Mental disorder or something magical?

Each generation finds their own way of understanding mental distress. The ‘shell-shocked’ soldiers of World War I were understood at the time to be of weak character, although now we might diagnose them with post-traumatic stress disorder (PTSD). Victorian women were subject to ‘hysteria’ and fainting fits, something we might now understand as non-epileptic seizures. The way that we understand distress is deeply rooted in our culture and time, but it doesn’t feel like that to us. We tend to think that the way we understand things now is the right way, superior to previous generations and other cultures.

Which makes our current time a particularly interesting one to be working in mental health. The dominant way to understand mental distress in the West in the last 70 years has been the medical model. This sees distress and unusual behaviour as symptoms of an underlying mental disorder. Diagnosing clinicians compare a person’s experiences to lists of criteria and give them (or not give them) a diagnosis. That diagnosis should lead to treatment, which should then (hopefully) lead to an improvement in symptoms. 

This system is one of categorisation. It matters which diagnosis a person gets because that will affect the services they receive. Get a diagnosis of PTSD and you’ll find yourself offered very different treatment than if you are given a diagnosis of ADHD, even if your symptoms have similarities. The system is pragmatic and structures many mental health services. A psychiatric diagnosis is a description, rather than an explanation. It gives a name to a cluster of symptoms.

However, in recent decades, the fundamental principles of the diagnostic system have been undermined by neuroscientific and behavioural genetic research. Research has failed to find biological correlates for the diagnostic groupings defined by the manuals (called DSM and ICD). According to behavioural geneticist Robert Plomin, instead of finding ‘genes for schizophrenia’ as expected, large scale studies have shown that many genes combine in tiny, cumulative, and generalised effects. Studies of mental health have consistently found dimensionality. Symptoms such as anxiety, or hearing voices, or low mood vary across the whole population, and a diagnosis draws a line where none exists in nature.

The implications of this for how we conceptualise mental health are profound. Researchers are working on dimensional frameworks and influential neuroscientists argue that a reliance on diagnostic categories is holding back advances in research. It has become increasingly clear that diagnostic groups may be practical, but they don’t reliably reflect distinctions between people.

However, alongside this revolution in how scientists understand mental health has come the advent of social media and a huge cultural shift. Here the way in which psychiatric diagnoses are understood have also changed dramatically in the last few decades, but in a very different way.

On social media, psychiatric diagnoses have become identities and online communities have formed around them. ‘Mental health influencers’ post about their symptoms and put their diagnoses in their bios. Some of their followers start to define themselves in the same way, or even to develop new symptoms. We are only just starting to understand how influential social media can be.

For many, these diagnoses signify far more than a list of symptoms. They provide an explanation as to why they are the way that they are and validation that their life struggles are not their fault. The mainstream media have also adopted this narrative, with articles published with titles like ‘My New Life: Being Diagnosed with ADHD in My 40’s has Given Me Something Quite Magical.’

This has led us to the strange situation where just as scientists are moving away from grouping people by diagnosis, more people than ever before are thinking of themselves as belonging to a diagnostic category. Many are self-diagnosing, and several clinicians have informed me of official complaints after they told service users that they didn’t fit the criteria. If a person sees a diagnosis as the key to something magical, it’s understandable that they are furious if it is withheld.

There has always been a gulf between how the general public understands mental health and how scientists and clinicians conceptualise it. What perhaps is new is that many now see a diagnosis as their route to compassion and community, as an affirmation of who they are. This was not what the medical model was designed for, and it is not well-suited to the task. Psychiatric diagnoses were intended to identify pathology in order to provide treatment.   

Waiting lists soar as a result, and when a person finally does see a clinician, expectations can be very different to the reality. Anger grows when people are not able to get the diagnosis they feel they need or when their diagnostic assessment doesn’t provide the validation they were hoping for.

We’re in the middle of a cultural clash in the way that we understand mental health. As science is pushing us towards reconsidering diagnostic categories, those same categories are becoming ever more important in popular culture. This inevitably leads to tension. ‘Mental disorder’ or ‘something magical’—can a diagnosis be both at the same time? Or are there other ways to understand mental distress entirely?

_{Feature image by Brooke Cagle on Unsplash.}