Edgar Allan Poe suggested that we should believe none of what we hear and only half of what we see. While it is wise to not be gullible or naive, his suggestion seems a little extreme. Perhaps “Believe half of what you hear and most of what you see” is more, well, believable. Afterall, 27. 14% of all facts are made up on the spot (I think), and, especially if you have a forensic background, you know that some of what we witness can be feigned. Such informed skepticism serves us well in our diagnostic evaluations, but is not always heeded, especially at the outset. As a starting practitioner, I recall reflexively concurring with others’ assessments simply because they were more seasoned or well-respected, so figured they must know better.
A graduate school professor once mentioned that when we inherit a patient with a diagnosis, we should see if there is evidence against it rather than acquiesce. In other words, investigate its accuracy. This didn’t resonate much with me then, but as I practiced and became acutely aware of misdiagnosis being blindly passed along, it became an integral part of my process. This is especially true when I see “popular” diagnoses like Bipolar Disorder, Autism, and ADHD that, according to diagnostic experts like Allan Frances, are likely to be more liberally applied merely given their attention. It is also my experience that these diagnoses tend to be made popular in the media. Media frequently misrepresents diagnoses, such as making Bipolar Disorder out of a single symptom like mood instability, that uninformed or new practitioners may rely on. Remember, most professionals starting out have had a mere semester of psychopathology and are not yet honed, so may simply use what they know, however they know it.
Gaining experience, I remember beginning to question what I was seeing, versus the history I was supplied. For example, Schizoaffective Disorder had a moment in the sun as an en vogue diagnosis where I worked. It seemed that any patient mentioning mood and psychotic symptoms received the diagnosis. From what I recalled of psychopathology class, this was a rather rare condition. How were all the cases ending up in my neck of the woods!? Not only was it a rare condition, but I knew it caused significant, usually chronic, impairment. How were people who had been out of treatment for the past year and living on the street not showing any prominent symptoms? My then-supervisor, a highly analytical practitioner, noted my increasing curiosity about some of our patients’ diagnoses. He then let me in on a secret: it’s no secret many patients are ascribed a convenient, arbitrary diagnosis. In the case of Schizoaffective Disorder, it was simply an easy way for an evaluator to account for mood and psychotic symptoms.
I’ve also learned over the years it’s no secret a lot of professionals feel accurate diagnosis isn’t all its chalked up to be because, “we treat symptoms and not disorders.” This ideology has always been a point of contention for me. As noted in a previous post, many diagnoses share symptoms, but that doesn’t mean they’re treated similarly. Diagnosis allows us to conceptualize the nature of the symptoms and thus understand their etiology, function, and prognosis, guiding proper treatment. Treating Schizoaffective Disorder is not the same as treating, say, Major Depression with Psychotic Features. The former relies heavily on pharmacology, stress management and improving social skills, similar to working with Schizophrenia. The latter, while the person may be very impaired during the psychotic depressive spell, once stabilized, can manage beautifully with talk therapy and antidepressants. If the depression is kept at bay, such patients often do not require continued use of antipsychotic medication with their potential significant side effects. Clearly, there are serious implications to accurate diagnosis.
While it is nice to honor the opinions of our peers enough to accept, at face value, what diagnosis they may have assigned to a patient we’ve inherited, it is nonetheless irresponsible to skip your own thorough diagnostic evaluation. On the surface, it could seem that they’ve eased your work burden, taking the diagnostic piece out of the equation so you can hop right to helping. But is it really helpful if we pick up where they left off and potentially continue “treating” a misdiagnosis? Treating someone for a diagnosis they don’t have is as bad as not treating them for one they do.
The propensity for some to adopt this practice, and it’s fallout, has never been driven home to me harder than during a forensic evaluation I once performed. In the upcoming post we’ll explore the case and review what you can do to not fall into the habit of taking a patient’s historical diagnosis at face value.
Frances, Allan (2013). Saving normal: an insider’s revolt against out-of-control psychiatric diagnosis, dsm-5, big pharma, and the medicalization of ordinary life. Harper Collins.