[D66] A Psychiatric Diagnosis Is Not a Disease

[A.OUT]

A Psychiatric Diagnosis Is Not a Disease
By
Psychology Today
psychologytoday.com
4 min
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In my first week as a psychiatry faculty member, an advanced psychiatry
resident—I’ll call her Dr. G—staffed a case with me. That’s medical
speak for discussing a patient with a teacher. Dr. G gave me some
demographic information, then began listing the medications she was
prescribing.

“Hold on,” I said. “What are we treating her for?”

“Anxiety.”

“How do you understand her anxiety?”

Dr. G cocked her head to the side with a blank, non-comprehending look.
I rephrased. “What do you think is making your patient anxious?”

She cocked her head to the other side.

“What is causing her anxiety?"

Dr. G pondered, then brightened. “She has generalized anxiety disorder.”

“Generalized anxiety disorder is not the cause of anxiety,” I explained.
“That is just the label we use to describe it.”

Another blank look. I tried a different tack. “What do you think is
going on psychologically?”

“Psychologically?”

“Yes, psychologically.”

 “I don’t think it’s psychological, I think it’s biological.”

“Okay, that’s a start,” I said. “Tell me why you think that.”

“Her mother was anxious.”

“This means your patient’s anxiety is biological?”

“Yes.”

It was my turn to cock my head.

“Let's try a thought experiment. Suppose your patient was adopted at
birth and is not biologically related to the mother who raised her. Do
you think an anxious mother, who is continually communicating that the
world is unsafe, could make a child anxious?”

“I never thought about it that way.”

I suppressed a momentary urge to bang my head against the cinderblock
wall. Then I signed Dr. G’s treatment plan and hoped I had planted at
least a seed of curiosity.

Diagnoses listed in the DSM—the Diagnostic and Statistical Manual of
Mental Disorders, the so-called bible of psychiatry—do not cause
anything. They are not things. They are agreed-upon labels—a kind of
shorthand—for describing symptoms. Generalized anxiety disorder means a
person has been anxious or worried for six months or longer and it’s bad
enough to cause problems—nothing else. The diagnosis is description, not
explanation. Saying anxiety is caused by generalized anxiety disorder
makes as much sense as saying anxiety is caused by anxiety.

The same is true for other common DSM diagnoses. Major depressive
disorder means a person has had continually depressed mood, or lack of
interest or pleasure in activities, for two weeks or longer, along with
several other symptoms that often accompany depressed mood. Major
depressive disorder does not cause the symptoms, it is the term we use
to describe them.

Here is the circular logic: How do we know a patient has depression?
Because they have the symptoms. Why are they having symptoms? Because
they have depression.

Confusion arises because other medical diagnoses point to etiology—to
underlying biological causes. This is why “chest pain” is not a
diagnosis, it is a symptom. Atherosclerosis, myocarditis, and pneumonia
are diagnoses. They describe underlying biological conditions that may
cause chest pain.

Psychiatric diagnoses are categorically different because they are
merely descriptive, not explanatory. They sound like medical diseases,
especially with the ominously-appended disorder, but they aren't. If we
speak of generalized anxiety disorder and major depressive disorder as
if they are equivalent to pneumonia or diabetes, we are committing a
category error. A category error occurs when we ascribe a property to
something that cannot possess it—like emotions to a rock.

The American Psychiatric Association made the same point. Until
recently, its website included this crystal-clear caveat about the DSM:
“Diagnostic criteria provide a common language for clinical
communication... Patients sharing the same diagnostic label do not
necessarily have disturbances that share the same etiology nor would
they necessarily respond to the same treatment.”

When the National Institute of Mental Health concluded that DSM
diagnoses do not map underlying causes and cannot be a starting point
for mental health research, the American Psychiatric Association agreed.
“DSM, at its core… is a guidebook to help clinicians describe,” the
chair of the DSM-5 Task Force wrote in response. “It provides clinicians
with a common language.”

How could Dr. G misunderstand this? How did she come to think of
generalized anxiety disorder as a disease that causes anxiety?

Our struggling students, in their moments of concreteness, hold up a
mirror to our hypocrisies.

The American Psychiatric Association says patients with the same
diagnostic label do not necessarily have the same disturbances or
respond to the same treatments. Then researchers develop treatment
manuals based on DSM diagnoses. Professional organizations publish
practice guidelines based on DSM diagnoses. Health insurers insist that
providers follow treatment algorithms based on DSM diagnoses. And
pharmaceutical companies run television ads that say, “Depression is a
distinct medical condition… it causes intense mood and physical
symptoms.” Of course they do.

Doublethink, anyone?

Recently, I saw a self-exam in the American Psychiatric Association
study guide for DSM-5. The format is case vignettes followed by
multiple-choice diagnoses. One vignette described a patient with a fear
of flying, followed by the question: “Which of the following disorders
is the most likely cause of his anxiety?”

My write-in answer would have been: “None of the above, because DSM
diagnoses are descriptive labels, not causes.” The study guide answer
was “c) Specific-phobia—situational type.”

I would have failed that exam. My student, Dr. G, would have aced it.