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Pitfalls of diagnostic labelling

Categorizing mental disorders when they should be personalized

Labels serve a variety of purposes. Assigning a name to something can offer a false sense of comfort and understanding, and labels within the mental health care system are no exception. Diagnostic labelling has been a controversial issue within clinical psychology for decades. Following last year’s release of the fifth revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), many of these criticisms have resurfaced, and the debate over the most appropriate diagnostic model has become more heated than ever.

With a listing of nearly 400 mental disorders, the DSM-5 – often referred to as the “Bible” of psychiatry – takes a largely categorical approach to disorder classification. For Ethan Macdonald, a member of the Inclusive Mental Health Collective at McGill, these solid walls between psychological conditions are too limiting. Macdonald believes that individuals should be given room to make sense of their own experiences, outside of the psychiatric diagnoses that bind them in their everyday lives. “The act of coercing someone into a DSM category […] in order to access services is but one way we marginalize and oppress the psychologically diverse. A diagnosis can have a major impact on the way one lives, and yet here we have groups of people who can’t access resources if they don’t fit into the proper category,” he wrote in an email to The Daily.

Macdonald is not the only one who finds the current categorical approach to be problematic. Individuals in the community concerned with mental health issues have brought up the troubling phenomenon of “diagnostic inflation.” They point out that many new disorder categories are introduced with each DSM revision, despite the fact that there are significantly more disorders than treatment options and the same drugs are used to treat patients with supposedly distinct conditions. According to Frédéric Fovet, director of the Office for Students with Disabilities (OSD) at McGill, “Almost all forms of human behaviour can now [fit] into the description of a ‘dysfunction.’” Not only could this be a waste of limited resources, but more importantly, it also runs the risk of unnecessarily subjecting people to harmful treatments and stigma. “Literally tens of millions of new patients will be created overnight with no evidence that they can be accurately identified, no proven effective treatment, and every indication that the medication treatments offered can have very harmful side effects,” said Allen Frances, chair of the task force responsible for the previous DSM, in a Medscape interview shortly before the DSM-5 was set to be published.

“A diagnosis can have a major impact on the way one lives, and yet here we have groups of people who can’t access resources if they don’t fit into the proper category.”

Studies have also revealed that DSM diagnoses show poor accordance between diagnosticians. These findings become particularly worrisome considering that psychiatric treatments can only ever be as dependable as their corresponding diagnoses. In 2005, a study published in the Archives of General Psychiatry found that 45 per cent of people who met criteria for a single DSM-IV disorder met it for at least two more. Overlapping risk factors and symptoms found between DSM diagnoses raise concerns about blurred boundaries between the presently established categories. Joel Paris, a professor in McGill’s Psychiatry department, notes that there is a distinct lack of scientific evidence supporting the current breakdown of disorders. “Categories can be arbitrary, and in psychiatry all diagnoses are based on signs and symptoms, not on underlying mechanisms,” states Paris.

Due to the weaknesses in the present diagnostic paradigm, an increasing number of professionals believe that the field of psychiatry should reject discrete mental illness labels altogether and take a continuous, dimensional approach instead. This involves using quantifiable measures to determine where patients stand on a continuum. Recent brain-imaging studies show strong support for the use of disorder spectra. For example, a study published in 2012 in the Journal of Neurodevelopmental Disorders found that people with mood disorders and people with anxiety disorders showed similar activation patterns in the amygdala region of the brain – which plays a major role in the processing of feelings and memories – in response to particular emotions.

In fact, the original goal of the DSM-5 was to make a complete switch to dimensional psychiatry, but the task force was too idealistic. During the development process, enthusiastic proponents of this approach suggested a variety of dimensions, such as a schizo-obsessive spectrum which merged schizophrenia and obsessive-compulsive disorder. Unfortunately, the majority of these dimensions did not pass field trials, as diagnoses were too inconsistent between psychiatrists. One notable spectrum that did make the final cut, however, involved Asperger’s syndrome, which was removed as a separate diagnosis and placed under “autism-spectrum disorder.”

“Categories can be arbitrary, and in psychiatry all diagnoses are based on signs and symptoms, not on underlying mechanisms.”

Moving toward dimensionality would inevitably alter psychiatric drug administration, posing a problem for drug companies. Clinical research, charities, and support groups would be impacted as well, since familiar diagnostic labels and mental disorder ‘brands’ would lose their power and visibility. All in all, critics argue that it is too early to make such a drastic shift to the diagnostic paradigm, as the field is still lacking sufficient genetic and neuroscientific knowledge about the links between various disorders. “Proposals to make all classification dimensional are premature, and run the risk of labelling [healthy] people as having sub-clinical forms of illness,” explained Paris. He adds that “future DSM revisions should await real scientific breakthroughs, which I don’t expect to see for several decades. It is the best we have for now, with all its problems.”

For certain professionals like Fovet, a more ecological and holistic approach may be the most appropriate alternative while waiting for an actual solution. He notes that an increasing number of student services at McGill, including McGill’s Counselling Service and the OSD, have chosen not to rely so heavily on diagnostic instruments. These services focus instead on how to benefit the individual client by teaching students useful skills to manage their problems and remove barriers in the environment whenever possible. “Diagnosis therefore becomes almost irrelevant,” states Fovet.

As for the DSM-5 and its faults, Fovet believes that not all hope is lost. “The good news is that a fair section of the psychology-psychiatry field is now pushing back and ridiculing this last embodiment of the DSM. Perhaps this grotesque excess in one direction will have positive outcomes after all.”