The issue of over diagnosing in medicine has been a growing concern for many professionals in healthcare. The late Dr Lisa Schwartz, her husband Dr Steven Woloshin and Dr H. G. Welch in their book Over Diagnosed: Making People Sick in the Pursuit of Health (2011), warn of the emerging trend of over aggressive diagnosing in the medical field.
With advances in new technology there is a greatly increased ability to detect abnormalities in patients when undergoing investigations. Yet without fully understanding the clinical significance of these abnormalities the physician, fearful of being accused of negligence is more likely to make a diagnosis and later embark on unnecessary treatment. They question the impact that this trend may have on patients with milder symptoms and transient medical conditions.
The authors note: “While failing to make a diagnosis can result in lawsuits, there are no corresponding penalties for over diagnosis.”
They warn of an epidemic of diagnoses, where everyday experiences of physical or mental discomfort may become a diagnosis. This trend is seen especially in younger patients where sleep difficulties become insomnia, cough and breathlessness after exercise becomes asthma, a reading difficulty is dyslexia, restlessness and inattention is ADHD and unhappiness becomes a depressive disorder.
This issue is well exemplified by the results of a survey published in Ontario in 2019 which reported that 65% of college and university students stated experiencing overwhelming anxiety in the previous year and 46% complained of disabling depression.
One commentator has asked: “If everyday experiences are labelled in this manner, and more than half of us are sick, what does it mean to be normal?”
Mental Health: What is Normal?
So in terms of our mental health; what is normal? How do we define mental illness? Is a sociopath mentally ill?
Open a psychiatric textbook and you will read that mental illness refers to disorders of the mind that result in significant changes in a person’s thinking, emotions and/or behaviour and these disorders are classified into diagnostic categories. The two most important systems of these categories being the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
But what do these systems of categories really tell us? They provide us with a description of disorders neatly collected into tidy groups having in common shared symptoms. Examples being Major Depressive Disorder or Obsessive Compulsive Disorder. However these diagnoses tell us nothing about the complex biological, cultural or psychological human experiences in which these disorders are embedded.
Mental illness has been recognized throughout history in every society and has been known by many different names. Culture and ethnicity play an important role and influences how so-called abnormal behaviour is interpreted and understood. One culture’s abnormality is another’s cherished tradition.
Unlike medical illnesses such as pneumonia, where the diagnosis is decided by blood tests and X-rays, there are few objective laboratory tests for use in routine clinical practice in psychiatry. The making of a diagnosis of a disorder, is much more subjective and is biased in different ways by the rich complexity of human nature and the accepted mores of society at any given time.
And so to go back to our earlier question: Is a sociopath mentally ill? Well, in looking for an answer and we open the DSM-5 manual, we find that sociopathy is definitely catered for under the diagnosis of Antisocial Personality Disorder. Are we to conclude that the sociopath’s behaviour which can sometimes be criminal, be understood as a manifestation of a mental disorder which requires treatment rather than a jail sentence?
And more about this issue later!
Karl O’Sullivan MD