This is a guest post by Lance Dodes, M.D.
The question of Donald Trump's emotional fitness to serve as President has made psychiatric diagnoses a hot topic in the news these days. This interest has underscored how much confusion there is about the very nature of a psychiatric diagnosis. To begin, it's important to note that there are two, very different, ways to describe psychological problems.
The official system of the American Psychiatric Association published in the Diagnostic and Statistical Manual (the “DSM”) is the one most familiar to people. The DSM is a categorization of diagnostic labels, each defined by a menu of mostly observable behavioral traits, with the diagnosis made by endorsing a certain number of them, e.g. 4 out of 7.
The DSM was developed to provide a standard set of definitions of psychiatric labels for research, administrative, and insurance purposes. It was never meant to be a compendium of psychological knowledge or to explain or understand psychological problems. However, when someone's overt speech and behavior matches the traits listed in the DSM, it is reasonable to apply that diagnostic label.
In psychoanalysis, diagnosis has quite a different meaning reflecting the complexity of any individual’s mind, and recognizing that it can never be fully described in a single label. This sort of diagnosis addresses a person's emotional life—his or her psychology. It focuses on what matters most to them and the ways in which they adapt or defend themselves to deal with conflicts and loss. When defenses are unhealthy, they create problems in relationships and at work. Paranoia, for instance, is an overt, observable condition in which others are seen as having bad, hostile, or dangerous traits. Being overt, paranoia could be described in a DSM-style label. Its underlying psychological basis, however, is a defense against recognizing that those very feelings are within oneself, telling us that the person has feelings that he is bad or dangerous, and has developed a dysfunctional way of managing them.
Psychoanalytic diagnoses are far more accurate and complete than a simple label. They follow from the complexity of our minds, which in turn follows from the complexity of emotional development. For example, children who don’t feel loved, valued, and well-treated may develop multiple overt problems in adulthood, including paranoia, grandiosity (defending against feelings of worthlessness), contempt for others (projecting self-disparaging feelings onto others), cheating and lying (because of failure to develop normal empathy or compassion when one has not been treated with those qualities), and so forth. Each of these aspects of observable traits could be, and sometimes are, labeled a separate "diagnosis." It is important to realize that they can all be true simultaneously. People who are not psychologically aware sometimes think that multiple diagnostic labels mean the observer doesn't know what he's talking about. Exactly the reverse is true—psychiatric diagnoses are complicated.
An example of the two systems
Mr. A has a clear case of alcoholism. If we were to diagnose him using the relevant DSM label, "Alcohol Use Disorder," he would need to have at least 2 of a list of 11 traits listed in that manual. These are mostly simple observable actions such as drinking despite efforts to cut down, drinking despite continuing problems caused by it, drinking in hazardous situations, etc. The benefit of this system is that it can be accurately assessed by anyone, expert or not because it is a list of overt facts.
A psychoanalytic diagnosis, in contrast, would focus on the question, Why does Mr. A drink too much? What is going on in his mind that leads him to feel compelled to do something so bad for him? We might learn, for instance, that Mr. A feels the urge to drink whenever he feels ignored by somebody he looks up to. His "diagnosis" would include this aspect of Mr. A's emotional life as well as where it came from, why this issue is so difficult for him, and how it bears on his relationships with others and his feelings about himself. Unlike the DSM label, this "diagnosis" addresses the cause of the problem, and what Mr. A, and his therapist, need to know in order to treat him.
Is an interview needed to make a diagnosis?
In the opinion of this author, to apply a DSM diagnosis, it is only necessary to note the overt traits -- speech and behavior -- listed in that manual. No interview is needed to determine whether the DSM traits exist, and therefore whether one can correctly make the relevant DSM diagnosis. For example, an individual who has persistently been deceitful, recklessly disregarded the safety of others, and shown a lack of remorse, can be correctly said to meet the DSM criteria for "antisocial personality disorder" since those are exactly the traits by which the DSM defines this diagnosis.
The complexity of a psychoanalytic diagnosis would require multiple face-to-face interviews. That's what it would take to learn about the unique individual factors that make that person who he is: the traumas he has faced, the conflicts in his mind, his inner feelings about others and himself, the healthy or pathological defenses he uses, and so on.
Both diagnostic systems can be accurately used, so long as we understand which one we are using. And it is important to realize that multiple labels are frequently relevant for any one person, in either system, because of the complexity of our minds
This means that when people observe overt traits of an individual, private or public, such as those listed in the diagnostic categories of the DSM they can believe the evidence of their own eyes and ears. If there are enough of these overt traits to meet the requirement of the DSM, it is appropriate to apply that diagnostic label. However, when one is using the psychoanalytic system, it is necessary to actually get to know a person (interview him or her) in order to assess what lies within.
The same applies to observing yourself. If you notice problems in your own behavior you can, and should, trust what you see. That places you in a good position to use that knowledge when seeking help from a professional to figure out the psychodynamic factors underlying these troubles.
About the Author: Lance Dodes, M.D. is an assistant clinical professor of psychiatry at Harvard Medical School (retired), Training and Supervising Analyst Emeritus at the Boston Psychoanalytic Society and Institute, and a faculty member of the New Center for Psychoanalysis (Los Angeles). He has been honored by the Division on Addictions at Harvard Medical School for "Distinguished Contribution" to the study and treatment of addictive behavior and has been elected a Distinguished Fellow of the American Academy of Addiction Psychiatry.