On Diagnosis

I’d like to be clear about something that is inherently unclear.

In this post, I am not referring to the occurrences of identifying, recognizing or understanding that go on in everyday life. Like diagnosis, they all concern knowing and are certainly related. Yet diagnosis has a particular connotation. Diagnosis implies the intent to identify a problem with a concurrent aim to resolve it, usually involving a set of measurements or observations conducted by a someone with experience or credentials who then follows up with a recommendation or treatment depending on those findings.

This process is not as straight-forward as it might sound, particularly when it comes to mental health.

Reporting and making objective sense of data, and how we even select for that data, can be very difficult—despite the existence of tests, tools and checklists that give an impression to the contrary. In true to human form, clinicians might only find what they know to look for, or be loath to admit that they don’t know.

Even if a diagnosis accurately describes or classifies a problem, it doesn’t necessarily point to etiology, nor an effective treatment. I’ll take a common condition that has been around a while and that most people consider bad: Anxiety. Do you have anxiety because you had an insecure attachment to your mother? Because you were bullied in school? Because you have dysautonomia? Because you’re in perimenopause? Because you have a scary boss and can’t quit your job? Because of global warming? Anxiety can be multidetermined and so have multiple avenues to alleviate it.

As a psychoanalyst, my relationship with diagnosis has always been somewhat complex.

I was trained up in a tradition that has a complicated history with diagnosis, as well as ongoing differences of opinion amongst ourselves and with other disciplines. In fact, psychoanalysts have our own diagnostic manual separate from the Diagnostic and Statistical Manual of Mental Disorders (DSM); it’s called the Psychodynamic Diagnostic Manual (PDM). Like psychoanalysis itself, the PDM positions itself outside the mainstream while taking care to not to invite attack by suggesting it replaces the DSM. Instead, it is its complement.

Maybe it will comfort those who rail against the DSM today to know that those within the field have, too. The PDM first came out in 2006 in response to what was felt to be an overemphasis on symptoms and behaviors. It positioned itself as a “taxonomy of people,” instead of disease, with a tilt towards “what one is rather than what one has” (2006, p. 17). Upon the publication of the 2nd edition, several of its authors explained that the PDM provided a third way, dissolving a bind clinicians were in to be either “for” or “against” the DSM.

They wrote:  

In summary, the PDM aims to detect and describe patients’ characteristic mental experiences, thereby increasing the capability of clinicians to relieve the psychological distress of the distinctly individual patients who seek their help. It attempts to restore the connection between deep understanding and treatment, without the requirements of other diagnostic systems that [might] be useful for demographic studies, billing, institutional record-keeping, syndromal research, and other ancillary uses…. (Lingiardi and McWilliams, 2015)

What was in the foreground during my training days was a sense that the DSM was a necessary nuisance. Without a diagnosis code from its pages, a patient did not exist. Without a disorder, services could not be rendered. I’d need to think about the person’s presenting problem and translate it into one or more of the DSM’s categories after spending 45 minutes with them. A treatment plan would then follow based on this diagnosis. Unsurprisingly, the plan usually involved weekly psychotherapy.


In addition to belonging to a body of clinicians that has “resisted thinking about their patients in terms of categorical diagnoses” (Lingiardi and McMilliams, 2015), I am among a group of licensed mental health practitioners ambiguously allowed to use the DSM by New York State, while being denied “diagnostic privilege.” In 2022, a law was passed changing that condition, giving me a vague pathway to raise my status and join the ranks of nosology-lovers and pencil-pushers. There was some considerable gatekeeping involved in this development, having less to do with patient well-being and access to care than longer-standing professions’ control of market share.

Perhaps you can tell I have mixed feelings about this state of affairs.

Diagnosis can be so valuable, but it can also obscure where the problem actually lies or mislead with false certainty. Discovering drapetomania six years ago altered something within me and my relationship to mental health diagnoses, not that I was keen at the outset. It convinced me that diagnostic manuals are living cultural artifacts. That is to say, some categories can be more a reflection of us than they are of objective reality. Drapetomania, which pathologized the enslaved person who ran to freedom, was discounted before the DSM came into existence, but homosexuality was included among its many disorders and it wasn’t until 1973 that it was removed (Drescher, 2015). Shocking, right? These “mental illnesses” weren’t real, but reflections of the bias of the dominant culture. And sadly, the very real “treatment” that followed was legitimated in the service of returning “the afflicted” to “normalcy” or “health.”

People can be disturbingly certain about what they know sometimes.

I imagine I’ll be writing more on mental health diagnosis because it bothers me. I live in tension with it. I find it urgently relevant and outdated. The underpinning of what I do and utterly beside the point. A means for significant aid and a gateway to harm. I’m clear that I’m unclear—I’m hoping at least some others out there join me in that.