III. ISSUES IN DIAGNOSIS

Diagnosis of mental or physical illness is the clinician's determination of a clinical state or disease. However, as used in ordinary discourse, diagnosis is both a noun, signifying or denoting a particular clinical state, as well as a verb, describing an activity or process of determining diseases and clinical states. Clinicians ask "What is the patient's diagnosis?" as well as "What is your approach to diagnosis?" Considerations of the denotative aspects of diagnosis implicate the general classification and nomenclature of disorders or diseases (nosology), while the notion of diagnosis as a clinical process implicates various normative considerations of diagnostic practice—that is, considerations of fair, valid, and elegant diagnostic procedure. Ethical issues concerning the diagnosis of mental illness concern all of these permutations.

Mental Illness and the Self-Illness Distinction

The ethical issues involved in the diagnosis of mental illness can be considered as closely related to, perhaps even derivatives of, the enigmatic character of mental illness itself. At the core of this enigmatic character is the relation between mental illness and the self. In Western societies, sufferers of physical illnesses, diseases, or injuries can almost always distinguish their sense of self (the sense of who they are, the ownership and experiential domain of their unique mental life) from their affliction. For instance, a patient may have cancer, heart disease, a brain tumor, a cold, or a broken leg, but these conditions are over and apart from who the patient is, her holistic identity as a person. Ordinary discourse about physical illnesses often betrays this ego-alien character, where common linguistic metaphors portray disease as a malign force from outside the self: "She was struck down by cancer." "He had a heart attack."

Through their character as afflictions of psychological experience, this phenomenal distinction between self and illness is blurred in the case of mental disorders. Consider a few examples. The experience of depression saturates a patient's perception of herself, where the depth of her sadness and self-doubt overwhelms her sense of competence and worth. A man's schizophrenia wildly transforms his views of and relations with others and the world. Even amidst recovery from a drug dependency, the addict longs for the pleasure and tranquillity of intoxication. As these examples of mental illness illustrate, the afflicted may be unable to distinguish features of the self from features of illness (e.g., "I am depressed," not "I have depression"). Further, the mentally ill person may even value, or seek to preserve, some features of the illness, as in the case of the addict noted above, or, as another example, the person with bipolar disorder (manic-depressive illness) seeking the euphoria, confidence, and vigor of mania.

This weakening or loss of the self/illness distinction sets the stage for other ambiguities, and with them, a host of actual and potential ethical problems concerning the diagnosis of mental disorders. The intermingling of the personal self and the manifestations of mental illness confound Western cultural assumptions about the sick role. Parsons's notion of the sick role involved a forgiving of the sick individual's usual responsibilities; in Western societies the physically-ill person is thought incapable of the full range of her usual responsibilities, so subsequently, such incapacities are excused. Because of the difficulties in distinguishing aspects of the self from the manifestations of mental illness, this forgiving attitude toward the sick is often absent in the case of mental illness. Moreover, the often incomprehensible, annoying, or bizarre behavior of the severely mentally ill may generate fear in observers. These and other factors conspire to generate the most prominent manifestation of the sick-role confound: stigma, the vilification of "the mad."

Social stigma adds the additional burden of shame, humiliation, and exclusion to the ordinary suffering of mental illness, a burden by and large not shared by individuals with physical illnesses. Stigma subsequently ups the ethical ante in diagnosis, as a mere diagnosis of mental illness often has stigma-driven adverse social consequences, consequences relatively independent of the features of the illness itself. For instance, stigma may manifest itself through insurance or employment discrimination, harsh attitudes toward the homeless mentally ill, unfounded generalizations about the mentally ill individual's capacities, or the avoidance of treatment for mental illness.

Stigmatization of what is today called mental illness has been present throughout the recorded history of madness (Porter). At the beginning of the twenty-first century, stigmatizing attitudes toward the mentally ill often are justified by the view that the manifestations of mental disorders are willful and responsible, and the mentally ill fully choose their misery, if indeed they are miserable at all. The most prolific spokesperson for this kind of view is Thomas Szasz, a psychiatrist who since the early 1960s has argued that mental illness is a metaphorical concept that functions to regulate deviant behavior outside the usual sociocultural channels, such as the law, education, and religion (Szasz). For Szasz and like-minded authors, because psychiatric authority regulates deviance outside these usual channels in free societies, psychiatric practice undermines civil liberties on the one hand, and the responsible conduct of citizens, on the other. Psychiatric diagnosis, then, is an instrument of this subverted political authority.

Because of the aforementioned ambiguities concerning responsibility and the self/illness distinction, it is easy to recognize the general moral implications of either accepting or rejecting the Szaszian critique. If one accepts the Szasz position uncritically, one risks building a callous, uncaring society toward what could be catastrophic, with miserable illnesses affecting large numbers of people. If one does not take Szasz seriously, one risks stripping the mentally ill of their morality and their autonomy, as well as their unique value as individuals through reducing them to mere expressions of psychopathology or disease states. On the face of it, both these extremes seem unacceptable, so more recent work on the ethics of psychiatric diagnosis has focused on rethinking this problem or seeking a middle ground between conceiving the mentally ill as fully autonomous, responsible actors versus conceiving them as helpless, dependent incompetents.

Scientific Classification and Prudent Practice

Perhaps most influential in the scientific classification of mental illness has been the efforts of the American Psychiatric Association's committees on diagnosis to qualify and stipulate their diagnostic categories in ways that, in the ideal, serve to both constrain mental disorder diagnosis and validate it. This was not always the case. In the early twentieth century, official diagnostic classifications of mental disorders were primarily aimed for hospital registries and the accounting of patient flow. Only with the publication of the first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 was diagnostic classification intended as a tool of science and good clinical treatment. By the third edition (DSM-III) in 1980, and continuing to the present fourth edition (DSM-IV, 1994), the DSM's intentions have broadened even further (Wallace). Since DSM-III, the manuals have resolved to meet a number of objectives or goals:

1. To provide a useful aid to clinical diagnostic practice;
2. To provide a scientifically sound classification of psychopathology for mental health research;
3. To provide an enumerated coding system for recordkeeping and billing purposes;
4. To provide a comprehensible nomenclature for education efforts; and, of particular interest for this discussion;
5. To provide an extensive introduction to the manual that specifies prudent diagnostic practice and use of the manual.

The capability of this or any other diagnostic manual to accomplish such an ambitious range of objectives has been a ongoing source of debate. Subsequently, ethics-oriented criticisms of the DSM editions often betray disagreement over the particular balance struck between the various objectives (Sadler). For instance, some critics have noted that enumerated, rigorously-defined and scientifically-tested diagnostic labels oversimplify the complex condition of mental illness and impede the ill from engaging in discussions about themselves and speaking on their own behalf(e.g., Kovel). On the other hand, other critics note that the DSMs are excessively tied to clinical diagnostic traditions and are not scientifically rigorous enough (summarized in Sadler, Hulgus, and Agich). The ethical implication here is that scientifically-compromised diagnostic categories undermine the moral justifications for interventions like involuntary hospitalization or involuntary treatment, or indeed, treatment at all. As a third example, commentators have noted tensions between the values of clinical utility and clinician acceptability in the DSMs versus the efforts to have DSM categories fully reflect rigorous scientific values like validity and reliability (Sadler, Hulgus, and Agich).

Diagnosis and Mental Health Pluralism

As might be expected under the conditions of the blurred self/illness distinction, mental illness has been subject to an extraordinary range of competing and contrasting formulations or understandings. Until the recent ascent of alternative medicine, physical medicine has enjoyed relatively little competition from rival clinical practices based upon nonbiomedical explanatory models. This, however, has not been the case for mental illness, as the woes of the psyche have a long history of ministrations from diverse healing and/or helping traditions. What psychiatrists call mental illness may be conceived by nonmedical practitioners as spiritual crises, or as secular problems in living, or the result of supernatural forces, or irregularities in various moral, dietary, lifestyle, or other habits. Analogously, ministration to such psychic woes is offered by not just physicians, but pastors or spiritual advisors, hundreds of varieties of lay and professional counselors and psychotherapists, folk healers, alternative clinicians, family, neighbors, and friends. Any effort, then, to provide a common nomenclature for mental distresses is bound to generate disagreement, and the existence of such diverse resources is bound to generate controversy over the relative value of each.

In this sense, then, any mental illness diagnosis (in the broadest sense) under any system of clinical thought, medical or otherwise, can be construed as having an ideological character. Hence, for instance, biomedical psychiatry's predilection for prescribing pharmaceuticals for DSM-diagnosed mental disorders is criticized as the capitalist commodification of everyday life, while interpersonal narrative-based psychotherapies may be praised as more communitarian in their political alliances. Diagnostic practices, if they lend themselves to one or the other ideology, then, are similarly implicated. The DSM approach to this problem has been to develop inclusive and diverse committees in the construction of the DSMs, and invite outsider input so that the DSM categories reflect some measure of such pluralistic practices, and hence are open to a range of therapeutic options (Frances, First, and Pincus). The World Health Association's International Classification of Diseases—ICD-10 Classification of Mental and Behavioural Disorders (ICD) has sought to provide a common language for mental health practices all over the world, and in developing its classification solicits input from all of its member countries (WHO). As such, its ambitions as a diagnostic manual are necessarily more modest, focusing on providing an enumerated coding for record-keeping and billing, preferring fewer numbers of categories, and adhering more closely to practice conventions than the more innovative, and American-regional, DSM manuals. Nonetheless, the DSM manuals and the ICD manuals have a close relationship, as the DSM is obligated by international treaty to provide compatible diagnostic categories for the ICD manual, and in recent decades the development of each manual has been closely coordinated with the other.

Even within the biomedical paradigm, however, mental health practice (psychiatry, clinical psychology, psychiatric social work, and related fields) has been characterized by a diversity of theoretical formulations, empirical-scientific approaches, and conventions of practice. The approach of the American Psychiatric Association's DSM effort, along with the ICD classification of mental disorders, has been to work toward a diagnostic classification which minimizes, even perhaps eliminates, theoretical assumptions about the causes of mental illness. Moreover, with the DSM-IV effort, the process has included assembling comprehensive scientific literature reviews, a consensus scholar approach in interpreting aggregated studies, and extensive and detailed documentation of the developmental procedures and findings used in constructing the manual. With the addition of extensive field trials (empirical studies) of proposed or revised diagnostic categories, the DSM process aims to continuously improve the scientific validity and reliability of its diagnostic classification. Nevertheless, many non-psychiatric mental health practitioners lament having their own practicable alternatives and may view the DSM/ICD efforts as a de facto hegemonic effort by psychiatrists to dominate the mental health field (Beutler and Malik).

Inspired by the problem of adequately circumscribing psychiatric diagnosis (e.g., assuring that people diagnosed are truly ill, and those not so diagnosed are truly well), significant efforts have been made since DSM-III to provide a rigorous definition of mental disorder. This effort is part of the aforementioned goal to recommend good diagnostic practices in the DSM introductory material. Such definitions of mental disorder, and the concepts underlying them, were developed in the introductions to DSM-III and later editions. Since then, such attempts at defining mental illness have been subject to heated debate, as discussed by K. W. M. Fulford in his article "Mental Illness: I. Conceptions of Mental Illness" in this volume.

Preserving the Dignity of the Self

While short of providing explicit moral and aesthetic rules for the proper conduct of psychiatric diagnosis, the introductions to the DSM manuals do prescribe, and proscribe, clinician conduct in significant ways, though these guidelines for use of the DSMs are thought by some to be inconsistently read and heeded. For instance, recent editions of the manuals have included explicit categories and codes indicating diagnostic uncertainty; have used a multiaxial diagnostic system that provides for diagnosis of not just mental illness, but other factors like complicating physical illnesses, environmental stressors, and the global adaptive function of the individual; and have provided a cautionary statement recommending against the use of DSM categories in forensic or other nonclinical settings. At question is the efficacy of these efforts to facilitate a thoughtful and responsible diagnostic practice; critics claim that despite these efforts, the DSM is still used in a "cookbook" fashion and the individual under diagnostic evaluation is still likely to be labeled narrowly and conceived simplistically (discussed by various contributors in Sadler).

Amidst these clinician-generated efforts to provide fair and scientifically valid diagnoses, the diagnosed and the families of the mentally ill have increasingly organized to protect themselves against what they view often as stigmagenerating diagnostic pigeonholing and the diminution of their sense of self (Luhrmann). This movement is most concretely manifested in the terms the mentally ill increasingly use to refer to themselves: no longer patients, but now often clients, consumers, users, and even psychiatric survivors of mental health services. At present the mentally ill have little to no input into how their conditions are classified in systems like the DSM and ICD or how diagnostic criteria are phrased, nor do they have much of a forum for their views about prudent diagnostic practices (Sadler). How much influence this advocacy on behalf of the mentally ill will have on mainstream mental health diagnosis and practice remains to be seen.

The issue of the autonomy of the mentally ill and the ethics of diagnosis have collided in recent controversies over the handling of consent in clinical research settings. The issues were crystallized at the end of the 1990s by a debate in the United States over the National Bioethics Advisory Commission's (NBAC) report addressing the issue of protecting human subjects, as well as protecting research participation, with subjects with impaired decision-making capacity (Roberts and Roberts). Driven by concerns over the allegedly vulnerable but needy mental illness population, the NBAC recommended a series of protections that, from the research community's perspective, would make the clinical research enterprise a burden on researchers and subjectparticipants: these recommendations would make consent procedures and participation arduous, and create the risk of denying this population access to research participation, subsequently reducing the social benefits of the research. A significant component to this debate was the degree to which any diagnosis of mental disorder qualifies the potential subject as having an impaired decision-making capacity.

Cross-Cultural Validity

In the context of economic globalization and increasing cultural interchange, recent thought about the validity of mental disorder diagnosis has addressed the question of the validity of mental disorder diagnosis across cultures. Does the DSM-IV diagnosis of Schizophrenia apply equally to a white Anglo-Saxon Protestant from Normal, Illinois as to a Bantu African tribesman? What about Obsessive-Compulsive Personality Disorder or Anorexia Nervosa?

The issue of cross-cultural validity of mental disorder diagnosis has three general ethical ramifications. The first ramification concerns cultural assumptions of normality. The second concerns the practical matter of accurate detection of psychopathology in multicultural settings. The third ramification concerns which values should prevail in judgments concerning health or psychopathology.

As Dona Davis has noted, the sexual performance norms assumed by, for instance, DSM-IV sexual disorders do not apply to cultures where sexual performance as a cultural construct does not exist. For instance, how can someone have anorgasmia or premature ejaculation where there is no expectation of female orgasm? (Davis). The normative assumptions (taken-for granted beliefs about what is normal, adaptive, or acceptable) underlying diagnostic systems like the DSM or ICD classifications can pose dilemmas for clinicians working in diverse settings, where, for instance, couples of mixed ethnic origin may have clashes over acceptable and unacceptable behaviors. Normative assumptions underlying mental disorder diagnoses push the clinician into taking culturally-relative moral stands related to cultural assumptions, and more subtly, may mask the very cultural assumptions and beliefs that effective treatment must make explicit.

As a second example, mental disorders (like anorexia nervosa) that are closely conceived within cultural normative assumptions and expectations may not occur or may manifest themselves differently in other cultures. Diagnostic conceptions or criteria that are skewed toward the assumptions and values of Western industrialized cultures may have false-negative and false-positive diagnostic implications in practice. If Third World clinicians are not looking for anorexia nervosa, if indeed it occurs, they will likely miss an authentic disorder (false negative diagnosis). If Western clinicians are looking for anorexia nervosa in Third World populations where it is not endemic, they may nevertheless find cases who are not truly ill (false-positive diagnosis). Culturally invalid mental disorder diagnosis is then an ethical problem because of harms posed by the systematic potential for false-negative and false-positive diagnosis.

A third ethical ramification of cross-cultural validity concerns how mental phenomena are valued. Michael Jackson and K.W.M. Fulford present a case of a man who meets standard examination criteria for psychosis with the exception that his experiences are adaptive, and have enhanced his functioning and life satisfaction. M. Fakhr El-Islam notes that psychosis can be interpreted in fundamentalist Islamic cultures as a prophet's response to spiritual or religious stagnation, and the psychotic symptoms can confer positively valued mystical insights. How mental symptoms are valued have important implications on whether such phenomena are truly pathological.

Conclusion

Because of the ambiguity between mental illness and the self, mental illness poses a complex range of ethical challenges, whether one is a scientist engaged in the study of these conditions, a person afflicted with mental illness, or a clinician helping an ill individual. Ethical concerns arise from numerous directions, from the mere act of making a diagnosis, to considering the social impact of diagnosis, to the applicability of diagnosis across cultures.

john z. sadler

SEE ALSO: Beneficence; Coercion; Homosexuality; Mental Health, Meaning of Mental Health; Mental Health Services; Psychiatry, Abuses of; Psychopharmacology; Psychosurgery, Medical and Historical Aspects of; Race and Racism; Sexism;Women, Historical and Cross-Cultural Perspectives; and other Mental Illness subentries

BIBLIOGRAPHY

American Psychiatric Association. 1952. Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C.: Author.

American Psychiatric Association. 1980. Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). Washington, D.C.: Author.

American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, D.C.: Author.

Beutler, Larry E., and Malik, Mary L., eds. 2002. Rethinking the DSM: A Psychological Perspective. Washington, D.C.: American Psychological Association.

Davis, Dona L. 1998. "The Sexual and Gender Identity Disorders." Transcultural Psychiatry 35(3): 401–412.

El-Islam, M. Fakhr. 2000. "Mental Illness in Kuwait and Qatar." In Al-Junun: Mental Illness in the Islamic World, ed. Ihsan Al-Issa. New York: International Universities Press.

Frances, Allen J.; First, Michael B.; and Pincus, Harold A. 1995. DSM-IV Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.: American Psychiatric Press.

Jackson, Michael, and Fulford, K.W.M. 1997. "Spiritual Experience and Psychopathology." Philosophy, Psychiatry, & Psychology 4 (1): 41–66.

Kovel, Joel. 1982. "Book Review: Diagnostic and Statistical Manual of Mental Disorders, Edition III." The Einstein Quarterly Journal of Biology and Medicine 1(2): 103–104.

Luhrmann, Tanya M. 2001. Of Two Minds: An Anthropologist Looks at American Psychiatry. New York: Vintage.

Parsons, Talcott. 1958. "Definitions of Health and Illness in the Light of American Values and Social Structure." In Patients, Physicians, & Illness, ed. E. G. Jaco. Glencoe, IL: The Free Press.

Porter, Roy. 2002. Madness: A Brief History. Oxford: Oxford University Press.

Roberts, Laura W., and Roberts, B. 1999. "Psychiatric Research Ethics: An Overview of Evolving Guidelines and Current Ethical Dilemmas in the Study of Mental Illness." Biological Psychiatry 46(8): 1025–1038.

Sadler, John Z., ed. 2002. Descriptions and Prescriptions: Values, Mental Disorders, and the DSMs. Baltimore: Johns Hopkins University Press.

Sadler, J. Z.; Hulgus, Y. F.; and Agich, G. J. 2001. "Hindsight, Foresight, and Having It Both Ways. A Rejoinder to R. L. Spitzer." The Journal of Nervous and Mental Disease 189(8): 493–497.

Szasz, T. S. 1961. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Hoeber-Harper.

Wallace, Edwin R. 1994. "Psychiatry and Its Nosology: An Historico-Philosophical Overview." In Philosophical Perspectives on Psychiatric Diagnostic Classification, ed. John. Z. Sadler, Osborne P. Wiggins, and Michael A. Schwartz. Baltimore: John Hopkins University Press.

World Health Organization. 1992. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: Author.