Joel Paris is a Professor of Psychiatry at McGill University in Canada, where he served as Department Chair between 1997 and 2007 and Research Associate in the Department of Psychiatry at the Jewish General Hospital. He is a former editor-in-chief of the Canadian Journal of Psychiatry and the author of many books, including Psychotherapy in An Age of Neuroscience (Oxford University Press, 2017), Stepped Care for Borderline Personality Disorder (Academic Press, 2017), The Intelligent Clinician's Guide to DSM-5 (Oxford University Press, 2015), Fads and Fallacies in Psychiatry (RC of Psych, 2013), and Half in Love with Death: Managing the Chronically Suicidal Patient (Routledge, 2006).
As its title suggests, Overdiagnosis in Psychiatry: How Modern Psychiatry Lost Its Way While Creating a Diagnosis for Almost All of Life's Misfortunes is a tendentious work proclaiming on its first page that psychiatrists have acquired a propensity to pathologise all manner of reactions to ordinary life circumstances: ‘Psychiatrists have forgotten the listening skills and careful attention to clinical phenomena that once made their specialty unique’ (p. xii). His concern is that the Diagnostic and Statistical Manual of Mental Disorders (DSM) ‘makes many of life's misfortunes diagnosable, and implicitly offers psychiatry as a cure for unhappiness’ (p. xii).
Paris bewails the frequency with which patients are seen by psychiatrists for only ten to fifteen minutes and given little opportunity to speak about what is happening in their lives:
Diagnoses are made rapidly – and often inaccurately. Instead of listening, and asking about current circumstances, psychiatrists focus on a checklist of symptoms, a kind of parody of the criteria listed in the DSM manual. Based on the answers to these questions, prescriptions will be written for almost every problem – and ‘adjusted’ every time a patient comes in feeling distressed. (p. xiii)
He sees this form of doctor–patient relationship as one which leads to overdiagnosis and overtreatment. His motive for writing the book is to send a message that psychiatry is overstretched: ‘Instead of prescribing treatment for what Freud once called “normal human unhappiness”, we need to focus our efforts on patients who are seriously ill, and who need us the most. We do not need to diagnose the human condition’ (p. xiv).
Paris identifies the phenomenon of ‘diagnosis epidemics’, a term coined by Allen Frances, as having the potential to lead to incorrect and unnecessary treatment for mental disorders. He asserts that ‘biological reductionism has come to dominate academic psychiatry’ (p. 6) and points out that until such time as neuroscience may provide explanations for psychiatric disorders, clinicians have to continue to practise their craft and treat very difficult patients. At the heart of his analysis is the acknowledgment that ‘psychiatry is more or less where the rest of medicine was a hundred years ago – at the very beginning of a long quest for valid diagnostic procedures’ (p. 11). He attempts to place within realistic parameters the quest for biomarkers for psychiatric disorders, contending that they would only provide some of the data that clinicians require, recognising that psychosocial factors in mental illness are likely to retain major importance: ‘I would say [biomarkers] are potentially highly useful but conceptually and practically incomplete’ (p. 11).
Paris notes that psychiatry is no different from other areas of medicine – there is a bias towards false positives so as not to ‘miss anything’. He identifies that underdiagnosis is most likely when a disorder is unappealing – when it is chronic, making treatment complex or inaccessible. He instances the high levels of diagnosis of schizophrenia in the past but asserts that, faced with managing intractable cases, clinicians often look for ways to avoid making a diagnosis. He does not refer specifically to the stigma attaching to the ‘s’ diagnosis but could well have done so, asserting that ‘the reluctance to recognize a serious illness like schizophrenia reflects a universal human tendency to resist bad news. However, psychiatrists cannot make difficult patients go away by failing to diagnose them’ (p. 20).
Paris contrasts the modern incidence of diagnosing post-traumatic stress disorder (PTSD) and autism. However, he does not locate the problem with the DSM, Fifth Edition (DSM-5): ‘you need to focus on its practitioners, not on its manual. In short DSM-5 is not the problem, but the way we over-value it is’ (p. 32). He argues that while DSM diagnoses are convenient labels, they should not be thought of as ‘real’ diseases. He locates overdiagnosis in optimism about treatment methods and underdiagnosis in pessimism about treatability. He argues that the side effects of ‘typical’ antipsychotics have discouraged writing too many prescriptions but that the obverse is the case in the era of the ‘atypicals’.
Paris reflects on the difficulties that have been encountered within psychiatry in differentiating between a ‘mental disorder’ and a condition falling short of such a classification. His argument is that most mental disorders have ‘fuzzy boundaries’ and fade gradually into normality:
When does sadness turn into depression, particularly when life stressors (grief, job loss, breakups of intimate relations) that would upset almost anyone are present? When should anxiety and worry justify diagnosis if there is something real to worry about? At what point is substance use an addiction? (p. 63)
Paris argues that major depression is seriously overdiagnosed. He notes that the term dates back to the DSM, Third Edition (DSM-III), where there was an attempt to distinguish depressive episodes with clinically significant effects on functioning from minor symptoms that are passing and not disabling. He notes that the percentage of the United States population taking antidepressants had risen to 11% by 2011, expressing concern about the frequency with which treatment for depression is pharmacological and does not incorporate psychotherapy.
A second category of mental disorder identified by Paris as overdiagnosed is bipolar disorder. He notes that bipolar-II disorder is a new category that was inserted into the DSM, Fourth Edition (DSM-IV), characterised by hypomania instead of full mania. He regards overdiagnosis of bipolarity as ‘one of the most problematic fads in contemporary psychiatry’ (p. 82). He describes the ‘miracle of lithium’ as responsible for a dramatic increase in the diagnosis of schizophrenic patients as having bipolar disorder and being prescribed lithium therapy. He comments that the marketing undertaken by ‘Big Pharma’ encourages doctors and patients alike to believe that depression which antidepressant treatment fails to resolve indicates an underlying bipolar disorder that needs to be treated with other drugs. He is especially troubled by the increase in the diagnosis of bipolarity in children.
Paris singles out overdiagnosis of PTSD as the product of careless thinking and emotional bias. He observes that trauma is only a risk factor for PTSD, not a definitive cause: ‘The disorder only develops when adverse life experiences touch on temperament and vulnerability’ (p. 99). Controversially, while he does not dispute the legitimacy of the diagnosis of PTSD in principle, he argues that PTSD runs the danger of encouraging victimhood and discouraging a sense of responsibility for one's life: ‘The debate about this diagnosis is not just a matter of evaluating empirical data, but about society's concern over oppression and suffering. That cannot be good for psychiatry, which must put science ahead of politics’ (p. 103).
Unsurprisingly, Paris identifies the medicalisation of attention through the diagnosis of attention deficit hyperactivity disorder (ADHD) as fraught. He describes it as one of the most striking diagnostic epidemics of our times, asserting that the diagnosis is ‘driven by the use of stimulants. There is no doubt that these drugs help children with classical cases of ADHD, particularly the hyperactive subtype, although not all patients respond to them’ (pp. 107–108). His argument is that ADHD is a syndrome, not a disease, and he expresses concern about the difficulty of distinguishing it in children from conduct disorder. He argues that it has become a catch-all diagnosis for disruptive behaviour and that current mental health practice is not rooted in science.
Paris also identifies personality disorders – especially borderline, autism spectrum, and anxiety disorders – as being at risk of overdiagnosis. He does not refer to hoarding disorder, although he might have done.
Paris notes that consumerism plays a role in patients’ expectations of receiving a diagnosis for what troubles them, arguing in favour of psychiatry embracing evidence-based diagnosis: ‘Doing so would subject the diagnostic process to the same caution and scepticism as have been applied to the results of treatment research’ (p. 151). He contends that psychiatry needs to be characterised by diagnostic humility, and that the fallacy of overdiagnosis is the delusion that we know the answers: ‘We must have the courage to admit that, at this point, we don't’ (p. 152).
Paris’ Overdiagnosis in Psychiatry is a robust tome of the type that can only be written by a senior member of the profession who does not feel constrained by latter-day orthodoxies. It is a free-ranging critique of poor diagnostic practice, concentrating on overdiagnosis but also identifying the vice of underdiagnosis. It is well referenced and compellingly historically contextualised. Its point of view is accessible and powerful. Paris combines unpretentious scholarliness and clinical experience with rare skill. Fads always afflict diagnosis in medicine – and in no area more so than psychiatry. His argument in favour of evidence-based diagnosis and diagnostic humility is powerful and relevant both clinically and forensically – over-diagnosis can lead to civil litigation, as well as issues in sentencing in criminal trials.
Paris’ Overdiagnosis in Psychiatry is deceptively easy to read. It contains much wisdom and highlights many clinical challenges. With the recent escalation in the diagnosis of PTSD, bipolar disorder, autism spectrum disorder, and ADHD – to name but some of the conditions he focuses on – there is a risk of over-pathologisation with all of the risks that this entails in terms of not just patients’ self-image but also the over-prescription of psychotropic medications. Paris leaves mental health practitioners, lawyers and patients with much food for thought. Overdiagnosis in Psychiatry deserves wide readership and debate.