The Backlash Against Overdiagnosis and Self-Diagnosis Has Fed Into Mental Health Stigma
It might be assumed that the problems of mental health overdiagnosis and self-diagnosis culture would only serve to promote more openness around mental health (despite the fact they sometimes pathologise normal and understandable distress). However, the backlash against these intertwined phenomena has resulted in increased cynicism and scepticism towards a general culture of emotional openness. While this scepticism can be a healthy response to an unhealthy tendency to excessively pathologise our distress, when it becomes broadly applied to all complaints of mental health problems, it may encourage a culture of reticence.
This increased reticence can happen for a number of reasons. For example, let’s take on board the legitimate concerns that attention deficit hyperactivity disorder (ADHD) can be, and has been, overdiagnosed. This does not mean, concurrently, that there is also not a problem of underdiagnosis. After all, ADHD has high rates of comorbidities, such as anxiety, depression, and autism. This may lead to misdiagnosis and, in turn, underdiagnosis of ADHD. As a group of psychiatrists argued in a 2022 paper, “Ultimately, focusing on the idea of “overdiagnosis” among providers may be harmful, particularly for these populations, as this may present additional barriers to them receiving appropriate care.”
Indeed, narrowly viewing mental health complaints through the lens of ‘overdiagnosis culture’ or ‘self-diagnosis culture’ can instil in individuals experiencing severe, chronic, and impairing distress with the notion that they don’t need to seek professional help because their problems are normal. In this way, the backlash against the real problems of overdiagnosis (or diagnostic inflation) and self-diagnosis culture on social media can lead to a restigmatisation of mental health problems. This ‘backlash culture’ can take legitimate criticism of self-indulgence, attention-seeking, and trendiness around mental health labels and overgeneralise this. It can make individuals who are suffering — and those around them — view distress with suspicion. It can ultimately lead to self-judgement and judgement from others: a culture of dismissiveness, downplaying, minimising, denying, and ignoring. The result then would be avoiding self-disclosure, help, and support.
We can see this backlash culture in the public discourse, often (although not exclusively) expressed by those with more conservative views. Work and Pensions Secretary Mel Stride recently criticised Britain’s approach to mental health as having “gone too far”, with the “normal anxieties of life” being diagnosed as illness. I am sympathetic to these kinds of concerns, which I have previously written about. But it is the additional comments from Stride, tied into these legitimate concerns, that many take issue with. He said that “as a culture, we seem to have forgotten that work is good for mental health,” and he voiced concerns that people were being signed off too easily. He is also “troubled” by social media trends like “quiet quitting” and “lazy girl jobs”. Thus, he has taken what could be a legitimate criticism of self-diagnosis culture and turned it into a conservative talking point of mental health complaints being used as excuses for laziness, reflective of a kind of mollycoddling, Nanny State culture.
Some people may self-diagnose the “normal ups and downs of life” as a sign of illness or disorder, as Stride argues. But claiming that this is what all self-diagnosis and so-called ‘mental health culture’ amounts to is myopic and cynical. As Micha Frazer-Carroll — the author of Mad World: The Politics of Mental Health — contends in a piece for The Guardian:
There’s virtually no evidence to back Stride’s sweeping claims, which scapegoat disabled people and thinly veil a cold-hearted government cost-cutting measure. While we might all be able to describe elements of work that help us feel well — for example, camaraderie with co-workers, or feeling we have a sense of purpose — work is also responsible for much of our suffering in contemporary life.
In the same interview with The Telegraph, Stride unveiled a new plan to push 150,000 people with “mild” conditions back into work. Against this ‘get back to work’ conservative talking point, the Mental Health Resistance Network stated in 2015, “We should not be put under pressure to look for work unless we feel capable. The competitive, profit-driven and exploitative nature of the modern workplace is not suitable for people whose mental health is fragile.” In his book Sedated, James Davies points to how the cost-effective treatments offered to people who are struggling — psychiatric medications and cognitive behavioural therapy — are consonant with the neoliberal approach to mental health: return people to productivity as quickly and cheaply as possible. This is an approach that ignores the social, cultural, political, economic, and cultural roots of distress (e.g. how factors like work, money, and housing underlie many people’s chronic depression and anxiety). Frazer-Carroll states:
As a result, we should be highly critical of the ways that economically motivated ministers choose to diagnose and treat the problem of widespread suffering. This also applies to Stride’s comments about people “self-diagnosing” with mental health problems. This is something that young people, in particular, are frequently lambasted for, with critics suggesting that we are overpathologising ourselves. Millennials and generation Z are often framed as work-shy, or as falling out of employment due to a failure to pull ourselves up by our bootstraps or accept the demands of modern life, rather than any “real” illness.
Emotional distress has long been tied to productivity, including in mainstream psychiatry, as it is often a focus in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which psychiatrists use to diagnose psychological difficulties. This can be very in keeping with the neoliberal ideology that seeks to individualise distress (blaming individuals for it, and claiming they alone need to solve it) and turn attention away from the political causes of our distress, brought in and maintained by successive governments. As Frazer-Carroll forcefully puts it:
The work and pensions secretary refers to the “normal ups and downs of life”, but there is nothing normal about the decades of neoliberal austerity that have decimated communities and left many people to fend for themselves. The conditions we currently live in are maddening, and being stripped of benefits and pushed into low-paid, precarious work will offer no respite from this. It is not the conversation around mental health that has gone “too far”, but more than a decade of policies that harm the most marginalised, and then punish us for suffering.
Stride criticises people’s tendency to self-diagnose and the trendiness of this. However, if his government didn’t strip the NHS of funding — leading to long waiting lists to get diagnosed, and making costly private treatment the only option — then perhaps people wouldn’t be forced to self-diagnose. Moreover, while it can be questioned if people can accurately diagnose themselves, self-diagnosis can be legitimate and accurate. After all, many people who self-diagnose themselves later receive an official diagnosis that confirms what they knew all along. As we have seen, psychiatrists also often misdiagnose people, and it can take years before a psychiatrist validates someone’s more accurate self-diagnosis.
We should keep in mind that the DSM, and all its iterations, have a highly subjective component. You cannot diagnose most mental health conditions like physical ones. There are no objective tests for depression. Nonetheless, if we adopt a phenomenological approach to distress, which respects people’s first-hand, subjective reports, then it can become apparent that emotional distress does take distinct forms. While ADHD has several comorbidities, this does not mean the experience of ADHD itself does not have a unique phenomenological character. This also applies to depression, anxiety, obsessive-compulsive disorder (OCD), autism, psychosis, and so on and so forth.
Types of mental distress can occur together, and boundaries between types may blur, but an individual can still know (sometimes better than an outside, professional observer) whether they are shy or have social anxiety. This is not to say professionals do not help to clarify these comorbidities and distinctions (that’s what they’re meant to do, and trained to do). However, we should avoid dismissing all individuals’ assessments of their inner worlds. The problems of overdiagnosis and self-diagnosis culture can occur alongside the legitimacy of some self-diagnosis. Yet the backlash against the former has blinded people to the latter. The loss of nuance has encouraged a culture of blanket cynicism, which benefits no one.
When someone opens up about an experience of mental distress, and attaches a mental health label to it, it can be tempting to adopt an attitude of suspicion: here’s another person falling into the trend of self-diagnosis. In our words, we might even respond sceptically, questioning whether this person is mistaken. But we should ask ourselves what this ultimately achieves. Does this help or frustrate openness around mental health? Are we speaking from a place of judgement or genuine concern? The subject is complicated, and conversations will vary on a case-by-case basis. But what I am personally trying to keep in mind, in general, when I consider my own distress and those of others is whether or not my immediate thoughts and reactions are reflections of stigma. Healthy scepticism surrounding certain aspects of mental health need not close us off to the emotional weight of our lives and those of others.
Originally published at https://www.samwoolfe.com on April 1, 2024.
