「过度诊断」之惑

疯狂从来不可能存在于我们之中——不可能存在于我们之中——因为它被关在精神病院的高墙之后。我们所拥有的任何问题都不可能是那种古老的疯狂，不是某种孤立、异类、纯粹缺陷、毫无意义、无话可说的存在——而必定是某种新的、更熟悉的、我们在亲友身上、电视里和自己内心遇到的东西，某种更可理解的、能发声的事物——更适合被称为心理健康问题，逐渐融入平凡或不平凡的生活困境。当疯狂存在于社群中，它就转化成了另一种东西……”

—— 德里克·博尔顿，《何为精神障碍？》（牛津大学出版社，2008年），第242页

很少有比心理健康领域「过度诊断」的公共讨论更混乱恼人的事了。公众争论往往围绕着模糊的抱怨展开，比如「现在有太多人患有多动症、焦虑症、自闭症……」，却对「太多」的具体定义缺乏共识，甚至对过度诊断的真实含义也莫衷一是。

当人们使「过度诊断」一词时，实际可能指代以下不同情况：

1. 对未诊断和治疗也不会造成显著痛苦或伤害的状况进行诊断。
2. 将本会自然缓解的短暂心理困扰诊断为疾病。
3. 将几乎无损功能的认知行为差异标签为障碍。
4. 将诊断错误误称为过度诊断。
5. 对未达到官方诊断标准的阈下症状进行诊断。
6. 不考虑识别率提升和基于官方标准的流行病学数据，直接将诊断率上升等同于过度诊断。
7. 表达对精神疾病能见度提高的文化焦虑。
8. 批评诊断手册（DSM、ICD）不断拓宽的诊断标准。
9. 假设患者追求诊断是出于跟风心理。
10. 认为人们渴望「病人角色」而并无真实损伤。
11. 将过度诊断与过度治疗混为一谈。
12. 对用医学框架看待情绪困扰感到不适。

阐明诊断的根本作用

临床诊断的核心关切在于识别那些令人痛苦、功能受损、具有危害或处于风险中的状态——这些状态能够通过临床干预（心理治疗、药物、脑刺激疗法等）获得改善。当存在实际痛苦或潜在伤害时，医疗专业人员便能提供专业支持。这种支持通常包括获得治疗的机会，同时也涵盖评估、检查、临床视角、正式诊断、适应性调整等服务。理解这一根本作用有助于澄清和解决围绕诊断的常见误解。

从这个角度看，诊断的核心要义不在于基于生物功能异常来识别疾病实体或作出"障碍"判断，也不属于医学与心理学/社会工作之间的领域之争。但它确实引发出一些值得严肃对待的重要问题：当我们试图识别那些可能受益于临床干预的痛苦/损害/风险状态时，我们对精神科诊断和医学模型存在哪些误解？这些误解（如本质主义思维）如何扭曲我们的自我认知，使我们更容易受到医源性伤害？我们该如何权衡临床诊断带来的实际利弊？

即便是反对诊断的专业人士，也不得不承认某些痛苦和功能损害确实需要专业干预。一个强烈反对诊断的心理治疗师可能会抱怨太多人被贴上「精神障碍」标签（并被开具药物），但与此同时，这位治疗师却每周为自称经历「对生活境遇的正常可理解反应」的来访者提供开放式心理治疗。既然声称是「正常可理解反应」，为何又需要临床医师提供的专业治疗？这种矛盾从未得到合理解答。这类治疗师表面上提供「正常化」的安慰，但其行为本身已隐晦承认：当事人的痛苦程度确实需要临床关怀——这也正是他们提供服务的前提。

严格意义上的「过度诊断」（#1、2、3）

严格来说，「过度诊断」描述的是通过主动筛查手段，将本不会造成重大伤害或功能障碍的情况列为临床治疗对象的现象。癌症筛查就是典型例证：常规检查可能发现那些生长缓慢、对生命威胁极小的肿瘤。映射到心理健康领域，过度诊断可能表现为：医疗机构通过筛查发现的可能自愈的短暂性情绪困扰，或给那些仅存在轻微注意力困难或社交笨拙（未导致明显功能障碍）的个体贴上疾病标签。

虽然这种现象确实存在，但其实际规模是否值得当前舆论的担忧程度仍存疑。西方世界各类精神障碍的临床诊断率普遍未大幅超过流行病学预估数据，甚至往往低于预期值。

以英国纵向家庭研究为例，「未确诊的痛苦」人群（症状严重度符合临床诊断标准但未就医）数量是「无症状却获诊断」人群的 12 倍。

从临床实践来看，严格符合过度诊断标准的案例其实罕见。我虽可能不认同患者既往的具体诊断名称，但他们呈现的痛苦程度和功能损害几乎都达到了需要临床干预的标准。目前并无有力证据表明存在"无症状/无功能损害者被批量诊断为精神障碍"的流行病现象。

自我诊断则是另一回事。确实存在功能损害未达专业求助标准却自我贴标签的情况。但这类自我诊断往往以非病态化、非临床化的方式呈现（如神经多样性概念）。因此，当那些社会功能良好但性格内向的「书呆子」用「自闭症」自称时，这并非临床意义上的过度诊断——而是人们因认知价值而将临床概念拓展至非临床领域，以此构建更完整的自我认同。

误诊与亚阈值诊断（#4、5）

围绕过度诊断的公众讨论常将上述严格定义与相关现象混为一谈，例如诊断错误（误诊）、对未达阈值症状的诊断、将轻度与重度障碍笼统归入同一诊断类别，以及过度治疗。若某人被错误地贴上某种疾病的标签（即其实际并不符合该疾病的公认临床标准），这并非过度诊断，而是误诊。

当有人质疑ADHD、自闭症或双相情感障碍等特定诊断存在过度诊断时，他们通常实际指的是误诊。我个人确实认为这类误诊相当普遍，但必须将其置于精神科诊断评估者间信度较低的背景下来理解。我经常会对接诊患者重新诊断，但也不敢自诩为唯一正确的诊断裁决者。

然而令我困扰的是，不同领域的专家常利用这一点来推销其偏好的诊断。双相障碍专家声称「多数 ADHD 诊断实际是双相障碍」，ADHD 专家则断言「多数双相诊断实际是ADHD」的情况屡见不鲜。PTSD 是另一个典型——在某些专家眼中，要么万物皆是 PTSD，要么 PTSD 根本不存在。对此现象我只想说：别太自以为是！精神病理学的复杂程度远超你们各自专攻的狭小领域。

某些人信奉的「精神疾病否定论」变体，仅针对特定诊断生效。在他们看来，有些诊断是真实存在的，但 ADHD、PTSD 和自闭症这类「时髦诊断」就值得怀疑。那些极力寻求这些诊断的人，不过是在将普通生活问题小题大做。生活本就艰难，人们却总想走捷径。他们需要学会咬牙忍耐，重拾坚忍克己的精神云云。在我看来，这类论调实质上是未能正视患者真实的痛苦与功能损害，也忽视了临床治疗的价值。

“被诊断为心理问题的人太多了！”与文化焦虑（第6、7点）

对许多评论者而言，「过度诊断」的判断完全基于主观感受和对上世纪 80 年代的怀旧式比较。心理健康诊断率的上升并不能为「过度诊断」提供实质证据——因为这既未考虑更高诊断率可能反映了社会认知水平的提升，也未考量当前数据是否正逐步接近基于现行诊断标准的流行病学预测。

关于「过度诊断」的呼声，实则折射出某种针对精神疾病公开化的文化焦虑。部分人怀念那个精神障碍被拘禁在收容所、或被污名化遮蔽的年代；有些人则希望精神疾病足够罕见，以便继续用「隔离」作为应对策略，从而维持「只要不谈论，精神问题就不存在」的假象（更有彻底否认「精神障碍」概念者，或拒绝将心理痛苦视为合理医疗诉求的群体——对他们而言，任何"精神障碍"诊断都是过度诊断）。

这些现象共同反映了我们集体面对疾病、病痛与残障关系时的文化焦虑。从这个角度看，「过度诊断」实质是对当代诊断文化不适感的简略表达，而非对临床实践过剩的客观描述。相比以建设性方式直面和处理这种焦虑，哀叹「过度诊断」显然轻松得多——尤其当涉及疾病本质的探讨本就复杂艰深，穷究答案只会令人精疲力竭时。

诊断手册与过度诊断（#8）

许多人将过度诊断归咎于 DSM 和 ICD 连续修订版中诊断标准的不断拓宽。这种艾伦 · 弗朗西斯式的「拯救正常」论调，至今仍在当代争论中回响——失控扩张的分类体系正在威胁正常状态的边界。我曾认同这种观点，但随着临床实践积累，我越发认为 DSM 标准实则相当保守。它既未能全面描述精神病理学表现，其分类范围也不足以涵盖所有需要诊断的、具有临床意义的心理痛苦与功能损害。特定诊断的排除标准将大量日常生活遭受显著痛苦与功能障碍的患者拒之门外。

人们从根本上误解了精神科诊断率上升的动因——总体而言，临床医生并非在给抗拒诊断的患者强行贴标签（尽管这种情况确实存在）。诊断标签作为理解工具存在着巨大需求，传统民间心理学范畴已无法应对海量的痛苦与功能障碍现象。DSM 将心理痛苦和功能障碍合法化为值得识别治疗的医疗问题，但专业领域始料未及的是：具有临床意义的痛苦如此普遍，诊断手册始终疲于追赶。

大量临床实践涉及标准未能充分涵盖的真实痛苦，这导致医生不得不扩展现有诊断或使用模糊的「未特定」类别——并非源于诊断草率，而是框架本身存在缺口。同理，受限于接诊时间和治疗手段，一线医生常会跨诊断使用 SSRIs 类药物。全科医生并不特别在意患者究竟是「伴混合焦虑抑郁的适应障碍」、「伴焦虑痛苦的重度抑郁障碍」、「恶劣心境」还是「广泛性焦虑障碍」，因为最终处方都是百忧解。

患者主导的诊断（#9,10）

所以真相是什么？人们究竟是专业诊断的受害者，还是过度掌控了自己的医疗标签？
——杰西·梅多斯《过度诊断恐慌时代》

关于过度诊断的讨论常暴露出对个体认知自身障碍能力的不信任。患者通常主动寻求诊断，标签能带来确认与澄清。诊断文化的批评者时而暗示患者被动接受专业标签，时而指责他们在社交媒体和残障平权影响下激进自我诊断。

多数对「过度诊断」的公共批评并不以患者为中心。ADHD 可能因各种原因成为潮流，但这不应妨碍我们承认患者终生受困于注意力缺陷及其情绪后果；DSM 对正常哀伤的病理化争议尚存，但临床工作者不该漠视被哀伤瘫痪数年生活的求诊者。

这场辩论有个耐人寻味的现象：某些讨论明确承认经济动机与公共资源短缺有关。比如英国政府似乎认为无力承担持续增长的临床治疗与残障福利支出。但相关方并未坦承「我们希望有足够资源照顾所有人，但必须优先重症」，反而对轻症群体实施煤气灯效应——暗示他们夸大或误解自身状况，尽管鲜有证据表明这种现象大规模存在，或能解释福利需求增长。

过度治疗（#11）

有时人们谈论过度诊断时，实际指的是"过度治疗"。是否存在"因接受治疗却未获益的患者众多"意义上的过度治疗？这种现象不可避免。没有任何治疗是完美的。除非需治疗人数（NNT）为 1，否则按此定义总会存在"过度治疗"。阿司匹林用于预防糖尿病患者心血管事件的NNT高达153——这意味着需要治疗 153 位糖尿病患者，才能预防 1 人发生心血管事件。患者有权在充分知情的情况下选择治疗方案，有权获得医疗服务，也有权了解治疗的局限性和潜在危害。医疗决策绝非仅凭个人偏好，而是需要临床研究证据指导，权衡风险收益比，考量公共安全因素、成本效益、医疗公共资源及医保覆盖范围等。但在这些宏观约束条件下，仍存在充分考虑个人偏好的灵活空间。无论如何，过度治疗引发的议题具有独特性，不能简单归入过度诊断范畴。

透过医学视角看待情感痛苦 (#12)

在「过度诊断」所涵盖的议题中，有一个方面我颇为认同。这就是传统的"医学化"批评——社会学和哲学领域的批判观点认为，如今人类痛苦经常被不恰当地置于医学框架下解读。临床概念化处理和诊疗方案并非放之四海皆准，对某些人可能毫无助益，甚至造成伤害。部分人群确实更适合通过非临床途径来理解和应对痛苦：自助指南、精神信仰、生活方式调整、专业辅导、社会保障、政治改革、经济改善、存在主义思考、同伴支持等。问题在于，我们缺乏有效的事前判断标准来区分哪些人适合临床干预。

若将临床诊断和治疗视为理解与改善状况的途径之一——而非唯一途径，更非必然能达成所有或任何预期效果的最佳方案——那么我们必须建立多元化的认知体系和干预措施。诊断只是审视个人困境的片面视角。

多元主义为我们指明了富有建设性的前进方向。临床诊断不过是众多有效应对个体痛苦的视角之一，与医学、心理、存在主义、社会、精神等视角并列。不同情境需要不同方法。承认这种多元性并不会削弱诊断分类的价值（它们具有重要的实用功能），而是促使临床工作者乃至整个社会保持灵活应变能力，以开放态度接纳对人类痛苦的多重理解。若将丰富多元的视角简化为单一主导叙事（无论这种叙事多么权威），实则是剥夺我们理解自我与世界的工具。

临床概念体系之所以吸引人，在于它提供了诠释问题的实用镜片。如果我们过度依赖这副镜片，解决之道不是人为限制其使用、剥夺人们获得临床诊疗的机会，而是开发其他能提供同等或更优效用的认知框架，从而促进对医学镜片更审慎明智的运用。

我最终倡导的是：深思熟虑的态度、清晰的概念界定、以人为本的照护、多元主义理念，以及对临床治疗保持现实预期。「过度诊断」是个粗暴的结论，只能催生粗暴的解决方案。我们理应——也能够——做得更好。

“Madness never could be among us—not among us—because it was behind asylum walls. Whatever we may have cannot be the old madness, not something isolated, different, pure deficit, meaningless, with nothing to say—but rather it would have to be something new, more familiar, something we come across in friends and family, on TV and in ourselves, something more understandable, having a voice—something better called something like mental health problems, fading into ordinary or extraordinary problems of living. Madness transforms into something else when it is in the community...”

Derek Bolton, What is Mental Disorder? (OUP, 2008), p. 242

There are few things as muddled and irksome as the public debate on “overdiagnosis” in mental healthcare. Public discussions frequently hinge on vague complaints such as “too many people these days have ADHD, anxiety, autism…” without clear agreement on what exactly constitutes “too many,” or even a consensus on what overdiagnosis actually means.

Here are different sorts of things people have in mind when they use the term “overdiagnosis”:

1. Diagnosing conditions unlikely to cause significant distress or harm if left undiagnosed and untreated.
2. Diagnosing transient psychological distress that would resolve spontaneously.
3. Labeling minimally impairing cognitive and behavioral differences as disorders.
4. Mislabeling diagnostic errors as overdiagnosis.
5. Diagnosing subthreshold symptoms not meeting official diagnostic criteria.
6. Equating rising diagnostic rates directly with overdiagnosis without considering improved recognition and epidemiological estimates based on official criteria.
7. Expressing cultural anxiety about mental illness’s increased visibility.
8. Criticizing broadening diagnostic criteria in diagnostic manuals (DSM, ICD).
9. Assuming patients seek diagnoses because they are trendy or fashionable.
10. Viewing people as desiring the sick role and lacking genuine impairment.
11. Confusing overdiagnosis with overtreatment.
12. Expressing discomfort with viewing emotional distress through a medical lens.

Clarifying the fundamental role of diagnosis

The fundamental concern when it comes to clinical diagnosis is recognizing distressing, impairing, harmful, or at-risk states for which clinical interventions (psychotherapy, medications, brain stimulation, etc.) can be helpful. There is suffering and harm, or the prospect thereof, and healthcare professionals have something to offer. This something is usually access to treatment but also includes things such as assessment, work-up, clinical perspective, official diagnosis, accommodations, etc. Recognizing this fundamental role helps clarify and resolve common misunderstandings surrounding diagnosis.

Seen in this manner, the fundamental concern of diagnosis is not identification of disease entities or “disorder” judgments based on biological dysfunction, nor is it an issue of medicine-vs-psychology/social work turf wars. But it does bring up important questions of its own, questions that I take seriously. In our efforts to recognize distressing, impairing, harmful, or at-risk states for which clinical interventions can be helpful, what do we get wrong about psychiatric diagnosis and the medical model? How do these misconceptions, such as essentialist thinking, derail our sense of identity and make us vulnerable to iatrogenic harm? How can we best negotiate the practical trade-offs surrounding clinical diagnoses?

Even professionals opposed to diagnosis cannot avoid acknowledging distress and impairment warranting professional care. A staunchly anti-diagnosis psychotherapist may bemoan that too many are being diagnosed with “mental disorders” (and being prescribed medications), and yet the anti-diagnosis therapist also offers open-ended, weekly psychotherapy to people who are experiencing, by their own description, “normal, understandable reactions to life circumstances.” Why allegedly “normal, understandable reactions” require professional treatment offered by clinicians is a contradiction that is never satisfactorily addressed. What such a therapist is offering is the superficial comfort of normalization while also behaving in a manner that implicitly recognizes that the person’s suffering is such that it can benefit from clinical care, and hence their services.

“Overdiagnosis” in the strict sense (#1, 2, 3)

Overdiagnosis, strictly speaking, describes a scenario in which conditions unlikely to cause significant harm or impairment if left untreated are identified as targets for clinical treatment, usually through proactive screening efforts. Cancer screening exemplifies this clearly: routine tests can reveal slow-growing tumors that pose minimal threat to one’s life. Translated to mental health, overdiagnosis could refer to screening in healthcare settings that detects transient distress likely to resolve spontaneously, or labeling individuals with mild attention difficulties or social awkwardness that cause no or minimal impairment.

While this certainly happens, it’s not clear that the magnitude with which this happens merits the degree of concern and alarm that is directed towards it. The rates of clinical diagnoses of various psychiatric disorders generally do not exceed epidemiological estimates by a wide margin in the Western world, and if anything, they are usually below what is estimated.

To put this into perspective, in the UK Longitudinal Household Study, there were 12 times as many people with “undiagnosed distress” (symptoms severe enough to meet clinical diagnostic criteria) as there were people with diagnoses in the absence of clinically significant symptoms.

Clinically speaking, it is also rare for me to encounter a patient who I believe had been overdiagnosed in the strict sense; I may disagree with the exact diagnosis they have been given in the past, but the degree of distress and impairment is almost always to such a degree that some clinical diagnosis is warranted. We don’t have compelling evidence to suggest an ongoing epidemic of asymptomatic or unimpaired individuals receiving psychiatric diagnoses.

Self-diagnosis is a somewhat different story. Some self-diagnosis does happen in the absence of substantial impairment warranting professional help. However, such self-diagnosis is often conceptualized in non-disordered, non-clinical ways, such as neurodivergence. Hence, however people may feel about seemingly functional, nerdy, socially awkward individuals using the term “autism” to refer to themselves, it is not an instance of clinical overdiagnosis. It is an instance of people reclaiming a clinical concept and extending it beyond the clinical sphere because of its epistemic value, because it allows them to make better sense of who they are.

Misdiagnosis and subthreshold diagnosis (#4, 5)

Much public debate around overdiagnosis conflates the strict definition above with related phenomena, such as diagnostic error (misdiagnosis), diagnosis of subthreshold symptoms, diagnostic lumping of mild and severe impairment in the same category, and excessive treatment (overtreatment). If a person is incorrectly labeled as having a condition that they do not actually have (i.e. they don’t meet accepted clinical criteria for that condition), that’s not overdiagnosis; that’s misdiagnosis.

When some take issue with specific diagnoses such as ADHD, autism, or bipolar disorder being overdiagnosed, they are usually thinking of misdiagnosis. I personally do think that misdiagnosis is fairly common in this sense, but this also has to be understood within the context of poor inter-rater reliabilities of psychiatric diagnoses. I frequently re-diagnose patients I see, but I cannot pretend to be the one, true arbiter of correct diagnostic judgments.

What annoys me, however, is that this point is used by various professionals to push for their pet diagnoses. It is not uncommon for bipolar experts to say, “Most cases of ADHD diagnoses are actually bipolar disorder,” and for ADHD experts to say, “Most cases of bipolar disorder diagnoses are actually ADHD.” PTSD is another one of those disorders such that in the opinion of some professionals almost everything is PTSD or almost nothing is. I don’t have much to say about this phenomenon other than: Get over yourselves! There is far more to psychopathology than whatever corner of it you specialize in.

Some people endorse a version of mental illness denialism except that it is circumscribed in its application to select conditions. Some diagnoses are real for such folks, but trendy diagnoses like ADHD, PTSD, and autism are kinda suspect. People clamoring for ADHD, PTSD, and autism diagnoses are just trying to make a big deal out of ordinary life problems. Life is hard; people want it easy. They just need to suck it up; they need to learn to deal with it. Bring back stoicism and the stiff upper lip. Etc. Such sentiments, in my opinion, are products of a failure to recognize the distress and impairment that people experience and the value of clinical treatment in such instances.

“Too many people are being diagnosed!” and cultural anxiety (#6, 7)

For many commentators, the judgment of overdiagnosis is entirely based on vibes and nostalgic comparisons to the 1980s. Increasing rates of mental health diagnoses do not provide actual evidence of overdiagnosis since this does not take into account whether higher rates reflect better awareness and recognition, and whether rates are catching up with epidemiological estimates based on current diagnostic criteria.

The cry of overdiagnosis reflects a particular kind of cultural anxiety over the public visibility of mental illness. Some people long for a past when mental disorders were invisible, confined within asylums or hidden by stigma. Some people want mental illness to be rare enough that containment can work as a strategy, and they can pretend that mental disorders don’t exist except when they are talking about them in a hushed and scandalous manner. (Some reject the concept of “mental disorder” altogether or do not view psychological suffering as a legitimate healthcare concern. For such folks, any diagnosis of a “mental disorder” is overdiagnosis.)

All this reflects cultural anxiety over our collective relationship with illness, sickness, disability. Seen in this manner, “overdiagnosis” functions as a shorthand for an unease with contemporary diagnostic culture, not a literal description of clinical excess. It’s easier to lament “overdiagnosis” than it is to recognize and process this anxiety in a productive manner. This is particularly so because these questions about the nature of illness are complex, and trying to answer them drives us to exhaustion.

Diagnostic manuals and overdiagnosis (#8)

Many blame overdiagnosis on the broadening of diagnostic criteria in consecutive revisions of the DSM and ICD. This is the Allen Frances style “Saving Normal” argument, still echoing in contemporary debates. Normality is under threat from out-of-control, ever-expanding classifications. I used to be sympathetic to this line of thinking, but the more I practice, the more I am of the view that the DSM criteria are rather conservative. DSM falls short of a comprehensive description of psychopathological presentations, and the categories are not broad enough to capture all clinically relevant forms of psychological suffering and disabilities for which diagnosis is needed. The criteria for specified diagnoses exclude a significant number of patients who experience considerable distress and impairment in their daily lives.

People fundamentally misunderstand the impetus behind increasing rates of psychiatric diagnosis—by and large, clinicians are not imposing labels or disorder judgments on reluctant patients who would rather not have a name for what they are experiencing (although it does happen). There is a tremendous demand and appetite for diagnostic labels as tools of understanding. The amount of suffering and disability is vast; our traditional folk-psychological categories have been inadequate for this task. The DSM legitimized psychological distress and disability as healthcare problems deserving of recognition and treatment. The profession was unprepared for the magnitude of clinically significant distress out there, and the diagnostic manuals have struggled to keep up.

Much clinical practice involves clinicians responding to real suffering inadequately captured by official criteria. This leads to stretching existing diagnoses or utilizing vague “unspecified” categories, not from diagnostic carelessness but due to genuine gaps in the diagnostic framework. Similarly, frontline clinicians, burdened by time pressures and limited therapeutic tools, often prescribe treatments such as SSRIs broadly regardless of the precise diagnostic criteria. PCPs do not particularly care whether a patient has “adjustment disorder with mixed anxiety and depression,” vs “major depressive disorder, with anxious distress,” vs “dysthymia” vs “generalized anxiety disorder” because all they are going to do is put the patient on Prozac.

Patient-led diagnoses (#9, 10)

“So which is it? Are people victims of professionals labelling them, or are they taking too much control over their medical labels?”

Jesse Meadows, The Age of Overdiagnosis Panic

Much discourse around overdiagnosis betrays a distrust of individuals’ abilities to accurately recognize their own impairments. Patients generally seek diagnoses willingly, finding validation and clarity in diagnostic labels. Critics of diagnostic culture sometimes imply patients are either passively labeled by professionals or aggressively self-diagnosing driven by social media and disability activism.

A lot of public criticism of “overdiagnosis” does not strike me as very patient-centered. ADHD may be trendy, for good or bad reasons, but that should not stop us from acknowledging a patient’s lifelong struggles with inattention and focus, with resulting negative emotional consequences. DSM may or may not pathologize normal grief, but we should not clinically disregard a patient whose life has been paralyzed by grief for years.

A curious feature of this debate is that some clearly acknowledge that an important motivation is economic and pertains to scarcity of public resources. The UK government seems to think, for instance, that it cannot afford increasing rates of clinical treatment and disability benefits. Rather than transparently stating, “We wish we had sufficient resources to care for everyone, but we must prioritize severe cases,” many stakeholders instead gaslight those with milder impairments, implying that these individuals exaggerate or misunderstand their conditions when there is little evidence that it is happening at a mass scale or that this accounts for the rising demand for disability benefits.

Overtreatment (#11)

Sometimes people talk about overdiagnosis when they actually mean “overtreatment.” Is there overtreatment in the sense that there are many people who take treatment who are not helped by it? That is inevitable. No treatment is perfect. Unless the Number Needed to Treat (NNT) is 1, there will always be “overtreatment” by this definition. The NNT of aspirin for preventing cardiovascular events in diabetics in 153. We must treat 153 diabetic individuals with aspirin to prevent a single cardiovascular event in one person. People deserve to make informed choices about treatment, and people deserve access to care. And people deserve to know about the limitations of treatments and potential harms. Medical treatment is not simply about preference. It is guided and informed by clinical research, considerations of risks vs benefits, public safety considerations, cost effectiveness, public resources available for healthcare and health insurance, etc. But within these larger constraints, there is still a lot of flexibility and room for personal preference. In any case, issues around overtreatment bring up distinct considerations and cannot be subsumed under overdiagnosis.

Emotional suffering viewed through a medical lens (#12)

There is one aspect of what gets covered under “overdiagnosis” that I’m somewhat sympathetic to. This is the old “medicalization” criticism, used in sociological and philosophical critiques to argue that human suffering is now being frequently and inappropriately interpreted through a medical lens. Clinical conceptualizations and treatments are not universally helpful. For some they will be useless, and for some harmful. Some people are better off trying to understand and manage their suffering through non-clinical approaches: self-help, spiritual, lifestyle, coaching, social safety net, political, financial, existential, peer support, etc. The problem is that we don’t have a good way of knowing in advance who will benefit from the clinical approach and who will not. Epidemiological estimates of mental disorders provide a rough upper limit on who could stand to benefit from clinical care, but only a subset will actually benefit.

If clinical diagnosis and treatment are understood as one way of conceptualizing and helping a condition and not necessarily the only way, and not automatically the best way of helping to achieve all or indeed any desired outcomes,1 then this necessitates a robust pluralism of conceptualization and interventions. Diagnosis is a partial perspective on a person’s challenges.

The pluralistic approach offers a productive way forward. Clinical diagnosis is just one perspective among several—medical, psychological, existential, social, spiritual—that can effectively address individual distress. Different contexts demand different approaches. Recognizing this plurality does not negate the value of diagnostic categories, which serve essential pragmatic functions. Instead, it encourages clinicians and society at large to remain flexible, responsive, and open to multiple understandings of human suffering. To reduce this plurality of perspectives to a single dominant narrative, whatever that may be, is to impoverish our existence and to deprive us of the tools we need to make sense of ourselves in relation to our worlds.

Clinical concepts are appealing because they offer a useful hermeneutic lens through which to look at our problems. If we are over-relying on this lens, the answer is not to artificially restrict its use and deny people access to clinical care, but to develop other frameworks that can offer people similar or better utility and facilitate more informed and mindful use of the medical lens.

The answers I ultimately advocate for are thoughtfulness, conceptual clarity, person-centered care, pluralism, and realistic expectations around clinical treatments. “Overdiagnosis” is a blunt verdict offering blunt solutions. We deserve and can achieve better.