There was a report this week from the British Psychological Association Division of Clinical Psychology entitled Understanding Psychosis and Schizophrenia. I think it’s fair to say that some responses to this report have shown that old battle lines and divisions still run deep within the mental health professions. I want to add my own thoughts to this discussion at some point but not today for a couple of reasons; the principle one however is that I’m tired, feeling confrontational, and found some of the comments and discussion in relation to the report derogatory and do not want to respond in kind. So, I want to let that rest in my mind for a while, re-read the report, and come back to it with a less jaundiced gaze in a week or so.
So I thought instead I would write about something that I continue to wrestle with and that came to a head earlier this week during a discussion on Twitter about the validity of the diagnosis of Borderline Personality Disorder – although I actually think that the points here can be extended beyond BPD to a number of other mental disorder diagnoses.
The role of Diagnosis
A quick google search reveals:
Diagnosis (noun) – the identification of the nature of an illness or other problem by examination of the symptoms.
The origin of the word is from Greek and then Latin but essentially means to differentiate or tell apart.
In my medical training I was taught that when I listened to a patient and then examined them and ordered tests I was engaging in an act of narrowing my differential diagnoses until I reached a final diagnosis which then served the following functions:
- It aided understanding – both for other professionals and the patient
- It guided treatment
I want to start by thinking about the idea of diagnosis aiding understanding. The first question is understanding by whom?
Traditionally I feel that we think about understanding working in dyads – If I communicate directly with you in a conversation we work together to develop mutual understanding of the phenomena involved. This is simple when there is a clear subject of discussion – for example a stone, we can describe its properties and likely agree on a level of understanding to describe it that can then be shared with others.
In physical health I believe this analogy holds – I work with you to understand your difficulties; tightness and pain in the chest, sweatiness, sense of impending doom, breathlessness, panic and I conclude that you may be suffering from a heart attack. If (once I have resuscitated you) we choose to continue to discuss your experiences I can talk about blood supply to the heart, narrowing of arteries, fat emboli or similar and ultimately lack of oxygen to the heart’s muscle. The analogy becomes more tenuous with chronic illness – but to my mind still holds true, it’s just that we need to widen our scope of consideration to include your on-going life experiences.
But consider this analogy in mental health – does it hold? I suspect this depends on personal experience far more than it does in physical health care. For me the analogy can not hold. Now the difficulties that you describe to me are fully integrated into your life experiences – to separate them becomes almost meaningless. I do not believe we can talk of depressed mood for example without considering the precipitants of this and the continuing effect it has on you. So… If after speaking with you we reach the conclusion that you have a diagnosis of Depressive disorder, current episode moderate severity are we actually any clearer in our understanding then when you first began the conversation and said you were feeling low in mood?
Communication in terms of diagnosis involves more than a clinician and patient however. The clinician must communicate with their colleagues in order to allow coordinated support to be provided. Does diagnosis aid us in this communication? The combinations of symptoms available that all meet a diagnosis of Schizophrenia is simply huge. As a result a simple communication using the diagnostic terms becomes untenable.
What about communications outside of healthcare? What does the person receiving a mental disorder diagnosis make of that communication? I think that there is a strength of diagnosis here in that delivery of a diagnosis can deliver two factors:
- A sense of normalisation – ‘I am not alone in feeling this way’
- Hope – ‘If there is a diagnosis, there is treatment’
Unfortunately many diagnoses also carry stigma. Consider the diagnosis of Borderline personality disorder – to my mind this is an inherently stigmatising diagnostic category – what is it exactly that is disordered? My personality is a reflection of who I am as a person, so are you saying that I am inherently disordered in myself? There are other critiques of the diagnosis: – For example the feminist argument that it is a modern extension of hysteria – a diagnosis used to dismiss the suffering of women (the majority diagnosed are women) and to imply that deviation from a paternalistically defined manner of responding to distress is to become disordered. We also know that professionals can stigmatise people who receive a personality disorder diagnosis – they are deemed ‘manipulative’, ‘attention seeking’ and not worthy of care. To my mind this could be an expression of our inability to confront distress that we can not ourselves contemplate, or control, and so we seek to diminish the person with that distress to the point where they are no longer fully human, or deserving of our care.
Diagnoses also currently fulfil an additional role in that they facilitate access to care or support, for example DLA or the equivalent and that brings us obliquely to the next purpose of diagnosis – to guide treatment.
Diagnosis guiding treatment
Does psychiatric diagnosis guide treatment and understanding of treatment? Partially it does – if a person is psychotic it would seem reasonable that they are receiving an antipsychotic drug. But – I have prescribed antipsychotics to people with depressed mood and no psychotic features and I know that I am not alone in this. Antipsychotics are prescribed also as mood stabilisers (e.g. Quetiapine). The treatment is not specific to the diagnosis.
Does diagnosis lead to an understanding of the nature of treatment to be offered? I don’t think it does. Psychosis is commonly referred to as being due to a hyperdopaminergic brain – there is simply too much dopamine at neural synapses and we must reduce it with antidopaminergic drugs. The earliest antipsychotics blocked dopamine receptors with varying degrees of affinity – but as dopamine is also involved in regulation of movement control (among other things) this treatment is associated with a variety of movement disorders. Then along comes Clozapine – still probably the most ‘potent’ antipsychotics available but Clozapine binds to many other receptors except from Dopamine. The other ‘second generation’ antipsychotics (Olanzapine, Risperidone etc) bind with varying degrees of affinity to serotonin and dopamine receptors and produce effects that are predictable based on this binding. Finally there is Aripiprazole – a drug that attempts to maintain the anti-dopamine activity by hitting the receptor and then relaxing away, the hope being that you gain antipsychotic effects without the movement side-effects. In my experience Aripiprazole can be useful in certain situations, but ultimately in many people also causes a severe feeling of agitation and restlessness.
It is now probably quite apparent that I struggle with psychiatric diagnoses. There are counterarguments and ripostes to these arguments to be had and the representation above is simplistic and partial – but I am not certain that this is the correct vehicle for a more in depth discussion. Unreferenced as it is it is clearly not an academic argument. Also I would not wish in any way to suggest that in arguing the nature of diagnosis in mental disorder I am seeking to diminish any form of suffering.
What are the alternatives to diagnosis? Formulation, which I’ve written about previously, is one alternative. Through formulation two people work together to develop a mutual understanding as to the nature of one’s distress, possible causes in their psychosocial life and means of working together in order to tackle problems raised. This is my preferred way of working clinically – trying to develop that mutual understanding.
As I’ve said above diagnosis has a role beyond the understanding of distress – currently they fulfil functions of normalisation, access to care and other means of support. They are problematic, may be stigmatising but they also carry tremendous strength in terms of the social understanding they can bring. Sometimes this understanding can be complicated and I want to think more about the moral implications of diagnosis in a future post that I’m planning. However for the moment I do not believe that we are in a position where they can be dropped. Society now expects that diagnoses will be delivered – and when diagnosis is not delivered it is sometimes viewed as a dismissing of suffering.
How do we work to change this? Should we work to change it? I think those are some quite big questions and beyond the scope of me musing at my keyboard for the moment… Ultimately these difficulties affect me and leave me uncertain, so if anyone feels like dismissing my arguments with a clear riposte I would welcome it.