Lies, Damned Lies, and the DSM

It's a tragedy to reduce a human being to four letters. It's also, for many people with ADHD, profoundly validating and humanising to receive a diagnosis.

“Recognising a child’s ADD should be simply a way of understanding that helping him calls for some knowledgeable and creative approaches, not a judgement that there is anything fundamentally or irretrievably wrong with him. This recognition should enable us to support the child in fulfilling his potential, not to further limit him.”

(Gabor Mate, Scattered Minds)

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So there I am, bright-eyed (mad-eyed?) in the lecture hall, knees jiggling, pen in my mouth, flicking through my absolute weapon of a textbook. Seriously, have you ever held a copy of the DSM in your hand? You could kill someone with it.

It hadn’t occurred to me yet that people already do.

So far, I’m not impressed by Psychopathology and Diagnosis 101 or by our “lecturer” Mitch, who (as far as I can tell) isn’t planning on lecturing us at all. I was expecting a serious person, a scientist, someone with expensively tailored power suits and painstakingly collated PowerPoint decks. A person with citations and footnotes, brain scans and results tables, a person with answers. Mitch is a question mark in human form, dressed like a thrift-store mannequin and fond of responding “what feeling does uncertainty bring up for you?” in response to perfectly reasonable questions. I gave up a job to learn from this frizzy-haired fruitbat, with her sensible shoes and visible bra straps. Sure, it was a job I hated, but still.

I force my squirming, recalcitrant (and in those days, unmedicated) brain to focus.

“You could say, I suppose, that what you are here to learn is how you as a practitioner will think about diagnosis,” Mitch says. Her eyes, which are almost black, sparkle with a sort of cheeky curiosity. I will come to adore her in about six weeks, once I can get past my itching desperation to be a good therapist, and my absolute certainty that being a good therapist involves knowing which box a person belongs in and applying the correct treatment, like prescribing antifungal cream for a nasty rash.

The Drama of Diagnosis

There’s a lot of history behind how the DSM and our current understanding of diagnosis came to pass, which I’m not going to get into because (1) it’s not all that important right now, and (2) inevitably I’ll fuck some of it up and undermine the strength of my point. But in short, we ended up here because the earliest pioneers of psychiatry wanted to be classed as scientists, so they jammed their findings into the framework of the medical model.

It wasn’t a great fit.

Medicine is generally pretty good at straight answers. The Covid test comes back positive. The biopsy shows a myxoma. The blood test indicates low iron. Diagnosis tends to follow biomarker results that aren’t reliant on self-reporting, or subject to a practitioner’s hunches or biases. Psychiatric diagnosis, on the other hand, has no such testing and no irrefutable answers. Even brain scans are profoundly limited in what they can tell us. For example, activity in an area of the brain may indicate suppression taking place, i.e. if the “anxiety” centre of your brain is fired up you might be really anxious or not able to feel anxious at all. Even though we know anxiety probably has something to do with the amygdala, I promise every single Psychology Today article you’ve ever read that calls the amygdala “the brain’s anxiety centre” isn’t worth the time it’ll take you to read it and forget it.

Psychiatric diagnosis is often, painfully, a process of guesswork and revision, where lives and livelihoods swing precariously on the judgement of a given physician. As I’ve written about previously, ADHD’s DSM criteria overlaps significantly with a litany of other diagnoses, without even getting into the fact that you rarely have only one of them.

Unfortunately, as Mitch was attempting to teach us, we can’t escape the systems we live and work in. Psychiatric diagnosis, as flawed as it is, is what we have. But if I was to distill the key lesson of Psychopathology and Diagnosis 101 down and offer it to you, at least from a psychotherapist’s perspective, it would be this:

Psychiatric diagnosis, done thoughtfully with an open mind, provides a good starting point. You can choose the treatment approach most likely to be helpful when you know roughly what you’re dealing with. But the more strongly you are bound by the limits of diagnosis, the more the unique and unfathomable complexity of the human in front of you is lost and this also impacts successful healing.

Diagnostic rigidity is how we end up with bullshittery like labelling people in treatment “noncompliant”. If they’ve been given a diagnosis, and they’re not doing well with the research-backed agreed-upon treatment for that diagnosis, then it’s the patient’s problem. It’s not an invitation to think creatively, or expansively, or to go back to the drawing board and consider other possibilities.

Which brings us to ADHD.