At some point in their lives, between 5.4 percent and 7.3 percent of U.S. adults qualify for a diagnosis of intermittent explosive disorder, concludes a team led by sociologist Ronald C. Kessler of Harvard Medical School in Boston. Those percentages, which depend on whether the syndrome is narrowly or broadly defined, correspond to between 11.5 million and 16 million people, respectively.” (Science News)
This is the study that is getting alot of popular press. I am glad to see the research team acknowledge that the diagnostic category will expand or contract depending on how broad or narrow the inclusion criteria are; you know that all ‘official’ psychiatric diagnosis is done essentially by checklist. Research psychiatrists just want to know if a given subject qualifies ‘in’ or ‘out’. In contrast, we clinicians are interested in whether it is meaningful to understand a person in terms of a given diagnosis in relation to their difficulties in living. One of the consequences of the ascendency of research-driven diagnostic classification is to ignore this contextual issue. For this reason, we should take with more than a grain of salt all the studies that come out loudly trumpeting the fact that this disorder or that is much more prevalent than we had suspected. Moreover, many psychaitric diseases are not a matter of ‘yes’ or ‘no’ as much as they are a matter of degree, and ctieria such as how angry a person is surely exist on a continuum. But in current diagnosis, you’ve either got it or you haven’t. That just doesn’t make sense in thinking about people and individual variability.
Which brings me to my next point, regarding the widely varying notions of ‘prevalence’. For example, a broad definiition of intermittent explosive disorder (IED) entails at least three rage attacks during one’s lifetime; the narrow one at least three such attacks during the same year. Just consider how intuitively different those two definitions are!
And that’s just the systematic type of diagnosis. As readers of FmH know, one of my pet peeves is ‘intuitive’ diagnosis. If diagnosis by criteria divorced from life context is meaninglessly overinclusive, consider how many people yet will receive a diagnostic label iwhen it is done because they ‘feel’ like they have a disorder to the examining clinician. Consult a mental health professional because you are upset about an anger outburst you just had toward your family member, perhaps present with an angry ‘feel’, and risk the IED diagnosis. ADHD is perhaps the modern example par excellence of this problem. As readers of FmH know, I consider the ‘epidemic’ of ADHD in our society largely a result of brain-dead, meaningless diagnosis by feel, from the hip, by fad, by bandwagon, by naiveté..
Although it may be welcome for justifying coverage of care from a third party payor, there are profound consequences to receiving a needless diangosis, to start with in terms of needless or harmful medication prescribing. In addition, carrying around a label has weighty influences both on self-concept and on how others both in the healthcare and social services sectors and in the general public conceive of you. (It would be a different polemic to go off on the unfairness of stigmatization of psychiatric patients; suffice it to say that it is real and prevalent). How we understand our society as well is altered by altered notions of the prevalence of disorders such as IED.
And finally, overinclusive diagnosis is horrible for psychiatric research. As I have often written, if the members of a diagnostic category are neurochemically and physiologically diverse (i.e. if they really do not have the same disease process on a biological level), there is no chance that biological research, e.g. medication trials, will reach any meaningful conclusions. The more you look, the more diffuse it gets. And the more diffuse, the more meaningless.
