Blog
Diagnosis in Psychiatry: Creating Communities and Addressing Stigma
- August 20, 2024
- Posted by: Harry Kearns
- Category: Blog
Everyone with psychological problems or mental ill-health suffers in a different way in the unique context of their personal circumstances. But while everyone is different, we also have much in common, even when we suffer.
General diagnostic terms such as ‘depression’ or ‘anxiety disorder’ inevitably miss out on the uniqueness of each person to a certain degree, but they help to identify symptoms that frequently co-occur, help to create a common language for psychiatric suffering, and facilitate research and understanding.
Additional benefits of diagnosis include addressing stigma, alleviating the blame or guilt that people sometimes feel about mental illness, facilitating the establishment of networks of people affected by similar problems, and crafting treatment and management plans in an open, collaborative, accountable way. These advantages of diagnosis are worth exploring in a little more detail.
Addressing Stigma
Judicious diagnosis can help to reduce the stigma that is often wrongly associated with mental illness and its treatment. Too often, people are given the message that their problems are ‘all in your head’ or, more recently, are entirely ‘psycho-social’ in origin.
The latter interpretation recognises important social factors that amplify many problems, but also commonly, if inadvertently, downplays the power and agency of the individual (presenting their experiences as entirely the product of social circumstance), diminishes or denies the reality of their impairment (implying that their problems are solely psychologically or socially constructed), and intimates that if social circumstances were different their problems would not only be lessened (which is likely true for many people) but would be entirely eliminated (which is regrettably untrue for most people who attend mental health services).
The careful, judicious, and compassionate use of clear diagnostic systems can help to address some of these issues, legitimise a person’s suffering, draw attention to their strengths, and start to build a shared understanding of a path forward. A broader formulation of the person’s problems is another necessary step to address stigma and achieve these goals.
Bio-Psycho-Social Psychiatry
It is important to contextualise any diagnosis using psychiatry’s broad bio-psycho-social approach. This encompasses not only ‘psycho-social’ dimensions of the person’s situation, but also biological considerations which will apply to varying degrees in different people. Any truly holistic approach will consider all relevant biological, psychological, and social factors in the particular circumstances of the individual, rather than being limited to a reductive ‘psycho-social’ model that diminishes or denies biological dimensions.
Thoughtful use of classification systems can play an important role throughout this process and help de-stigmatise mental illness and its treatment, provided diagnoses are explored carefully, flexibly, humbly, and with a broad awareness of context.
Diagnostic systems can also help to alleviate the disproportionate blame or guilt that individuals or families sometimes feel when a person develops psychiatric symptoms or a mental illness. Given that the root causes of many psychiatric conditions remain resolutely obscure, there is a tendency to assign significance to circumstances or events in people’s lives, some of which might be relevant (e.g., traumatic experiences), but some of which might not have contributed.
In this process, family members or others can feel that they are being held responsible to a degree that is not always justified, with resultant blame and guilt among family, friends, co-workers, or other people who play significant roles in the person’s life. Sometimes, there is no trauma, and there is nobody to blame.
Searching for Causes
The search for causes of mental illness reflects a very human desire to understand why people develop particular psychological states or mental illnesses at specific points in time. But it can also prove harmful and hurtful to the very individuals that the person needs now more than ever. Using a diagnostic system like the World Health Organization’s ICD-11: International Classification of Diseases (Eleventh Revision) (ICD) demonstrates that a person’s condition has (in general terms) been experienced by other people in the past and broadly maps onto a certain pattern of human suffering that has been described before.
This sharing of experience immediately alleviates some of the disproportionate guilt and blame that can be felt in these situations, affirming that this person’s experience, although unique in certain respects, is not entirely unprecedented. As a result, and in the absence of other factors (such as abuse), family members and others (including the patient) should not feel uniquely or solely responsible for the situation.
This sense of commonality and community leads to another one of the benefits of classification systems that describe psychiatric symptoms in detail, which is assisting with the creation of networks of people and families affected by similar conditions. Psychological distress can be an isolating experience owing to the presence of unusual symptoms that the person has never had before: hearing voices, feeling that thoughts are being inserted into their head, or developing an impulse to self-harm. These are often upsetting, frightening occurrences which can leave a person feeling distressed, confused, and, sometimes, unable to find the words for what they are going through.
Symptom-based diagnostic symptoms help by outlining shared experiences such as these and suggesting language for particular patterns of symptoms. Reading through lists of symptoms and experiences can help to relieve some of the loneliness, recognising one’s own experiences in some (but rarely all) of the features of a given condition outlined in ICD. Or, alternatively, identifying with specific symptoms that are described under different diagnostic headings, indicating that this person’s individual experiences are not entirely unique, even if their particular combination of them is.
All of this facilitates self-awareness, sharing, discussion, and reaching out to people who can use similar language to describe their experiences. Nobody needs to suffer alone. No matter how imperfect, a common language helps us to connect. Used well, ICD can provide that language.
Guidance for Treatment
Finally, clear diagnostic systems help to guide patients, families, and clinicians in choosing the best treatments for mental illnesses or for particular combinations of psychiatric symptoms. Evidence-based care lies at the heart of mental health services and is integral to these decisions. Before deciding which treatment to offer, it is important that clinical trials provide robust information to guide choices about interventions that are proven to help with particular collections of symptoms. Clear diagnosis is essential to perform these research studies.
Careful diagnosis is also required if the information from such research is to be applied correctly in clinical practice. In other words, open, accountable diagnosis can link specific problems with interventions that are proven to help in particular situations. In this way, diagnostic systems like ICD play a central role in crafting treatment and management plans in a collaborative, effective, and accountable fashion.
Of course, after a treatment is given to a particular person, only one clinical trial matters: how does this person benefit from this treatment at this time?
But to get to that point, some degree of diagnosis is essential to ensure that the likelihood of benefit is as high as possible, by informing both research studies and individual care decisions with humble, flexible, person-centred diagnosis.
Brendan Kelly is Professor of Psychiatry at Trinity College Dublin. This is an edited extract from his new book, ‘The Modern Psychiatrist’s Guide to Contemporary Practice: Discussion, Dissent, and Debate in Mental Health Care’, which is available online free of charge: https://www.taylorfrancis.com/books/oa-mono/10.4324/9781003378495/modern-psychiatrist-guide-contemporary-practice-brendan-kelly