Diagnosis and Human Experience

I am human, and I think nothing human is alien to me. - Terence

Years ago, I was having lunch with a friend who was a graduate student in psychology. He’d been studying the DSM (Diagnostic and Statistical Manual of Mental Disorders) and learning that he was a good fit for many disorders. Darkly amused, he said, “So now at least I can name exactly what kind of mess I am.”

First published in 1952, and now in its 5th edition, the DSM makes an impressive contribution to the catalog of patterns known to cause suffering. Even if you’ve never read it, its terms and categories suffuse our ways of talking about mental illness. At its best, the DSM is phenomenological, which means it describes the appearance of basic psychic patterns. That’s why my friend could see a little of himself in so many of its descriptions. He was using the DSM as a kind of map to the territory of his lived experience.

Unfortunately, the DSM suffers from some disorders of its own. Some it works to address, others remain largely unnoticed by its authors and the medical establishment they represent. Let’s look at a couple difficulties it seeks to address. They offer us a way to start thinking about where diagnosis fits in human experience.

The first difficulty is that the DSM sometimes pathologizes perfectly healthy psyches; the second concerns its categorical method of classification. To understand the first, we keep in mind that to describe is not the same as to judge. To describe the sun as appearing to move across the sky is not to assert that the sun actually moves across the sky (which it doesn’t). Likewise, to observe someone appears “emotionally unstable” or “anxious” is not to assert there is any disorder or illness. Description is one thing, judgment another. Calling something a “disorder” is a judgment, and usually carries negative connotations. After all, if something weren’t wrong, we wouldn’t follow a diagnosis by proposing treatment.

Sometimes these judgments wrongly pathologize healthy ways of being human, simply because they are not the norm, or go against cultural norms. That’s why until 1987 homosexuality was associated with a mental disorder by the DSM. A more recent example of trying to avoid the stigma associated with diagnosis is the movement to rebrand “disorders” like autism and ADHD as “differences” that fall on a continuum of “neurodiversity”. In effect, the movement wants us to describe without judging.

Of course, the DSM would be practically useless if it didn’t hazard judgments about what constitutes dysfunctional and thus disordered psychic patterns. To a large extent, these judgments reflect a cultural consensus; that’s why homosexuality could be named a disorder—until the culture changed, and it wasn’t. In addition, the categorical system for judging whether someone has a disorder simplifies the work of diagnosis. It also provides a common set of terms for communicating about, researching, and treating mental illness.

A page from DSM-5

But though it strives for objectivity, the DSM can’t avoid prejudice and bias. It is after all a human artifact produced by the psychiatric community, and reflects the wisdom, ignorance, and biases of that community. One takeaway is that, as helpful as the DSM can be, it’s a good idea to be skeptical whenever it departs from mere description and starts making judgments or offering explanations. We also do well to be skeptical of the medical establishment’s attempts to explain the causes and treatment of psychic “disorders”. (Dr. Gabor Maté’s most recent book, The Myth of Normal, documents how mainstream medicine has yet to integrate current research regarding the causes and treatment of psychic suffering.)

As for the second difficulty, the problems with the DSM’s categorical system stem in part from its virtues. By providing a clear set of criteria for diagnosing a disorder, it makes diagnosis easier. At the same time, it fosters the illusion that mental illnesses are things that you either “have” or don’t have, the way you do or don’t have Covid. Thus it gives the false impression that the criteria are less arbitrary than in fact they are, and that our psyches are less dynamic than in fact they are. This has real-world consequences, for example, leading some diagnosed with personality disorders to assume they are stuck with that pattern.

Aware that there are problems, the most recent edition of the DSM includes an alternative system for classifying personality disorders. Broadly speaking, this “dimensional” system better acknowledges the complex and dynamic character of psychic experience—including that our experience usually falls on a continuum rather than fitting neatly into categories. It makes room, say, for being a little borderline, without being diagnosed with a personality disorder.

This is a long way of saying that my friend was speaking truly when he noted that he appeared to have a little of this, a little of that—and in some places a lot more of this or that. We can relate to different diagnostic patterns, even in their subclinical presentations, because these represent regions of human experience. It’s not the experience of addiction or depression or anxiety or emotional instability, or whatever, that makes it diagnosable; rather it’s the intensity and duration of the experience. After all, since we are human, nothing human is truly alien to us. It’s just about where we fall on the continuum.