Psychiatric diagnosis is an ethical issue, not only a medical one

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That’s actually part of a special collection from the 2014 Journal of Bioethical Inquiry.


Debating DSM-5: diagnosis and the sociology of critique
Martyn D Pickersgill

When psychiatric diagnosis becomes an overworked tool
George Szmukler

Psychiatric diagnosis: the indispensability of ambivalence
Felicity Callard

Psychiatry’s new manual (DSM-5): ethical and conceptual dimensions
J S Blumenthal-Barby

The definition of mental disorder: evolving but dysfunctional?
Rachel Bingham, Natalie Banner

(The author of the OP article has published in this journal as well: How Sex Selection Undermines Reproductive Autonomy)

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Thank you for posting this, this is really an issue!

And it is indeed a double-edged sword: On one hand a proper diagnosis is indispensable in order for the person to get the necessary help, as our whole system of health insurance etc. (I only can say for the German one) will not pay for a treatment without a diagnosis, and on the other hand it is labelling the person and in some cases can go along with significant drawbacks!

For example a teacher’s chances to acquire the status of an official (having a better payment and a better social security than being just an employee) will drop significantly when they have been treated of a mental illness. Therefore I know people who would prefer to pay their psychotherapy on their own just so that it won’t show up in the records of their health insurance which in these cases is identical with their employer!

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I think employers should pay people with psychiatric diagnoses more. At least you have some idea what you’re getting in to!

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Commonly described as a more severe form of premenstrual stress (PMS), PMDD has been accused of labelling as a mental disorder normal and understandable reactions to the sort of stressful circumstances that disproportionately affect women in a modern society that still has not achieved gender equality.

So please stop labeling women as “mentally ill” when they are going through peri-menopause or just feel rotten and grumpy when they have their period! We all have our share of emotional baggage and that’s just normal and when you don’t sleep for a while or feel physically drained, it is normal that those things come up.

It’s part of our Dhamma path to work through these things but nobody is perfect and this takes time. It does not help if there is a stigma or taboo because that just causes people to repress these emotions. You have to understand and accept them first.

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Another issue which was discussed recently in UK is ‘parity of esteem’ - physical diagnoses get far better treatment. They are more acceptable in most cultures. Culturally, the definition of mental illness varies and there have been attempts to identify a level of mental illness which was universally acceptable. It is likely towards the schizophrenia (ie psychosis) end of the spectrum. Neurosis (depression, anxiety, trauma, OCD etc - without hallucinations and delusions) are more acceptable. Incidentally the terms psychosis and neurosis have now entered the lay domain and aren’t used much in psychiatry, except as shorthand. It is interesting however that Western populations now have increased awareness of mental health issues than any culture in history… probably. Psychological awareness is an immensely useful tool in reducing suffering, which would otherwise be considered ‘normal’.

So serial killers (like Angulimala) would be diagnosed (possibly, and it isn’t) with Dissocial Personality disorder (psychopathic personality disorder). Devadatta may have had Narcissism/personality disorder. They were considered as having a normal personality in the culture at the time, just unethically motivated in their actions- if someone were to look at it from an ethical perspective. However if Devadatta and Angulimala had been helped right from the start things may have turned out differently, after all it is just causes and effects. Having said that there a Safeguarding issues for potential victims who come into the range of people with these issues. It is important to have compassion for these individuals as well. Many books have been written for families with these conditions on how best to survive relationships with them and how to support them without developing mental distress/disorders themelves. It is difficult to describe what happens but perhaps it is sufficient to say that even trained mental health professionals needs debriefing sometimes following contact with this kind of disordered behaviour. It used to be that early retirement is offered to mental health professionals, before the funding cuts - it’s not all rosy on the mental health front.

Roses have thorns and needs to be carefully handled. It is a bit like the dhamma- we learn to manage it slowly and carefully.

With metta

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By the way, note that the DSM-5 is not used very much in psychotherapy; it’s more of a research & psychiatry tool. With respect to the concerns of the OP article, I want to point out that addressing these sorts of issues has long been underway. For example, a useful clinician’s companion to the DSM is the The Psychodynamic Diagnostic Manual, now in a second edition.

Now, the article mentions issues worth exploring, but how many people know how the DSM is actually used in the first place? Who can also list a few of its benefits? I ask because it’s worth trying to prevent oversimplified understandings of psychological science; articles like the one in the OP tend to obscure relevant nuance in order to make a more general point.

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As someone not very familiar with how this all works, can you tell us a little about how how the DSM-5 affects practice? I can imagine that if you’ve been a therapist for a long time, a changing definition in a book isn’t going to immediately change what you’ve learned from experience. And this would apply to psychiatrists, too. But then there is the whole thing about different fields, each with their own practices. Is DSM-5 relevant to psychotherapists at all?

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My wife is a Marriage and Family Therapist. The DSM-5 comes up mostly when it comes down to diagnosis of new patients, insurance and government services (like medicare and state and county agencies). When she treats someone, she has to have a justification for insurance as far as what she is doing, why she is doing it, and for how long. Of course, if people private pay, then this is of less importance.

For therapists working in a much more medical type of environment, there is what is called the ICD-10 codes, which is basically for billing. I know from working in medicine that increasingly everything has a code attached to it (patients, specimens, imaging, medications, etc).

But from what I am told, nobody recognizes the DSM as having any legitimacy in terms of accurately describing actual mental illnesses precisely or even reasonably.

Remember that in previous versions of the DSM (sadly, not as long ago as you may think), homosexuality was considered a mental illness.

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Thanks, that’s really useful.

I’ve suffered with Borderline Personality Disorder for years and years now, and the way the psychological health system deals with it in particular is perfect proof of how flawed it is. For years I was given a Bipolar diagnosis, as Borderline is one of the most difficult to diagnose, and lived with a stomach full of lithium and a mind full of static, before they finally realized this was not what I was suffering from. I had never had a classic manic/psychotic episode usually required for a true Bipolar diagnosis. Not too terribly long ago they brought in a new diagnosis called Bipolar Type 2, which was basically to satisfy all the people coming in saying they had Bipolar because they were happy and sad, even though they had never had a true manic episode and were really only afflicted with being human. It was this Type 2 diagnosis I received even though they prescribe the exact same medication as Type 1. Borderline is also one of the only mental illnesses often considered an untreatable psychological affliction, not just incurable, but “untreatable,” and many psychologists and psychiatrists won’t even take you on as a patient because of it. You end up playing this game of perpetual referral toward someone who has the necessary “tools for the job” so to speak. Not only must we re-think diagnosis, but we must entirely re-think psychological treatment. It wasn’t until I started contemplative practices that I was able to find even a semblance of relief, although I am of course still a great distance away from a cure or even just a stable and maintenanced psyche.

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Thank you for bringing up this subject Bhante @Sujato!

My experience is that especially in Buddhist circles people look down on you if you show emotions. If you show anything, you are “not equanimous” and therefore a bad practitioner or worse, are labeled as “mentally ill”.

You are expected to always smile and be happy and then you are a good Buddhist. But that’s not the reality we always feel. It is OK to talk about emotions like I do here, in a fairly rational and distant manner, but if you try to talk to somebody about how you personally feel, or worse, you want to just cry with somebody, a lot of doors suddenly close.

I can be a fairly emotional person at times, but I’ve also learned to hide it and just put on a smile. But that has also led me to suppress emotions in the past rather than to face up to them and to accept them as a natural part of me, just formed by causes and conditions.

But at some point suppression no longer works and it all comes out. And thus there is the label of “mentally ill”. Nobody knows what kind of “mental illness” you are supposed to have but if you cry because it has all become too much, there must be something wrong with you so you’d better go to the psychiatrist to get some Prozac.

It is as if this “happiness culture” does not want to see that emotions are a real part of ourselves and that we have to acknowledge them and to accept them before we can let go of them.

I felt especially touched by the replies of @Cara and @Aminah to my first post because they actually had the courage to talk about how they feel in the open, in a place where people know them. I’m the one with the “scaredipants orientation” because I am anonymous. Way to go girls! You’re a real example for others!

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DSM 5 (US system) and ICD 10 (rest of the world!) are two established systems of diagnosis. They are broadly parallel to each other and conflict to minor and varying degrees, but are workable and very useful ways of talking about mental illness. Importantly research criteria are based on specific research criteria that are used in diagnosing a mental illness- which means, that when a potential medication is tested, it is researched against a specified diagnosis- which leads to effectiveness of a medication known for the given diagnosis. This leads obviously to stringent criteria being used when someone is diagnosed as otherwise the medication prescribed might be not the most optimal for the given condition. The frontline staff that detect mental illness in UK are GPs and many are not trained in mental health. For some strange reason, even when nearly 20% or more of their patients are there for treatment for mental illness, the governing body (Royal college of GPs) haven’t made training in psychiatry mandatory, in their training period for new GP trainees, AFAIK. IMO this often leads to poor diagnosis or detection rates, the latter as proven by research.

There are all kinds of problems with diagnostic labels as there can be stigma associated more or less with certain diagnoses if not all diagnoses of mental illness, partly due to ignorance. Certain disorders are hard to diagnose as ‘diagnosing’ a jhana- just see the degree of variation present, without special training and experience. Bipolar spectrum is contentious even for psychiatrists, and personality disorders even more so not to mention schizo-affective disorder. Most psychiatrists wouldn’t be able to notice an adult on the mild end of the autistic spectrum, IMO.

Some aren’t aware of the most efficacious medication like Lamotrigine for bipolar type 2 and may have patients on antidepressants that don’t work on their own, for such conditions. Psychological therapies are also researched based on diagnoses and orgnisations like the National Institute of Clinical Excellence publish national guidance in UK, bringing together all the best available evidence based treatments under each condition.
https://www.nice.org.uk/guidance/published?type=apg,csg,cg,mpg,ph,sg,sc

DSM shouldnt really be needed for therapy as they are not diagnosis based in their approach but based on psychopathology, defenses, coping mechanisms, interpersonal patterns etc. However in the US I think they are used for billing, in medical insurance, making them a necessity.

with metta

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Dear @Aoife,
That is rare and beautiful encouragement which I truly thank you for :bowing_woman:
However it goes both ways you know! Your courage and strength also inspires and uplifts us, no matter what you may think of it!

I agree that’s it’s hard to really be genuine and vulnerable in Buddhist settings, as your weaknesses are usually seen as a sign of your poor kamma/poor practice instead of workable problems that everyone has. But I realized greater peace came to me doing what I believed was right and best for me. When I go back to my cushion, it’s my mind I have to deal with. Better to please it than try to live up to others impossible expectations! There will always be praise and blame.

Everything @Mat has said is very important and relevant. I also think diagnosis can sometimes be helpful. I didnt realize for years I had anxiety. I thought I was just ‘restless’. ‘When I get good meditation, it will go away’. But of course you can’t when you have anxiety!

But when I realized ‘oh THAT’S what this is!’ I could think, ‘well now that I know it and see it - I can deal with it. That’s not really “me” that’s the anxiety’. I finally found a bit of peace and contentment both on and off the cushion :joy:

While I get the ethical side, I guess it shows, diagnosis can be both helpful and harmful. What people need most of all (rather than a diagnosis as a label and a prescription for pills) is dignity, options and support for treatments.

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I have seen this to be true many times over. Often people are relieved that they finally have a handle or name for the nameless thing they have been grappling with and often blaming themselves and being blamed over it.

with metta

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Absolutely! Last month I had a too high dose of my thyroid medication and did not know it. I could only sleep 2 hours per night, felt absolutely drained, could not focus on anything, was snappy and emotional and thought I was the worst person in the world. I even started getting panic attacks. This took weeks.

Once I knew what it was and realized I was not going crazy, it was such a relief, even though it took a while to get back to normal. The worst is if people around you don’t understand (how can they, if you don’t understand what’s the matter yourself) and start blaming you over it or misunderstand your intentions when you try to talk about it.

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Jimi, thanks for your wonderful post. For many years, I have worked a bit with issues concerning BPD in families, and have great compassion and desire for education for both the person with the traits, and the family members and relationships that are sometimes affected by BP behaviors.

The DSM-5 has redefined the diagnostic criteria for what has been called BPD, and I feel that better informed clinicians more properly look to issues of emotional dysregulation and other traits and symptoms, and are trying not to use the term “Borderline Personality” as much anymore, simply because of the poor understanding among clinicians as to its many variations. There are many very cool, well functioning people that might meet criteria for BPD, and we know, conversely, of what most clinicians ( from their inpatient population training) know of the low functioning “borderline.”

You may know of Dr. Marsha Linehan’s landmark treatment for traits of BP, that being DBT, or Dialectical Behavioral Therapy. Most cities in the US, Europe, Australia have DBT programs, and there are wonderful support groups (even through MeetUp) that have groups for people with BP traits, and for family members that love and want to learn better how to support their family members with BP traits.

It’s been said that most all people have some BP traits, but it’s just with the disorder that these very human traits get amplified (via emotional dysregulation, anxiety) such that they interfere with close relationships, work, etc. Attachment issues from childhood, childhood trauma or invalidation/abandonment in childhood can contribute to instability in adult life with emotional regulation, abandonement fears, self-identity and self-esteem, and instability in adult relationships and career. These issues are very amenable to treatment, and the DBT success rates are very high.

Helping all associated with BPD is the understanding that support through DBT, cognitive therapy, support groups, meditation and body grounding/calming practices such as yoga, can bring one out of the shadows of BPD, and into a light of more wellbeing.

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My mother could not sleep for many years and she was diagnosed and prescribed with Mdd medications . she was bullied by the husband and relatives , I don’t think her conditions were treatable with these pills . But , I would think she could not get out of the recycling of the pains in her mind which I believes is the main cause .
But , unfortunately she could not understand her situation even though I tried to console her and sharing some of the dhamma to her .

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