Armchair Diagnosis: Just Don’t

Lay people seem to have a growing understanding of medicine, especially psychiatry. At this point, it’s likely we won’t need doctors at all in a few years, because people seem to be so confident that they can perform diagnostics on the basis of looking at someone, interacting for a few minutes, or reading a letter sent by a family members[1. Yes, Dear Prudence, I am looking at you.]. This particularly applies to mental illness; evidently everyone has been reading the DSM and taking notes, because everyone and their sister is ready with a mental health diagnosis to hand whenever someone puts a toe out of line.

This goes beyond primetime medical school, because of the way it swirls around mental illness in particular. Yes, people absolutely do engage in armchair diagnosis with physical conditions, but it’s most common with mental illness, and people love throwing diagnoses around; someone is ‘totally bipolar’ or ‘clearly has borderline personality disorder’ or ‘obviously has depression or something.’

It’s women in particular who tend to be victims of armchair diagnosis, where people make judgments about their mental health status on the basis of their behaviour, often with very limited information. People seem to think they are qualified to practice psychiatry because they know diagnostic terms, and they feel very comfortable using them even when they don’t actually understand what those terms mean. Or how they are used to marginalise people, pathologise perfectly normal behaviour, and force people out of conversations.

The thing about armchair diagnosis is that it mutates. First it’s a ‘friend’ deciding that someone must have bipolar disorder because of some event or another. Over time, that’s mutated into an ‘actual’ diagnosis, repeated as fact and accepted. Everyone tiptoes around or gives someone sidelong glances and makes sure to tell other people. Meanwhile, someone is completely puzzled that other people are treating her like she’s, well. Crazy.

People sometimes seem to think they are doing someone a favour with armchair diagnosis. They’re explaining that a behaviour isn’t someone’s ‘fault’ by attributing it to mental illness. In fact, they do neither the person they’re diagnosing, nor the mentally ill community in general, a favour. By insisting that behaviours that are weird, or out of alignment with how someone usually acts, or distasteful are the result of mental illness, people are engaging in distancing. They’re saying that no ‘normal’ person could do that sort of thing. It’s impossible, for example, for someone who has been having a bad day of work to snap at someone and collapse in tears. Obviously she’s paranoid and has schizophrenia.

Dismissing any kind of behaviour you don’t like as mental illness suggests that mental illness is the root of all behaviour you don’t like. In fact, many of us walk among you unnoticed and undetected, and sometimes we’re assholes, or upset, or frustrated, or suspicious because we’re human beings, not because we are crazy. Sometimes someone with bipolar disorder has a high energy day and it’s not mania. It’s just a good mood, a good mood like other people have that is the result of things going well; maybe the weather’s nice and there’s fresh fruit on top of the fridge and a friend is coming to visit soon. Sometimes, people with depression have down days that aren’t about biochemistry, and have everything to do with everything going wrong and being in a bad mood.

And sometimes, people without mental illness do things that are weird. Sometimes children don’t talk to their parents, or people get snappish, or someone is grumpy for a few days. None of these things are evidence of mental illness. They’re evidence of being human, because this is what it is like to be alive. Things happen and you respond to them and work through them and you don’t always react the way you want. But that’s how it goes.

At the end of last year, Emily Yoffe busted out the armchair diagnosis in two Dear Prudence columns in quick succession, and they really highlighted the problems with this practice. First she told readers that an adult woman having an affair with her stepfather ‘…has an undiagnosed mental illness, possibly bipolar disorder.’ Weeks later, she was informing us that ‘Something went terribly wrong with your brother. Given that he at last is appearing to try to make amends, I hope that means he has gotten a diagnosis and some medical help.’ The original letter writer had made no mention of mental illness in a discussion about an estranged family member.

Yoffe pathologised perfectly normal behaviours, and utterly failed to consider other explanations for them. Maybe the stepdaughter and the stepfather fell in love. Maybe the stepfather is a creepy predator. Maybe those ‘outlandish accusations’ were based in very real experiences of abuse and molestation that went undiscussed, unremarked, and unaddressed. Who knows. Certainly not Yoffe, not on the basis of a single letter telling only one side of the story, but she felt totally comfortable making armchair diagnoses, and she, like a lot of advice columnists, does it on a regular basis. I had no idea that a degree in psychiatry was part of the package when you became an advice columnist.

Armchair diagnosis harms people, and it’s deeply counterproductive. If someone is behaving unusually, the first response shouldn’t be to pathologise that and ignore it, but to find out why, and to see if there is something to be done to help. Because, sometimes people just need a friendly voice or a kind hand or some sort of human contact, and providing it, rather than cracking out the DSM, might actually do some good.