My patients often ask if I think they have a particular psychiatric diagnosis, such as bipolar disorder, attention deficit hyperactivity disorder or autism. The way they ask suggests they believe that as their psychiatrist, I can identify hidden attributes in their brains, much in the same way one of my physician colleagues might diagnose a patient with a genetic mutation or bacterial infection.
The reality is messier and, in some ways, unsettling. When psychiatrists say that you “have A.D.H.D.,” what they really mean is something like this: After spending time listening to you, talking with people who know you and observing how you think and behave, I’ve made a judgment call that your experience fits a behavioral pattern we currently call A.D.H.D. It’s a cluster of problems and tendencies that travel together often enough that we’ve observed it, given it a name and studied it. Patterns like these are handy for picking treatments that might be helpful, but they don’t settle the deeper questions about how your brain works or what kind of person you are.
For decades, the public conversation about mental health has been routed through the categories in the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., the American Psychiatric Association’s official compilation of psychiatric disorders. Symptom-based categories have been convenient for professional communication, insurance billing and conducting clinical trials, but they have given the false impression that each mental disorder is a relatively distinct problem with clear boundaries and an essence that makes it what it is.
Scientific evidence accumulated from multiple lines of inquiry, including genetics, brain imaging and circuity, and measures of the brain’s electrical activity, shows that while there are biological irregularities associated with mental illnesses, the patterns we see in these scientific studies don’t neatly match up with diagnoses in the D.S.M. For instance, two people might have a similar genetic profile, but one will be clinically diagnosed with bipolar disorder and the other with schizophrenia. Neither genetics nor brain scans can distinguish a person with depression, A.D.H.D. or autism from one without.
That doesn’t mean that psychiatric diagnoses are meaningless labels or arbitrary symptom collections. They are practical tools that provide a shared language to describe very real patterns of distress and impairment and can help shape treatment. In practice, clinicians use them flexibly rather than rigidly.
The problem is that when categories are the only language we have for talking about mental health difficulties, and when public discourse treats them as definitive explanations, patients and the public are left with a picture of the mind that is far too simple.
Here is what I want my patients to know:
1) Symptoms of mental illness exist on a continuum. Research has shown that they are distributed continuously in populations, similar to height, intelligence and temperamental features. This is one reason that some researchers have proposed replacing traditional diagnostic categories with alternative approaches that treat mental health problems more like a series of volume knobs than an on-off switch.
2) The symptoms of mental illness reinforce one another. An important theory in psychiatry, known as network theory, posits that mental health problems emerge from symptoms pushing and pulling on one another in self-reinforcing loops. Being unable to sleep can fuel daytime nervousness; nervousness can drain energy; low energy can lead to social isolation; isolation can worsen depressive rumination; and rumination can make it difficult to sleep. And so on. Symptoms are often triggered by life stressors, but once the symptom arrangement becomes self-sustaining, it continues on long after the stressor has disappeared.
3) At the start, mental health problems are open-ended and can evolve into various different diagnoses. Just as conditions like cancer and diabetes are seen as developing through stages, researchers are increasingly talking about stages of mental illness, from stage 0 (at risk) to stage 4 (resistant to common treatments).
The progression is not always linear or predetermined, especially in early stages. A 14-year-old presenting with anxiety could grow into a person with an anxiety disorder but could as easily develop depression, psychosis or substance abuse, or live a healthy life. Parents often want to know the precise diagnostic category for their child’s mental health challenges, but the truth is that the symptoms are inherently ambiguous and dynamic, and it is better not to force them into an ill-fitting fixed category.
4) Diagnostic labels are frequently blind to the collision between who people are and what their life demands of them. A woman prone to nervousness might struggle in a stressful work environment. A man diagnosed with A.D.H.D. as a child might have never needed stimulants until he started working two jobs to support his family and the chronic sleep deprivation made his attention problems unmanageable.
These are not straightforward cases of disorders internal to a person. They are mismatches between a person’s particular traits and capacities and what the individual’s circumstances require of him or her. They are also some of the most common problems in mental health care.
5) Understanding symptoms only in terms of disorder can obscure their meaning. We have forgotten that symptoms are not always diseases. Many uncomfortable bodily and mental experiences — pain, cough, fever, anxiety, low mood — are signals that evolved because they were useful to our survival in the course of evolution. Not being anxious in the presence of a predator is more costly than being anxious at rustling sounds that turn out to be just wind.
From an evolutionary perspective, sadness and worry are mental defenses against futile persistence and potential danger. Just as pain is your body’s signal that you are injured, sadness and worry can be signals that something in your life goals or situation needs to change. The problem is that these defenses can frequently misfire or get stuck, just as a cough can persist long after the infection is gone.
6) Personality shapes the expression and treatment of mental health problems. In my clinical experience, this is where some of the most important differences between patients lie. Two people may have the same symptoms of anxiety but for entirely different psychological reasons and with different treatment needs.
One person’s panic may be linked to a deep fear of abandonment; another’s may be tied to harsh self-criticism and shame. Some people are prone to self-blame and sensitivity to loss, while others crave connection and attention. Mental health problems are shaped by the interaction between these enduring personality patterns, as well as a person’s strengths and weaknesses in regulating emotions and impulses.
In my practice, I routinely see patients who have been diagnosed with depression and anxiety by one clinician, bipolar disorder by another and post-traumatic stress disorder by a third, at different points in their lives. They arrive confused and frustrated, asking: What disorder do I really have? The honest answer is: all of them and none of them. Each of these labels can capture something useful and inform treatment options, but none of them do justice to the dimensional and dynamic nature of mental illness.
Your mental health problems are not caused by a simple thing that you either have or don’t have. They are patterns shaped by who we are as people and that, in turn, shape the people we become. This is a more complicated story than “chemical imbalance” or “brain disease.” But it is closer to the truth. And an honest story is what you need to make sense of what is happening to you and to find your way through it.
Awais Aftab is a psychiatrist who runs the newsletter Psychiatry at the Margins. He is working on a book about psychiatric diagnoses.
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