Trying to carve nature at its joints: the complexity of psychiatric diagnosis

Louise Stone (@GPswampwarrior) is an Australian GP with clinical, research, teaching and policy expertise in mental health.

It would be nice if the world of mental health fell neatly into a taxonomy. It would be nice if we could, as Plato wrote, carve nature at its joints.¹ We would find it so much easier to cope if all human suffering could be allocated to a relevant, and distinct, category that encapsulated the likely cause and course of the disease. However, in psychiatry, the landscape is not so simple. It’s just easier in many ways to pretend it is.

Psychiatric taxonomies such as DSM 5 and ICD 11 help us to categorise mental illness into a series of diagnoses based on observable characteristics. These taxonomies have helped guide research, and the diagnoses contained within them undoubtedly ground evidence and therefore guide treatment. We have been moving towards simplifying the diagnostic process, using tools in less expert hands to screen and categorise patients, allowing these decisions to guide our treatment pathways.²

It is a seductive model, where diagnostic tools lead to psychiatric diagnosis leads to evidence-based therapy. This industrial approach to care allows us to roll out increasingly simplistic protocols of care that can be provided, in aliquots, to tightly defined populations. And it works for some. Unfortunately, in general practice we are well acquainted with the large patient population who do not fit this botanical view of the world.

Fortunately, categorical diagnoses are not the only way to see mental illness. Throughout history, there have been ways of understanding mental illness that incorporate the lived experience of the person with the disorder, understanding aetiology and potential therapy in the light of this experience. Lived experience narratives represent and respect culture, trauma histories, identity and context. Psychological interventions utilise these narratives to shape therapy that is patient-centred and recovery focussed. Of course, one could argue that the patient’s narratives are important with any illness. However, mental disorders are conditions that disturb a person’s unique sense of self, a self that is biological, storied, encultured, social, political and existential.³ Bluntly, you do not ‘have’ schizophrenia the way you ‘have’ a broken leg, because mental illness is not just about ‘having’ it is also about ‘being’.⁴

Good psychiatric diagnosis respects both these perspectives: A good clinician will weave together the warp threads of categorical diagnosis (like major depression) with the weft threads of lived experience (such as childhood trauma) to create an explanation that respects both points of view. At the moment, our shared experience of natural disasters and pandemic will dramatically change the weaving. Post COVID, we will not simply have more mental health disorders to deal with: what we see will be qualitatively different, shaped by the change in our collective lived experience.

We are expecting mental health fallout across the population, and it will not just be in disorders. Parents of newborns will not have access to social support, people will grieve alone, people who are experiencing homelessness will have temporary housing with its associated temporary empathy, and will have difficulty readjusting to life without support again. The economic consequences of COVID will mean the emergence of anxiety and depression in people who had previously enjoyed a life of generous privilege. We, after months of trying to project empathy through a mask or down a phone line, will have to confront the ongoing task of caring in a world where a sustainable life as a GP seems ever more precarious. And many people, including us, will know the pain of grief and loss.

GPs are masters of complexity and uncertainty, but complex tasks take time. It is undoubtedly quicker to make categorical diagnoses via checklists and questionnaires, but without understanding the patient and their context, the risk of iatrogenic harm is high. Its time we recognised, respected and researched the difficult process of holistic psychiatric diagnosis in the GP setting.

As GPs we see all patients, no matter what category they fall into. They all deserve our understanding and our care.

 

References

1. Rapley M, Moncrieff J, Dillon J. Carving nature at its joints? DSM and the medicalization of everyday life. De-Medicalizing Misery: Springer 2011:1-9.
2. Parker BL, Achilles MR, Subotic-Kerry M, et al. Youth StepCare: a pilot study of an online screening and recommendations service for depression and anxiety among youth patients in general practice. BMC Family Practice 2020;21(1):2.
3. Sadler JZ. Values and psychiatric diagnosis: Oxford University Press 2005.
4. Kraus A. How can the phenomenological-anthropological approach contribute to diagnosis and classification in psychiatry? In: Fulford B, Morris K, Sadler JZ, et al., eds. Nature and Narrative: An Introduction to the New Philosophy of Psychiatry: Oxford University Press 2003.

 

Featured photo by Priscilla Du Preez on Unsplash