A Retired Psychiatrist’s Reflection on Fad Diagnoses in Psychiatry

Only solid training and consistent education of practitioners can protect us

Among the various medical specialties, some have the difficult job of distinguishing normal life changes from illness. How much weight should a pregnant woman gain? When should a toddler learn to walk? How sad should you be after a major loss in life? For each question, there are clear normal and clear problematic areas. There is also much room for uncertainty. Competent clinicians recognize the gray zones and know how to work with patients to navigate their way through.

However, gray zones are also fertile grounds for fads to develop. We have all seen them in pregnancy, child-rearing, and these days most visibly in psychiatry. I recently wrote an article about the vast over-diagnosis in bipolar disorder taking place in clinics across the country. I have practiced and taught psychiatry for 30 years and this is just the most recent chapter in a longer tale of fad diagnoses within psychiatry.

While other specialties deal with what concerns people about themselves and their loved one. In psychiatry fads often develop to explain what bothers us about other people; people who may be a little bothersome and unsettling, or very annoying and scary (and everywhere in between). Their behavior can be impulsive and their moods labile. If you are close to one of these people you will commonly be blindsided by a rapid and dramatic mood change or shocked by some thoughtless action.

I’d like to describe the most common fads and biases in psychiatric diagnosis over the past 40 years or so. I’ll present them in the order in which they became popular. This is not a strict chronology as there is much overlap, but it does coincide with important changes in thinking.

When I was a psychiatrist in training in the late 1980s the dominance of psychoanalytic theory (based on Freud’s theories) was taking its last breaths. Biological psychiatry was quickly supplanting Freudian thinking as a way to understand and treat mental illness. But because of lingering Freudian influence, the diagnose of borderline personality disorder was the common explanation for troublesome, impulsive, highly emotional patients. This diagnosis represented the most up to date psychoanalytic theories. The movie Fatal Attraction in 1987 added immense fuel to the fire by stoking fear of people with this personality disorder.

Borderline personality disorder is a syndrome of unstable moods, extreme interpersonal sensitivity and impulsive, often self-destructive behavior. The label could be used in a demeaning way as well as a clinically insightful and helpful guide in treating difficult patients.

In the 1990s new interest surfaced in the effects of sexual abuse in childhood. This may have been part of the emphasis on borderline personality disorder as these people (usually women) have a frequent history of sexual abuse as children.

Unfortunately for psychiatry and many patients, this led to the “recovered memory movement”. The claim here was that many people with profiles like borderlines were in fact sexually abused as children but had repressed the memories. Somehow, the therapist could recognize (sometimes in a matter of minutes of meeting you) if you had memories to recover and would help you “remember” what you did not already know.

To further complicate what would become a disaster and embarrassment for the mental health professions, the recovered memories movement morphed into the recognition, and common diagnosis of Multiple Personality disorder (MPD). For the record neither recovered memories nor MPD exists. It is now known from research that people who have traumas, children included, remember them. As for MPD, psychiatry now recognizes a very watered down version called Dissociative Identity Disorder, which itself is quite controversial.

So for much of the 1990s, MPD was the explanation for moodiness and troublesome behaviors. The sham nature of this was exposed by showing deep flaws in the studies supporting MPD (exhaustively covered in the book “Rewriting the Soul”) and in following survivors of traumas such as the Oklahoma City bombing. By the end of the 1990s, the outlandish claims of the recovered memories movement quickly faded.

As is often the case, there was interest waiting in the wings and soon the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) gained frequency. ADHD had been believed to be a disease of childhood that burned out during adolescence. But research showed this not to be the case. It can and does persist into adulthood sometimes at great detriment to the patient.

The common patient is a man who is disorganized, unsuccessful, and develops marital problems for just these issues. He may not be as labile and self-destructive as the borderline or MPD, but he could leave a trail of destruction in unfinished projects and poor relationships. Later either mood problems in the form of depression or substance abuse are common and are often the source of the real disharmony.

ADHD is a common problem, but it is still over-diagnosed in my experience. The problem is that attention (in the form of concentration or sustained attention) is affected by anxiety, depression, stress, and mostly any psychiatric issue. It should not be newly diagnosed in an adult until s/he is clear of these interfering factors. Drug abusers now know which practitioners are quick to prescribe the stimulants, which are the mainstay treatment of ADHD, and try to see them.

Finally, we get to our original subject, bipolar disorder. As I mentioned in my article, anyone with impulsive behavior (especially purchases or sexual activity) or moods that change quickly is often diagnosed as bipolar. Unfortunately, mood changes, irritability, and thoughtless behavior take place in depression, personality disorders, substance abuse, and even stress. As my article discusses, new medications and old, misapplied teaching continue to feed this fad.

If I could draw a conclusion from witnessing these fads in diagnosis over the years, it’s that there is no substitute for thoroughness in psychiatry. We do not have blood tests or useful brain scans. But people know how they feel and if a clinician knows what to ask an explanation will eventually emerge. Extreme thoughtfulness must go into this process as a label we give someone can follow them, unchallenged, for many years.

Questionnaires have taken the place of thorough diagnostic interviews. These forms only provide clues. If these are not followed up with a comprehensive discussion by someone very familiar with common diagnoses, there will inevitably be problems.

Only solid training and consistent education of practitioners can protect from the most fertile soil for biases: what upsets and frightens us.