"The short version: Most psychiatric conditions aren’t a binary like the flu, where you either have it or you don’t. They’re a continuum, like being rich, where some people are richer than others, all the way up to millionaires and billionaires, but there’s no simple way of dividing the world into two clearly-separated “rich” and “non-rich” groups. This means the psychiatric project of either diagnosing or not-diagnosing someone with a condition is at best a hack and at worst actively confusing. Instead of fretting about whether you do or don’t qualify for a diagnosis, you should assess how much a certain set of symptoms affect your functioning.
Imagine a guide to identifying rich people. You can diagnose someone as “rich” only if they meet at least three of the following criteria:
1. Owns five or more cars
2. Has a house in a gated community
3. Has an income of $1,000,000 a year or above
4. Takes first-class flights at least three times a year
5. Engages in rich-person activities (horseback-riding, golfing, reading the New Yorker) at least twice a month
…and then every few years economists get into huge fights about whether maybe we should change this and say you have to own six or more cars, or whether there should be an exemption for people who own fewer cars but do have a private jet, and they all take it really really seriously.
The problem isn’t that the criteria are wrong. All of these are perfectly reasonable characteristics to correlate with richness. The problem is that your project of dividing the world into “rich” and “not rich” is fundamentally not a scientific one, and is more likely to confuse than to enlighten. Someone with an income of $999,999 isn’t interestingly different from someone with an income of $1,000,001; owning four cars blends seamlessly into owning five.
This isn’t to say you never want to do something like this. Suppose Bernie Sanders wants to increase taxes on the rich, but not on everyone else. He needs some regulation about who the increased taxes hit, and maybe something like this checklist (or more realistically just the income cutoff at $1,000,000) is the way to go. It’s fine if he wants to set something up like that – as long as economists don’t look at his division of people into two bins and mistake it for the discovery of an underlying cosmic secret that there are two types of people, rich and non-rich, separated by the $1,000,000-a-year mark.
Are psychiatrists mistaking moderately useful bins for underlying cosmic secrets? It’s hard for me to tell exactly how many people make this mistake; the people who understand what’s going on and are just using the categories as rules-of-thumb tend to sound a lot like the people who don’t. My guess is most professionals, and an overwhelming majority of laymen, are actually confused on this point, and this confuses them in a lot of ways.
An economist or sociologist looking for the causes of wealth or poverty understands that they’re doing a pretty complicated thing. In the horribly complex system that is human economic behavior, they will probably find that all sorts of factors like upbringing, education, genetics, health, discrimination, and luck interact to determine how much money you have. On the other hand, a microbiologist looking for the cause of the flu will be hoping to find a single specific thing – one virus that all flu patients have and all healthy people don’t. I think a lot of people still want psychiatry to deliver the single specific thing. It’s not going to be able to do that. If you hold out hope, you’ll either end up overmedicalizing everything, or you’ll get disillusioned and radicalized and start saying all psychiatry is fake. I think either would be a mistake.
In my practice, I’ve moved away from asking questions like “does this patient really have ADHD”? Those kinds of questions make me feel like I’m trying to decode their symptoms to uncover some secret variable that could be either 0 or 1. But there is no such variable. Instead, I ask “how much trouble does this person have with paying attention?”. This is usually pretty easy to figure out; the patient will just tell me if I ask!
Likewise, I’ve moved away from thought processes like “If this person has ADHD, they genuinely need a stimulant; if not, they’re just faking”. Instead, I try to think of how much the patient’s symptoms are disabling them, whether a stimulant would relieve some of those symptoms, how likely the symptoms are to go away without an stimulant, and, based on all this, whether the benefits of a stimulant outweigh the risks.
(this has another implication: stimulants shouldn’t be thought of as magic bullets that “cure” “ADHD” by fixing the underlying cause, in the same way that Tamiflu cures the flu by blocking flu viruses. They should be thought of as things that affect the underlying stew of variables that cause ADHD in some helpful way. By comparison, giving someone a college scholarship might help them become richer, but it’s not “curing” “the” “cause” of “poverty” in a way that flips them from a “not rich” to a “rich” status.)
Also, this is why I don’t like the pressure to use person-centered-language (eg instead of “autistic person”, you should say “person with autism”). This sends exactly the wrong signal. If autism is dimensional, we should think of it the same way we do height and wealth – and we say “tall person” and “rich person”. Saying “person with Height” or “Person with Richness” is strongly suggestive of “person with the flu” – it implies a binary class that you either fall into, or don’t. But that’s the opposite of what most research suggests, and the opposite of the thought process that will help you think about these conditions sensibly."
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