The devaluation of diagnosis

You meet a lot of people in general practice who defy conventional psychiatric categories, but who are equally clearly some way beyond the realm of any concept of normality. There are some people whose personality seems so eccentric and whose ways of thinking and speaking are so bizarre that you sometimes wonder how they survive in a world that requires considerable skills of coping and survival. But, in their own ways, they do. You also meet a lot of unhappy people, indeed by Friday evening you would readily agree with H.D.Thoreau that many, if not most, people 'lead lives of quiet desperation' (Thoreau 1854:50). In some their distress is expressed in physical symptoms, of total body pain or feeling tired all the time; in others it is openly proclaimed as sadness, loneliness or rage.

In John Berger's celebrated 'story of a country doctor', he wrote that the task of the doctor when confronted with an unhappy patient offering an illness was to recognise the person behind the illness (Berger, Mohr 1967:69). This act of recognition itself can help to overcome hopelessness and even begin to offer 'the chance of being happy'. To make an unhappy person feel recognised, the doctor 'has to be oblique' and yet has to appear to the patient as a comparable person, a process which demands 'a true imaginative effort and precise self-knowledge'. This well captures the challenge of general practice.

'The whole process' of recognition, observed Berger, 'as it includes doctor and patient, is a dialectical one'. The doctor must recognise the patient as a person, but for the patient, 'the doctor's recognition of his illness is a help because it separates and depersonalises that illness'. This is why, he continued, 'patients are inordinately relieved when doctors give their complaint a name'. Even if the name means little, it gives their condition an independent existence: 'they can now struggle or complain against it'. For the patient to have a complaint 'recognised', in the form of a diagnosis which is 'defined, limited and depersonalised...is to be made stronger'. Reading Berger's account more than thirty years after it was written, we can still appreciate the importance he placed on recognition. What has changed is the healing power of diagnosis: we can no longer claim that giving the patient a name for their illness makes them stronger, even if it may still give them some relief. If we look, concentrating on the sphere of psychiatry, at the three features of the diagnosis that he considered gave people strength to deal with their afflictions, major changes are apparent.

Whereas in the past mental illnesses were few and clearly defined, today disease labels are both more numerous and more diffuse. In 1952, the Diagnostic and Statistical Manual of American psychiatry recognised 60 categories of abnormal behaviour; by 1994 this had expanded to 384 (plus 28 'floating' diagnoses) (American Psychiatric Association 1994). Furthermore psychiatric authorities have identified a much wider prevalence of 'sub-syndromal behaviour'. Some reckon that many, if not most, people in society are suffering from 'shadow syndromes', mild or partial forms of familiar psychiatric conditions, such as depression and anxiety, obsessional compulsive disorder and autism (Ratey, Johnson 1997). Clinical psychologist Oliver James, author of the popular book Britain on the Couch, snappily subtitled 'why we're unhappier compared with 1950 despite being richer: a treatment for the low-serotonin society', reckons that around one third of British adults could be diagnosed as having some form of 'psychiatric morbidity' (James 1997:307). Adding those manifesting tendencies towards 'violence and aggression' brings the proportion of those deemed in need of intervention 'to around one half—perhaps twenty million people' (James 1997:308-9).

At the time that Berger wrote, there was a general inclination to emphasise the discontinuity between the normal and the abnormal; today the concept of a continuum has become fashionable. The invention of new disease labels—such as 'attention deficit hyperactivity disorder' in children or diverse forms of addiction in adults—reflects the trend to define a wider range of experience in psychiatric terms. It also results in a further blurring of the boundary between the normal and the abnormal. Whereas diagnoses previously suggested the limited character of the condition, modern disease labels imply disorders that are un-restricted in the scope of the symptoms to which they give rise and in the duration of their effects. Post-traumatic stress disorder or recovered memory syndrome, for example, can be expressed in the widest variety of symptoms, which may arise long after the traumatic events believed to have triggered them. There is also a widespread conviction that these may continue indefinitely as people are 'scarred for life' by past traumas. Today's sufferers from addictions or compulsions can never claim to have been cured; they live their lives 'one day at a time' in an on-going process of 'recovery'.

The depersonalised character of traditional diagnoses allowed the sufferer to objectify the condition as something 'out there', perhaps a somewhat forced abstraction, but one with some pragmatic value. By contrast, a diagnosis like 'chronic fatigue syndrome', or 'ME', is inescapably personal and subjective in character. Every sufferer exhibits a different range of symptoms, and there is no way of objectively confirming or monitoring the course of the illness (Wessely 1998). The net effect of the dramatic expansion in the range of psychiatric diagnosis is that, instead of conferring strength on the patient, bestowing any such label is more likely to intensify and prolong incapacity. The proliferation of diagnoses and the tendency to apply them to ever wider sections of the population reflects a profound demoralisation of society and a deep crisis of subjectivity. To illustrate these trends, let's look at one example— addiction.

Getting to Know Anxiety

Getting to Know Anxiety

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