In Defense of Diagnosis

In “Why I Do Not Attend Case Conferences,” Paul Meehl (1973) described reasoning errors that emerge during case conceptualization conversations among mental health professionals. One of the issues Meehl discussed at length (pp. 272-281) was an antinosological bias, defined as “an animus against diagnosis.” Here’s his response to a common objection to diagnostic labels:

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Meehl described his style there as “highly critical and aggressively polemic,” which he justified by saying, “If you want to shake people up, you have to raise a little hell.” The second section has a much more constructive tone. Both sections are valuable, and I agree with his overall thesis that compassionate, effective mental health care requires clearheaded case conceptualization. Meehl is also correct that 1) meaningful diagnostic systems are crucial for advancing the field and 2) some critiques of the Diagnostic and Statistical Manual of Mental Disorders (DSM) reflect misunderstandings of the diagnostic process. I’ll discuss some of the major criticisms and benefits below.

Criticisms

1. The DSM pathologizes nonpathological behavior.

Barbara_Gittings,_Frank_Kameny,_and_John_Fryer_in_disguise_as__Dr._H._Anonymous_

Barbara Gittings, Frank Kameny, & Dr. H. Anonymous, gay rights activists at a 1972 APA convention

This is true in specific cases. One of the most well-known examples is homosexuality being labeled as a mental disorder in older versions of the DSM. As a result of persistent, organized activism bolstered by research, homosexuality was removed from the DSM. You can learn more about it in excellent podcast episodes by This American Life and Radiolab. Currently, the DSM developers attribute elevated mental health problems among lesbian, gay, and bisexual people to discrimination, actively oppose conversion therapy, and push for policies and law that reduce disparities. In order to prevent future harm, this history must be considered in diagnostic decisions. As Martin Luther King, Jr. said, psychology shouldn’t label people as maladjusted for not adjusting to bigotry.

However, we should also consider that appropriate diagnoses have helped people access beneficial services (e.g., children with intellectual disabilities or autism receiving accommodations in school and other public places). Additionally, the DSM specifically instructs clinicians to only assign diagnoses when a cluster of multiple symptoms: 1) causes clinically significant distress and/or impairment, 2) is persistent and severe for a length of time, 3) deviates significantly from developmental expectations, and 4) cannot be attributed to other factors (e.g., medical, cultural). These types of safeguards reduce the likelihood of pathologizing nonpathological behavior.

2. People are over/misdiagnosed.

Misdiagnosis occurs for many reasons ranging from improper assessment procedures, failure to consider pertinent contextual factors, and biases. For example, attention-deficit/hyperactivity disorder is a meaningful diagnostic category with real-world implications. Nonetheless, there’s evidence that it may be overdiagnosed, which can lead to inappropriate treatment plans.

Issues that exacerbate the problem include 1) lack of funds/insurance coverage for comprehensive assessment procedures and 2) diagnosers who rely too much on their intuition instead of established diagnostic tools. The Ethical Principles of Psychologists and Code of Conduct lays out stringent rules for assessment. A system that ensures adherence to these rules would reduce misdiagnosis while permitting proper diagnosis for people who need treatment and/or services.

use of assessments

3. Classification decisions are made by people with conflicts of interest.

There have been some egregious examples of psychiatry researchers receiving large sums of money from pharmaceutical companies and not properly disclosing them. One instance is covered in a PBS Documentary and in this New York Times article:

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In an effort to address this problem, DSM-5 panel members were required to disclose conflicts of interests. Cosgrove and Krimsky (2012) made a compelling case that further action was needed:

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To be clear, psychiatric medications have helped numerous people and are warranted in particular circumstances. However, steps must be taken to reduce potential biases driven by the pharmaceutical industry.

4. Labeling someone with a mental disorder is stigmatizing.

Despite signs of improvement, prejudice and stigma continue, especially for certain mental health conditions. The solution is to eradicate the stigma rather than the nosology (but it’s worth listening to Szasz’s arguments opposing that idea). When properly applied and understood, diagnoses can alleviate suffering by pointing to effective treatments, connecting people with support and advocacy groups, and evoking compassion. This was nicely demonstrated in Crazy Ex-Girlfriend:

I’m aware mental illness is stigmatized/But the stigma is worth it if I’ve realized/Who I’m meant to be/Armed with my diagnosis

5. Diagnostic categories do not accurately reflect nature.

There are different versions of this, but I’ll focus on the most common: 1) most mental health problems are dimensional (occurring on a continuum) rather than categorical (e.g., there are gophers and chipmunks, but no “gophmunks“), 2) there’s too much variability within diagnostic categories for them to be meaningful, and 3) DSM symptoms are not necessarily the core symptoms of disorders (e.g., for depression).

In response, 1) people have proposed replacing the categorical model with empirically-informed dimensional models (e.g., even if psychopathy occurs on a continuum, it’s quite meaningful to diagnose those in the highest range), 2) diagnostic presentation variability depends on the diagnosis (e.g., people with bulimia nervosa have more in common, on average, than people with borderline personality disorder) and fewer diagnoses with more specifiers could help (e.g., see Pincus, 2011), 3) network analyses are useful for identifying the central symptoms of mental disorders. A concern about major DSM changes is that they will disrupt the work of clinicians and researchers (see Pilkonis et al., 2012). Despite these issues, we need to create a DSM that’s better at carving nature at its joints rather than resisting change or giving up the enterprise altogether.

Benefits

1. Agreed upon definitions facilitate clinically-relevant research.

I agree with McFall’s Manifesto (1991), which states that “the future of clinical psychology hinges on our ability to integrate science and practice” (to hear this debated, check out this Talk of the Nation episode). For example, treatment research for bipolar disorder has more generalizability to real-world clinical settings when therapists and scientists use the same operational definition of bipolar disorder. Moreover, consistent mental disorder definitions across studies makes cumulative knowledge possible. Classification systems enhance communication and research, which contribute to the big picture goal: alleviating suffering.

2. Diagnoses convey useful information when derived from appropriate assessment procedures.

Accurate diagnoses point to literature on the causes, correlates, and effective treatments for specific mental health problems. If an adolescent girl is accurately diagnosed with anorexia nervosa, we learn that she has an increased risk for bone fractures, arrythmias, depression, and suicide and should be monitored for each of these dangers. Importantly, we also know that family-based treatment is likely to be a good treatment option for her and that her parents can connect with parents experiencing similar struggles. To learn more about the process for evaluating levels of empirical support for therapies, look here for youth treatments and here for adult treatments.

3. Diagnostic feedback (when done well) can lead to positive effects.

People tend to experience positive feelings (e.g., optimism, relief) after receiving diagnostic information derived from appropriate assessment procedures and delivered in a collaborative, constructive manner. Similarly, there’s evidence that taking personality inventories and being told about the results from a therapist leads to increased self-esteem, more perceived self-competence, and lowered distress. Why would people feel better after learning about their mental health problems and potentially maladaptive personality characteristics? My guess is that people already know that they’re experiencing certain kinds of issues. When a therapist demonstrates an understanding of the problems by placing them in a meaningful context, they feel validated and hopeful that they can be helped.

4. Diagnostic labels enhance communication between treatment team members and aid continuity in care.

Diagnostic labels ease the transition for clients from one therapist to another (e.g., by saving them from having to repeat assessment procedures) and by communicating efficiently to other members of their treatment team (e.g., social workers, psychiatrists, physicians, clergy).

5. The DSM-5 has improved since the original version and has built-in mechanisms for change.

Despite the hindrances mentioned above, the DSM has formal, built-in processes for evolving with new scientific discovery. New versions are created with the explicit goal of making the classification system better reflect nature. Hyman (2010) argued that we should not reify existing diagnostic constructs. Instead, we must remember that diagnoses are constructed for clinical and scientific purposes. Therefore, improving the DSM requires openness to change and flexibility.

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In conclusion, despite the concerns highlighted above, I agree with Meehl that antinosological biases impede progress and that mental health classification systems should be improved rather than abandoned altogether. I’m grateful for the dedicated clinicians and scientists working to deepen our understanding of mental health and feel encouraged by efforts to use that information to improve people’s lives.

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In an effort to keep this post relatively brief, I highlighted some main points and examples. Some of the more technical, in-depth things I’ve co-written about classification are linked below:

The Classification of Eating Disorders – The Oxford Handbook of Eating Disorders

Empirical Approaches to the Classification of Eating Disorders – Developing an Evidence-Based Classification of Eating Disorders

Nonsuicidal Self-Injury Disorder: A Preliminary Study – Personality Disorders: Theory, Research, and Treatment

Patients’ Affective Reactions to Receiving Diagnostic Feedback – Journal of Social & Clinical Psychology

Suicidal Behavior on Axis VI – Crisis

Taxometric Analysis: Introduction and Overview – International Journal of Eating Disorders

The Validity and Clinical Utility of Binge Eating Disorder – International Journal of Eating Disorders

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A major inspiration for creating the Jedi Counsel blog and podcast was to demystify issues surrounding diagnosis through analyses of fictional characters.

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10 Hamilton Quotes for Therapists

Hamilton

Like many people, I am enamored with the music from Hamilton. There are so many things to like – all the hip-hop (e.g., Cabinet Battle #1!), the psychologically complex and nuanced development of the characters, the diversity of the creators, cast, and crew, and the powerful storytelling of US history. Because I like to explore mental health in fictional characters, I was tempted to with Hamilton as well (i.e., why did Burr and Hamilton end up on such different trajectories?). However, they are based on real people and real lives, so I don’t want to speculate about them (at least not in a blog post). So, similar to what I did with Star Wars, I decided to make a list of 10 quotes from Hamilton, that in my opinion, may be useful for therapists working with Hamilton fans (who are numerous these days).

1)  On mindfulness and gratitude:

Look around, look around at how/Lucky we are to be alive right now!

2) On taking healthy risks and decreasing unhealthy avoidance:

Rise up! Time to take a shot!

3) On acceptance, patience, resilience, and meaning-making:

Love doesn’t discriminate
Between the sinners
And the saints
It takes and it takes and it takes
And we keep loving anyway
We laugh and we cry
And we break
And we make our mistakes

Death doesn’t discriminate
Between the sinners
And the saints
It takes and it takes and it takes
And we keep living anyway
We rise and we fall
And we break
And we make our mistakes
And if there’s a reason I’m still alive
When everyone who loves me has died
I’m willing to wait for it
I’m willing to wait for it

4) On self-empowerment/accepting that one cannot change other peoples’ behavior:

I am the one thing in life I can control

5-6) On understanding historical context for clients who may belong to marginalized groups:

You want a revolution? I want a revelation
So listen to my declaration:

“We hold these truths to be self-evident
That all men are created equal”

And when I meet Thomas Jefferson

I’m ‘a compel him to include women in the sequel!

A civics lesson from a slaver. Hey neighbor
Your debts are paid cuz you don’t pay for labor

7) On not equating self-worth with work achievements

I don’t pretend to know
The challenges you’re facing
The worlds you keep erasing and creating in your mind

So long as you come home at the end of the day
That would be enough

We don’t need a legacy

8) On self-compassion:

Look at where you are
Look at where you started
The fact that you’re alive is a miracle

9) On not letting perfectionism interfere with productivity:

Burr (on the U.S. Constitution): And if it fails?
Hamilton: Burr, that’s why we need it
Burr: The constitution’s a mess
Hamilton: So it needs amendments
Burr: It’s full of contradictions
Hamilton: So is independence
/We have to start somewhere

10)  On prioritizing health and balance:

Take a break

10 Star Wars Quotes for Therapists

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In anticipation of The Force Awakens, I rewatched all of the Star Wars movies over the last few months. I noticed a number of quotes that I believe exemplify therapeutic concepts and have listed my top 10 below. If you’re trying to build rapport with a Star Wars-loving client, engage students with pop culture examples, or just love psychotherapy and Star Wars, this post is for you. If you’re not interested in any of the above, stay tuned for the next post, which will focus on tips for becoming a disciplined writer!

1. Acceptance

Anakin Skywalker: I don’t want things to change.

Shmi Skywalker: But you can’t stop change any more than you can stop the suns from setting.

2. All-or-Nothing Thinking (Cognitive-Behavioral Therapy)

Darth Vader: If you’re not with me, then you’re my enemy.

3. Autonomy (Self-Determination Theory)

Princess Leia: He’s got to follow his own path. No one can choose it for him.

4. Doing What Works (Dialectical Behavior Therapy)

Anakin Skywalker: Sometimes we must let go of our pride and do what is requested of us.

5. Easy Manner (Dialectical Behavior Therapy)

Han Solo: Fly casual.

6. Mental Filter, Jumping to Conclusions (Cognitive-Behavioral Therapy)

Anakin Skywalker: She hardly even recognized me. I’ve thought about her every day since we parted. And she’s forgotten me completely.

Obi-Wan Kenobi: You’re focusing on the negative, Anakin. Be mindful of your thoughts. She was pleased to see us.

7. Mindfulness

Qui-Gon Jinn: Don’t center on your anxieties, Obi-Wan. Keep your concentration here and now, where it belongs.

Obi-Wan Kenobi: But Master Yoda said I should be mindful of the future.

Qui-Gon Jinn: But not at the expense of the moment.

8. Normalizing Difficult Emotions (Acceptance and Commitment Therapy)

Padmé Amidala: To be angry is to be human.

9. Reframing (Motivational Interviewing)

Padmé Amidala: All mentors have a way of seeing more of our faults than we would like. It’s the only way we grow.

10. Wise Mind (Dialectical Behavior Therapy)

Luke Skywalker: How am I to know the good side from the bad?

Yoda: You will know when you are calm. At peace, passive.