R. D. Ordovich Clarkson, MD
September 18, 2022
Mental health diagnoses have been controversial since the dawn of the profession, due in large part to the ever-present stigmas associated with mental illness. Terms such as “hysteria” which pertained to women “misbehaving” and “imbecile” or “moron” to describe those suffering from cognitive impairment are no longer used in professional parlance. Furthermore, terms such as “crazy” are universally shunned by the behavioral health community as a pejorative, though the colloquial understandings of such terms remain both descriptive and impactful. However, despite using more politically correct terms, the fact of the matter is that the meaning of the term still remains. Dr. Steven Pinker famously described this as the euphemism treadmill whereby polite society and professional institutions attempt to assuage the negative connotations of a word, despite the definition of the term itself catching up to the new nom du jour (Pinker, 1994). At the end of the day, we should never be rude to individuals, particularly in a professional setting. But with that, adequate diagnostics do serve an important purpose in allowing professionals to understand what it is they are attempting to treat and address.
One must understand that patients are not one-dimensional. Diagnostics can be highly nuanced, helping to develop a deeper understanding of patients on an individual basis. In the 1960s, famous psychiatrists such as R.D. Laing who eschewed some of the mainstream notions of diagnostic labels still stating that, “no one has schizophrenia, like having a cold. The patient has not ‘got’ schizophrenia. He is schizophrenic. The schizophrenic has to be known without being destroyed. He will have to discover that this is possible” (Laing, 1965, p. 34). Laing’s view was one that the schizophrenic perspectives were simply divergent from those held to be as “normal,” and that schizophrenic individuals had a different worldview than those who were “sane.” Today, in order to better understand patients, the Diagnostic and Statistical Manual of Mental Illness (DSM-5, 2013) has a helpful feature for clinicians.
Cross-cutting symptoms used in the DSM are not used for diagnostics, but are instead used as an adjunct to the treatment and management of patients on a more individualized basis (Clarke & Kuhl, 2014). Furthermore, cross-cutting symptoms are used to further assess the severity of the chief presenting symptoms—that is, co-occurance of several cross-cutting symptoms make both prognosis and treatment of mental disorders increasingly severe (Clarke & Kuhl, 2014). As explained by Clarke & Kuhl (2014), cross-cutting symptoms in the DSM are equivalent to the ‘review of symptoms,’ though on specifically mental grounds, using 12-13 psychiatric symptom domains that “cut across” different diagnostic boundaries. Clark & Kuhl (2014) describe how such cross-cutting symptoms include, “depression, anger, mania, anxiety, somatic symptoms, sleep disturbance, psychosis, obsessive thoughts and behaviors, suicidal thoughts and behaviors, substance use (e.g., alcohol, nicotine, prescription medication, and illicit substance use), personality functioning, dissociation, and cognition/memory problems in adults.” In order to factor in all these co-factors, clinicians can not only identify the fundamental needs of a patient, but can reduce or escalate the treatment modalities on a case-by-case basis.
A SOLUTION TO THE LABELING PROBLEM
In an interesting exchange between a mental health professor and I, she asked how while considering Dr. Laing’s approach, how we would be able to correspond with clinicians who do not agree with “labeling clients as schizophrenic.” That is, that such clinicians feel that labels are negative in impact and it is better to state that a patient is a schizophrenic vs. a patient with schizophrenia. This is a great consideration, particularly insofar as we are more than our diagnosis.
Individuals are defined by complex variables in their lives, and a clinical diagnosis should not overshadow our other characteristics. Personally, when I refer to patients, I refer to them as "patients with X," such as a "patient with diabetes," or a "patient with depression." I tend to regard individuals suffering from disorders as being an individual first who has to, on a secondary basis, contend with their illness, whether it be somatic or psychological. By in large, unless the patient has severe cognitive dysfunction rendering them without capacity, I will speak to them in honest terms regarding their condition.
As a very close and personal example, my father has been diagnosed with senile dementia and has recently suffered from a occipital lobe stroke. When he talks about his "incident," I don't make that focus of attention. Instead, I will talk to him about ways to deal with the consequences of these conditions. In other words, he will need to be careful when standing up, and will need assistance to get from point A to B. When he forgets things, I don't necessarily tell him that it's the consequence of his dementia, but I try to help him exercise his mind and regain some of his cognitive and motor faculties.
Patients will suffer from a myriad of conditions. The best thing we can do is, in a non-judgmental and finger-wagging fashion, help them contend with their symptoms and to help them pave a better and more flourishing life. Mental health diagnosis also remain stigmatized in the greater lexicon, thus it is good to reinforce the patient and help them understand that they are not alone. Many people suffer from similar conditions and we are there to help them heal and regain their faculties.
DIFFERENT STROKES FOR DIFFERENT FOLKS
Depending on an individual’s age, gender, or cultural background, clinicians may need to adjust their diagnostic and treatment approach, taking all aspects of the patient’s demographics into consideration. What may be considered an aberration in one demographic, may considered the norm in another. Driving on the right side of the road in the United States, for instance, is the norm, whereas in the UK, you would be going the wrong direction. This reminds me of a wonderful personal anecdote that exemplifies this perfectly.
While in medical school at Ross University, for example, my behavioral health professor, Dr. Steven H. Fox, discussed an African tribe that he studied during his PhD dissertation. When an individual communicated with spirits, the person was not regarded as ‘psychotic,’ but instead consulted with the tribal shaman. A particular woman was being tormented by a spirit, which the shaman determined was a spirit infatuated with the woman. The shaman asked the woman to negotiate with the spirit, which she did, agreeing to entertain the infatuation while allowing her to act as a median with other spirits in the transcendental detentions. Eventually, this woman became an extremely successful and highly sought after spiritual median in the community. Through a Western medical lens, the woman would have been regarded as psychotic or schizophrenic and likely medicated to dispense with her spiritual delusions.
Schwyzer & Rubin (2014) provides a similar example, stating that, “the DSM alerts us that an individual’s cultural and socioeconomic background must be taken into consideration when making a diagnosis of Schizophrenia, especially when the client’s cultural or socioeconomic background differs from the clinician’s since ideas that appear to be delusional in one culture may be commonly believed among another population” (p. 50). Other factors are also discussed by Schwitzer & Rubin (2014) involving gender. Among men, for example, bipolar disorder and antisocial personality disorder are more common. On the other hand, women have a higher incidence of major depressive disorder (MDD), schizoaffective disorder, as well as histrionic personality disorder.
CONCLUSION
Sometimes mental health diagnoses carry serious stigmas that are difficult to shake off. Despite this, diagnoses help to better understand what the patient is experiencing on an objective basis. When diagnosing symptoms and developing treatment plans, it is critical to factor in not only the presenting symptomatology, but also take into consideration the patient as a whole. The patient must be regarded as a sum of all parts, and clinicians along with society writ large must avoid reductive judgements on patients, regarding them as nothing more than a label or diagnosis. A holistic approach therefore means we must consider how old the patient is, are they male of female, where are they from, and even what belief systems do they prescribe to. Only then can we adequately address the patient’s mental health needs.
REFERENCES
Clarke, D. E., & Kuhl, E. A. (2014). DSM-5 cross-cutting symptom measures: a step towards the future of psychiatric care?. World psychiatry : official journal of the World Psychiatric Association (WPA), 13(3), 314–316. https://doi.org/10.1002/wps.20154
American Psychiatric Association [DSM-V]. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Publisher.
Laing, R. D. (1965). The divided self: An existential study in sanity and madness.
Pinker, S. (1994, April 5). Opinion | The Game of the Name. The New York Times. https://www.nytimes.com/1994/04/05/opinion/the-game-of-the-name.html
Schwitzer, A. M., & Rubin, L. C. (2014). Diagnosis and treatment planning skills: A popular culture casebook approach (2nd ed.). Sage Publications. ISBN-13: 9781483349763
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