The Fallacies of Psychological Diagnosis

As you may have heard, the American Psychiatric Association is in the midst of a revision to its Diagnostic and Statistical Manual of Mental Disorders, used to identify different mental illnesses and assign diagnostic labels to patients.  This newest edition, the DSM-V, will be published some time in 2013.   Among the more controversial changes is the elimination of five of the 10 personality disorders currently listed, the best known of which is Narcissistic Personality Disorder (NPD).

This revision seeks to move diagnosis toward a greater emphasis on descriptive traits, based on the undeniable fact that individuals diagnosed with one personality disorder often demonstrate traits associated with another.  As many clinicians have pointed out, the personality disorders exist along a spectrum.  I suppose this refinement in the DSM is a step in the right direction as it appears to treat people a bit more like individuals than categories, but I have a more fundamental problem with the idea of assigning diagnostic labels in the first place.

The fundamental assumption behind the DSM is that its categories of mental illness, with their official code numbers, actually correspond to a discrete syndrome exhibited by real people; in this sense, it is meant to be the psychological counterpart of the International Classification of Diseases 9 (ICD-9) used by physicians to diagnose and label physical illness.  In theory, applying the DSM-IV label Narcissistic Personality Disorder should carry the same weight and have as much scientific validity as an ICD-9 code for, say, diabetes.  The impending elimination of NPD from the DSM-V proves that such an analogy is fallacious.   Can you imagine if the American Medical Association suddenly announced it intended to eliminate diabetes from the ICD-9?

The two code manuals are analogous in one important respect, however:   insurance companies require a code from one or the other before they will reimburse for services provided.  This is the raison d’etre of the DSM:   it exists because providers of psychological services must support claims with diagnostic categories and code numbers, just as physicians must do when they treat physical disease.  In my view, the analogy ends there.  True, there are certain familiar disorders with a proven genetic component (ADHD) or that present in consistent ways (PTSD); but by and large, people who suffer from depression, anxiety, bipolar disorder or NPD do not fall into neat categories.  Each psychological “disorder” (if we should even call it that) is unique to the person, no two of them alike.

[NOTE:  SINCE WRITING THE ABOVE SENTENCE ABOUT A “PROVEN GENETIC COMPONENT” IN CERTAIN DISORDERS, I HAVE RECONSIDERED AND WITHDRAW THAT STATEMENT; INSTEAD OF DELETING THAT SENTENCE, HOWEVER, I LEAVE IT INTACT AND REFER YOU TO DR. JEFFREY KAYE’S EXCELLENT AND WELL-RESEARCHED COMMENT FOLLOWING THIS POST.]

If it were only a matter of making insurance companies happy, that would be one thing; unfortunately, the general public believes these diagnostic labels have more validity than they actually do.  The average person believes the pseudo-scientific claims of the DSM and readily accept the labels.  Sometimes this is because people who suffer from mental illness often feel a great deal of shame; to a degree, they feel relieved to have an identifiable clinical syndrome with an official name and code number because it feels less shameful, especially if the doctor tells them it’s a chemical imbalance that can be treated with
appropriate drugs.  On websites that function as support groups for certain disorders — among them autism, bipolar disorder, and NPD — I’ve also noticed a subtle pride in the diagnostic label, as if it grants a kind of distinction.  I wonder if any of those people will experience the elimination of NPD from the new manual as a kind of narcissistic injury.

These diagnostic labels also have value for the pharmaceutical companies; if they can develop a drug that has a clinically “significant” effect on a  disorder enshrined within the DSM, they stand to make billions of dollars because insurance companies will pay for it.  Insurers prefer discrete syndromes with generally accepted modes of treatment, which is
one of the reasons why cognitive-behavioral therapy has become so popular.  With its easily defined methods and short-term treatment approach, it gives the non-professional evaluating an insurance claim something he or she can understand and approve.  Gone
are the days when psychotherapy was a slow, meandering and completely unscientific journey of self-exploration, an inquiry into the meaning of psychic pain.

One of my teachers in graduate school once told me we therapists needed to stop trying to justify our discipline as if it were a science akin to medicine.  I couldn’t agree more.  Psychotherapists are more like skilled artisans than scientists or physicians; effective therapy depends more on the psychological fit between therapist and client (the emotional capacities and understanding of the former, the trust and courage of the latter) than following a scientifically-based treatment plan for an identifiable syndrome.

People who’ve experienced good results in psychotherapy understand this, but alas, it’s not a point of view accepted by insurance companies, or even the public at large.

Finding Your Own Way:

Here’s a link to a resource based on the Diagnostic and Statistical Manual-IV.  Spend a little time browsing around, visit different diagnostic categories and find out how many of their features apply to you.  The experience can be a bit like reading the Physician’s Desk Reference and starting to worry about all the “symptoms” you’ve lately been experiencing.  My point is not that you should find the diagnosis that best suits you but to highlight the imprecision of diagnosis.  People are unique individuals not categories.

Maybe the new DSM-V will resemble a la carte ordering rather than a prix fixe menu, where clinicians can choose from a whole smorgasbord of symptoms.  A little bit of NPD with some histrionics thrown in, and a side order of Asperger’s.

Have fun!

Joe is the author and the owner of AfterPsychotherapy.com, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.

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14 comments

    This is really interesting. I’ve often thought that although ‘practice’ is something that becomes part of the body of skills, and therefore, knowledge that psychotherapists hold, it’s not really understood. It also seems not to be understood in other areas, for example, teaching, and with medicine.
    I don’t think that medicine is truly scientific, but more akin to a craft, but since God disappeared from Western thought (not all together) Science has replaced it, and people have mistakenly tried to say that only the scientific is valid in certain types of discourse, and this reasoning has also been applied to medicine.
    This seems to lead to innumerable problems, with people falsifying claims, (in other areas) and alluding to data or research that does not even exist in order to appear more prestigious, when they need not. It’s interesting that psychotherapists seem to tend not to do this, even though there is little data to support what they do, perhaps, because there is more latent knowledge around that shows that it’s helpful and more properly meaningful in today’s world, than say, astrology or some of the other practices that get mentioned in ‘bad science’ for example.
    Perhaps one way of measuring the validity of some of these things would be to measure the degree of defensiveness of practitioners when questioned. I’m a firm believer in the importance of psychotherapy, but when you have to put a price on your mental health, that’s when it becomes very difficult. What’s going on with the DSM is encouraging.
    People should remember that the ‘gnosis’ in diagnosis is entirely different to the ‘episteme’ of propositional knowledge or the ‘techne’ of a skill but alludes to a higher sort of knowledge (I think) that can sometimes transcend facts whether known or implicitly felt. Can’t see the pharmaceuticals going for that though.
    I really enjoy your blog; keep up the good work. You often write about such complex things that it’s difficult to even write comments back, but I’m sure there are a lot of people out there gaining a lot from what you write (and practice).

    I appreciate that you took the time to write such an intelligent response, and of course I agree with you that medicine is less scientific than it would appear to be. On the other hand, blood tests that show reductions in cholesterol levels as the result of taking a statin are surely more scientific (i.e., more measurable/quantifiable/verifiable by others) than, say, a subjectively reported improvement in one’s sense of well-being.

    I’m not sure there’s any value at all in measuring the validity of psychotherapy (although I know it must nonetheless be attempted) because the effects and value are essentially ineffable. I have clients who feel that they would have overdosed on drugs or committed suicide without therapy; how to you measure the value of a life? I personally spent a very large amount of money and many years in my treatment; most people would be shocked at how much and how long but for me, it was the best investment I ever made. How do you place a value on having the kind and quality of life that would never have been possible without expensive and time-consuming psychotherapy?

    Can anyone see that diagnoses are almost irrelevant when what is need, urgently, is not a description of the problem? What the patient needs, also urgently, is treatment of the problems.
    Diagnoses might be interesting on an acedemic level but …….. Relieving the patient’s suffering would be far more humanitarian. Don’t you agree?

    Wow. You’ve touched on many of the points that critics of psychiatry get upset about. I get the sense that therapists are much more holistic on their views that a psychiatrist would be so am curious if they’d concur. Other than telling more people to read your blog, what are suggestions you have for trying to change the issues you address?

    I’m not sure where to even start! I think this is just the way things are in our world; hopefully, you can get a few people to think differently, and then a few more. Over a long period of time, attitudes may change.

    People are unique.

    A rewarding, though frustrating employ, I had as a substance abuse counselor at a 28 day in-house facility. Objective, method, results and conclusions…unfortunately, the conclusion is a high rate of recidivism. I have no idea where to begin either; with the exception that people do have to WANT to ‘find(ing) their own way’, as the rock and the hard place appears to have little effect.

    A career change, I took the Red Cross classes and became an LNA at a nursing home. This was my most rewarding employ, in this setting, everything (physical and psychological coding) came into play.

    At the nursing home, at about 5:45 p.m., on January 15, 2007, I took a bite of a sandwich…ten days later, I had a diagnosis of 350.1. Medication reaction 695.15, (3) failed surgical procedures (an MVD and two radiosurgeries) resulting in 851; it’s been a hoot!

    About two years ago, I sought out therapy, hoping to address what had happened to my life. The therapist thought I had a good grasp of my medical and mental condition and wanted me to “open up” about my childhood. Needless to say, I no longer seek this type of clinical support.

    Moments ago, I called 911 for a neighbor who was screaming “Help me, I don’t want to live anymore” (a 52 year old Gulf War Veteran, suffering from PTSD and alcoholism).

    I don’t multi-task very well, though I find this conversation fascinating.

    I suspect that I am a little bit of everything in all of the manuals, with a side order of gratitude.

    Hi Dr. Burgo,

    I am a bit confused by your statement: “…True, there are certain familiar disorders with a proven genetic component (ADHD)…”

    What ‘proven genetic component’ are you speaking of and exactly how did modern psychotherapy discover it?

    I only ask because I am of the opinion that ADHD is just a made-up excuse to drug children into oblivion along with the rest of us (Columbine, et al). I would be very interested in reading some proof that ADHD has a legitimate physical or genetic component that manifests itself in children.

    Also if this is a true medical mystery that has been solved, how does this impact modern psychology? What medical tests do psychologist administer to make a diagnosis of ADHD? And since when are psychologist on a par with medically-trained doctors allowing them to diagnose medical conditions and dispense drugs for them?

    Thanks for your time.

    This is what happens when I try to appear “balanced” and express opinions not entirely my own. I totally agree that ADHD is widely over-used as a diagnosis and that what used to be considered typical or normal behavior (esp. for boys) has now been re-defined as pathological. On the other hand, I do know kids who have major difficulties in the attention area, with hyperactive behavior; and there’s a familiar history of the problem. I honestly don’t know if science has identified the genes involved, but I believed some have been implicated. That still doesn’t mean that drugs are the answer. From my limited and anecdotal experience, I’d say the current preferred medications do little.

    While I found your article interesting, and can agree with its general import, I was bothered by your statement that “there are certain familiar disorders with a proven genetic component (ADHD)…”

    I think this is a misleading statement. A recent article for the journal European College of Neuropsychopharmacology (9/15/09) puts it this way:

    “ADHD belongs to the multifactorial, i.e. complex disorders (Kuntsi et al., 2006). Due to the small effects of individual genetic risk factors, the identification of genes for ADHD has been very difficult. Up to now, only a small number of susceptibility genes have been found (Li et al., 2006; Franke et al., 2009), explaining no more than 5% of the genetic component of the disorder.”

    At NIH’s genome.gov, they note “research studies have suggested that there may be a genetic component to this disorder.”

    The uncertain epistemological status of psychiatric diagnoses cannot be satisfied by recourse to genetics. This is as bad as making DSM categories into real definable entities. We’ve been all through this with schizophrenia, depression, etc.

    There is a huge difference between heritability and genetic causation, and also between familial and genetic relations. See this article for analysis of the problems with heritability analysis on traits like IQ, ADHD, etc., as put forth by population geneticists.

    Stigma over being diagnosed with a “mental illness” is a real factor.

    I really dislike the whole concept of labeling people who have need for help with feelings or behavior (wouldn’t that be everyone in the world?)

    I, myself, have been seeing a therapist for depression for most of my life – and in order for me to receive insurance payments; of course I had to be “diagnosed” and categorized. While I was glad to be able to have financial help with the enormous costs associated with psychotherapy – this caused me another problem. I have a position that requires me to hold a security clearance – and one of the factors that could possibly result in not being granted the clearance is receiving treatment for mental “illness.” This has caused me enormous stress and embarrassment when I have had to “defend” my “need” for therapy – and it also causes my therapist to have to be interviewed regarding my suitability to be trusted with sensitive information.

    Of note: President Bush did allow change to the interpretation of the “infamous question 21” on the security clearance questionnaire to enable troops to receive psychological treatment after trauma received during combat – without jeopardizing their clearance status or (hopefully) their reputation.

    http://www.washingtonpost.com/wp-dyn/content/article/2008/05/04/AR2008050401577.html

    I also had to laugh out loud at the following comment – partially because I was thinking the same thing! “I wonder if any of those people will experience the elimination of NPD from the new manual as a kind of narcissistic injury.”

    Kat, this issue of diagnosis is one I often raise with my clients — that it can follow you around for life. While we understandably want reimbursement from our insurance carriers if possible, it’s sometimes better just to come out of pocket in order to maintain our privacy.

    Thank you for this post. I have spent the last 9 months in and out of treatment centers (from inpatient to partial to outpatient) for Bulimia Nervosa and OCD. It was a discombobulated mess of treatment for myself and I watched few people receive continuous care and many get bumped around and passed off by insurance companies. For myself, this was my first time seeking treatment after spending 10 years with my Bulimia. I have been discharged from treatment because of insurance declining further services. My conclusion is that I was purely a case number with a well explained illness to my insurance company while I fought my way through the thoughts of even trying to accept my Bulimia and what it was for me. I’m still struggling and I am trying so hard to work this idea of a program, that was severed so many times and stopped so suddenly. I just can’t help but wonder why my insurance company is so sure I would be doing well when I am undoubtedly failing. So thank you, it really helps to know that a professional agrees, I am not just my Bulimia and OCD. I am; in fact, myself with a box of issues and I don’t want tissues to go with them.

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