Expanding boundaries in psychiatry: uncertainty in the context of diagnosis‐seeking and negotiation

Abstract

Psychiatric diagnosis has become pervasive in modern culture, exerting an increasing influence on notions of personhood, identity practices and forms of self‐governing. The broadening of diagnostic categories and increasing awareness regarding popular diagnostic categories has led to an increased demand for formal diagnosis within clinical encounters. However, there is continuing ‘epistemological uncertainty’ (Fox 2000) surrounding these entities, in part due to their lack of associated clinical biomarkers and their ‘fuzzy boundaries’. Meanwhile, this diagnostic expansion has encountered resistance from those concerned with the alleged ‘over‐pathologisation’ of emotional distress. Drawing upon the concepts of ‘diagnostic cultures’ (Brinkmann 2016) and the ‘looping effects of human kinds’ (Hacking 1995), this article considers some of the competing forces acting upon the contested boundaries of diagnostic categories as they play out within diagnostic interactions. The study involved ethnographic observations of diagnostic encounters within several UK‐based mental health clinics. By focusing on interactions where diagnosis is negotiated, findings illustrate the role played by different kinds of diagnostic uncertainty in shaping these negotiations. It is argued that diagnostic reification plays a key role in the moral categorisation of patients, particularly where there is uncertainty regarding individual diagnostic status.

Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions

“…bipolar disorder and autism). It also enables informal diagnostic practices by professionals, including diagnostic denial from multidisciplinary team members without formal rights to assign diagnosis (Lane 2019). We also see ontological uncertainty as the validity of the psychiatric categories and whether they should be conceptualised as disease entities or as reactions to life events is called into question.…”

“…We also see ontological uncertainty as the validity of the psychiatric categories and whether they should be conceptualised as disease entities or as reactions to life events is called into question. Assigning a diagnosis is a functional method of securing access to services – ‘usefulness’ is therefore prioritised – but it entails moving from the practicalities to objective markers, proving the underlying reality of disorder (Lane 2019). This ‘essentialist’ model of diagnosis presents the ‘truth’, evidenced in the distinguishable form and nature of disorders.…”

“…This ‘essentialist’ model of diagnosis presents the ‘truth’, evidenced in the distinguishable form and nature of disorders. The ontological status of autism as an entity, slips from view despite Lane’s insights that an individual may ‘have’ this disorder and learn how to hide it (Lane 2019).…”

“…Diagnoses associated with psychosis (e.g. bipolar disorder and schizophrenia) hold greater value than personality disorder or common mental problems (such as anxiety‐related disorders and depression), creating a moral hierarchy of diagnosis within psychiatry (Lane 2019).…”

“…Lane describes the tensions in mental health, between patient level work to broaden diagnostic categories (legitimised by lay narratives related to underdiagnosis ), and professionals’ reliance on categorical dimensions, which enables tightening functionality in relation to professional categorisation practices within clinical assessments. Individual diagnostic uncertainty ‘bumps up’ against reified functional categories and allows for a downgrading to less medicalised categories, shifting responsibilisation of this uncertainty to patients (Lane 2019).…”