Rethinking Diagnostic Expansion: Psychology, Normality, and the Pitfalls of Over-Diagnosis

Thanks to Mark Eltringham for highlighting the increasing rush to diagnoses for inevitable deviations from a tendentious norm, via Dr Hannah Spier's article.

Society’s Desire for Diagnosis: The Comfort of Labels in the Search for Certainty

Contemporary society exhibits a powerful urge to categorize and explain human difference through diagnosis. In the face of complexity and behavioural ambiguity, there is comfort in attaching a label—not just for those seeking help, but for families, clinicians, educators, and society at large. The dramatic rise in autism diagnoses, as Hannah Spier highlights, exemplifies this trend. Whereas classic definitions of autism once focused on profound social and communicative impairments, today’s vastly expanded spectrum encompasses wide-ranging differences that can include quirks and idiosyncrasies formerly considered within the range of normal.

The Myth of ‘Normality’: Freud’s Insight

Sigmund Freud, the founder of psychoanalysis, repeatedly observed that there is no single ‘normal’ human personality—only a spectrum formed by endless individual variations. Everybody exhibits traits that differ from an imagined norm, a fact recognized by generations of clinicians and researchers. Freud himself noted that “every normal person, in fact, is only normal on the average. His (sic) ego approximates to that of the psychotic in some part or other, and to a greater or lesser extent.” In other words, strict lines between ‘disorder’ and ‘normality’ can be misleading and artificially rigid.

Over-Diagnosis and Diagnostic Creep

The alarming increase in autism diagnoses (now estimated at 1 in 100 children in the UK, 1 in 36 in the States) cannot be explained by genetics or environmental factors alone. Instead, diagnostic criteria have broadened in successive editions of the DSM (the Diagnostic and Statistical Manual of Mental Disorders). These criteria continue to lower the clinical threshold, capturing behaviours that have, until now, lived within the wide span of typical human development. This process, often referred to as ‘diagnostic creep,’ erodes meaningful clinical distinctions and risks pathologizing difference. Similar trends have been observed with diagnoses such as ADHD, bipolar disorder in children, and trauma-related conditions.

Contributing Factors:

• Cultural Valorization of Difference: As Spier highlights, today’s culture often reframes neurodivergence as a mark of uniqueness or superiority, sometimes detaching it from its roots in impairment or distress.

• Parental and Social Pressures: Families may seek diagnoses to access support, resources, or to make sense of a child’s uniqueness—sometimes out of anxiety or the need for a narrative.

• Medicalization of the Everyday: Increasingly, emotional struggles and atypical behaviours are interpreted through normative medical and psychological lenses, encouraging over-diagnosis.

• Media and Popular Culture: Iconic portrayals of characters with ‘quirky’ features reinforce the desirability of being different, yet ‘special’ subtly influencing the self-perception of individuals and families. Badge Sherlock Holmes, Katie Morag, James Bond and Scarlett O'Hara as you like, but this will not be as they were seen, either by their fictitious contemporaries, or by their creators.

The Cost: Loss of Nuance and Psychological Understanding

When ordinary variations are swept into diagnostic categories, true psychological insight is lost. Rather than exploring the complexities of personality, emotional development, and relational dynamics, there is a temptation to shortcut explanation via diagnosis, neglecting the deep, nuanced understanding central to psychology. A diagnosis can become a shield, relieving individuals of the work of self-examination or adaptation, and encouraging society to treat diversity as disorder.

Over-diagnosis is not simply a technical error, but a failure of psychological imagination; a retreat from understanding the complexity of human difference, struggle, and adaptation. It risks stigmatizing those at the margins and flattening the rich terrain of individual experience into simplified categories.

Thanks for reading. C

Toward a More Nuanced Approach

• Respect Personality Variation: Recognize that difference is not deficit. Personality spans a broad spectrum, with 'deviations' from the mean usually representing innate diversity, not a condition in need of treatment.

• Rediscover Psychological Meaning: Move beyond checklist diagnoses to understand the unique stories, motives, and needs of individuals.

• Guard Against Over-Medicalization: Use diagnoses judiciously, prioritizing functional impairment and distress, not mere difference, as the threshold for intervention.

• Promote Critical Media Literacy: Encourage scepticism about pop-culture narratives that glamorize or pathologize certain traits. Doctor Who isn’t the only professional bent on cod-psychological simplism at the expense of a programme's raison d'être.

 Spier’s article powerfully calls attention to problems in the current diagnostic landscape. Instead of seeing a diagnosis as the only valid route to understanding, psychology, medicine and society would do well to reclaim Freud’s – and indeed Jung’s, Klein’s, Adler’s, Chodorow’s etc. - timeless insight: nobody is truly ‘normal.’ Every individual is worthy of nuanced understanding, far beyond labels.

Further reading

https://www.statnews.com/2023/03/23/autism-epidemic-cdc-numbers/ https://www.cdc.gov/media/releases/2023/p0323-autism.html Freud, S. (1916). Introductory Lectures on Psychoanalysis.