Wednesday, 13 June 2018

Diagnostic underwriting

We have become accustomed to the idea of diagnostic overshadowing, where the presence of a psychiatric diagnosis causes doctors to miss physical health problems. A pain or swelling, or a lack of energy is regarded as being the result of a mental health issue and an altogether clearer medical cause is missed (overshadowed).

Anecdotally it seems that people are especially vulnerable to diagnostic overshadowing when they have received a diagnosis of borderline personality disorder. Because clinicians tend to associate this diagnosis with the classical idea of "hysteria" - the supposed eruption of emotional distress into the realm of the physical symptom - physical complaints or apparently neurological signs are apt to be considered psychosomatic. Thus a person with this diagnosis may have clear medical causes of physical pains that fail to get discovered.

We may need a similar terminology for what happens when a diagnosis alters other aspects of our self understanding; when the thing obscured is not a diagnosable medical illness, but a particular understanding of - or relation to - a mental state. 

Consider what can happen when someone is diagnosed with depression (though we could configure this example differently to make it applicable to other diagnoses); the diagnosis changes their understanding of the nature of their mood. What it means to be clinically depressed is for your mood to be significantly down, and for this to be attributable to a process lying beyond your more quotidian miseries. The depression is an illness, or a reaction, or a response, or something that makes the diagnosing clinician feel that it should be treated and not just lived.

But of course even without a depression in the picture, deep feelings of sadness, grief and despair are a part of our lives. We accept this and we live through our sorrows. They teach us about who we are and what our life is. Without a diagnosis of depression, our experience of such feelings is seen as part of the mix of ourselves and our context.

Diagnostic underwriting would occur where a depressed person's ordinary feelings of misery are mistakenly attributed to their depression; chalked up to a disorder that appears to account for things that it can't.

It might look like this: You feel hopeless all of a sudden, or guilty. You would have done regardless of diagnosis; it was something you experienced, thought or did that made it so. But because you have the diagnosis on hand, you don't understand it as a part of yourself but as a part of something else that has attached itself to you. You have attributed part of your experience to a phenomenon it doesn't belong to. Diagnostic underwriting has occurred. 

Note that what I am suggesting here is that an individual with a disorder could come to attribute their ordinary feelings to pathology. I am not making the nearby claim (which might be made by committed opponents of diagnosis) that it is constitutive of psychiatric diagnosis that all emotions in this case are "ordinary" and are being misattributed. For the opponent of diagnosis there are only "understandable" feelings. In the case  of diagnostic underwriting, there are feelings that are linked to the diagnosis and there are feelings that should not be. The diagnosis tracks something real, but it also has an impact on how we see other mental states.

Note too that diagnostic underwriting might be imaginable in theory but impossible to discern in reality. Who can say what really is me and what is really is my disorder? Who can really discern between ordinary and pathological feelings? In any case aren't these false distinctions? There is no safe place to stand in teasing this out, but the idea would be to talk about what happens as you claw your way out from under the emotional cloud of an alien experience.

Scared to feel and to trust what they feel, the individual recovering from a mood disorder has a twinge of emotion: "is this sadness OK, or is it going to be the start of my fall back into depression?" The answer may be practically unknowable, but the question is still an important one to grapple with. 

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