“Unlike the problems many physicians see from day to day – a rash, a virus, a tumor, a broken bone – most of the illnesses psychiatrists treat and study are incredibly hard to describe and open to multiple interpretations. Compared to other branches of medicine, psychiatric diagnosis is highly subjective.”
-Roy Richard Grinker (2007, p. 2)
One problem has plagued the field of psychology since its inception: While there’s no doubt that psychology is a real science, and there’s also no doubt that people struggle with psychological issues, the process of actually assessing and classifying these conditions has always been (and probably always will be) based more on subjective opinion than science. There are no blood tests that will tell you if a child has a behavioral disorder. There aren’t any reliable psychological markers that will diagnose a psychiatric condition such as bipolar depression or schizophrenia.
Making matters worse, psychology is highly vulnerable to the influence of suggestion and popular culture. So it’s a lot like the ? Heisenberg? Uncertainty principle in quantum mechanics: you can never get an accurate picture of reality because the mere act of observing and measuring something changes its nature. Likewise, a psychiatric diagnosis is always a heavily skewed assessment, the product of a culture’s perceptions of “healthy,” a parent’s anxieties, and a clinician’s prejudices.
The guidelines used to assess and diagnose mental health and behavioral disorders in this country leave a lot to be desired, to put it mildly. When doctors and psychiatrists are assessing a patient, they use a behavioral/symptom checklist in what is referred to as the “psychiatric bible” A book called the Diagnostic and Statistical Manual (DSM) published by the American Psychological Association. This reference book was first introduced in 1952 as a spiral bound pamphlet describing 11 categories of mental disorder. It received a major overhaul in 1980 with the DSM-III, which was revamped in an attempt to add some sort of validity to the field of psychiatric diagnosis. With its easy to use checklist, the idea was to code patients who all displayed similar symptoms under a particular label.
Being Sane In Crazy Places
One classic experiment exposed the serious flaws in psychiatric diagnosis. In 1972, Stanford University psychologist David Rosenhan and several of his colleagues wanted to test just how reliable doctors were at assessing patients. He and his associates were able to dupe psychiatrists into diagnosing them with schizophrenia simply by saying they heard voices as their sole complaint. They were then committed to mental hospitals, where they were held against their will. The 7 individuals, all healthy psychology students, were held in 11 different psychiatric wards for periods between 8 and 52 days. There doctors force fed them antipsychotic medication (2,100 pills in all), which the students were mostly able to pocket or stuff in cheeks. In concluding his study, Rosenhan argued there was no way to accurately diagnose mental illness. (Rosenhan, 1972)
It was a wake-up call to the American public, showing that not only were psychiatrists acting in an unscientific manner, but they were routinely violating human rights and could do some serious harm through their interventions.
Plenty of other research since then has demonstrated just how flawed this process can be. One study showed two different sets of American psychiatrists and British psychiatrists a videotape of a socially awkward man described in the tape as a 30-year-old bachelor, and asked them to give a diagnosis. Sixty-nine percent of the American psychiatrists diagnosed the man with schizophrenia, compared to only 2% of the British psychiatrists. The latter group leaned towards manic-depressive in most cases. (Kendell et al., 1977) Exact same subject, two different outcomes – based not on what was in the patient’s head, but on the biases and perceptions that existed in the clinician’s head.
I see a potato, you see a rocket ship
In 1949, American psychologist Philip Ash found that three psychiatrists evaluating the same patient with the same information would agree on the same diagnosis only 20% of the time. (Spiegel, 2005) Professional diagnostic manuals such as the DSM–with its checkmark system for evaluating patients – were meant to fix this. But while they may have added a little more reliability when it comes to grouping certain symptomatic behaviors under certain labels (which says nothing about whether these groupings and labels are real or accurate to begin with), even this system has left much to be desired.
One study compared researchers and clinicians from both the U.S. and the U.K. to see how the two groups would assess the same 36 boys, ranging in ages from 6 to 11. Each group used their respective manuals, the ones that were supposed to eliminate such gross discrepancies. The results weren’t pretty. Psychiatrists came up with many different diagnoses-schizophrenia, childhood psychoses, personality disorder, conduct disorder, and so on. Research teams agreed overall on 3/4 of cases when using the ICD-9 (The U.K. ‘s version of the DSM) and two-thirds of cases when using the DSM-3, but clinicians agreed with each other only about 25% of the time using either manual, showing that the clinicians who actually assess kids have little evidential overlap, especially between countries. (Prendergast et al., 1988)
As psychiatrist Daniel Carlat notes, “The DSM has always been a primitive field guide to the world of psychological distress because we know very little about the underlying neural chemistry of psychological symptoms.” (Jabr, 2012) Ferris Jabr calls it an ambitious attempt to capture an evolving, often ambiguous science.” (ibid) Others have stronger words for it: Carol Tavris remarks that it’s nickname of the psychiatric “bible” is an apt description, since “readers usually disagree in their interpretation interpretations of the ext; and be living it is an act of faith.” (Tavris, 2013)
Ferris Jabr notes that “Suspiciously, between 40 and 60 percent of all psychiatric patients are diagnosed with a personality disorder,” which suggests a significant overlap between conditions and ambiguous symptoms that don’t fit neatly into diagnostic labels. (Jabr, 2012, p. 32) But it gets worse: The third most common personality disorder is “personality disorder not otherwise specified.” Which means that not only is there a great deal of overlap between symptoms, but many people’s symptoms are so scattershot that psychiatrists can’t fit them into the official definitions.
It’s not just that practitioners vary so much when it comes to assessing patients; even the conditions themselves are the subject of much debate and confusion. Scientists have never reached any consensus on these disorders; they are birthed in the same way the senate passes a bill: lots of arguing, a bit of compromise, and a vote to create it once enough of the members agree it should exist. Not only is there disagreement when it comes to the major disorders, but there is great controversy surrounding many of the more recent additions, as the APA has continued its expansion of the definition of mental illness to include virtually every person under the sun. In his book Saving Normal, Dr. Allen Frances compared the criteria established for many of these disorders as being “sometimes barely better than two monkeys throwing darts at a diagnostic board.” (Tavris, 2013)
As Roy Richard Grinker notes, “even the disorders that have been researched the most by psychiatrists, neuroscientists, geneticists, and epidemiologists remain mysterious.” (Grinker, 2007, p. 120) One of the reasons they remain so mysterious is that there are no definitive tools to measure these conditions by. Columbia University psychiatrist Michael First, who was an editor for the 4th edition DSM, wrote in November 2010 edition of the Canadian Journal of Psychiatry that “not one single laboratory marker has been shown to be diagnostically useful for making any DSM diagnosis.” This means that all diagnoses will ultimately boil down to a matt3r of interpretation. As Dr. Frances acknowledges, “all of our diagnoses are now based on subjective judgments that are inherently fallible and prey to capricious change.” (Tavris, 2013)