0And the nature of atheoretical diagnosis means that any given patient may qualify for several.<\/p>\n Many psychiatrists feel they “understand” a patient better if they can establish one or more DSM diagnoses \u2014 although, being atheoretical, \u00a0such diagnoses don’t actually explain anything. \u00a0They do, however, point reassuringly to recommended treatments, usually pharmaceutical. \u00a0Moreover, medications are FDA-approved for each of these indications separately. \u00a0This has marketing advantages for drug manufacturers. \u00a0Shyness doesn’t sound like a psychiatric problem to be treated with medication, but “Social Anxiety Disorder,” essentially a synonym for shyness, does. \u00a0Dividing anxiety into Generalized Anxiety Disorder, Social Anxiety Disorder, and many other types created markets for various medications. \u00a0In a parallel fashion, health insurers demanded more specific diagnoses in order to pay for psychiatric treatments. \u00a0There is money, and therefore politics, behind dividing human misery in these particular ways.<\/p>\n Perhaps the most interesting part of my reader’s question is why some patients are attracted to these labels. \u00a0Her experience with teens and young adults may, in part, reflect embracing these labels in an ironic or mocking way: \u00a0“Now I have MDD, OCD, and<\/em> PTSD. \u00a0Isn’t that a kick?” \u00a0Probably more relevant is the concrete way a diagnosis seems to account for one’s frightening instability. \u00a0Better to be “ADHD” than merely a scattered teen who can’t study. \u00a0The former confers scientific legitimacy, promises specific treatments, and even justifies entitlements such as extra testing time in school. \u00a0These 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.” \u00a0Despite the persistent stigma of psychiatric diagnosis, these labels have enough psychological and practical advantages that some patients wear them proudly.<\/p>\n The downside to all of this is that individuals can become known, even to themselves, by impersonal diagnostic labels. \u00a0Knowing oneself as PTSD, ADHD, and\/or OCD can dehumanize. \u00a0It can prematurely close off inquiry and self-reflection. \u00a0And DSM diagnoses do not actually explain anything; they are better conceptualized as statistical categories. \u00a0Such diagnoses are useful tools, but like all tools they can be misused.<\/p>\n","protected":false},"excerpt":{"rendered":" Earlier this year a reader asked me:<\/p>\n “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. 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