Some Psychiatric Diagnoses Are Circles
A lot of people confuse labeling something with understanding it. This is rampant in psychiatric diagnoses.
Here’s an oversimplified example. Imagine I decide to define a new disorder. I call it: Smells Bad Disorder (SBD). Here are the criteria:
For a diagnosis of Smells Bad Disorder, it is necessary to meet 2 of the 3 following criteria for a period of at least 2 weeks:
1) Patient smells bad most of the day, nearly every day, as indicated by subjective reports or observations by others
2) People find patient smells bad in at least 2 different settings
3) Patient’s smell has consequences in work and interpersonal relations
The thing that the average person doesn’t grasp is that having this diagnosis doesn’t actually say anything about what is occurring in the individual.
People assume that a diagnosis means something, that a person with the label has a tangible/objective something that underlies their neurology/psychology (and that it something aberrant from normal). They think that a person with the diagnosis has some sort of meaningful objective pathology.
But that’s not necessarily the case.
What we actually see with Smells Bad Disorder is that it’s a label that in reality is just a circle. All that can be said of a person with the diagnosis of Smells Bad Disorder is that they smell bad. What is missing here is everything. The diagnosis/disorder says nothing about the individual. It says nothing about their brain. It says nothing about their psychology. It says nothing about the underlying cause, in fact, it doesn’t even suggest that there is an underlying cause. The problem is that our associations with a diagnosis (and thus mental illness) implies all these things.
Here's a text conversation every mental health worker has had with their friend:
Friend: “Hey I just watched the Netflix Show Undomiciled Dating. The main guy Steve couldn’t get a date because no one would go near him because of his smell! What his diagnosis?”
Psychiatrist: “I think he has Smells Bad Disorder”
Friend: “I knew it! I told my wife he must have some sort of mental illness!”
Psychiatrist: “Yes Smells Bad Disorder is really devastating. Most people don’t know that a core aspect of the illness is they struggle with developing new relationships”
I hope you see what I’m trying to get at here. Our friend here thinks that the psychiatrist’s label imparts some deeper meaning into what is going on with poor lonely Steve, when in reality all that is being said is that Steve smells. Automatic associations/assumptions pop up when we hear someone has a mental health diagnosis/disorder. There’s an implicit assumption that someone with a disorder 1) has diminished responsibility for some of their actions, 2) deserves reasonable accommodations, 3) deserves some of our sympathy. Etc.
And I’m not saying that this is or isn’t the case. I’m saying that a lot of labels that appear to make sense of something are just circular definitions. I’m challenging the fact that a diagnosis gives meaningful information about what is going on (rather than the reality that it is merely a description of something that may or may not be worth classifying as "mental illness”).
I’ll take this further. My friend is a neurologist and has been studying Smells Bad Disorder. His team has discovered objective neural correlates using brain imaging, which might suggest Smells Bad Disorder isn’t just psychiatric nature, but perhaps can be classified as a neurological disorder.
Comparing populations of individuals with Smells Bad Disorder with controls has revealed a general reduction of volume in certain brain structures, especially the piriform cortex, primary olfactory cortex, and amygdala. Direct comparisons in functional imaging show decreased functionality in areas involved in executive functioning (with decreased metabolism present in the DL-PFC and anterior cingulate cortex. We believe this reflects a deficit in smell-mitigating behavioral strategies.
My neuroscientist friend and has chimed in with his findings:
Compared to untreated controls, populations treated with Venlafaxine have shown mild but consistent improvement in the HSQ-7 (How Smelly Questionnaire-7). This suggests Smells-Bad-Disorder might have foundations in serotonergic and noradrenergic aberrations, with current models suggesting a major role of the locus coeruleus-noradrenergic system. Further research is needed to parse out the hypothesized abnormalities in the dopaminergic and glutamatergic pathways.
My clinical psychiatrist friend developed an evidence-based treatment algorithm for Smells Bad Disorder.
With enough time, Smells Bad Disorder will have (valid) diagnostic tests, (real) neurological correlates, (evidence-based) treatment algorithms, etc. And with enough research I am certain it will be considered one of the “most valid” diagnoses in psychiatry.
I’m not saying smelling bad isn’t “real”. I’m not saying people who smell don’t suffer. I’m not saying smelly people don’t deserve treatment. What I am saying is that it is entirely possible to build a diagnosis with all the infrastructure of scientific backing by converting “this person smells bad” into a label.
And yeah, maybe you can apply this to ADHD.
Your central concern here seems to be that psych diagnoses are syndromes, ie groups of symptoms empirically observed to frequently cluster together, rather than fully elaborated pathophysiologies. This is trivially true, and I think most psychiatrists reading this would say, "Yes, they're syndromes, duh. I wish we understood the disease process better and why our meds sometimes work, but in the meantime we can use described syndromes as guides for when and how to treat." There's value in identifying the clustering patterns but sometimes it really is just defining a cutoff at the extreme end if a spectrum of traits. That said, I completely sign onto your criticisms of the implicit assumptions about psychiatric diagnoses (like diminished responsibility for actions), but that's more a broader problem of the.broader culture having conflicting ideas about agency.
There is another point of contention where I couldn't tell if you were being humorous, which is to say a condition is neurologic rather than psychiatric. In general what this usually means is "can we image it with current technology " (if yes, it's neurological.) Obviously if someone consistently is found to have a set of cognitive or behavioral traits, some physical.charctteristics of their central nervous system are causing it, even if it's just the circuits that are the neural correlates for a set of dysfunctional beliefs that would be best treated with CBT. Again trivial, but this nuance is often lost among physicians who just need to decide which specialty to refer to, and take the distinction to be one of kind rather than a pragmatic one based on diagnostic technique.
This is a good take. I'm not sure I understand what your conclusion is, though.
To follow your example, let's assume the following things are true: SBD generally leads to a decreased quality of life. People suffering from SBD are not as likely to help themselves as they are to get help from healthcare. Healthcare provides interventions, some of which help with SBD and seem to improve the patient's life.
The obvious question in this case is: what does it matter if we do not have an encapsulating definition on the precise etiology of SBD? If these people need help, and if we can help them, shouldn't we help them even if we knew we didn't understand precisely why the help works?
Research is ongoing, and perhaps some people will even question whether SBD exists as a disease by itself, as contrasted with it being a symptom or a manifestation of some other issues. And this is beneficial, ok and useful, but I think it's obvious we should still help people with SBD during that conversation.
Yes, perhaps this also applies to ADHD.
Particularly, I think that argument holds for most diseases we can identify and treat, more or less succesfully. Only in very rare cases do we understand nearly all of the necessary pathological processes, but in a lot of cases we understand enough to be able to treat.
That is, so what if ADHD doesn't exist? So what if 'coma' doesn't exist? So what if 'psychosis' doesn't exist? If we know we're in a dark maze and we know a way out, I don't think it's necessarily bad to follow that way out even if we don't really know why it is a way out, or whether it is the best way out.
Yes, I'm sure medicine in the 2000s is prone to cargo cult -like behavior (as in the case of SBD) just like it was 200 or 300 years ago, although less so. However, I think that merely pointing that out accomplishes relatively little. It's an important piece of meta-information to hold in the back of our minds, especially if a disease turns out very difficult to understand or treat, but I don't think it's very useful most of the time.