A Retired Psychiatrist’s Reflection on Fad Diagnoses in Psychiatry

Only solid training and consistent education of practitioners can protect us

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Among the various medical specialties, some have the difficult job of distinguishing normal life changes from illness. How much weight should a pregnant woman gain? When should a toddler learn to walk? How sad should you be after a major loss in life? For each question, there are clear normal and clear problematic areas. There is also much room for uncertainty. Competent clinicians recognize the gray zones and know how to work with patients to navigate their way through.

However, gray zones are also fertile grounds for fads to develop. We have all seen them in pregnancy, child-rearing, and these days most visibly in psychiatry. I recently wrote an article about the vast over-diagnosis in bipolar disorder taking place in clinics across the country. I have practiced and taught psychiatry for 30 years and this is just the most recent chapter in a longer tale of fad diagnoses within psychiatry.

While other specialties deal with what concerns people about themselves and their loved one. In psychiatry fads often develop to explain what bothers us about other people; people who may be a little bothersome and unsettling, or very annoying and scary (and everywhere in between). Their behavior can be impulsive and their moods labile. If you are close to one of these people you will commonly be blindsided by a rapid and dramatic mood change or shocked by some thoughtless action.

I’d like to describe the most common fads and biases in psychiatric diagnosis over the past 40 years or so. I’ll present them in the order in which they became popular. This is not a strict chronology as there is much overlap, but it does coincide with important changes in thinking.

When I was a psychiatrist in training in the late 1980s the dominance of psychoanalytic theory (based on Freud’s theories) was taking its last breaths. Biological psychiatry was quickly supplanting Freudian thinking as a way to understand and treat mental illness. But because of lingering Freudian influence, the diagnose of borderline personality disorder was the common explanation for troublesome, impulsive, highly emotional patients. This…