A note on 'diagnostics'...

I will be looking at more terms that have crept into our language from therapy consulting rooms and other sources (I’ve peeped at ‘codependence’ which launched into the mainstream after a best-selling book, and ‘gaslighting’ which first became a verb in response to a chilling British play and film, while ‘narcissism’, ‘empath’ and many others have gained their traction online). However, I also look at some terms that differ from the rest, because they are ones used by mental health professionals to diagnose – such as OCD, PTSD, narcissistic personality disorder or ADHD.

A mental health diagnosis is made after assessing symptoms against written descriptions and criterion that are set out in diagnostic manuals (the two most important ones I’ll come onto describe), and other clinical guides. A clinician’s experience and personal understanding of their patient comes into play in diagnosing too, as much of the assessments made will be subjective, and there will always be room for interpreting things differently. Ultimately, diagnosis needs to be done very carefully, and to be left to the professionals – and I’ll come onto explain that most of us, including me, aren’t in that camp.

In my posts I refer to the manuals but also return to the idea of how diagnosis – even when done by a qualified practitioner – is a double-edged sword. While it means you may be able to access treatment (if available), and have a useful meaning-making to distress, many feel that many diagnoses reduce the complex nature of a human distress to a simple label (perhaps better stuck on a jar). For example, I have had a client diagnosed with ‘major depressive disorder’ to find this de-humanising and critical, while another found it relieving to know they aren’t at fault for their struggle to function.

Diagnoses made in mental health settings tend to be made for two main reasons, firstly, as just mentioned, to identify an appropriate treatment pathway, such as, say for depression, a referral for Cognitive Behavioural Therapy or for a prescription for an anti-depressant SSRI drug. They also make communication between clinicians, and within research communities, easier as they can compare like for like. In other words, a GP may refer her patient to a psychiatrist for an assessment for OCD, and both doctors have a ballpark idea of what the concern is.

Our whole system of diagnosing in mental health care has become a battleground of late, and you may be familiar with the split between those who think we are diagnosing mental health conditions too much (in particular, ADHD and anxiety), and those who point to the swell of waiting lists for assessments, and think we aren’t diagnosing enough. You may well also be confused about who can or can’t make a diagnosis too.

In my posts to follow, I show how diagnostic categories have drawn lines where smudges may be better – or at least there could be different lines that capture our suffering better than they currently do. Their demarcation is also bound up with the profound question as to what makes a psychiatric ‘disorder’ or ‘condition’ in the first place, which has been the focus of much debate amongst anti-psychiatry advocates since the 60s (when both the Scottish psychiatrist RD Laing and the French historian Michel Foucault challenged received ideas of who, or what, decides if we are ‘sane’ or not). Many feel that the current tilt toward our concentration on mental health symptoms ignores the relevance of the many causes of anguish, the contexts in which they arise, nuanced subjective experiences, and our individual dignity.

In the UK, a loud dissent against our ‘medical model’ of symptom-led diagnostics that we currently have is reflected in the growing alliance behind ‘The Power Threat Meaning Framework’, launched in 2018 by senior psychologists such as Lucy Johnstone and Mary Boyle, and other mental health advocates. They want to shift the fundamental premise of diagnosing from one of ‘What is wrong with you?’ to a broader enquiry of: ‘What has happened to you?’ This more compassionate approach seeks to re-frame observed symptoms – such as those of anxiety - as understandable, and appropriate, human responses to adversities, as opposed to being problems to fix per se.

So, for example, anxiety can be understood to result from a constellation of factors - such as our evolutionary biology (our brain is wired toward negative thinking), our politics and culture (with a media feeding us negatives stories, as well as truly negative stories), family and social influences (such as experiences of deprivation or abuse). This new way of diagnosing asks us to consider the whole story of someone’s distress so that we can respond with more appropriate treatments than the ones we have now – such as offering help with housing or family relationships, rather than just a prescription for drugs.

As a psychotherapist, I am freed of diagnostic categories to fit, or bend, my clients into, and I have been trained to respond to my clients in ways like this. For me, and my colleagues, the ‘what has happened to you?’ question sparks the most of my early conversations in the consulting room. I can’t diagnose a client, even after a five-year training (including a lengthy placement in a psychiatric unit), and over twenty years’ experience of full-time work in the field. In the UK, psychotherapists, counsellors, mental health support workers, and social workers may share their view on the matter with someone who can diagnose, but we can’t act alone.

It’s worth bearing in mind that typically, mental health diagnoses are made by psychiatrists (who have completed medical school and further training in mental health), who can also prescribe medication, such as anti-depressants and anti-psychotics. Clinical Psychologists with doctoral-level qualifications (usually a DClinPsy or PhD in Clinical Psychology) can make some diagnoses too, but they cannot prescribe medication. General Practitioners can also make initial diagnoses for common mental health conditions, like depression or anxiety, as well as prescribing some commonly prescribed drugs, but they tend to refer patients to psychiatry for more complex or severe conditions.

In the US though, things are a little different and given lots of us read US literature online and watch US shows and films, it’s useful to know that they work differently. Psychotherapists there can diagnose, typically using the diagnostic manual of the Diagnostic Statistic Manual (I’ll come onto shortly and mention a few times in this book). This is partly because insurance companies that cover therapy bills need DSM diagnoses with specific codes to process claims and determine coverage. (I have met US therapists who dislike having to ‘reduce’ their clients into diagnostic boxes so much that they work privately, outside the insurance system. However, the unhappy trade-off means having to charge private fees, which many can’t afford.)

US psychotherapists can’t prescribe medication just as I can’t, unless they are medically trained as well. So, they also refer clients onto a psychiatrist for this, which means many US ‘patients’ or ‘clients’ (depending on who is saying this – I’ll come onto explain!), see two professionals for their mental health as mental health prescriptions are at a far higher rate in the US. In some states, clinical psychologists can also prescribe if they have been trained and licensed to do so.

Just to complicate things a little further, psychoanalysts, who practise the Freudian form of psychotherapy (or those of his affiliated schools), can also use their own diagnostic language amongst themselves and to their ‘patients’ (they use the language of medical doctors here, while most psychotherapists, like me, refer to their ‘clients’. Few refer to the older term of ‘analysand’ instead). Early psychiatric diagnoses, in the 40s, 50s and 60s were heavily influenced by Freudian thinking, and while they have since drifted away from this, some terms linger. For example, you might have heard the terms ‘schizoid personality’ or ‘Oedipus complex’ or ‘anally retentive’ which aren’t diagnoses, but complex descriptions that are best left to discussions between analysts.

So, to re-cap, diagnostic terms should be used by those with specialist training, and they rest upon classifications that have evolved since medical authorship began in the late 17^th century. We’ve had some sort of psychiatric ‘nosology’, or classification of disease since then, but this only really began to take off in the way that we are familiar with after the Second World War when in 1948, the World Health Organisation published the sixth revision of its International Classification of Diseases, ‘ICD’, with a dedicated section for mental disorders for the first time. The American Psychiatric Association (APA) responded with their own Diagnostic Statistic Manual, the ‘DSM’ in 1952, then a far slimmer volume than today’s more weighty iteration (and as I mentioned above, heavily influenced by Freudian thinking).

I will refer to editions of both the DSM and ICD and although the DSM doesn’t govern UK diagnostics, it does govern international research literature and is often referred to in US journalism and other first-person accounts. You’ll see how each edition responds to growing research and even the politics of the time, which means diagnostics evolve over time too – including the creation and deletion of conditions. I show how this happened, for example, in the context of anxiety, depression, PTSD and autism in this book. You’ll also see how every diagnosis has room for interpretation, subjective assessment and, in some cases confusion and controversy.

It’s worth adding that in England, that mental health diagnostics are also heavily influenced by guidelines from the National Institute for Health and Care Excellence (NICE) which provide evidence-based recommendations for the prevention, diagnosis, treatment, and management of health conditions. They often reference ICD classifications and use its language, rather than material from the DSM. GPs also use various assessment tools to screen for depression, anxiety and other commonly presenting conditions, and research continues to amend and improve on these too. However, I have spoken with GPs who have so much experience in mental health – sometimes more than other health problems – that they don’t need to refer to guidance (which is why you might have had a diagnosis without completing a form).

Diagnosing a mental health condition must also be done after a thorough, and confidential, assessment of the person concerned. As tempting as it is to define someone as having a ‘narcissistic personality disorder’ or as a ‘psychopath’ - especially with the words and behaviours of many male politicians baffling our minds on the world stage – none of us should be diagnosing from afar, including the experts. This so-called ‘Goldwater Rule’ should really apply to us all.

Barry Goldwater was a Republican US senator in 1964 and his extreme views became associated with his saying ‘Extremism in the defense of liberty is no vice!’ in his acceptance speech for the Republican nomination for President. During his campaign, Fact magazine published an article, ‘The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater’ having canvassed 12,356 psychiatrists for their view on whether Goldwater was psychologically fit to be president. Of the 2,417 psychiatrists who responded, 1,189 declared Goldwater not to be, with some offering specific diagnoses, although none had met him. (One wrote, ‘A megalomaniacal, grandiose omnipotence appears to pervade Mr. Goldwater’s personality giving further evidence of his denial and lack of recognition of his own feelings of insecurity and ineffectiveness’).

Goldwater successfully sued the magazine for libel, and since 1973, his nominal rule has been embedded as an ethical guideline in the APA’s Principles of Medical Ethics and has since been extended to other mental health professionals in the US and endorsed by the UK’s Royal College of Psychiatry. This makes it unethical to offer professional opinions about the psychology of any public figures who have not been properly assessed, unless they have given their explicit permission for such opinions to be made.

The Goldwater Rule reminds all of us to take care when we use clinical diagnostic terms. Even if you have listened to many podcasts or TikTok posts about social anxiety disorder and think you, or your friend has it, it’s best to hold this idea lightly and consider finding an expert opinion, and further support for your distress. You may be right of course, but if you aren’t, you could run the risk of ‘boxing yourself in’ and underestimating your built-in resilience. I come back to these ideas more in my posts that follow.