Is the diagnosis correct?
Source: Photo by Alex Green from Pexels
Among the different medical specialties, some have the challenging job of distinguishing normal life from true health problems. How much weight should a pregnant woman gain? When should a toddler begin to talk? How long should sadness last after a major loss? For each question, there are clear normal and clear problematic areas. There is also much room for uncertainty. Competent clinicians recognize the gray zones and know how to work with patients to navigate their way through.
However, gray zones are also fertile grounds for fads to develop. We have all seen fads in pregnancy, child-rearing, and, these days, in mental health treatment. In clinical practice, we are constantly faced with behaviors or feelings that can be perfectly normal by themselves, but when frequent or excessive may suggest problems. When you add into this mix the possibility that the behaviors make the person difficult to deal with, fad diagnoses pour in.
I am referring to these diagnoses as “fads” because they are vastly overused, not Because they are not actual mental disorders, with one exception: Multiple Personality Disorder—which was believed to be real at the time. In fact, except for Multiple Personality Disorder, the disorders in question are all quite common.
In addition, those making fad diagnoses include not only clinicians but anyone familiar with the terminology. We often diagnose those close to us because it is just their behavior that we find troubling. Ultimately, it is gray-zone quantities of behaviors which we find difficult to deal with that motivate us to place a label on them.
As we’ll see below, these diagnoses are morally neutral; that is, they do not have a negative connotation. In fact, I believe they do the work of taking that connotation away and classifying people who cause us stress in a way we understand and believe we can control. It organizes what we find unacceptable. Unfortunately, the process leads to common misdiagnoses. I’d like to describe the most common fads and biases in psychological diagnosis over the past 40 years or so. I’ll present them in the order in which they became popular.
When I was a psychiatrist in training in the late 1980s, the dominance of psychoanalytic theory (based on Freud’s ideas) was taking its last breaths. Biological psychiatry and cognitive-behavioral therapies were quickly supplanting Freudian thinking as ways to understand and treat mental illness. But because of lingering Freudian influence, the diagnosis of borderline personality disorder was the common explanation for troublesome, impulsive, highly emotional patients. The 1987 movie Fatal Attraction added fuel to the fire by stoking fear of people with this personality disorder. Borderline personality disorder is a syndrome of unstable moods, extreme interpersonal sensitivity, and impulsive, often self-destructive behavior. Unlike others in this group, the label can be used in a highly judgmental, demeaning way—or correctly as a clinically insightful and helpful guide in treating difficult problems.
In the 1990s new interest surfaced in the effects of sexual abuse in childhood. Unfortunately for the mental health professions and many patients, this led to the “recovered memory movement.” The claim was that many people with profiles like borderline personality were in fact sexually abused as children but had repressed the memories. (sometimes in a matter of minutes of meeting someone) that a patient had memories to recover and could help the individual “remember” them.
To further complicate what would become a disaster and embarrassment for the mental health professions, the recovered memories movement morphed into the recognition, and common diagnosis, of multiple personality disorder (MPD). To be clear, neither recovered memories nor MPD exists. It is now known from research that people who have traumas, children included, remember them. The memories may be cloudy due to the emotional nature of the trauma itself, but the fact of its occurrence is not hidden. As for MPD, psychiatry now recognizes a watered-down version called dissociative identity disorder, a diagnosis which itself remains controversial.
For much of the 1990s, MPD was the explanation for moodiness and impulsive or self-destructive behaviors. The sham nature of this was exposed by exposing deep flaws in the studies supporting MPD (exhaustively covered in the book Rewriting the Soul) and in following survivors of traumas such as the Oklahoma City bombing. By the end of the 1990s, the outlandish claims of the recovered memories movement quickly faded.
Unfortunately, the gap was soon filled and the diagnosis of attention deficit hyperactivity disorder (ADHD) quickly became frequent. ADHD had been believed to be a disease of childhood which diminished during adolescence. But research showed this not to be the case: It can and does persist into adulthood, sometimes at great detriment to the patient. The common patient is a man who is disorganized and struggling professionally, and who develops marital problems for just these issues. He may not be as labile and self-destructive as borderline personality, but he could leave a trail of destruction in the form of unfinished projects and poor relationships. Later, mood problems in the form of depression or substance abuse are common—and often the reason they seek treatment.
ADHD is a common disorder, but it is still over-diagnosed in my experience. The problem is that attention (in the form of sustained focus) is affected by anxiety, depression, stress, and any negative state of mind. It should not be newly diagnosed in an adult until she is clear of these interfering factors. (Drug abusers have learned which practitioners are quick to prescribe stimulants—the mainstay treatment of ADHD—and try to see them in order to abuse or sell the drugs.)
Finally, we get to our current fad diagnosis, bipolar disorder. Anyone with impulsive behavior (especially regarding purchases or sexual activity) or moods which change quickly is often diagnosed as bipolar. Unfortunately, mood changes, irritability, and thoughtless behavior take place in depression, personality disorders, substance abuse, and even stress. This has led to an epidemic of overmedicated people, usually with, under-treated depressions.
There are some conclusions we can draw from these unfortunate tendencies in the mental health world (and in people’s personal lives). First, are the costs: Patients receive treatments for things other than their actual problems, including unnecessary medication. Not surprisingly, they do not get better.
Second, there is no substitute for thoroughness in mental health treatment. We do not have blood tests or useful brain scans. But people know how they feel, and if a clinician knows what to ask, an explanation will eventually emerge. Extreme thoughtfulness must go into this process, as a label we give someone can follow them, unchallenged, for many years.
A related point is that questionnaires have taken the place of thorough diagnostic interviews. These forms only provide clues and can be helpful in information gathering. No self-administered questionnaire (done by yourself) can provide a reliable diagnosis. If these are not followed up with a comprehensive discussion by someone very familiar with common diagnoses, the evaluation is incomplete.
Only solid training, consistent education, and experience can protect us from the most fertile soil for biases: what upsets and frightens us. People who are moody, unpredictable, or explosive, or those we do not like, such as manipulative and unreliable individuals, will always be with us. Mental health treatment offers help to many of these individuals—but only if it is applied carefully, thoroughly, and by qualified clinicians.