Think back to the last time that you took a sick day – at what moment did you become certain that you were ill? Was there a particular symptom that ‘proved’ it to you? Have you had days where you felt under the weather, but weren’t sure if your discomfort was due to illness or, say, a poor night’s sleep?

We often take categories like ‘health’ and ‘illness’ for granted. But the boundary between them is ambiguous: there are many ways to define illness. In fact, there is an entire branch of medicine (called nosology) devoted to working out how best to do so!

At HRW, we work across many different therapy areas. From this vantage point, we see how various medical disciplines go about answering the deceptive trick question: what is illness? Using the expertise of our expert neuroscience hub, HRW Synapse, we can peek behind the curtain of psychiatry’s unique philosophy on illness and offer some reflections on what it means for patient experiences and decision-making dynamics.

The symptom-based approach
The standard approach in non-psychiatric medicine is to define diseases on the basis of their microphysical causes (like genes or pathogens). Consider, for example, cystic fibrosis. We are lucky to have a good understanding of the biological mechanisms behind cystic fibrosis symptoms: an inherited gene mutation causes the body to produce excess mucus. Knowing the biological mechanism behind the symptoms, we are able to distinguish cystic fibrosis from other diseases with similar symptoms.

Psychiatrists, however, do not typically have this luxury. Despite great efforts, we do not know much about the microphysical causes of psychiatric disorders. In the face of this important unknown, psychiatrists must outside-the-box about how to define mental illness.

In the 1980s, the American Psychiatric Association proposed a solution that has remained the status quo: the symptom-based approach. This philosophy sets aside speculation on underlying causes in favour of diagnosing patients via “diagnostic criteria”: a diagnosis is made if a patient displays a sufficient number of observable symptoms defined in the Diagnostic and Statistical Manual (the major handbook for psychiatric diagnosis).

Take Major Depressive Disorder (MDD), one of today’s most common diagnoses. The criteria include behaviours (e.g. crying frequently) and emotions (e.g. low mood). Using these criteria, psychiatrists can diagnose MDD while remaining agnostic about the cause.

It may take decades before we know enough to move beyond the symptom-based approach in psychiatry. Meanwhile, we are forced to grapple with some curious consequences of this approach.

One consequence that we regular encounter in our research at HRW is the role that gender politics plays in psychiatric diagnostic processes.

‘Boys don’t cry’: how gender norms infiltrate psychiatric diagnosis
Since psychiatry relies on behaviour-based symptoms to define its diagnostic categories, gender plays an especially influential role in how mental illness ‘presents’ in patients. This is because behaviour-based symptoms, like all behaviours, are subject to gender norms.

In psychology, the social norms that dictate how emotions can be expressed are called ‘display rules’. The basic idea is that cultural standards of expression are learned at a young age and thereafter shape how we display our emotions. For example, you might learn from your parents that raising your voice is an acceptable display of anger, but that damaging property is not.

In the same way that cultures vary in how they emote, it is well-established that display rules are different for men and women. Namely, they tend to map onto gender stereotypes.

For instance, we are all familiar with the stereotype that boys don’t cry. Observational studies of children show how this cultural rule is taught to boys: boys who cry face reprimands by their caretakers and bullying from peers. Resultantly, display rules around crying (consciously and non-consciously) constrain how all genders express themselves as adults.

Recalling that tearfulness is a symptom of several psychiatric disorders, crying exemplifies the way that gender-stereotypes shape how patients experience disorders. HRW’s qualitative research with patients with MDD and treaters has also revealed how stereotypes shape what medical practitioners expect psychiatric disorders to ‘look like’ for patients of different genders. For instance, when seeking diagnoses, a fixation on thinness can be easily overlooked in a female patient. Similarly, in evaluating whether to escalate treatment, a psychiatrist may be particularly moved by a male MDD patient’s (display-rule-defying) tearfulness vs a female equivalent.

Behavioural Science Meets Psychiatry
Another consequence of the symptom-based approach that we encounter in our work at HRW is the increased role for certain cognitive biases.

Ambiguity aversion – our tendency to avoid things that feel unpredictable or vague – is particularly relevant in psychiatry. The ambiguity inherent in working with a diagnosis without knowing its cause motivates a bias toward choices that feel more certain and/or familiar. For example, psychiatrists might avoid treatment switches with stable yet suboptimally-treated patients because they could ‘rock the boat’.

Another bias we regularly see in psychiatric research is personalisation discourse – when power given to the idea that treatment should be customised to the uniqueness of every patient. Viewing a disease through the lens of its underlying cause has a universalising effect, which increases treaters’ comfort with adopting a more universal approach. Lacking this universalising perspective, psychiatrists become committed to taking a case-by-case approach, such that communications that imply a ‘one-size-fits-all’ solution can backfire.

Unique settings, unique solutions
Overall, psychiatry’s unique philosophy of illness has many downstream effects on patient experiences, doctor-patient interactions and decision-making dynamics. For this reason, communications and interventions that work effectively in non-psychiatric medicine do not always translate in psychiatric settings. Business problems in psychiatry therefore demand carefully-tailored solutions. At HRW, we established Synapse to meet precisely this need.

If you have any questions about the research, please do not hesitate to get in touch with the HRW Synapse Team at hrw_synapse@hrwhealthcare.com.

By Emma Neville

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