As you can see from the previous post, it is dangerous business to highlight one symptom as reason for a diagnosis. It unfortunately is easy for otherwise well-meaning clinicians to latch onto a diagnostic buzz word and quickly transition to whatever diagnosis they are familiar with that harbors it as a key feature. With that mindset, hallucinations mean Schizophrenia, social awkwardness means Autism Spectrum, obsession means OCD, and the list goes on. This isn’t entirely their fault- supervision deficits and the fact that there is little preparatory training in diagnosis other than a survey of the DSM in most programs, are set-ups for such diagnostic habits. The good news is, despite these hurdles, I’ve found most new clinicians are interested in honing diagnostic skills because it indeed leads to better treatment outcomes and boosts confidence.
Seeking sound supervision and attending trainings on diagnoses will of course help you hone skills. As far as remembering not to diagnose based on one symptom, while the edicts of psychiatry past are often forgotten, we can still take a cue from Emil Kraepelin, the father of modern psychiatric disease classification. Kraepelin who told us, “A single symptom, however characteristic is may be, never justifies a diagnosis by itself…” (Spitzer et al., 2002, page 487) and that the whole picture must be considered.
In the meantime, it is OK if you’re not 100% sure of a diagnosis, and even seasoned clinicians often take time to know for sure. In fact, some researchers on diagnostic accuracy have recently shown that the most-sound diagnostic outcomes are associated with practitioners who take their time (Bruchbiel, et al., 2019). If a diagnosis is yet unclear but one must be applied, such as for billing purposes, the DSM 5 gives us the “Unspecified” and “Other” categories (formerly collectively referred to as “Not Otherwise Specified” [NOS] in previous DSM editions) to hold us over. For now, The New Therapist readers may want to just familiarize themselves with those categories. These are found at the end of each diagnostic chapter of the DSM 5, and we’ll further address their application in a future post.
Even if we’re not entirely sure of the diagnosis, treatment can begin in the form of establishing therapeutic alliance, implementing stress management and exploring strengths-based interventions such as cultivating things the client has found helpful in managing. Keep in mind, however, that despite seeing some gains in treatment without fully knowing the diagnostic picture, this does not mean we can forget about accuracy. Revisiting the “Bipolar” patient in the previous post, perhaps their moods briefly stabilize with a new stress management skill we show them. However, we’d be remiss in simply trying to introduce a revolving door of new coping mechanisms whenever they discuss their moods getting in the way. We need to be vigilant to the pattern, which sheds light on the diagnosis, and ultimately the more sustaining work of managing the fears of abandonment driving the pathology. Otherwise, we maintain a game of clinical “whack a mole” and the patient never reaches any sustained stabilization.
Next week, we’ll review another often-overlooked source of symptoms important to the diagnostic process: medical mimicry.
Bruchbeil, J.K., & Keely, J.W. (2019). Pathways linking clinician demographics to mental health diagnostic accuracy: An international perspective. Journal of Clinical Psychology, 75 (9) 1715-1729.
Spitzer, R. L., Gibbon, M., Skodol, A. E., Williams, J. B. W., & First, M. B. (Eds.). (2002). DSM-IV-TR casebook: A learning companion to the diagnostic and statistical manual of mental disorders (4th ed., text rev.). American Psychiatric Publishing, Inc.