Introduction to the ABAI Practice Community Blog and Practice Board member bios.
Making Sense of Diagnostic Categories
What is a diagnosis? While psychiatric jargon has become part of everyday vocabulary, what does a psychiatric diagnosis like major depressive disorder, anxiety disorder, or autism spectrum disorder mean? Making sense of diagnoses, or explaining diagnostic categories to clients and their families, tends to be vexingly difficult. For this reason, we – the members of the ABAIs Practice Board – have generated blogs to address current thinking related to diagnosis. The purposes of these blogs are three-fold:
- to generate informed practitioners;
- to facilitate communication with clients or their care partners about psychiatric diagnoses; and
- to generate a shared vision for the future.
Part 1: What is a diagnosis?
According to the Oxford English Dictionary, the word “diagnosis” is synonymous with discrimination – telling things apart. The word comes from Latin diagnōsis, Greek διάγνωσις. It refers to the active processes of distinguishing and discerning (διαγιγνώσκειν; δια- through, thoroughly, asunder + γιγνώσκειν to learn to know, perceive). Laypeople’s belief is that, with sufficient training, practitioners learn to distinguish naturally occurring disease categories and to “carve nature at its joints.” As we describe below, where mental health is concerned, this belief is a misconception, an erroneous belief that persists despite much evidence to the contrary.
To begin, consider the preface of the Diagnostic and Statistical Manual (DSM-5-TRTM) of the American Psychiatric Association:
“The American Psychiatric Association’s [DSMTM] is a classification of mental disorders with associated criteria designed to facilitate more reliable diagnoses of these disorders. With successive editions over the past 60 years, it has become a standard reference for clinical practice in the mental health field. Since a complete description of the underlying pathological processes is not possible for most mental disorders, it is important to emphasize that the current diagnostic criteria are the best available description of how mental disorders are expressed and can be recognized by trained clinicians.” (Emphasis added.)
In other words, excepting some irreversible neurodegenerative declines in adulthood (formerly called “dementias”) which are now categorized as due to Alzheimer’s, Huntington’s, and other neurological diseases, and some genetic syndromes associated with neurodevelopmental disorders, we cannot link any of the current diagnostic categories to underlying physiological conditions. There are no biomarkers, no genetic tests, and no physical exams that uphold the diagnostic categories listed in the DSMTM.
Instead, sociocultural processes – also involving the professional community of scientists and practitioners – give rise to categories of behaviors deemed in need of change. Difficulties are not a sign of some underlying disease categories. Instead, samples of behavior are categorized as clinically significant. To underline: Society at large influences which behaviors are viewed as intervenable, and the psychiatric diagnostic systems tend to reflect these sociocultural assumptions. By way of these social processes, prior renditions of diagnostic manuals are at odds with our current thinking and assumptions.
Diagnoses are best thought of as labels that describe highly correlated patterns of behavior. These patterns indicate that a person is suffering in their current and/or past sociocultural context. From a scientific perspective (see the statement by the American Psychiatric Association above), the label is silent as to the reason for the suffering. Consider the research conducted by Hops and colleagues in the 1980s: They found that the social withdrawal patterns of women with a diagnosis of depression helped these women avoid coercive interactions in the home. Here, the familial system needed an intervention. Similarly, many adults in skilled nursing facilities do not participate in scheduled activities such as bingo or trivia and complain of hopelessness and worthlessness. These adults often receive diagnoses of depression. Should the intervention occur at the individual or at the institutional level when facilities do not provide access to meaningful activities or choices? What would you do if you could not live in line with your values or preferences? Finally, what about the members of minoritized or marginalized populations who encounter limited access to resources and frequent interpersonal hostilities? Martin Luther King suggested in his 1967 speech to behavioral scientists that in the presence of coercion and oppression, we should all be “maladjusted” rather than strive to produce conformity with systems in need of treatment.
If scientists agree that diagnoses are labels for patterns of behavior without indication of causality, why do we continue to search for physiological underpinnings? Ryle, a philosopher, would say that reification – trying to locate patterns in a structural space and giving them object-like qualities – is a pitfall of our language. He gives the following example:
[Imagine you are] visiting Oxford or Cambridge for the first time and [are] shown a number of colleges, libraries, playing fields, museums, scientific departments and administrative offices. [You] then ask, “But where is the University? I have seen where the members of the Colleges live, where the Registrar works, where the scientists experiment and the rest. But I have not yet seen the University in which reside and work the members of your University.” It then has to be explained to [you] that the University is not another collateral institution, some ulterior counterpart to the colleges, laboratories and offices which [you have] seen. The University is just the way in which all that [you have] already seen is organized.
Just as the university is an abstract organizational label associated with activities in given buildings, so is a diagnosis an abstract organizational label for the behavior patterns of people. In the same way that we ask, “where is the university,” and immediately notice that this is a futile question, we ask, “where in the brain/body is the depression,” and here most of us fail to recognize the question’s futility.
Indeed, many researchers and practitioners are familiar with the futility and faulty logic of diagnoses: We reify the labeled patterns and then use the label to justify the pattern within circular reasoning. Here is the common example: “Why is the person sad?” – “Because they are depressed.” – “How do you know they are depressed?” – “Because they are sad.” These researchers and practitioners are trying to free us from these never-ending loops through innovation and the design of new classification systems. The social construction of diagnoses means that the system by which we – as a verbal community – decide what patterns are intervenable could look very different. “Social construction” indicates that the status quo can be changed, and there is hope for better and more equitable assessment and categorization systems in our future.
Sources and Further Reading
Diagnostic manual
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Dictionary
Oxford English Dictionary and Historical Thesaurus (OED Online). Retrieved from https://www.oed.com
Questioning the status quo
Martin Luther King, Jr.’s challenge to the nation’s social scientists. Retrieved from https://www.apa.org/topics/equity-diversity-inclusion/martin-luther-king-jr-challenge
Comprehensive review of the biomedical model
Deacon, B. J. (2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review, 33(7), 846-861. https://doi.org/10.1016/j.cpr.2012.09.007
History
Chesler, P. (2005). Women and madness (1st, rev. and updated.). Palgrave Macmillan.
Drescher, J. (2015). Queer diagnoses revisited: The past and future of homosexuality and gender diagnoses in DSM and ICD. International Review of Psychiatry., 27(5), 386–395. https://doi.org/10.3109/09540261.2015.1053847
Greco, M. (2016). What is the DSM? Diagnostic manual, cultural icon, political battleground: an overview with suggestions for a critical research agenda. Psychology & Sexuality, 7(1), 6-22. https://doi.org/10.1080/19419899.2015.1024470
Scull, A. (2022). Desperate remedies: Psychiatry’s turbulent quest to cure mental illness. Harvard University Press.
Whitaker, R. W. (2019). Mad in america: Bad science, bad medicine, and the enduring mistreatment of the mentally ill (Third trade paperback ed.). Basic Books.
Examples of functional approaches to behavioral health case formulation
Haynes, S. N., O’Brien, W. H., & Kaholokula, J. K. (2011). Behavioral assessment and case formulation. John Wiley & Sons.
Hops, H., Biglan, A., Sherman, L., Arthur, J., Friedman, L., & Osteen, V. (1987). Home observations of family interactions of depressed women. Journal of Consulting and Clinical Psychology, 55(3), 341-346. https://doi.org/10.1037/0022-006X.55.3.341
Philosophy
Hacking, I. (1999). The social construction of what?. Harvard University Press.
Ryle, G. (2002). The concept of mind. University of Chicago Press.