I was listening to a radio interview with a psychotherapist who is critical of the so-called Bible of Psychiatry: the Diagnostic and Statistical Manual of Mental Disorders or DSM. One of his criticisms is that psychiatry as a practice tries to make the diagnoses in the DSM like medical diagnoses, which have their basis in biology. He said something like “Depression isn’t like diabetes, where there’s a biological disorder that can be treated with insulin.”
His point was that while a medical diagnosis is based on something objective—namely, a patient’s biological condition or the action of some biologically active agent—a psychotherapeutic diagnosis is a construct devised by authorities without reference to any biological process. So a diagnosis such as schizophrenia cannot lead to a treatment in the same way that a diagnosis of diabetes leads to treatment with insulin.
This view ignores, for example, the significant effect that malnutrition has on mind and mood. It also ignores the effect of environmental exposures such as wireless technologies. Sounds like biology to me.
The heart of the critique is that a psychotherapeutic condition is more complicated and patient-specific than a diagnosis such as diabetes. This ignores the fact that diabetes (as well as the growing number of other chronic diseases) is more complicated than “just take some insulin” and is very patient specific.
I run across this contrast frequently: some health condition isn’t like diabetes because it doesn’t have a simple and dramatic treatment like insulin. I’m diagnosed as diabetic and I find this it’s-not-like-diabetes argument mildly offensive because it displays a profound ignorance of both my condition and the politics of diagnosis generally.
As far as I’m concerned, psychotherapeutic and medical diagnoses are cut from the same cloth. There are two reasons for this.
The first is that a diagnosis is about what they are going to do to you. It’s not what you do for yourself. It’s about how professionals experience your condition, not how you experience that condition.
I say this not as criticism but as critique: a diagnosis isn’t about you, it’s about whatever it is that went wrong.
The second reason that all diagnoses are cut from the same cloth is that the politics of what can go wrong is in the hands of the professionals, not you. In other words, a medical as well as a psychotherapeutic diagnosis is a matter of institutional politics. The typical narrative of a diagnosis obscures that it is political (“politics” meaning the social process by which people use power). The typical narrative tells a story about a few scientists discover that diabetes is this thing and schizophrenia is that thing and the rest of the scientific community agrees. It seems a rather murky process.
What really goes on is shown by the recent decision by the American Medical Association to classify obesity as a disease. There were internal and external critics of the decision.
Proponents presented a resolution to the delegates at the AMA’s annual convention. The delegates voted in favor.
First note that the AMA’s own Council on Science and Public Health recommended against the designation. Then note that it was only the delegates present, not the entire membership of the AMA; that most doctors are not members of the AMA; and that the population of MDs from which the AMA membership is composed constitute of a fraction of all health care providers. Finally note that there is no generally accepted definition of what constitutes obesity and that health effects seem to occur only with very high or very low ratios of weight to height.
So what was the force behind the delegates’ approval?
“Some doctors and obesity advocates said that having the nation’s largest physician group make the declaration would focus more attention on obesity. And it could help improve reimbursement for obesity drugs, surgery and counseling.”
We have long known that to name a thing is to have power over it. In this case, to name obesity as a disease is to have power over the people diagnosed. But not always.
About a year ago, the clinic I use started writing and phoning about how, as a diabetic, I needed to have tests and checkups every three months. I ignored them. I’ve been managing my condition quite well for decades. They didn’t give up. I told them to buzz off.
Now they leave me alone. One of the things I told them is that I know more than they do about my condition. Which doesn’t mean I spend my days in reckless disregard of my compromised energy metabolism and endocrine system. On the contrary, I pay very close attention to the things you’d expect: nutrition and physical activity in particular. I also pay attention to things outside the conventional bag of tricks, in particular environmental exposures.
This is all to say that what’s gone wrong with me is not a deficiency of insulin. Even if I did use insulin, I’d be a fool to think that’s all I need to do. It’s just ignorant to think otherwise.
That’s why my condition isn’t like diabetes—despite the diagnosis.
