What a Mental Illness Diagnosis Does and Does Not Do
Sometimes referred to as the bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth edition (DSM-5), has had a number of criticisms levelled at it. It’s been accused of being so non-specific that almost anyone could be diagnosed with a mental illness, pathologizing normal human experience such as grieving, and being entirely subjective with no objectively verifiable biological markers associated with the various diagnoses.
For all the criticisms, though, right now it’s the best we have. The science just isn’t there yet to make diagnoses based on lab tests or imaging studies. That means that, at least for now, the best we’ve got is diagnostic constructs based on subjective evaluation.
We can gripe about it, or we can focus on ensuring that diagnosis actually benefits people living with mental illness.
What are those potential benefits? From my perspective, the greatest benefit comes in pointing the way towards treatment that’s most likely to be effective. Are the treatments we have now perfect? Not by a long shot. However, if the diagnosis isn’t right, the likelihood of the chosen treatment being effective is much lower.
Diagnosis can make it easier to understand and contextualize what one is experiencing. Knowing that I have a diagnosis of major depressive disorder that consists of a certain set of symptoms, I am in a better position to evaluate how I’m doing and which experiences I’m having are likely related to illness and which aren’t.
Developing and being diagnosed with a mental illness often requires some work around identity construction. Some people identify with their illness, some people do not. The ease of adopting an illness identity will inevitably be influenced by how the individual was socialized with respect to mental illness.
A common stigmatized belief is that people are primarily defined by their mental illness identity. This isn’t true in that particular sense, but a lot of people living with mental illness will identify that illness as a major part of their identity that is pervasive throughout multiple domains of their lives.
Taking on a mental illness identity can be a way to access meaningful support from others within the mental illness community, and connect through shared experiences.
Something inherent in diagnoses based on fallible human constructs is that those diagnoses are not set in stone. Ideally, the diagnostic formulation should be adapted to better suit an individual’s current presentation. This is not always the case. Many people have experiences of being misdiagnosed or going undiagnosed for lengthy periods of time.
Sometimes the issue is less with the diagnostic construct itself and more about the skill (or lack thereof) on the part of the clinicians conducting assessments. A highly skilled clinician will be able to elicit all of the relevant information from a patient, whereas a clinician with poor interviewing skills may not be able to get the whole picture.
Another potential problem is the way in which mental health services are paid for. Each diagnosis in the DSM-5 has a numerical code, and it is based on these codes that mental health practitioners are paid. This doesn’t necessarily pose a problem for diagnostic accuracy, but it certainly leaves the door open.
While there are pros and cons of the current system for psychiatric diagnosis, we can make the most of it by keeping the lines of communication open between clinician and patient and checking judgments at the door. The top priority should always be finding ways for people living with mental illness to live the lives they want to live.
My new book Making Sense of Psychiatric Diagnosis: Understanding the DSM-5 is available now, and features contributions from members of the mental health blogging community, including Johnzelle Anderson.