The Limits and Pitfalls of Mental Health Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) is a nearly 1,000-page long manual that details to clinicians how to diagnosis clients with a plethora of mental health “disorders”. However, the DSM-V, in spite of its gargantuan length, still fails to address a plethora of issues facing clients that clinicians work with every day. The most poignant example that comes to mind is the specification of simple versus complex post-traumatic stress. As many clinicians who work closely with populations who have experienced trauma understand, there is a quite a difference between presentations of complex (multiple-instance) and “simple” (single-instance) trauma presentations in life. At the time of its inception, many trauma therapists argued for the American Psychiatric Association to include complex-PTSD as a diagnosis due to its distinctive qualities. In spite of this complex-PTSD was not included in the DSM-V, and many people have struggled needlessly due to this mistake. Additionally, many diagnoses that currently exist within the DSM-V are subject to much scrutiny by the mental health community and wider society. For example, the diagnosis of Oppositional Defiant Disorder (ODD) that exists for children under the age of 18. The criteria for diagnosis of ODD include:

“A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

Angry/Irritable Mood

1. Often loses temper.
2. Is often touchy or easily annoyed.
3. Is often angry and resentful.

Argumentative/Defiant Behavior

4. Often argues with authority figures or, for children and adolescents, with adults.
5. Often actively defies or refuses to comply with requests from authority figures or with rules.
6. Often deliberately annoys others.
7. Often blames others for his or her mistakes or misbehavior.

Vindictiveness

8. Has been spiteful or vindictive at least twice within the past 6 months.

B. The disturbance in behavior is associated with distress in the individual or others in his or her
immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on
social, educational, occupational, or other important areas of functioning.

C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive,
or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.”

(American Psychiatric Association, 2013)

This long list of criteria can be boiled down to a few words: this child is angry. What this diagnosis fails to address or understand is the why. If we can acknowledge that a child is angry, and their behaviors are existing outside of the range of expected behavior for a child of their age, the question becomes why? It is exceedingly rare for a child (or anyone, for that matter) to exist as an “angry person” for no reason whatsoever. People are social creatures, and we react to our circumstances and experiences. However, what we see time and again as clinicians is that once this diagnosis is given by a provider to a child, the stigma of having ODD sticks to the child for the rest of their lives. In fact, children diagnosed with ODD are more likely to be diagnosed with Antisocial Personality Disorder. Again, what diagnosis fails to address is that an epidemic of angry children is likely not because the children themselves are “bad” or “sick”, but because they live in traumatizing conditions and are reacting in the only way they know how to those conditions. Societally, our failure to appropriately diagnose and treat the core issues of why children become angry leads to these children being labelled, ostracized, and spit back into a system that would rather ignore and pathologize them than understand their struggles and how to help them. ODD is only one example of a diagnosis that fails to conceptualize and address the core issues. I suspect many of the children who get diagnosed with ODD are suffering from traumatizing home and community circumstances, and that the addition of a diagnosis such as complex-PTSD would help them to better conceptualize their own struggles, and more importantly, work on ways to heal from their traumatizing experiences. Rather, what diagnoses such as ODD tend to do is pathologize without a clear understanding of a way forward.

Diagnosis is important in a few aspects. Firstly, it helps insurances to understand how to bill and helps on the legal side of things with enuring that clinicians are utilizing treatment approaches which have been deemed as evidence-based and appropriate for specific ‘disorders”. Second, diagnosis may help to destigmatize experiences. Especially, as discussed in my last blog post, for people who may identify as neurodivergent. Diagnoses can serve as a community-building aspect for many who may have struggled for a long time with feeling unseen and unheard. Diagnosis helps us to label, but as stated previously, labels can present their own dangers, and clinicians should be careful about approaching diagnosis in a way that empowers their clients instead of disenfranchizing them.

Diagnosis has some major pitfalls. Many clinicians before me have pointed out the issues that come about from conceptualizing mental health from an illness-focused model. First, this model posits that the absence of “symptoms” indicates health, and that “symptoms” are a problem to be fixed by medication or talk therapy. However, this is a very narrow framework of viewing human experiences and can often ostracize those whose “symptoms” are prevelant or lifelong, or whose “symptoms” do not respond to the traditional Western methods of mental healthcare. It can make people feel as though their lived experiences are problems to be fixed, when in actually they are perhaps better accepted and contextualized.

Understanding the limits of diagnosis can help us as clinicians to better understand how to help our clients within the mental health systems and framework available to us, and can help our clients to feel less ostracized and more accepted.

In my next blog post, I will dive deeper into the ties between mental health struggles and the prevelant prison industrial complex in the United States.