Thinking about diagnosis

In psychiatry, a diagnosis can only ever be an ‘expert opinion’, because there are no x-rays or blood tests to show what is going wrong in the brain or nervous system. Over the last twenty years, much effort and expertise has been spent on trying to refine psychiatric diagnoses and make the process more ‘scientific’, so detailed questionnaires and structured interview schedules have been produced with sophisticated statistical analyses to show ‘validity’ and ‘reliability’. Although this ‘scientific’ process has helped researchers to define who should be in their research studies and who should not, it has misled public opinion and given the process of diagnosis an importance and authority it does not deserve. It is not coincidental that a great deal of psychiatric research is funded by the pharmaceutical industry, and funding for psychotherapy research is very much lower.

Problems include:

·         The internationally agreed diagnoses are agreed by committees of experts with no objective or incontestable basis (such as radiology or biochemistry).

·         The need for diagnosis, at least in America, is driven by the medical insurance industry.

·         Until recently, diagnostic systems have deliberately excluded anything concerned with the cause of the disorders.

·         The diagnoses all have ‘fuzzy edges’, and often overlap with diagnoses that sound quite different (as Stephen Fry has said, “it is a moot point where bipolar disorder ends and personality disorder ends” )

·         Most people with severe problems have overlapping problems which can be given more than one diagnosis.

·         In mainstream practice, which is usually based on a biomedical model, there is neither time nor expertise to untangle somebody’s symptoms into very tightly defined diagnoses. It is more important to see what somebody’s immediate needs are, and to address them.

·         In psychotherapeutic or trauma-informed practice, a narrative to make sense of the symptoms – a formulation – is produced, ideally in full collaboration with the subject. Although this is normally experienced as helpful in understanding the symptoms and problems, it is opposition to the diagnostic approach. This is because it a formulation is  different for everybody, and not generalisable. Therefore, without a diagnosis, however flawed it may be, it is not possible to be precise or systematically about deciding treatment.

However, things are changing. The new edition of the World Health Organisation’s diagnostic manual (International Classification of Diseases version 11, “ICD-11”) has just been published on their website, and is due to come into full operation in a couple of years. It contains some interesting changes from the previous version.
Here are some of them:

·         There is a new section called ‘Disorders specifically associated with stress’ (6B41) which includes PTSD, Complex PTSD, Prolonged grief and adjustment disorder. The important one here is ‘Complex PTSD’ which requires repeated or prolonged stress – and have many symptoms overlapping with what we previously called ‘Borderline Personality Disorder’. Because of this, it may well now be better-justified – as well as more acceptable to patients/clients/service users - to use the CPTSD diagnosis instead of BPD.

·         Personality Disorder itself has been given a complete make-over in the new classification. All the old categories like paranoid, avoidant, borderline, antisocial, narcissistic and histrionic have gone, to be replaced by a simple measure of severity – severe, moderate and mild. There is also a ‘personality difficulty’ level, which includes a large proportion of the human population – but is not classified as a disorder. For greater descriptive power, each level of severity can be assigned one or more of six ‘flavours’, which are somewhat similar to the old categories: ‘negative affectivity’; ‘detachment’; ‘dissociality’; ‘disinhibition’; ‘anankastia’ or ‘borderline pattern’. This means that each person will only have one diagnosis, not many – although the more severe diagnoses are likely to have more ‘flavours’. The lines between the levels of severity have not been firmly specified yet, but are intended to reflect how many areas of a person’s life are affected, and how persistently.

·         Another new section - much elaborated from the old single condition – is ‘dissociative disorders’. This itself reflects the greater prominence given to internal mental mechanisms – and indicates a less biomedical approach to mental life. The particularly interesting new addition is Dissociative Identity Disorder (DID – previously also known as ‘multiple personality disorder’). This is a diagnosis that has generated much heat and little light amongst psychiatrists in the past, and its addition to ICD-11 might leave some old-school psychiatrists – and their modern followers – rather unhappy. There is also a milder category of the same condition called ‘Partial DID’, which is less continuous and pervasive:

The non-dominant personality states do not recurrently take executive control of the individual’s consciousness and functioning, but there may be occasional, limited and transient episodes in which a distinct personality state assumes executive control to engage in circumscribed behaviours, such as in response to extreme emotional states or during episodes of self-harm or the re-enactment of traumatic memories.

As with Complex PTSD (above), this may well become a popular replacement for the old ‘Borderline PD’ or ‘Emotionally Unstable PD’, or alternative to the new ‘Personality Disorder with Borderline Pattern’.

All in all, this looks to represent a movement away from the biomedical hegemony towards a more open and flexible diagnostic system. It does not answer the critics of westernised psychiatry’s colonisation of the territory, across the world, but it goes some way to acknowledging that ‘what happened to you?’ is more important than ‘what’s wrong with you?’.