Monday, July 16, 2012

On the validity of psychiatric diagnosis

Witness, on BBC World Service, last month broadcast about the Rosenhan experiment (listen to podcast). Rosenhan died earlier this year (see Stanford Law School news). There's also an earlier, longer radio programme by Claudia Hammond in the Mind Changers series.

I do think Rosenhan's 1973 paper in Science, On being sane in insane places, is still relevant. It very much contributed to the crisis in psychiatric diagnosis that led to DSM-III trying to tighten up the definition of the different syndromes by operationalising them. We're still struggling trying to revise DSM on this basis (see previous blog entry).

We need a different reaction to Rosenhan. Psychiatry need not have been so defensive about his experiment. Of course psychiatric diagnosis is arbitrary to some extent. Trying to put a patient's psychiatric presentation into a single word isn't going to be sufficient, nor is it always going to be very helpful. I'm not against trying to classify psychiatric disorders, but the limitations need to be recognised. They're idealised descriptions which do not describe entities as such. The extent to which psychiatric diagnosis is subjective is not a sign of scientific deficiency but of its meaningful nature.


Anonymous said...

sorry Duncan but I do think it's a sign of scientific deficiency.
Formulation is an alternative to diagnosis

Schizophrenia at the Schoolgate said...

I would like to add my views on the use of diagnosis. As a young woman I was diagnosed with schizophrenia, and told that I would never recover and that I would need medication for the rest of my life. Now that I have recovered (am happily married with four young children, an author, working as a Peer Specialist) I have been told that I never had schizophrenia - or rather, that if I presented with those symptoms now, I would not be given that diagnosis.

This, to me, illustrates why diagnosis is not a good thing. It is an illustation of 'doublethink' - basically guesswork - if I had never recovered, presumably I would always be considered to have had schizophrenia - because I got better, it turns out that the diagnosis was wrong.

Furthermore, the diagnosis itself is extremely damaging - it acts as a barrier to recovery, to quote Clare Gerada in a recent Schizophrenia Commission meeting.

I am very glad to have found that there are mental health professionals who accept that drugs are not the solution to all forms of emotional distress. I hope that you continue to think in ways which challenge attitudes to mental illness - the more sufferers can be normalised and accepted in society, the quicker their problems will be resolved.

All the best

Sam Barnett-Cormack said...

I think this extends beyond mental health - we need, as patients, to understand and be told about the difference between a functional diagnosis and an aetiological one. The vast majority of psychiatric diagnoses are functional - these can be clinically useful, to make informed guesses about what treatment will work, and about prognosis. The same is true of some non-psychiatric diagnoses, like migraines (and classifications of such), ME/CFS or fibromyalgia. They are real, we can understand things about them, but the aetiology is unclear or totally unknown, and thus there is no clear test for them.

Aetiologically understood diagnoses have, often, higher degrees of confidence, objective diagnostic tests, and so forth - but this confidence is the main advantage in the short-term clinical context, in my opinion. It also has advantages in determining new treatments, of course, but that's not relevant to an individual consultation (most of the time).

Researchers, especially pharma companies, want to find aetiologies for psychiatric disorders. Some have strong evidence for organic origins (I understand certain forms of schizophrenia fall into that category), others it's all guesswork, sometimes based on what medications help! However, just from my own experience of my own mental health, I think it likely that most cases are an interaction of psychological and organic factors.