Are Diagnostic Labels Valid? Tldr:No

There is a big problem with the way most people talk about mental health and mental disorders today. People talk of ‘having’ depression or ‘having ADHD’ or being ‘mentally ill.’  These words matter. These words cause many people to think about diagnostic labels (eg. Depression, ADHD, Autism, Bipolar, Schizophrenia, etc.) as real entities, as something akin to cancer or diabetes. This view is widespread but false. It’s a myth that remains popular, not just among healthcare providers, but even among leading experts, professional organisations, and government agencies. This myth, is hanging around like a bad smell.  And to understand why I need to tell you a story – fascinating story - the story of the Diagnostic and Statistical Manual of Mental Disorders (DSM).  Buckle up.

History of the DSM

Our story begins in 1980 with the publication of DSM-III.  This third edition marked a radical departure from the first two editions of the DSM (1952, 1968) which were psychoanalytic/psychotherapeutic in their approach. The third edition presented diagnostic terms and labels as medical illnesses like diabetes, heart disease and cancer.  Why did the authors choose this path? Well, the charitable side of me says because they believed it. The more cynical side says because it made them look more legit. See, prior to DSM-III psychiatrists had a bit of an PR problem.  They were seen, or felt they were seen, as a bit woo woo, as…not ‘real doctors.’  They were mostly sitting in offices all day with patients doing psychoanalysis which was increasingly seen as eccentric and unscientific. So, taking advantage of the technological advances that were happening at the time in neurology and neuroscience, they presented their diagnostic labels in medical terms, as ‘disorders’ with ‘symptoms’, implying they were ‘real’ things, with biological markers. They rebranded (many of them even started wearing white coats)! Did they know what the biological markers were for any of these disorders? No, they didn’t. But it was just matter of time they said. ‘Not long’, they said, ‘and we will know what they are and we will know what causes depression, and schizophrenia, and mania’.

Soon, the public began hearing about how the different disorders were caused by specific chemical imbalances in the brain. Depression was due to low serotonin, schizophrenia to too much dopamine, and ADHD to not enough dopamine. This was a story of diagnoses that had been proven to be brain diseases—the pathology of these major disorders had been found.

All of this told of great medical progress. Prozac was introduced into the market in 1988, touted as a “breakthrough medication,” and other companies soon produced me-too SSRIs. Then, in the mid-1990s, atypical antipsychotics arrived on the market, which were also heralded as “breakthrough medications.” The new drugs were touted as medicines that “fixed the chemical imbalances that cause schizophrenia, depression and other major disorders,” and thus were “like insulin for diabetes.”

These were heady days. In 1995, the editors of the American Journal of Psychiatry wrote that DSM diagnoses had been “validated by clinical description and epidemiological data . . . The validation of psychiatric diagnoses establishes them as real entities.” A few years later, APA president Carolyn Rabinowitz was even more emphatic. “Mental disorders are [now] recognized as real illnesses,” she said, adding that just “as cancer is highly treatable and can be cured, we are experiencing a similar success in psychiatry.”

Things were looking up: Psychiatrists were a respected class once again. The public was hopeful all mental ills could be cured. And drug companies were laughing all the way to the bank.

There was only one problem…the story was a lie. It was all one big house of cards. But a house of cards that hasn’t quite collapsed like it should have.

The (in)validity of DSM diagnoses

There is now widespread acknowledgement that research since 1980 failed to validate the diagnostic categories in the DSM. Such confessions have come from Allen Frances, who was the chair of the DSM-IV task force; Nancy Andreasen, editor-in-chief of the American Journal of Psychiatry, and former NIMH director (2002-2015) Thomas Insel, among others.

Just prior to DSM-5’s publication Insel wrote: “While DSM has been described as a ‘bible’ for the field, it is, at best a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’ – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity.” (Insel, 2013). At a 2005 American Psychiatric Association meeting, Insel stated that the DSM had “0% validity”.

My favorite quote comes from Nassir Ghaemi, at the Tufts Medical School Department of Psychiatry, who wrote in 2013:

“When I graduated a generation ago, I accepted DSM-IV as if it were the truth. I trusted that my elders would put the truth first, and then compromise for practical purposes when they had no truths to follow. It took me two decades to realize a painful truth, spoken now frankly by those who gave us DSM-III and DSM-IV: the leaders of those DSMs don’t believe there are scientific truths in psychiatric diagnosis—only mutually agreed upon falsehoods. They call it reliability.” Ouch.

Incels predecessor as NIMH director, Steven Hyman was equally scathing: “[The creators of the DSM-III] chose a model in which all psychiatric illnesses were represented as categories discontinuous with ‘normal’. But this is totally wrong in a way they couldn’t have imagined. What they produced was an absolute scientific nightmare.”

According to renowned British-based psychologist and author Dorothy Rowe: “Apart from where it deals with demonstrable brain injury, the DSM is not a valid document. The DSM is a collection of opinions. When the committee of psychiatrists change their opinions, a mental disorder might be removed from the DSM and some new one included. Believing in the DSM is much the same as believing in, say, the doctrines of the Presbyterian Church. Neither can point to evidence that supports the doctrine that lies outside the doctrine itself. When our ideas are supported by evidence, we can regard them as truths. Ideas unsupported by evidence are fantasies.” (Rowe,2010, p.130)

I reject the idea that problems of thinking, feeling, and behaving are valid medical illnesses or diseases. Although biological factors like genes and brain structure and function play an important role in our psychological experience, there is no reliable scientific evidence that biological abnormalities are a major cause of "mental disorders" like major depression, schizophrenia, bipolar disorder, anxiety disorders, ADHD, eating disorders, or addictions. There are many biological correlates of psychiatric diagnoses, which is not surprising because all psychological phenomena are associated with biological processes (i.e., the mind and brain are connected). However, no disorder of body structure or function has been shown to cause any "mental disorder," or to even be specifically correlated with any psychological problem to a degree that is useful in making a diagnosis. That is why "mental disorders" are diagnosed with questions and subjective judgment rather than objective tests as with medical diseases.

On occasion, a psychological problem turns out to be caused by physical pathology such as a bacterial infection or genetic mutation. In such cases, the problem is understood to be a medical disease and is no longer classified as a "mental disorder" or treated by "mental health" professionals. It makes no sense to diagnose a person suffering from a bona fide medical disease with a "mental disorder." Popular pronouncements that "mental disorders" are caused by brain pathology, such as the claim depression is caused by a "chemical imbalance in the brain" and the claim that psychiatric drugs work by balancing brain chemistry, are scientific myths that can harm those who believe them. It is important for clients to understand this so they can make informed choices about their care based on accurate information.

Unfortunately, the scientifically discredited claim that psychological problems are medical diseases caused by a chemical imbalance remains popular, not just among healthcare providers, but even from leading experts, professional organisations, and government agencies. For example, the Royal Australian & New Zealand College of Psychiatrists, of which Dr. McGorry is a prominent member, falsely claims that "Medications work by rebalancing the chemicals in the brain." The Australian Department of Health misinforms the public, "Depressive disorders are thought to be due, in part, to a chemical imbalance in the brain. Anti-depressant medication treats this imbalance." Similar misinformation is often promoted in high-profile "mental health literacy" and "anti-stigma" campaigns.  It is nearly impossible for people in our society to make informed choices about the professional help they receive when they are routinely misled by doctors, trusted authorities and organisations, the medical profession, and even the government about the nature of their psychological struggles and psychiatric drug "treatments" for them. 

This issue also has serious public health implications. A 10-year study of 3000 people in South Australia found that those with high "mental health literacy," in other words who believed Beyondblue's message that depression is a medical illness caused by a chemical imbalance, were much more likely to become clinically depressed during the study than those who did not believe this message. Apparently, rejecting the idea that depression is a medical disease is protective against depression. 

What are ‘mental disorders’ then?​

If "mental disorders" are not medical diseases, what are they? In reality, diagnoses like "obsessive-compulsive disorder" and "major depressive disorder" are simply descriptive labels for types of psychological problems. They do not explain the cause of such problems, unlike medical diseases caused by physical pathology which by definition explain why people experience symptoms. Psychiatric diagnoses like "social anxiety disorder" are concepts, whereas diseases of the body can be directly observed and diagnosed with medical tests. ​It is thus a mistake to think of "mental disorders" as real biological entities ("things" that people "have," like a cancerous tumour), no different than medical diseases like diabetes, that cause symptoms. Psychiatric diagnoses don't cause psychological problems, they are psychological problems; what causes them is a different matter entirely. A diagnosis of "major depressive disorder" does not explain why a person feels depressed, it simply describes the fact the person feels depressed. This is very different from a diagnosis of diabetes which explains, through a well-understood pathological biological process, why a person has symptoms like weakness and fatigue. Thus, it is easy to see that the popular claim "mental illness is a disease like any other" is both misleading and harmful. 

There is no scientific justification for assuming, in the absence of direct medical evidence, that people who are diagnosed with a "mental disorder" are medically ill, have a malfunctioning brain, or that their thoughts, feelings, and behaviours are "symptoms" of a literal disease from which they suffer. This is important to understand because people who believe their psychological problems are medical diseases are more pessimistic about improvement, feel like they have less control over their own lives, make less effort to control their behaviour, and believe therapy will be less effective than psychiatric drugs even in cases where science-based therapies are the best available approach. And psychologists and psychiatrists who believe psychological problems are medical diseases have less empathy for their clients, view them in less human terms, and are more pessimistic about the benefits of psychological therapy. ​​​

The notion that psychological problems are medical diseases caused by brain and genetic defects is scientifically unsupported, disempowering, and stigmatising. People dealing with psychological issues are not sick with a "chemical imbalance" in their brain, their experiences are not symptoms caused by a medical disease, and they are not fundamentally different from anyone else because psychological struggles are part of the human condition. This reality is empowering to those who accept it, including both clients and therapists. 

If people who experience psychological problems do not have a "broken brain" or "chemical imbalance," they do not necessarily need to take psychiatric drugs to fix it. Drugs can be helpful for some clients, but they do not correct brain pathology (because none exists) and are therefore not necessary in the way insulin is for a person with diabetes. The choice to take a psychiatric drug, as with any intervention, should be based on fully informed consent about its risks and benefits, both alone and relative to alternative evidence-based interventions. Individuals who have been misled by their doctor or another trusted authority like RANZCP to believe they need to take psychiatric drugs to correct a chemical imbalance in the brain are unable to provide informed consent, cannot engage in shared decision-making about their care, and are at risk for undergoing treatment that may not be in their best interests. 

I do not use language, causal explanations, or therapeutic approaches that might cause clients to view themselves as abnormal or defective, reduce agency, lower self-efficacy, and cause pessimism about improvement. I have met many people whose experience in the mental health system tragically transformed what might have been a temporary stress-related period of distress into a chronic and disabling psychological struggle. Often, such individuals were told they have a chemical imbalance in their brain, were taught to view their unwanted thoughts and feelings as "symptoms" of "mental illness" that must be controlled or eliminated, were given diagnoses that altered their identity and invited stigma and discrimination, and were prescribed experimental psychiatric drug cocktails that worsened their psychological wellbeing and physical health. Although such practices are common in the mental health system, a compelling body of scientific research demonstrates that they routinely make clients worse in the longer-term. I strive to protect clients from the potential harms of this pseudoscientific biomedical approach. In doing so, I strive to follow the most important ethical principle for healthcare providers: "First, do no harm."