Conference themes

One critical and quite early contribution to an analysis of ‘diagnosis’ is seen in the uncovering and deconstruction of the procedures and styles of reasoning which underpin the establishment of a biomedical diagnosis. For example, detailed explorations of how the definition of the menopause was developed in biomedicine show how a diagnosis becomes incorporated into clinical practice, and demonstrate the discrepancy between the diagnostic definition of menopause and women’s everyday life symptoms. Today, this social constructionist and feminist approach is particularly seen in relation to the proliferation of, for example, psychological disorders and also lifestyle diagnoses. Central discussions concerning disease classification systems, such as DMS IV and V (Diagnostic and Statistical Manual of Mental Disorders, Fourth and Fifth Edition), fruitfully involve contributions from medical anthropology. These discussions question the labeling of human conditions and ask whether the suffering and poor conditions experienced by many people correspond with a clinical diagnosis of depression. In other words, do bodily and emotional states such as melancholy, tristesse, moodiness, ‘the blues’, or apathy really conform to the label of depression, i.e. are they pathological states? Maybe we actually experience and see more of these conditions because society creates them – epidemiology creates the diagnostic evidence, i.e. the diagnoses reflect real sufferings in our world. Another possibility is the hypothesis of ‘pathologisation’ which claims that empirically we see excessive concern and obsession regarding health, leading to a therapeutic culture with an overload of diagnoses and a tendency to pathologise nearly all human conditions. The tendency to pathologise, it is argued, is created by the actual practice of diagnosing, which goes hand in hand with a tendency to focus more on symptom patterns that will justify a diagnosis rather than on which etiology underpins a given condition.

Further, the focus on symptoms and the pervasiveness of risk discourses (including pre-diagnostic labeling) are presumed to be related to the abundance of screening programs, testing and the use of technology in diagnostic processes. In medical anthropology these modes of creating diagnostic evidence are often critically studied. Increasingly, debates and a focus on ‘overdiagnosis’ as a central phenomenon are also emerging within the biomedical profession. These debates, both in medical anthropology and the medical profession, deal with, for example, risk discourses as part of creating a scenario of overdiagnosis. They are also critical towards the growing collection of biodata that govern people’s lives through self-monitoring via counting, weighing, and numbering, and how technology produces new diagnostic processes through e.g. screening and testing. Thus, on what basis a diagnosis is made, in relation to what evidence criteria, as well as its impact and consequence are crucial matters. A critical anthropological focus on diagnostic discourses is therefore much needed.

If we accept the suggestions that there is a tendency to pathologise increasingly more conditions, it becomes pertinent to investigate how the repertoire of diagnoses expands. Within studies on biopolitics and biopower different theories and explanations for an expansion are discussed, among others the role of the medical industry and the changing role of psychiatrists. What is highlighted, however, is the homogenisation of treatment (e.g. psycho-pharmaca) and the focus on psychiatric symptoms, making it easier to see a link between different types of suffering. Overall, biomedicine has developed into a system governed by biology and the life sciences that influences diagnostic practice in general and creates specific modes of subjectivisation in all individuals. In other words, symptoms /sensations are being transformed and recoded into diagnoses, often psychiatric diagnoses. We psychiatrise ourselves and are being psychiatrised in the context of biopower.

Related to this discussion on biology and medicine’s influential impact on everyday life are the notions of medicalisation and geneticisation. Medicalisation goes hand in hand with diagnostic practices where ‘subjectivity and symptom reporting are subsumed into medical pathologies and standard deviations from medical norms’ (Lock 2001). Further, geneticisation, and the desire for and the realisation of genetic knowledge, has the potential to restructure individual subjectivity, family relations and the politics of medical activism, highlighting that new configurations, resistance and considerations of ethical dilemmas, tensions, contradictions and conundrums pervade everyday life in health and sickness. Patients’ (and relatives’) responses are multifaceted and shaped by the complex intersections of gender, race/ethnicity, age, sexuality and other social differences. Thus, both diagnoses and medical technologies are used in subjectivisation processes in a contingent and situated way as a delicate interplay between everyday social lives, politics and medicine. Such contingencies and intricate relations between practices and medical structures will be highly relevant to explore further.

A paradox can be noted here: on the one hand are the trends towards pathologisation and medicalisation, against, on the other hand, the difficulties experienced by some patients of achieving/receiving a diagnosis when symptom patterns seemingly do not fit within existing diagnostic categories, i.e. functional disorders or medically unexplained symptoms. This raises questions, such as: Why are some symptoms, even those referring to a combination of unease, moodiness and strong physical sensations, proliferating without diagnoses, while some diagnoses proliferate without illness?

Investigating how a diagnosis is ‘born’ is important, be it as a scientific classification or as a process in diverse clinical and non-clinical settings and contexts. By digging deep into medical traditions, procedures and reasonings, researchers have demonstrated the construction of disease categories and diagnoses, and the creation of diagnostic evidence. Studying the development and consequences of diagnostic classification systems is another starting point, such as ICD (International Classification of Diseases) and DSM that are used in primary care and in psychiatric specialist settings. These systems call for specific analyses of how diagnostic evidence is established, what they emphasize and what their implications are, e.g. concerning definitions of normal versus deviant behaviour.

Biomedical health professionals tend to work within and with these and other diagnostic frameworks. To scrutinise the ways of crafting, enacting and practicing diagnoses opens up for explorations of diverse interactions, intersubjectivity and contextualisation of biomedical routines and procedures. In this way, not only physicians and healthcare professionals of different specialties are ‘doing disease’, but also the patient because s/he is always present and influences every step. To explore diagnostic processes and the ‘agents’ involved, some studies have examined clinical tests, while others have focused on how healthcare professionals train and learn to make diagnoses.

Biomedical diagnoses may not only be contested by patients or biomedical professionals, but also by non-biomedical professionals. This points to the need for explorations of how and what kinds of diagnosis are constructed by non-biomedical healthcare professionals, and in and through encounters between patients and practitioners of unconventional medicine. Further, the interplay between patients/patient organisations and non-biomedical healthcare professionals in constructing ‘new’ diagnoses merits further discussion.

Overall, these issues call for a critical analytic focus on the agency, mechanisms, technological tools and tests, as well as practices of being a patient, relative, health professional or a health scientist working with and enacting, using and applying, contesting and refusing diagnoses in their daily life world.

Intersubjectivity, patient perspectives and patient agency are driving forces in the making of a diagnosis. That is, diagnoses are established in a relational negotiation, including diverse clinical settings, through social movements and in individuals’ everyday lives.

Several studies have focused on clinical negotiations concerning treatment, decision-making or communication but few studies have paid close attention to the ways in which a diagnosis is developed in the clinic. However, as noted above, a diagnosis is a classification of utmost importance to patients, relatives and health care professionals. Whether a diagnosis is established or not has several consequences. Accordingly, and when ‘diagnosis’ is central to the research focus, important questions arise about the agendas of patients, relatives and healthcare professionals, and about the organisational frameworks that influence the process of making diagnoses. To further investigate these and related questions, analyzing the changing semantics of medicine and the creation of new diagnostic processes could prove relevant.

Diagnoses also proliferate outside clinical settings, and the practices and narratives of people who self-diagnose, who seek to find suitable diagnoses or who have received a diagnosis are of importance. This may be seen in contexts where patients become or are designated to be ‘users’ or ‘clients’ and in the general reframing of biomedicine towards promoting self-care, self-management and ‘awareness’ campaigns. Further, the quest for a diagnosis can be scrutinised through the key concept of ‘epidemic’ – e.g. How are diagnoses brought on? Which elements promote ‘communication/infection’ of a diagnosis? Further, investigations are needed of everyday practices at phenomenological and interactional levels that explore how patients, relatives and healthcare professionals create meaning and understanding of already received diagnoses and how they look for diagnoses. In particular, how they engage with the media/internet concerning diagnostic help, or incorporate ‘home work’ as individual self-care and draw on non-biomedical healthcare.

The meaning of a diagnosis is closely related to experience-near illness aspects. Diagnostic meanings influence one’s identity construction and may touch upon sociopolitical and economic aspects for the individual person. Meaning and narrativity of a diagnosis have been explored by several studies; e.g. patients with psychiatric disorders and the way they (and their relatives) perceive and live life with a diagnosis. In addition, patients with functional disorders have been studied to identify the meanings and implications of finally receiving a diagnosis as well as patients’ fight to receive a diagnosis. Likewise, narratives of meanings of diagnoses are also important in chronic conditions and life style diseases as well as in other conditions traditionally perceived as ‘acute’.

Closely linked here, and meriting in-depth anthropological explorations, is patients’ and relatives’ work in health social movements and activist groups/organisations, as well as the work of these movements and organisations. For example, embodied health social movements address disease, illness and disability experiences by challenging existing etiology, diagnosis, treatment and prevention, knowledge and practice, either from ‘within’ or ‘outside’ of biomedicine. Similarly, evidence-based activism seeks to imagine new epistemic inquiries by conjoining patients/activists and specialists/professionals, to gain biomedical recognition of illness symptoms and experiences, as well as their causes.