Psychiatric diagnoses often do not say much about what is happening with a person. Psychiatric terms do not carry much meaning if all they focus on is symptoms and not how conditions impact a person’s functioning. There are alternatives to the widely-used DSM-5 for better understanding the causes and impacts of psychiatric conditions.
You hear words like “depression,” “anxiety,” “narcissism,” and “bipolar” a lot these days. The way these psychiatric terms get tossed around, you would think they really say a lot about people. But in reality, the way psychiatric terms are used often does not mean much as people may think.
Take the term “anxiety” for instance. What is it? If you ask a psychiatrist or other mental health professional, they might say that it is some form of nervousness. You might even hear reference to the “flight or fight” response in animals, where humans get anxious because their instinct is to become aggressive or run away when there is danger.
These definitions might explain anxiety a little but they do not say when anxiety is a problem. In the animal world, “fight or flight” is not a problem. It is more of a problem if the “fight or flight” response is not there. Nervousness, feeling scared, and worrying are all considered, on some level, to be normal human responses. They may be responses to problem situations but they are normal responses. When do they become problems?
Enter psychiatric diagnoses. Now you have a way of connecting anxiety, for example, to an actual problem. When anxiety is a problem, this thinking goes, it is consistent with an anxiety diagnosis, for instance, generalized anxiety disorder.
Psychiatric diagnoses are less meaningful than we might expect. If you look at the diagnosis of generalized anxiety disorder in the main psychiatric diagnostic text, the Diagnostic and Statistical Manual, Fifth Edition or DSM-5 (American Psychiatric Association, 2015), you see it defined as the following:
- Excessive anxiety or worrying occurring more days than not for six months
- Difficulties controlling worry
- Three out of six symptoms for anxiety that include restlessness, fatigue, difficulties concentrating, irritability and muscle tension.
Looking at the definition of that one anxiety disorder, you really do not learn much about anxiety. It basically tells you that an anxiety disorder is when you have anxiety a lot and when you feel nervous a lot. Even the time frames seem unhelpful for defining what anxiety is and when it is a problem (why is it different if you have excessive anxiety two days per week rather than the required four?).
Psychiatric diagnoses are limiting because just talking about symptoms you observe does not tell you much about the condition. Looking at just the observable symptoms directly related to the condition, primarily done with the DSM-5, gives you very little information about what is actually going on. It can also limit understanding of what to do about treatment if you are not sure about causes and what problems to target.
However, there are alternatives to the DSM-5 that provide more detail about what is going on with psychiatric conditions. One is called the Research Domain Criteria (RDoC) and defines psychiatric conditions through observable behaviors and neurological measures (Cuthbert, 2020). In terms of observable behaviors, the focus is on how the person functions in their daily lives and what sort of response the person gives to positive situations and challenges. In this way, the behaviors are more related to how a condition like anxiety and its underlying causes affects the person and may not relate directly to symptoms.
Neurologically, this is measured in terms of how the person handles certain tasks. These are called “neuropsychological tests” and address what sorts of strengths and weaknesses the person shows in cognitive abilities.
Defining psychiatric diagnoses based on how the person functions and their strengths and weaknesses gives a much more in-depth understanding of the conditions than just symptoms. It also makes the diagnoses more in line with animal models of psychiatric conditions. This is a particular strength of the RDoC, as animal models are considered very important for understanding any conditions involving the brain. Putting psychiatric diagnoses and related treatments in line with animal models would be consistent with medical treatments, which often have to show consistency with animal models of disease before regulatory agencies approve them.
It is useful to keep in mind that when you hear about psychiatric conditions and, particularly, psychiatric diagnoses, what those terms mean is often very limited. There is a lot more information needed, some of it provided by diagnostic alternatives to the DSM-5, before understanding what those terms really mean.
So, if someone says you have “anxiety” or “depression”, or calls you “narcissistic” or “borderline”, ask them to define what they mean. Chances are they will struggle. It is also quite possible they are using the terms based on what they want them to mean, rather than what they really mean.
References
American Psychiatric Association (2017). DSM-5- Diagnostic and Statistical Manual of Mental Disorders- (American Psychiatric Association Publishing).
Cuthbert, B. N. (2020). The role of RDoC in future classification of mental disorders. Dialogues in Clinical Neuroscience, 22(1), 81.