A Mental Health Diagnosis is Not Personal

I want to discuss what I’ve learned, and share some of my thoughts on what a mental health diagnosis is and what value it provides.

Diagnosis: The nature of a disease; the identification of an illness.  -medicinenet.com 

When I began to pen my thoughts for this post, my original intent was to begin the conversation on Posttraumatic Stress Disorder (PTSD) as I’d promised a couple of weeks ago.  To get my definitions straight I went to what is often referred to as the “bible of psychiatry”: The Diagnostic and Statistical Manual of Mental Disorders. Specifically I went to  the most recent version, the fifth edition, DSM-5.  This is the standard reference manual for categorizing and diagnosing mental health disorders.

PTSD was first introduced in the third edition of the manual in 1980. The criteria for its diagnosis have evolved quite dramatically since that time. This isn’t terribly surprising as we should expect our understanding of the condition to have grown and in turn the ability to identify and characterize its symptoms. In fact, in the DSM-5, a new diagnostic category, “Trauma and Stressor Related Disorders” was created, and PTSD found its place there. It had previously been categorized as an “Anxiety Disorder”. The rationale for this move, as I understand it, is that PTSD also includes disruptions of other emotional states outside of the fear/anxiety spectrum. As I said it doesn’t surprise me that the diagnostic criteria have changed, but the fact that an entirely new category was created to accommodate the disorder is curious to me.

Even more peculiar to me is that the first diagnostic criterion in the DSM-5 is not a characteristic of the disorder. It is the identification of an external event that could have caused the disorder; “Exposure to actual threatened death, serious injury or sexual violence…”. I believe PTSD may be unique in the manual in this regard,  i.e., the identification of a presumptive cause is a requirement for the diagnosis.

This inconsistency results from, and points to a larger issue with the DSM; The diagnostic approach in the DSM doesn’t really describe “The nature of the disease[s]” it identifies, but rather provides a framework to categorize sets of subjective and behavioral symptoms. For this very reason there is a lot of controversy around the DSM, regarding its construction, its intent, its usefulness, and its validity in general. That’s not a conversation we’re likely to make much headway on here, but I do think it is important for us, the ones who rely on the health care system, to recognize that there are some notable limitations to this primary resource that our health care providers use to assess and guide their decisions about our mental health.

I mentioned above that the DSM is described as the “bible of psychiatry”. This sort of suggestive sacralization, even if not literal, is misleading and has had some severely negative consequences on the way we perceive mental health and the expectations we have for mental health care. I’ve got three major areas of concern:

A mental health diagnosis is not personal.
The diagnoses in the DSM are just labels and say nothing about our character or identity. While the conditions identified in the manual may be adequate starting points for our health care providers to understand and communicate our needs, they are not useful to us for purposes of self-understanding and awareness. 

Mental health is physical health.
The fact that the DSM diagnoses and their descriptions generally don’t include fundamental physiological characteristics is not an indication that mental health is not physical health.  This omission is an unfortunate consequence of historical misconceptions and limited scientific tools that frankly has resulted in the persistence of some highly suspect science. The good news is that the tools of biotechnology are now more commonly being applied to understanding matters of the mind, and we’re seeing increasing use of biological indicators to understand and diagnose mental disorders.

A mental health diagnosis is not personal enough.
One in five Americans is taking a prescribed medication, a psychotropic drug to change the way they think or feel. 80 percent of these medications are being prescribed by practitioners who are not mental health professionals. Certainly these medications are providing enormous life-changing, and often life-saving benefits to many people. But these numbers, to me,  just feel to be a little out of balance.

Our health insurance moderated system relies quite a lot on the DSM for making decisions about how our personal mental health needs get met.  Often a diagnosis based on the DSM is required for health insurance coverage for a treatment. A consequence of this is a certain restriction on how a doctor can treat the particular needs of a patient. Considering the vague and subjective nature of the DSM, this seems absolutely counterintuitive and counterproductive.   While the DSM might be an adequate starting point to help our providers understand our needs, individual attention and personalized treatment has to become the expectation if we are to have a strong and healthy community. 

‘A strong community is built of healthy individuals and
good health starts with a healthy mind’

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