Some Concerns Regarding Diagnosis

The mental health professions are currently awaiting the American Psychiatric Association’s newest version of the Diagnostic and Statistical Manual. The need for a fifth revision underscores the lack of satisfaction within the professions with our diagnostic schema. In this article we address several issues that have troubled us in the past versions and seem likely to do so in the forthcoming edition.

In modern medicine, there has been what is labeled as the laboratory revolution.¹ This stresses that verifiable biologic and chemical finds in the laboratory contribute greatly to diagnosis and treatment. However, it is abundantly clear that no such markers exist in the sphere of emotional disorders.^2,3

Lacking such markers, past diagnostic manuals have consisted of lists of symptoms grouped into syndromes with the groupings done by committees that were far from unanimous. In past editions, diagnoses have been shifted from one axis to another and definitions have changed. Therefore, there is good reason to question the validity and reliability of the resultant coding.

Specific diagnostic codes imply that these are discrete and separate entities. In practice, the boundaries are fuzzy and allow for much overlap and results in the listing of comorbid conditions. In physical medicine, comorbidity refers to conditions (diseases) existing at the same time but that are independent of the primary diagnosis.

Consider a patient presenting with strong compulsive behaviors who periodically experiences marked anxiety and bouts of depression. Most clinicians, even of differing theoretical orientation, would consider these to be intimately related. In the mental health field, comorbidity does not mean discrete separate issues but is a way of including mention of related aspects of the patient’s distress. Some view comorbidity as an artifact of the diagnostic system.⁴

A third troubling issue is what we describe as fluidity. People change over time in their modes of adaptation. A diagnosis is akin to a photograph. It may be accurate but it is also static. The very next frame would show a somewhat different picture. It is not uncommon to consult with a patient who has seen other therapists. The patient may currently show all the requirements for a diagnosis of depression. A report from the first practitioner offered the diagnosis of generalized anxiety disorder.

It is not usually a matter of one professional or another being right or wrong. Possibly both correctly categorized the patient as he/she was at that time. Presenting symptoms often change over time as part of the patient’s continuing efforts at adaptation and defense.

Concerns about the variability (weak reliability) and essential validity have inclined some to favor abandoning the concept of diagnosis. But, to be replaced with what? It is on this issue that the current authors differ. One of us (J.F.) believes that even with these constraints, diagnoses have utility. They enable practitioners to communicate some shared ideas about patients. They are used in research and in relation to insurers and governmental agencies. The task is to refine our schemes.

While a complete explication of the etiology of emotional disorders seems quite distant, it remains a worthy goal. As the professions make progress toward understanding the genetic predispositions and the impact of psychological trauma at various developmental stages, it might be possible to conceive of a more tailored therapy for these disorders. One such effort is the Psychodynamic Diagnostic Manual.⁵ Similar efforts from other viewpoints⁶ might provide commonalities upon which to build a richer diagnostic approach.

The other of us (R.E.K.) feels that while diagnoses have utility, there will probably never be clear “markers” as found in general medicine and that the idea of “chemical imbalances” or “neurotransmitter problems” is highly speculative.^7,8 The mental health field establishes so-called diseases out of patient behavior and reports; both are prone to conscious and unconscious distortions. Thus, it would be better to give up on establishing etiology and deal with what the patient presents.

We reunite on the important notion that the combination of psychotherapy, carefully used medication, and environmental manipulation stands a very good chance of helping people (not disease entities) lead more satisfying and effective lives.

References:

References1. Cunningham A, Williams P (Eds). The Laboratory Revolution in Medicine. Cambridge: Cambridge University Press; 1992.
2. Kendall R, Jablensky A. distinguishing between the validity and utility of psychiatric diagnosis. Am J Psychiatry 2003;160:4-12.
3. Sobo S. A Reevaluation of the Relationship Between Psychiatric Diagnoses and Chemical Imbalance. 1999 Grand Rounds of University of Alabama Medical School.
4. Maj M. Psychiatric comorbidity: an artifact of current diagnostic systems. Br J Psychiatry. 2005;186:182-184.
5. Greenspan SI (Chair). Psychodynamic Diagnostic Manual. Silver Springs, Md; Alliance of Psychoanalytic Organizations: 2006.
6. Oken D. Multiaxial diagnosis in the psychosomatic model of disease. Psychosom Med. 2000;62:171-175.
7. Kirsch I. The Emperor’s New Drugs: Exploding the Anti-Depressant Myth. Philadelphia: Basic Books; 2010.
8. Angell M. The Truth About the Drug Companies: How They Deceive Us and What To Do About It. New York: Random House; 2004.