From mental disorder to shared understanding: a non-categorical approach to support individuals with distress in primary care

This article argues that, rather than aiming for a psychiatric diagnosis, generalist professionals such as those working in primary care, as well as in other hospital and community settings, should use a non-diagnostic framework when encountering distress. The conceptual and empirical limitations of the psychiatric diagnostic system and evidence that psychological phenomena are dimensional suggest the need for an alternative approach; one that might also address problems of overdiagnosis and overmedication.¹

There are three key problems with the current Diagnostic Statistical Manual (DSM) and International Classification of Diseases (ICD) systems of psychiatric classification. The process can be stigmatising; diagnoses are not adequate representations of reality; and they are inadequate for informing an individualised management plan. The current categorical diagnostic system encourages the patient to understand their distress as a disease, rather than as an understandable response to current problems, genetic inheritance, and past experience of trauma, loss, and problematic attachments. Although some patients are comforted by labels, we propose that a more scientifically valid and individualised assessment can provide a deeper understanding, a sense of being understood, and access to specialised services and benefits if required.

During the 20th century, psychiatrists created a relatively unified practice through the closely related ICD and DSM systems. Despite notable exceptions, such as Balint² and more recently Dowrick,³ GPs have generally advocated the psychiatric model that is enshrined in the RCGP’s curriculum and in NICE guidance. Attitudes of professionals, however, are more mixed. Studies of practice show how diagnoses are not always offered, and that GPs’ talk often follows the patient’s view that the emotional distress might be related to social problems.⁴

The poor performance of the psychiatric diagnostic system demonstrates how diagnoses are inadequate models of …