A brief proposal for psychiatric diagnosis

A brief proposal for psychiatric diagnosis

I want to propose a change to mental health care.

It may sound unfeasible, unscientific or contrary to medical orthodoxy.

Please hear me out.

I propose that we do away with diagnoses in mental health. No longer would a doctor or psychologist or psychiatrist offer the solemn process of naming “what is wrong with you”. No longer would you be able to say “oh, I have schizophrenia” or “I have borderline personality disorder”. My proposal for what should replace single diagnoses – namely a “diagnostic cloud” and emphasis on pathological symptoms – lies at the end of this article.

I have reasons for proposing such a bold reform.

The first is the fact that the Diagnostic Statistical Manual – the “bible” of listing and describing mental illnesses – has been growing hugely from version to version. We now have literally hundreds of possible mental states that are defined as “sick” or “ill”. In many cases, the differences between possible diagnoses are not clear. And, in some cases, the criteria for diagnoses themselves are not clear. I am thinking here, in particular, of personality disorders; they are notoriously hard to define. I am not saying that people who have been diagnosed with these disorders are not suffering; rather, that the production of a single, simple diagnostic label for complex, nuanced human experience is problematic.

I think this argument can be well illustrated by the range of so-called “psychotic disorders”: schizophrenia, schizoaffective disorder, schizoid personality disorder, psychotic depression, perinatal psychosis and psychotic obsessive—compulsive disorder. These diagnoses cover a great range of human experience; a spectrum. These diagnoses also tend to fade into each other; where does schizoaffective disorder end and psychotic depression begin? The content of psychotic delusion or hallucination is almost as variable as the human imagination.

Perhaps the reason for this multiplication and blurring of diagnoses reflects the incredible complexity of the human brain and human experience. Simply put, the brain is vastly more complicated than the other physical organs, about which we can more certainly apply diagnostic labels. Mental illness also typically occurs with more or less intensity; a spectrum, if you will. A broken leg is a broken leg, but a broken mind can involve a vast range of phenomena and experience.

Indeed, I believe that psychiatric diagnoses are as individual and idiosyncratic as the people who experience uncomfortable mental phenomena. The way you experience anxiety may be quite different to the way I experience anxiety. Applying a single diagnostic category does not do justice to this individuality.

Finally, we may see one person experiencing multiple symptoms. Are all those symptoms part of one illness, or several illnesses?

Of course, there are very strong arguments in favour of using strict diagnostic labels.

They are the cornerstone of the modern medical method. They reflect a scientific approach to the subject-matter of brains and mental phenomena. A firm diagnosis can give a person who is suffering a sense of hope and understanding about what they are going through. A strict “diagnosis” suggests the best course of remedy (typically psychological intervention or psychopharmacology). Ultimately, we believe that mental diagnoses reflect isolatable, functional problems in the chemistry of the human brain.

How do we move on from this challenge?

I would like to make two proposals.

First, rather than giving firm and single diagnoses, I propose that we use “diagnostic clouds”. A diagnostic cloud recognizes the general nature of an illness (cognitive, emotional, behavioural, etc) and what areas of experience it affects, without pinning down a specific illness. The diagnostic cloud recognizes the complexity and nuanced nature of individual human experience, the spectrum of illness intensity and the shading of illnesses into each other.

Second, rather than fixating on the name we give to an uncomfortable human experience, we should focus on the specific nature of the pathological symptoms that are experienced. So, for example, a person who might be diagnosed as depressed would rather be recognized as experiencing lethargy, low mood and suicidal ideation. Treatment should focus on these symptoms, alleviating them, rather than following the prescriptive dictates of a diagnostic system.

I offer these considerations not as prescriptions but as proposals. I in no way wish to mis-recognise the suffering of people who are diagnosed or not diagnosed with mental illness. Rather, may these words be food for thought.


Dr. Richard Schweizer, Policy Officer at One Door Mental Health richard.schweizer@onedoor.org.au.  

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 Dr Richard Schweizer

Dr Richard Schweizer (Richard..."van Gogh")