The myth of mental health diagnosis

How much is art and how much is science?

Source: Photo by Matheus Viana by Pexels

On the eve of the release of Diagnostic and statistical guide for mental disordersFifth Edition (DSM-5) in 2013, field trials were conducted in real-world conditions to see essentially how useful this is Bible for mental health clinicians it is in making valid, reliable diagnoses.

For each major mental health diagnosis (eg schizophrenia, post-traumatic stress disorder, alcohol use disorder, etc.), a reliability score was calculated between evaluators, or in other words, how much two clinicians agreed with each other, that a person has a definite diagnosis. You’d think it would be pretty obvious if someone was depressed, right?

Wrong. Highly qualified psychiatrists who self-assess a person can only agree that the person is depressed between 4 and 15 percent of the time.1.

The score for reliability among evaluators also fell in this “doubtful” range of 4-15 percent (possible ranges are “very good”, “good”, “controversial” and “unacceptable”) for diagnoses of generalized anxiety disorder, mild craniocerebral trauma and antisocial personality disorder.2

Let’s think about it. This means that based on these findings, if you are diagnosed with depression by a clinician using DSM-5, there is an 85-96 percent chance that if you go to a second clinician, he will not diagnose you with depression (just like 4-15 percent chance that they would).

One of the reasons for the appalling lack of consistency of clinicians can be understood by comparing anxiety and depressive disorders.

Historically, we have treated anxiety and depression as two separate disorders. DSM, last revised in March 2022 and released as Ddiagnostic and statistical guide for mental disordersFifth edition, revision of the text (DSM-5-TR), defines generalized anxiety disorder (GAD) as “excessive anxiety and worry (fearful anticipation) occurring for more days than not for at least six months, for several events or activities (such as a work or school performance). “3

According to DSM-5-TR, in order to meet the criteria for major depressive disorder (MDD), “five (or more) of the following [nine] symptoms [must] have been present during the same two-week period and represent a change from the previous operation; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. “Four of these symptoms relate to difficulty concentrating, difficulty sleeping, easy fatigue, and changes in psychomotor movements. Interestingly, these symptoms that are the criteria for diagnosing MDD are too criteria for diagnosing GAD.

As you can guess, this overlap of symptoms has led to a high comorbidity between GAD and MDD, which means that many people diagnosed with one condition are also diagnosed with another. For example, a worldwide study found that 45.7 percent of people with severe depressive disorder throughout their lives also report a lifelong history of one or more anxiety disorders.

Nearly half of people with depression say they also have anxiety. Other studies have found that the comorbidity between GAD and MDD varies from 40-98 percent. High levels of comorbidity are not limited to correlations between GAD and MDD, but can be found between many DSM diagnoses.

All this, to say the least, we may have to accept mental health diagnoses with a drop of salt. You may get one diagnosis from one clinician and find that if you go to another, you may get a different diagnosis or several additional ones. Some clinicians may more often diagnose people with depression, while other clinicians may diagnose people with anxiety.6

This does not mean that diagnoses are completely useless, but it does mean that we need to treat them less literally and understand that two clinicians may look at the same symptoms but see and name them differently based on a different context, which may include the clinician’s own bias, differences in learning experience, and what the client chooses to report.

You can see a product in a bakery window at breakfast and call it a muffin, and I can see a similar product with icing on it for a birthday and call it a cake. Let us realize that our perceptions are subjective and there can be many truths. Let us treat our diagnoses as descriptions, not explanations.

Leave a Comment