DSM 5: Diagnosis Should Describe, Not Pathologize



Could we see a diagnosis as a description rather than a designation of pathology?

I've been thinking about Dan Peters's post about pathologizing the human condition. I understand and share his concerns about the influence of health insurance requirements on how people are diagnosed and how they can get help, but I think that's actually a separate problem from the question of “should we diagnose”. If people had freer access to health care in general, and mental health care in particular, there would be less pressure to diagnose for the sake of having access to a reimbursable treatment.

Let's assume for the moment that insurance is not a factor; the question of whether to diagnose still remains and hinges on the meaning we make of diagnosis itself. Does a diagnosis mean there is pathology? Does it mean there is something wrong that must be fixed? Is it a judgment on a person's worth? How we answer those questions depends on the social context, and the effect of a diagnosis on a person depends partly on how that diagnosis is seen by society.

Instead of worrying that the DSM 5 is pathologizing temper tantrums and grief, what if we examine what we mean by “disorder” in the first place? Is a developmental difference like Asperger's really a disorder? Do we call it a disorder because these differences cause suffering? Is every mental condition that causes suffering a disorder? Dyslexia is a similar example. Both can cause suffering but can also confer unusual strengths.

Is everything different from the norm a disorder? In contrast, PTSD could reasonably be seen as an emotional injury. PTSD is a documented human response to trauma. It certainly causes suffering, but if many “normal” people who are exposed to trauma develop PTSD, how can PTSD be abnormal?  It would be more accurate to describe it as a normal response to an abnormal situation.  And consider anxiety: anxiety is a normal human emotion and necessary for our survival. It's only a problem if the anxiety is excessive or somehow inappropriate to the situation. So anxiety itself is not a disorder, and we wouldn't want to completely eliminate it.  Still, all four of these are considered "disorders" by the DSM. Perhaps the DSM is unnecessarily pathologizing much of what it describes.

On the other hand, I think that the proliferation of diagnoses in the DSM 5 is the result of increasing specificity in our descriptions of mental conditions. That is not necessarily a bad thing! Categorizing mental conditions and exploring their differences are important steps toward greater understanding of the mind and brain. If our society conceptualizes those mental conditions as pathology, I don't think that's necessarily driven by the DSM. The DSM is a product of our social concept of mental health and seems to be a response to people seeking relief from various symptoms. If anything, it lags behind changes in society's views on mental health and illness. Our lack of knowledge about the causes of many mental conditions means that the DSM must consist of symptom-focused descriptions. I would be the first to agree that these are subjective and people sometimes mistake the symptoms for the cause, but description and diagnosis still serve important purposes.

The word “diagnosis” comes from Greek and means “to know apart”, in other words, “to differentiate between”. In its function of describing people, diagnosis does not inherently pathologize them. That's a judgment we place on the description after the fact. The best clinicians use diagnosis as a means to describe and explain a client's experience.

Diagnosis can validate people's experiences, empower people to seek treatment or accommodations, honor and encourage their adaptive efforts, and foster connections with others who share their experience. If I could change one thing about the DSM 5, it would not be to erase any of the descriptions, it would be the word “disorder”. Difference is not disorder. Emotional pain is not disorder. These are aspects of being human. Let's keep describing human experience in all its variety, keep trying to help those who are suffering, but work to change how our society views those who are different or in pain.

Tags: catharine alvarez, dan peters, diagnosis, disorder, dsm 5, pathology

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