Where Do We Go From Here?

This chapter concludes the book by examining the implications of its overall argument. It begins by discussing the increase of consumerism in medicine, examining the good and bad sides of trends leading to less power for professionals and more power for consumers. It explains why patients and their families can become even more attached to a doubtful diagnosis that professionals who care for them. This shift has been made possible in part by wider diffusion of information through the internet. The chapter suggests strategies for clinicians interested in overcoming the tendency to overdiagnose mental disorders. They include a greater commitment to science, a healthy suspicion of fads, a tolerance for ambiguity, and a sense of humility about our current state of knowledge about mental disorders.

The Rise of Aggressive Psychopharmacology

Aggressive psychopharmacology describes the current practice of prescribing a large number of medications to patients with almost any mental disorder. While there is some evidence for this approach in severe and, persistent mental disorders, it has spread to common disorders, most particularly major depression. Clinical practice guidelines, which offer a wide range options for patients who are resistant to standard treatments, are being interpreted as promoting polypharmacy for a very broad group of patient. These practices have a surprisingly weak evidence base, and tend to take psychotherapy options off the table. Aggressive psychoharmacology is driven by overdiagnosis and is strongly encouraged by the pharmaceutical industry.

Personality and Personality Disorder

Personality traits differ among normal people, and one should only diagnose a personality disorder (PD) in the presence of a clear-cut impairment of functioning. Most of these disorders lie on a spectrum with traits, but those that cause prominent symptoms present more often in psychiatry The most clinically important category of PD is borderline personality disorder (BPD), but this condition is widely underdiagnosed. Since these patients often present with depression and/or affective instability, clinicians often see them as suffering from mood disorders, and treat them unsuccessfully with antidepressants. However, this population, which shows repetitive suicidal behavior, needs to be correctly diagnosed to be referred for specialized psychotherapy.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) differs from other categories that are underdoing diagnostic epidemics, in that its treatment is primarily based on psychotherapy. PTSD tends to be overdiagnosed when clinicians attribute, rightly or wrongly, symptoms to a traumatic event. Yet most people who undergo trauma do not develop PTSD, and people without trauma can have similar symptoms. This chapter shows how the construct of PTSD arose historically. A problematic DSM definition, in relation both to the nature of stressors and the links between stress and outcome, causes PTSD to be overdiagnosed. The result is that many patients are receiving the wrong kind of psychotherapy for their problems.

Overdiagnosis and Overtreatment

Psychiatry has embraced overdiagnosis both because it does not understand the causes of mental disorders and because clinicians are keen to use the tools they already have for treatment. These trends have most notable effects on the overprescription of antidepressant drugs. Overdiagnosis has also infiltrated psychiatric epidemiology, since most studies are DSM-based. All these factors have supported diagnostic epidemics, in which identification of certain categories increases dramatically over relatively brief periods of time. When drugs are believed to be the main form of treatment, these trends have been further encouraged by the pharmaceutical industry, and by opinion leaders who are sponsored by Big Pharma.

How Do We Know What Is Normal?

Establishing the boundaries of disease with normality is somewhat easier in general medicine than in psychiatry. This chapter reviews the various definitions of normality and examines their strengths and weaknesses. It will reflect the concerns of many observers that the medicalization of human experiences can pathologize normality. It will also present a critique of an emphasis on early diagnosis, which extends the boundaries of psychiatry by treating people who are functioning within a normal range, and for whom the cost-benefit ratio of early intervention may weigh more on the negative side. Examples from general medicine are presented in which this scenario has also been played out.

Other Disorders in Which Overdiagnosis Is a Risk

This chapter will examine other disorders that tend to be overdiagnosed. Autism spectrum disorders (ASD), long considered to rather rare, have been much more frequently diagnosed in recent years. This increase may be largely due to the reassignment of patients previously seen as filling within other categories to ASD. Although there are few highly effective treatments for these patients, increase in diagnosis may also reflect a greater availability of services for patients if the seen as lying “on the spectrum.” The chapter will also make briefer mention of other categories, including social anxiety disorder, binge eating disorder, and neurocognitive disorders, all of which have an unclear boundary with normality.

Science, Philosophy, and Diagnosis

Diagnosis in psychiatry is not well based in science, mainly because we do not know the causes of most mental disorders, and are forced to identify them by their signs and symptoms, Diagnosis could be made more scientific by using external sources of validity, such as biomarkers for endophenoypes, but there is not enough knowledge do so. In general, attempts to apply reductionist models to the mind are limited in principle because neuroscience studies mental phenomena on a different level, and tends to exclude psychosocial factors. In practice, diagnoses tend to be used largely as heuristics leading to treatments believed to be effective. Moreover, there is no well-defined boundary between psychopathology and normality.

Transdiagnostic Approaches

Transdiagnostic approaches in psychiatry aim to replace qualitative categories with quantitative dimensional ratings. This chapter examines their advantages and disadvantages. The advantage is that dimensional scales could address the misleading levels of comorbidity that result from overlap between multiple diagnoses in the DSM-5 system. While transdiagnostic methods have thus far studied most extensively in personality disorders, they can, as proposed by a system called HITOP, be applied to any other group, The review in this chapter concludes that we lack the empirical data that would support such a radical change in diagnostic practices, and that given the complexity of these systems, and their unfamiliarity to clinicians brought up in medical models, they are not yet ready for prime time.

The DSM and Its Discontents

The DSM-5, published in 2013, met with a mixed reaction. This chapter reviews the history of this edition of the manual, examining its overall strengths and weaknesses. Since DSM-5 was not very different from its predecessors, more radical changes using alternative models have been proposed, such as a fully dimensional system (HITOP) and a system based largely on neuroscience (RDoC). However, the real problems lie in our lack of knowledge about the causes of mental disorders. The series of manuals were always intended to be provisional, but the flaws of the DSM system make it all too easy to overdiagnose its categories.