4 The survival of diagnosis

What you have read so far suggests that we should be more sceptical about diagnosis and try to understand distress both as part of the human condition and as a vehicle for avoiding an honest acknowledgement of our challenges and responsibilities in life. Despite this invitation to cast doubt on the simple view of anxiety and depression as being medical (rather than existential) conditions, the diagnostic view still prevails in many quarters. That view places all of the complexities and biographical idiosyncrasies of particular symptom presentations into pre-formed categories preferred by professionals (remember, this approach started with those like Kraepelin, who believed in the objective existence of natural categories of mental illness). In the light of those agreeing and disagreeing with a categorical view, we can now see the following sort of dynamic debate about diagnosis:

• Some defenders simply argue for a greater refinement of systems like the DSM and the ICD and their consistent use in medicine. This has been the history of the APA, which every few years revises the past edition of the DSM and adds more categories and occasionally drops others (an example here would be homosexuality, which disappeared in 1973).
• Some critics argue for the complete rejection of psychiatric diagnostic categories in favour of individual formulations about presenting psychological difficulties (for example, Bruch and Bond, 1998).
• Some defenders point out that the DSM has moved beyond simple categorisation (the logic of a disorder being present or absent) and now includes a dimensional view (mild, moderate and severe categories of various ‘disorders’). This tension between a categorical view (for example, a patient suffers from phobic anxiety) and a dimensional view (for example, we are all, to some degree, phobic about something) fuels ongoing debate (Kendell and Zealley, 1993).
• Some critics argue for the rejection of some types of people with difficulties from psychiatric jurisdiction. For example, some argue that only mental illness (psychotic and neurotic patterns of conduct) should fall within their jurisdiction. Those with acute transient distress, serious personality problems and substance misuse are not deemed to be worthy of formal psychiatric diagnosis. Others disagree and champion the treatment of these groups and even specialise in their diagnosis.
• Some accept the principle of diagnosis but emphasise cross-cultural sensitivity when assessing patients.