Consider the following statements: You look sad. I think you are depressed. You have a recurrent depressive disorder. Which of these is a diagnosis?
I imagine that many, if not most, readers would identify recurrent depressive disorder as a psychiatric diagnosis. You would also be correct to identify recurrent depressive disorder as a specific category of disorder, described in the Diagnostic and statistical manual of mental disorders (DSM-5)1 and the International classification of diseases (ICD-10).2 DSM-5 and ICD-10 are the two main psychiatric classification systems, used to separate different forms of mental distress and disturbance into types of disorder. Diagnosis is often associated or conflated with the classification of disorders.
Indeed, when doctors are asked for the patient’s diagnosis, they are usually being asked for the name of a disorder or illness, according to a classification system. It is probably not uncommon these days for therapists to see people who have been given a medical diagnosis of a depressive disorder (sometimes described simply as depression or clinical depression), particularly therapists working in healthcare settings. It is also relatively common to see clients who describe themselves as depressed. The therapist might then wonder whether it would be helpful to some of these clients to seek a medical diagnosis. Depressive disorder is, of course, only one of a range of psychiatric diagnoses with which a client might present.
The diagnosis might not be the reason for seeking, or the focus of, the therapy. But some clients might assume the therapist knows something about their diagnosis. Some clients might also seek information from the therapist about the diagnosis. Many clients might at least hope, or expect, that they can talk about their diagnosis in therapy sessions. They might, for example, want to explore the process of being diagnosed, or what the diagnosis means to them.
There might be wider psychosocial consequences to the psychiatric diagnosis that clients wish to discuss – the impact on relationships, for example. It is therefore important for therapists to consider what they know about psychiatric diagnosis and whether they hold any particular views. Do they, for example, see diagnosis as important, necessary, inappropriate or harmful? Therapists will then need to consider how their knowledge and views impact their work, both at an organisational level, if they work within an organisation, and with individual clients.
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I would like in this article to offer a conceptual and theoretical overview of psychiatric diagnosis, outlining the nature and use of psychiatric classification systems and the process involved in making a diagnosis. I will also explore some of the psychosocial consequences of being given a diagnosis, particularly the range of subjective meanings that people might attach to a diagnosis. A further aim is to encourage therapists to consider where they stand in relation to psychiatric diagnosis (and the medical model in which diagnosis is embedded) and how they might work with clients who have been given a psychiatric diagnosis.
It is worth acknowledging that the assignment of diagnostic names or labels has become the dominant way to conceptualise and express mental and emotional distress and disturbance in the Western world. It has become a key feature of discourse about mental health. It is central to the organisation of healthcare systems, the delivery of care and the bureaucratic machinery of services. Powerful agendas, as well as cultural and social forces, are at work. Indeed, to properly understand psychiatric diagnosis and the development of classification systems, it is important to see them through cultural lenses.
It is sometimes said, particularly by those who are challenging stigma, that mental illness is an ‘illness like any other’. The statement implies that a psychiatric diagnosis is similar to a diagnosis for a physical condition. As laudable as it is to challenge stigma, there are some misleading assumptions in this comparison. The fact is that a psychiatric diagnosis is different from most physical health diagnoses in a number of respects.
A common assumption about a psychiatric diagnosis is that it represents a medical condition, with a further assumption that the diagnosis is based on an underlying physical disease process. In other words, a psychiatric diagnosis is often taken to imply the existence of an actual entity – something pathological that exists in nature and therefore has an objective basis. The reality, however, is that a psychiatric diagnosis conveys nothing about any underlying disease or pathological process, because scientific research has not yet demonstrated that there is such a thing. Hypotheses about chemical imbalances of neurotransmitters in the brain are just that – hypotheses that remain unproven, and are now largely discredited.3,4 (In refuting disease processes, I am not referring to known physical pathology that can cause secondary mental disturbance, such as dementias, other neurological conditions or hormonal conditions.)
How a psychiatric diagnosis is made
For many physical conditions (although by no means all), a diagnosis is made on the basis of symptoms reported by the patient, a physical examination for signs of disease (for example, the palpation of a lump) and possibly some investigations, such as blood tests or scans, that can confirm, rule out or determine the extent of a disease process. There are usually some objective criteria, according to established scientific knowledge.
For mental disorders, in contrast, there are no biomarkers for disease processes. There are also no physical examinations or investigations that can be used to make a psychiatric diagnosis, other than to exclude a physical condition. Therefore, a psychiatric diagnosis relies entirely on the reporting and observation of symptoms, and those symptoms are the subjective experience of mental phenomena – thoughts, emotions, perceptions and related behaviours. The key word here is subjective, because not only does psychiatric diagnosis rely on a person’s subjective experience and how they communicate their experience, but also on the observation and subjective interpretation of experience and phenomena by the person making the diagnosis.
A psychiatric diagnosis is essentially based on an interview. A lot of data will be gathered from the combined process of taking a history and conducting a mental state examination. Information (experiences and observations) will also sometimes be gathered from third parties. Much of the data collected will be formulated in terms of symptoms; for example, low mood, difficulties sleeping, paranoid thoughts or hearing voices. After identifying the symptoms, how then do doctors know which diagnosis to make? This is where the psychiatric classification systems come in.
The DSM-5 and ICD-10 are broadly similar as compilations of categories of disorder. There are some differences between the two manuals in terminology and organisation of categories. However, both systems have checklists (identifiable patterns) of symptoms for each diagnostic category. Below is an example of how the so-called operational criteria (rules) are described in DSM-5 for each disorder, using the example of generalised anxiety disorder. Note the attempt to define which and how many specific symptoms need to be present, the length of time symptoms need to be present, some reference to severity of symptoms and exclusion criteria.
It should be clear that a psychiatric diagnosis is no more than a list of criteria, which have been arrived at by a consensus of expert opinion. The diagnosis does not offer an explanation of what has led to the distress (or cause). It is simply a system of naming, organising and classifying symptoms. Nevertheless, it is based on the notion and assumption of pathology, evidenced by the use of the term ‘disorder’, which implies a dysfunction, deficit or abnormality.
The notion of pathology leads to another important point, which is the assumption that it’s possible to designate mental experience and behaviour as normal or abnormal, with the implication that there might be an objective measure or criterion of abnormality, or an objective way of determining when an experience becomes a symptom. The reality, however, is that notions of abnormality rest on culturally determined judgments. In other words, we are in the realm of values rather than scientific facts.
Criticisms of psychiatric diagnosis
There are a number of criticisms of psychiatric diagnosis. A key criticism is the lack of scientific validity to categories of disorder, given the absence of proven physiological disease processes. The lack of reliability in the use of classification systems is another, as we can perhaps assume that doctors or researchers would not all reach the same diagnosis when presented with the same data. A Western cultural bias and general disregard for social context are other criticisms, as is the claim of medicalising and pathologising normal human experience – in other words, assigning a diagnosis or pathological status to experiences or stages of life that could be considered normal.
Nevertheless, psychiatric diagnosis serves a number of purposes. For example, it enables the efficient organisation and delivery of healthcare and other services, often based on the assumption that a diagnosis is needed in order to guide treatment. A diagnosis certainly is the basis for research into treatments and therefore treatment guidelines. It is communication shorthand for professionals, making it easier and quicker to exchange clinical information. A diagnosis is also necessary for systems of care that are insurance based. Whatever the criticisms then, there is no doubt that psychiatric diagnosis is the main gateway through which people are likely to receive help and support from health, social care and many other services. For example, the provision of educational support often depends on a child receiving certain diagnoses.
However, despite its utility from a clinical and organisational perspective, a diagnosis might also have a number of other, sometimes unintended, consequences. We can perhaps know and understand these most powerfully from clinical encounters with people who have been given a psychiatric diagnosis.
My previous experience of working in mental health services as a psychiatrist leads me to argue that therapists’ awareness and sensitivity to some of the psychosocial consequences and subjective meanings of psychiatric diagnosis place them in a uniquely important role. I say this because it became increasingly evident to me over the years that attention to the subjective meanings of psychiatric diagnosis is a much-neglected aspect of clinical practice, certainly within mental health services.
It was not something I was encouraged to be interested in during my training, or throughout my career. Many, if not most, psychiatrists accept that making a psychiatric diagnosis is a core function of their role. It becomes an activity to perform and prioritise as part of assessment and treatment planning. Some of the meanings, positive and negative, that can be attached to a diagnosis, many of which can be powerful, receive much less, if any, attention. As a result, therapy could be an important space for clients to talk about issues related to being given a psychiatric diagnosis.
There are a number of reasons why people might welcome a psychiatric diagnosis. I have witnessed many times how giving something a name seems to make it real in some way. A diagnosis can be experienced as a validation and recognition of suffering. It can communicate that a person is being taken seriously, which can be therapeutic. For some, a diagnosis might relieve feelings of shame or the feeling that their experiences and difficulties are their ‘fault’. It seems to externalise the problem in a way that brings relief, perhaps because it releases people from a sense of responsibility or certain roles. It is certainly the case for some people that a diagnosis can have a variety of helpful, social consequences, such as exemption from employment or access to benefits and other systems of support.
There is often a powerful sense of hope that the diagnosis will lead to particular support or the provision of treatment (or even the ‘right’ treatment), such as psychiatric drugs. It can also provide people with a sense of clarity and order, and perhaps a greater sense of control, helping them to cope better with a hitherto confusing tangle of thoughts, emotions and other mental experiences. Again, this can be powerfully therapeutic.
But it’s not all positive. I have also witnessed the way in which a diagnosis can lead people to view themselves as disordered and defective, to believe that something is wrong with them, or wrong in them. They might also see themselves as weak or a failure. In other words, a psychiatric diagnosis can impact negatively on a person’s identity and self-concept, creating feelings of shame and stigma, which could result in discrimination.
A psychiatric diagnosis can also have a disempowering effect, leading people to reluctantly, or perhaps readily, hand over control and responsibility to others, such as medical or other experts. A psychiatric diagnosis can powerfully affect personal agency. As a result, it can close down possibilities for self-directed growth and recovery, with preference given to a reliance on expert applied, technical treatments, such as psychiatric drugs.
In my role as a psychiatrist, I often noticed how people experienced a mixture of both negative and positive meanings – and also how these shifted over time. For example, initial relief at being given a diagnosis might give way to bewilderment and anger, particularly if the diagnosis does not lead to expected treatments, the treatment turns out to be unhelpful or there are unexpected social consequences, such as how a diagnosis can affect personal relationships or lead to a questioning of parenting abilities. Another common observation was, again, initial relief, followed by frustration at the lack of causal explanation for the diagnosed condition. Further layers of confusion are added when a person’s diagnosis is changed after a period of time, or by a different doctor, who sees things another way.
It should be evident, then, that there is a complex array of potential effects and meanings given to a psychiatric diagnosis. Some of these are succinctly captured in the following quote:
‘Diagnosis can turn the fright of chaos into the comfort of the known; the burden of doubt into the pleasure of certainty; the shame of hurting others into the pride of helping them; and the dilemma of moral judgment into the clarity of medical truth.’5
Here, a psychiatric diagnosis is clearly portrayed as positive and helpful. While it’s hard to deny that a diagnosis can be comforting for many, people experience the process of being medically assessed and diagnosed in a range of ways, influenced in part by the interviewing style and personality of the doctor.
It surely cannot be true that it is a benign or necessarily helpful process for everyone, even when intentions are good (‘the pride of helping’). People often feel as though they were treated like objects, particularly if the clinician adopts a detached and impersonal interviewing style. It’s perhaps interesting to note that doctors are sometimes taught the importance of emotional detachment as a means of ensuring objective evaluation during their training; I certainly was. A diagnostic assessment also places the power clearly in the hands of the expert, which means there is potential for misuse of this power. It is a process in which the expert’s knowledge and frame of reference carries the most weight, which might be experienced as disempowering or invalidating. For people who readily defer to the opinions and evaluations of others, the diagnostic process will reinforce this tendency. It can even re-traumatise those who have suffered abuse or oppression.
I am also struck by the phrase ‘clarity of medical truth’ in the above quote, and the notion that a psychiatric diagnosis represents a medical truth. Again, there are powerful consequences when a diagnosis is presented in this way, with authority assumed to lie in the hands of medical experts or medical science.
How helpful is a psychiatric diagnosis?
There is likely to be a wide range of responses from therapists to questions about the helpfulness of psychiatric diagnosis. Responses will, in part, depend on a therapist’s stance in relation to the medical model and whether this is regarded as an appropriate or helpful approach to mental distress and disturbance. However, wherever a therapist stands philosophically and ideologically, the fact remains that our systems of health and social care, as well as other forms of support, frequently rely on diagnosis. As long as this is the case, there is an argument for finding ways of working with, or alongside, diagnosis, whatever one thinks or feels about it. I would urge therapists to ask themselves two questions: to what extent does a client’s psychiatric diagnosis influence the therapist’s way of working? Does it influence whether to offer someone therapy in the first place?
In my own practice, a diagnosis might give me some clues about a person’s mental and emotional experience (types of symptoms), but it says very little about the unique individual, their attitudes, beliefs, values, motivations and strengths. It tells me little, if anything, about their hopes and expectations about therapy or how they might engage with it. There is so much that a diagnosis does not reveal about a person. Yet it can powerfully mislead.
I began this article with three statements. While only one refers to a diagnostic category from a classification manual, all three relate to diagnosis in the sense of naming an emotional or mental experience. However, there are differences in what they suggest about the roles and power dynamics within the relationship. Of the three statements, two are assertions of pathology from an expert position. The other statement could, if made in a certain way, be in the spirit of enquiry and attempt empathically to get alongside the person. It shouldn’t take a diagnostic classification system to be recognised, heard, understood or to experience comfort.
1 American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th edition) (DSM-5). Washington, DC: American Psychiatric Publishing; 2013.
2 World Health Organisation. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and guidelines. Geneva: World Health Organisation; 1999.
3 Moncrieff J. A straight talking introduction to psychiatric drugs. The truth about how they work and how to come off them. Monmouth: PCCS Books; 2020.
4 Paris J. Fads and fallacies in psychiatry. London: RCPsych Publications; 2013.
5 Reich W. Psychiatric diagnosis as an ethical problem. In: Bloch S, Chodoff P, Green S (eds). Psychiatric ethics (3rd edition). Oxford: Oxford University Press; 1999 (pp193–224).