Shreya Naresh
3rd Year Undergraduate Student
Ramaiah University of Applied Sciences, Bangalore.
21st September, 2024
According to the American Psychological Association (APA), diagnosis in psychology involves identifying and determining the nature of a disease or disorder by observing its signs and symptoms through various assessment techniques, such as tests and examinations, along with other available evidence. Psychological diagnoses are meticulously codified for professional use, prominently in manuals like the Diagnostic and Statistical Manual of Mental Disorders, often known as the “DSM,” and the International Classification of Diseases (ICD).
The process of psychiatric diagnosis is intricate, necessitating thorough history-taking and comprehensive evaluation. While therapists often have familiarity with various aspects of a patient's history, revisiting these factors is crucial as circumstances and patient insights may evolve over time. Initial screening tools, commonly completed by patients prior to assessment, are not diagnostic in nature. Thus, therapists must perform a complete assessment to establish a diagnosis.
Addressing current concerns involves exploring specific symptoms, the context of their occurrence, the timeline of symptom fluctuation, and factors that exacerbate or alleviate symptoms. Additionally, it is essential to inquire about challenging topics, such as suicidal thoughts. Delving into a patient's developmental history is equally important, including childhood experiences, trauma histories, interpersonal relationship challenges, and chronic physical health issues. The cumulative impact of adverse childhood experiences necessitates a sensitive approach to avoid re-traumatization, focusing on understanding that trauma occurred rather than its detailed recounting.
A thorough assessment also includes exploring family history, past medical and psychiatric history, and drug and alcohol use. Understanding a patient’s premorbid personality can aid in facilitating recovery, providing insight into their character before the onset of illness. The current social situation, including dependents, housing, exposure to violence, and financial concerns, also plays a significant role in recovery and treatment access.
A mental state examination (MSE) is a crucial component of the assessment, involving observations of appearance, behavior, speech, mood, affect, thought disorders, perception, cognition, intelligence, judgment, and insight. Furthermore, physical examination and investigations are vital to identify and manage comorbidities, especially when organic cerebral pathology is suspected.
Importance of Diagnosis
Diagnosis in mental health must be grounded in scientific rigor, with clear boundaries to differentiate between normal emotional responses, such as sadness, and clinical conditions like depression. Recent classification systems, such as the DSM-5 and ICD-11, emphasize the importance of reliable, objective criteria to frame diagnostic frameworks. These classifications form the basis for evidence-based treatment options, supported by scientific research into the neurology, endocrinology, and immunology of major mental illnesses. This scientific underpinning provides evidence for the efficacy of treatments, including medications and psychotherapies. Psychiatric classification not only guides treatment but also empowers patients and careers with information about the illness, fostering understanding and connection with others in similar situations.
Diagnosis plays a critical role in how healthcare professionals communicate with patients and with each other. In situations where multiple interventions are available, a clear diagnosis guides logical decisions about which intervention might be most effective, or whether no intervention is the best option. For instance, if an adult presents with symptoms like lethargy, weight loss, reduced activity, and decreased interest in life, it is essential to distinguish whether these symptoms indicate a temporary adjustment to life changes, cancer, heart failure, or a severe depressive episode with immediate risk of suicide. Diagnosis underpins evidence-based practice by determining which interventions will be most valuable.
The significance of diagnosis for patients is substantial and growing. A diagnosis reassures patients that their situation is not unique, mysterious, or inexplicable, and that a body of knowledge and experience can be applied to provide help. It can alleviate inappropriate feelings of blame, such as parents feeling at fault for their child's autism. Furthermore, diagnosis can reduce stigma by acknowledging the presence of illness, thereby countering the perception of symptoms as character flaws. It helps individuals understand their differences and mitigates feelings of shame, loneliness, and low self-esteem that may arise from being perceived as simply "odd" or "bad."
Diagnosis also facilitates effective communication between patients and healthcare professionals about support and service needs, including therapies and educational support. It enables patients and caregivers to connect with others facing similar issues, advocate for better services, and access relevant educational and self-help resources.
Diagnosis as an Art
The process of psychiatric diagnosis, while scientifically backed, also requires the finesse of an art form. It involves understanding why people are the way they are by exploring their life histories. It uses biological, psychological, social, cultural and spiritual elements.
For example, consider a therapist working with a patient named Anjali. Anjali presents with symptoms of depression, but a deeper exploration reveals a complex history of childhood trauma, strained family relationships, and recent job loss. By delving into Anjali's developmental history, the therapist learns that her childhood was marked by emotional neglect and occasional physical abuse. These experiences have left Anjali with a deep-seated sense of unworthiness and chronic anxiety. Her strained relationship with her family further exacerbates her feelings of isolation. Recently, losing her job, which she took immense pride in, has triggered a severe depressive episode.
Through sensitive and empathetic exploration, the therapist comes to understand that Anjali's current depression is not just a biochemical imbalance but a response to a lifetime of accumulated stress and trauma. This understanding allows the therapist to tailor the treatment plan to address not only Anjali's immediate symptoms but also the underlying issues contributing to her condition.
The art of psychiatric diagnosis lies in seeing beyond the symptoms to the person behind them. It involves recognizing the intricate systems at play, including past experiences, personal relationships, and individual resilience.
While diagnosis often focuses on pathologies and weaknesses, recovery should be strengths-based. Misdiagnosis can lead to inappropriate treatments and prevent access to more suitable interventions, such as trauma-focused care. A diagnostic label can impact a person's career, physical healthcare, social life, and self-perception due to stigma and discrimination. Therefore, diagnosis carries an ethical dimension, and therapists play a critical role in establishing a good therapeutic alliance, ensuring that the chosen intervention genuinely aids the patient's journey toward recovery.
Role of ICD and DSM in diagnosis
To fully appreciate the process and importance of diagnosis in mental health, it is essential to understand the DSM and ICD. These classification systems provide the structure and guidelines necessary for diagnosing mental health disorders.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a comprehensive reference book on mental health and brain-related conditions, published by the American Psychiatric Association (APA). The "5" in DSM-5 indicates its fifth edition, initially released in May 2013, with a revised version, DSM-5-TR, published in March 2022. This manual offers detailed definitions, diagnostic criteria, and classifications for a wide range of mental health conditions, aiding healthcare professionals in accurate diagnosis and treatment. While the DSM-5 and DSM-5-TR are technical resources intended for medical experts, they are accessible to the public for educational purposes. However, these manuals should not replace professional medical advice or treatment. The DSM is crucial for standardizing mental health diagnoses globally, with extensive contributions from professionals worldwide and translations available in multiple languages.
Conversely, the ICD is a broader classification system maintained by the World Health Organization (WHO) that covers all health conditions, including mental disorders. Its primary purpose is to provide a standardized system for recording, reporting, and analyzing health data worldwide. The ICD serves as a critical tool for epidemiology, health management, and clinical purposes, aiding in the monitoring of disease trends, allocation of resources, and formulation of health policies.
ICD codes are used extensively in medical records, health information systems, and research to classify diseases and other health problems. The classification system organizes diseases into chapters based on etiology, anatomical site, and clinical characteristics, ensuring that each condition has a specific code that allows for easy comparison and aggregation of health information across different regions and healthcare settings.
The latest revision, ICD-11, represents a significant evolution from its predecessors by incorporating a computable knowledge framework. This framework supports interoperability in digital health environments, allowing for more efficient data exchange and analysis. The ICD-11 includes a foundational database with detailed entries and synonyms, facilitating precise classification and enabling the system to adapt to new health conditions and scientific advancements. Moreover, ICD-11 emphasizes the importance of clarity and specificity in classification while maintaining flexibility to accommodate new diseases and evolving medical knowledge.
Challenges in diagnosis
However, there are inherent challenges and limitations in the utility of scientific classification in psychiatry. While some diagnostic categories, such as schizophrenia, have remained relatively stable over time, others have undergone significant changes, such as the concept of hysteria. Certain diagnoses have disappeared, like homosexuality, while new ones, such as various forms of internet addiction, have emerged. This lack of stability in psychiatric diagnostic systems reflects the complex nature of psychiatric illness and the influence of social expectations on society’s understanding of what constitutes a ‘disorder’.
Psychiatric diagnosis can be complex and evolving, making it difficult for simple tools to capture the full spectrum of a patient's condition. Comorbidity is common in psychiatry, occurring both with physical health disorders and among different psychiatric disorders. The features of various psychiatric conditions often overlap, complicating the diagnostic process. This is particularly challenging in young people, where symptoms and disorders are still developing.
Patients may find it difficult to disclose certain symptoms, such as hallucinations, disordered eating, or compulsive behaviors, due to feelings of shame and stigma. This can lead to premature closure of the diagnostic process, resulting in incorrect diagnoses and inappropriate treatment. Misdiagnosis through premature closure can cause iatrogenic harm, exacerbating the patient's condition rather than alleviating it.
Some mental health organizations promote a simplified diagnostic process, using tools in the hands of less-expert individuals to screen and categorize patients. In some instances, these tools enable patients to self-diagnose using online resources. While this model is appealing for its simplicity and accessibility, it risks oversimplifying the diagnostic process and failing to account for the nuances of individual cases. Simple diagnostic tools may lead to superficial assessments and potentially misguided treatment plans.
Diagnosis and labelling
Stigma can greatly exacerbate the experience of mental illness. Diagnostic classification, frequently used by clinical social workers, may intensify this stigma by enhancing the public’s sense of “groupness” and “differentness” when perceiving people with mental illness. The homogeneity assumed by stereotypes may lead mental health professionals and the public to view individuals in terms of their diagnostic labels. The stability of stereotypes may exacerbate notions that people with mental illness do not recover. Several strategies may diminish the unintended effects of diagnosis. Dimensional approaches to diagnosis may not augment stigma in the same manner as classification. Moreover, regular interaction with people with mental illness and focusing on recovery may diminish the stigmatizing effects of diagnosis.
One strategy to reduce stigma is to adopt a dimensional approach to diagnosis rather than a categorical one. Instead of classifying individuals into discrete categories, a dimensional approach assesses symptoms on a continuum. This method can help reduce the sense of groupness and the associated stigma by showing that mental illness exists on a spectrum and can affect anyone to varying degrees.
In mental health assessment, using a categorical approach could lead a professional to diagnose both Rajesh and Priya with Generalized Anxiety Disorder (GAD) based on specific criteria, despite their varying levels of anxiety severity and impact. This approach can perpetuate stereotypes and stigma by implying all GAD cases are identical. Conversely, a dimensional approach evaluates Rajesh's occasional, manageable anxiety differently from Priya's severe, debilitating anxiety, recognizing their unique experiences. Rather than applying a single label like GAD, this approach describes their anxiety levels individually, fostering personalized treatment plans, reducing stigma, and encouraging timely help-seeking. Similar to how hypertension is treated based on varying severity, this approach offers nuanced understanding and tailored support for mental health conditions.
Another effective way to reduce stigma is through personal contact. Interactions with individuals with mental illness can help dismantle stereotypes by highlighting the person’s individuality and unique experiences. For example, community programs that promote interactions between the public and individuals with mental illness can help reduce prejudice and discrimination.
Studies have also found that people are more likely to self-diagnose mental disorders if they have a broad understanding of mental health, feel distressed or impaired, know more about mental health, and don't feel stigmatized.
Self-fulfilling Prophecy effect
A self-fulfilling prophecy is a prediction that becomes true, at least in part, because a person believes or expects it to. This can happen when a person's unconscious expectations influence their actions, which in turn make the prediction come true. For example, in relationships, if someone believes that their partner is going to leave them soon, this belief might lead them to become more anxious, insecure, and perhaps even more clingy in the relationship. These behaviors can create tension and strain in the relationship, which might eventually lead their partner to feel suffocated or overwhelmed, potentially leading to a breakup. In this case, the initial belief that the partner would leave becomes partially true because the person's behavior inadvertently contributed to the outcome they feared. Thus, their belief influenced their actions, which ultimately played a role in the relationship ending.
During the Great Depression, rumors of bank insolvency spread rapidly among communities already facing economic hardship. As people became fearful of losing their savings, they rushed to withdraw their money from banks, fearing that the banks might collapse. This widespread panic resulted in actual bank insolvencies, as the banks were unable to meet the demand for withdrawals, further validating the initial fears and reinforcing the belief that the banks were indeed failing. This cycle of rumor, panic, and actual collapse exemplifies a self-fulfilling prophecy: the belief that banks were insolvent led to behaviors that caused them to become insolvent.
In the study on adolescent substance use prevention, researchers found that parents' perceptions about the value of their involvement in prevention programs significantly influenced their adolescents' alcohol use outcomes. Specifically, families who believed strongly in the importance of parental involvement in the prevention programs saw greater benefits for their adolescents in terms of reduced alcohol use. This effect persisted for up to a year after the completion of the programs.
In this case, parents who perceived their involvement in the prevention programs as valuable tended to engage more actively and positively in the program. Their active participation likely enhanced the effectiveness of the program in influencing their adolescents' attitudes and behaviors towards alcohol use. Consequently, the adolescents showed reduced alcohol use, thereby confirming the initial belief of the parents that their involvement would have a positive impact.
In another study exploring self-fulfilling prophecy effects within parent-child relationships, researchers found evidence of such dynamics specifically in mother-child dyads concerning hostility. Children's perceptions of their mothers' typical hostility predicted their own hostile behavior during interactions, which then predicted increased hostility from mothers in response. This sequence suggested a self-reinforcing cycle where children's expectations influenced their behavior, which in turn shaped maternal responses. While mothers' perceptions did correlate with children's hostility, this link was due to mothers' accuracy rather than a self-fulfilling prophecy. Interestingly, the study did not find reciprocal effects from mothers to children, contrary to expectations based on power dynamics in relationships. This highlights the complexity of self-fulfilling prophecy dynamics within family contexts, emphasizing the need for bilateral frameworks to fully understand interpersonal influences. Further research is needed to explore how such dynamics vary over time and in response to interventions aimed at improving parent-child relationships, offering insights into family relationship dynamics beyond traditional social influence models.
In clinical settings, the phenomenon of self-fulfilling prophecy significantly influences the diagnostic process, potentially resulting in misdiagnosis and subsequent therapeutic missteps. Early in their interactions with clients, clinicians often form initial diagnostic hypotheses, sometimes within the first moments of assessment. These initial impressions are shaped by a variety of factors including the clinician's therapeutic background, previous encounters with similar cases, and inherent biases (Gauron & Dickinson, 1969).
Once a tentative diagnosis is made, clinicians may unwittingly engage in confirmation bias during information gathering. This bias manifests as a tendency to seek out information that supports the initial hypothesis while potentially overlooking or downplaying contradictory evidence (Snyder & Swann, 1978; Snyder & Thomsen, 1988). For example, a clinician subscribing to a psychodynamic approach might focus extensively on exploring a client's childhood experiences to reinforce their belief that present symptoms stem from unresolved parental conflicts.
The chosen diagnosis significantly shapes subsequent treatment decisions, influencing the therapeutic approach adopted. Different therapeutic orientations, such as psychopharmacological versus psychodynamic approaches, lead to distinct treatment strategies that in turn influence how clients respond and behave in therapy (Snyder & Thomsen, 1988). For instance, a client hastily diagnosed with schizophrenia based on initial impressions might be prescribed antipsychotic medications, potentially reinforcing the perception of their condition despite the complexity of their symptoms.
An illustrative case from Dahlstrom (1993) underscores the risks of premature and biased diagnoses becoming self-fulfilling prophecies. In this instance, a young woman named Mary was initially diagnosed with schizophrenia and mental retardation without comprehensive testing. This diagnosis led to a restricted and pessimistic treatment plan until a different approach, incorporating objective psychological tests, revealed her actual cognitive abilities, contradicting the initial diagnosis.
Rosenhan's (1973) famous study further exemplifies how diagnostic labels can perpetuate misinterpretations in psychiatric assessments. Normal behaviors exhibited by pseudo-patients in mental hospitals were erroneously attributed to schizophrenia solely based on their diagnostic label. Despite these individuals demonstrating no abnormal symptoms thereafter, their initial diagnosis persisted, highlighting how diagnostic labels can influence subsequent observations and interactions to reinforce rather than challenge initial assumptions.
A self-fulfilling prophecy also profoundly impacts a client's decision-making and self-diagnosis process through various psychological mechanisms. At its core, a self-fulfilling prophecy starts with a client holding a belief about themselves, their capabilities, or their health. This belief shapes how they perceive their experiences and interpret ambiguous signals from their body or environment. For instance, if someone believes they are prone to frequent health issues, they might interpret minor symptoms, like fatigue or headaches, as signs of a serious illness, reinforcing their initial belief.
This perception then influences their behavior. Clients often unconsciously act in ways that align with their beliefs. For example, if someone believes they are socially awkward, they might avoid social interactions or behave nervously in social situations, thereby confirming their belief through their actions. In the context of health, if a client self-diagnosis with a specific condition, they may start exhibiting behaviors associated with that condition, such as avoiding certain activities or seeking out treatments, potentially without professional guidance.
Furthermore, the impact of self-fulfilling prophecies extends to how clients seek help and engage with healthcare providers. If a client firmly believes they have a particular health issue, they may actively seek out medical advice, sometimes insisting on specific tests or treatments based on their self-diagnosis. This can influence their interactions with healthcare professionals, affecting the diagnosis and treatment process.
Emotionally, believing in a self-fulfilling prophecy can be distressing. Negative beliefs about oneself or health can lead to anxiety, depression, or low self-esteem. For instance, someone who believes they are incompetent may feel constant stress or anxiety in situations where they perceive their abilities are tested, further reinforcing their belief in their own inadequacy.
Cognitively, self-fulfilling prophecies can create biases where clients selectively attend to information that confirms their beliefs while disregarding contradictory evidence. This selective perception can hinder their ability to objectively evaluate their situation and consider alternative perspectives or diagnoses.
Diagnosis and Mental health
Humans are complex beings, and understanding them goes far beyond mere diagnosis. Therapists must embrace a holistic view that considers the intricate interplay of biological, psychological, and social factors shaping each individual's mental health journey. This perspective recognizes that mental disorders emerge from dynamic interactions across multiple levels of analysis, as highlighted by recent research integrating complexity science into psychiatric practice.
For instance, studies by McLaughlin and colleagues emphasize how childhood trauma can influence various mediators like accelerated biological aging and altered emotional processing, leading to diverse forms of psychopathology. Similarly, the biopsychosocial nature of resilience have been underscored, illustrating how genetic, endocrinological, social, and psychological factors collectively determine responses to childhood adversity. These insights challenge traditional diagnostic approaches by suggesting that mental health states are not fixed categories but rather evolving states within complex systems.
Moreover, the network analysis conducted by Fritz revealed that resilience factors in adolescents are intricately interconnected, and disruptions in these connections following adversity can affect mental health outcomes. This underscores the importance of interventions targeting these resilience networks early in life to prevent the onset of psychopathology. Franklin's work on psychological primitives further deepens this understanding, proposing that psychological phenomena like suicidal thoughts emerge from fundamental building blocks of experience, demanding interventions that address these foundational components.
In psychotherapy, Burger et al. and Hayes and Andrews advocate for a systems approach that integrates computational models to enhance case conceptualization and treatment planning. This approach recognizes therapy as a process of navigating complex systems within individuals, aiming not just for symptom reduction but for holistic well-being and adaptive functioning.
Conclusion
In conclusion, while diagnosis plays a crucial role in mental health treatment by providing a framework for understanding and addressing symptoms, it is essential for therapists to recognize its limitations and complexities. The process of diagnosis, grounded in scientific rigor and guided by classification systems like the DSM and ICD, helps clinicians categorize and treat mental health disorders effectively. However, this approach must be complemented by a nuanced understanding of each client's unique circumstances and experiences.
Therapists must navigate beyond diagnostic labels to embrace the complexity of their clients' lives, considering biological, psychological, social, and cultural factors that shape their mental health. This holistic approach not only enhances therapeutic effectiveness but also mitigates the potential stigma and self-fulfilling prophecies that diagnostic labels can inadvertently perpetuate. By understanding clients' personal histories, interpersonal dynamics, and resilience factors, therapists can tailor interventions that promote resilience, facilitate growth, and support recovery.
Moving forward, mental health professionals should advocate for a balanced approach that integrates diagnostic precision with empathy and flexibility. This approach not only respects the individuality of each client but also fosters a therapeutic alliance built on trust, collaboration, and mutual understanding. By embracing client complexity in therapy, practitioners can empower clients to navigate their mental health journeys with resilience and authenticity, transcending diagnostic confines to achieve holistic well-being and adaptive flourishing.
Shreya Naresh is part of the Global Internship Research Program (GIRP) under IJNGP.
TAGS CLIENT FOCUSED THERAPY | LABELLING | DIAGNOSIS
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