Can there be too little stigma in psychiatry?

Main theme: Stigma in psychiatry

---

During my upbringing in Gothenburg in the 1990s, the diagnosis Deficits in Attention, Motor control and Perception (DAMP) had just been introduced. DAMP can briefly be described as a narrower phenotype of ADHD, including motor symptoms or coordination difficulties roughly corresponding to Developmental Coordination Disorder (DCD). Children ran around shouting "DAMP kid" at each other, and the term became a dominant insult in schoolyards, alongside derogatory terms related to sexual orientation. It also replaced the previously popular insult "CP" (cerebral palsy).

Karl-Axel Lundblad

MD, Board member of the Swedish Psychiatric association.

Before the 1990s, it was relatively uncommon for families to have contact with child and adolescent psychiatry services, and there was a pronounced stigma associated with such contact. Even describing one's mental state by saying, "I have anxiety," was considered deviant, and one was quickly placed into a category of being irrational or unstable. In summary, psychiatric care was heavily stigmatized.

However, something has changed. Psychiatric terms such as depression and anxiety have entered everyday language, and people readily discuss their own, their partners', and their colleagues' varying levels of "Aspie traits." Concepts such as trauma and PTSD are now used beyond their traditional clinical context (a topic that Professor Rück will explore in greater detail in a Swedish-language book to be published this autumn).

Figure 1. Left panel: Patient before 2000 is informed that they have a psychiatric diagnosis → Becomes upset. Right panel: Patient after 2000 is informed that they do not meet diagnostic criteria for a psychiatric disorder → Becomes upset.

Image shamelessly stolen by author from the internet group "Memes for Psychologists".

The most prominent example is, of course, the ADHD revolution and the exponential increase in ADHD-related assessments and treatment that has characterized child and adolescent psychiatry (CAP) for many years and, more recently, has also come to dominate adult psychiatry. For many years, ADHD has accounted for more than 50% of all patient contacts within CAP, and in recent years the same has become true for new referrals to adult psychiatric services. ADHD has become our bread and butter, necessarily so, since Swedish legislation permits only specialist psychiatrists to prescribe controlled stimulant medications, with a few complicated exceptions.

Figure 2. "When you get home from a party and the first thing you do is complete a RAADS-14 online screening test." (RAADS-14 is an autism screening instrument.)

With this diagnosis, a shift has occurred in which patients, to some extent, seek a diagnosis—or become frustrated when they do not receive one (and thereby gain access to treatment)—rather than trying to avoid psychiatric labeling and feeling relieved by being declared healthy or being able to discontinue medication.

At the same time, the problem of stigma clearly remains within adult psychiatry. Diagnoses such as substance use disorders, schizophrenia, and intellectual disability continue to carry substantial stigma. We therefore find ourselves in a situation characterized by both too much and too little stigma at the same time—or perhaps so it seems. □

Figure 3. A badass skeleton proudly declaring its autism.