Diagnostic labels allow clinicians and researchers to predict, with varying degrees of accuracy, the likely prognosis of a disorder - that is, the expected outcomes over time. Such labels also allow clinicians and researchers to understand aetiology - the potential causes or antecedents of disorders. Taken together, aetiology and prognosis inform the options regarding prevention and treatment. Diagnoses and labels are thus fundamental to the design of effective interventions for children with likely or identified impairments to their health and development. They may also mean that individuals reach the criteria or threshold required to access the services they require.

But there is a darker side to labels; they may be turned against those branded by them. Some consider labels to be the over-medicalization of human behavior and worry about the negative consequences of affixing labels to individuals. Labels of mental health disorders may carry unintended and malignant consequences. Dror Ben-Zeev, Assistant Professor and Academic Director of the Undergraduate Psychology Program at Illinois Institute of Technology and colleagues have argued that psychiatric diagnoses have the potential to stigmatize those assigned such a label and this may have deleterious effects over and above the disorder itself.

Mental health diagnoses, Ben-Zeev argues, may lead to “public stigmatization”: the process by which large social groups adopt and endorse stereotypes which may, in turn, lead to negative discrimination. It is a common yet false stereotype that, for example, those with psychosis are often violent. Public stigmatization may, in turn, lead to internalized “self-stigmatization” - the loss of self-esteem or confidence in one’s own ability to succeed or overcome adversity.

Ben-Zeev and colleagues say that this public- and self-stigmatization may carry crippling consequences: aside from the emotional toil it may wreck, stigmatization may also reduce opportunities for social and personal development, education and employment.

So how does the latest draft of the DSM rebuke these dangers? Ben-Zeev concedes that, in many ways, the fifth edition takes many welcome steps. For the first time there is a public consultation and greater openness and clarity regarding the development of diagnostic criteria. In addition, many of the specific diagnoses are more nuanced; and there is a greater emphasis on variability within diagnoses which should go some way to dispel blanket assumptions and stereotypes. While this may go some way to reduce self-stigmatization - assuming that clinicians are aware of the risk - Ben-Zeev is less optimistic that these changes will alter the likelihood of social stigmatization.

But what really keeps Ben-Zeev awake at night is the new “high risk categories” proposed for DSM-V. This involves stretching the reach of diagnostic criteria not only to label active impairments, but also to the identification and labelling of those individuals at the highest risk of developing a disorder. For example, it is proposed that DSM-V will include “psychosis risk syndrome” and “minor neuro-cognitive disorder” - essentially identifying those at greatest risk of psychosis or dementia.

This is, on one hand, laudable. Identification of those at high risk of subsequent impairment paves the way for early invention efforts: a cornerstone of prevention science. But the concern of Ben-Zeev and colleagues is that the science of prediction and prognosis is not up to such a task - many of those identified as “high risk” will not go on to develop the disorder but may nonetheless suffer the damaging effects of stigmatization.

It is thus a fine line to walk between the potential benefits and disadvantages of a diagnostic label. The final version of the fifth edition of the DSM will no doubt be greeted with both praise and concern. Perhaps the greatest challenge is not in the writing of the diagnostic labels themselves, but in how they are used in practice.

References:
http://www.dsm5.org