Crappy diagnostics (and masters-level therapists?)

[futureapppsy2]

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My clinical work largely focused on diagnostic assessment so maybe I’m hypersensitive to this, but it’s so frustrating to see so much just unbelievably bad diagnosis, and it seems even more common (although not exclusive) among masters-level providers, IME (and, to a somewhat lesser extent, among PCP physicians). I'm not talking about cases that are really complicated or are iffy on meeting criteria, but incredibly textbook cases being missed (or obviously wrong diagnoses being given) and patients not getting appropriate treatment as a result. The baffling thing is that patients seem okay with it (“You can’t really expect a therapist to diagnose well”) or
express that it was their fault for not doing the entire diagnostic assessment themselves, when that’s not their job. It’s so frustrating to me and makes me think more and more that psychologists should maybe directly supervise masters-level clinicians.

 

[ClinicalABA]

My clinical work largely focused on diagnostic assessment so maybe I’m hypersensitive to this, but it’s so frustrating to see so much just unbelievably bad diagnosis, and it seems even more common (although not exclusive) among masters-level providers, IME (and, to a somewhat lesser extent, among PCP physicians). I'm not talking about cases that are really complicated or are iffy on meeting criteria, but incredibly textbook cases being missed (or obviously wrong diagnoses being given) and patients not getting appropriate treatment as a result. The baffling thing is that patients seem okay with it (“You can’t really expect a therapist to diagnose well”) or
express that it was their fault for not doing the entire diagnostic assessment themselves, when that’s not their job. It’s so frustrating to me and makes me think more and more that psychologists should maybe directly supervise masters-level clinicians.

I used to teach the adult psychopathology course in an LMHC masters program. One semester, and cover all major categories in DSM (IV at the time). It was their only course in DSM diagnoses, and it was taught by ME! That's scary!

 

[MAClinician]

My clinical work largely focused on diagnostic assessment so maybe I’m hypersensitive to this, but it’s so frustrating to see so much just unbelievably bad diagnosis, and it seems even more common (although not exclusive) among masters-level providers, IME (and, to a somewhat lesser extent, among PCP physicians). I'm not talking about cases that are really complicated or are iffy on meeting criteria, but incredibly textbook cases being missed (or obviously wrong diagnoses being given) and patients not getting appropriate treatment as a result. The baffling thing is that patients seem okay with it (“You can’t really expect a therapist to diagnose well”) or
express that it was their fault for not doing the entire diagnostic assessment themselves, when that’s not their job. It’s so frustrating to me and makes me think more and more that psychologists should maybe directly supervise masters-level clinicians.

Can’t leave us hanging without examples!

 

[Fan_of_Meehl]

My clinical work largely focused on diagnostic assessment so maybe I’m hypersensitive to this, but it’s so frustrating to see so much just unbelievably bad diagnosis, and it seems even more common (although not exclusive) among masters-level providers, IME (and, to a somewhat lesser extent, among PCP physicians). I'm not talking about cases that are really complicated or are iffy on meeting criteria, but incredibly textbook cases being missed (or obviously wrong diagnoses being given) and patients not getting appropriate treatment as a result. The baffling thing is that patients seem okay with it (“You can’t really expect a therapist to diagnose well”) or
express that it was their fault for not doing the entire diagnostic assessment themselves, when that’s not their job. It’s so frustrating to me and makes me think more and more that psychologists should maybe directly supervise masters-level clinicians.

Primary care is pretty bad. 'What's the problem?' Insomnia?---> diagnose PTSD. Anger/irritability?---> diagnose PTSD. Drinking a half-gallon of whiskey at night, have uncontrolled sleep apnea, just lost your job, got divorced, lost custody of your kids, living in the alleyway and having problems concentrating? --- {you guessed it} > PTSD.

Then they send them to the psychologist who actually has to be the first provider to ask about military history, trauma history, psychiatric history, etc. etc. and inform them (often)...sorry, no PTSD.

 

[Therapist4Chnge]

My clinical work largely focused on diagnostic assessment so maybe I’m hypersensitive to this, but it’s so frustrating to see so much just unbelievably bad diagnosis, and it seems even more common (although not exclusive) among masters-level providers, IME (and, to a somewhat lesser extent, among PCP physicians). I'm not talking about cases that are really complicated or are iffy on meeting criteria, but incredibly textbook cases being missed (or obviously wrong diagnoses being given) and patients not getting appropriate treatment as a result. The baffling thing is that patients seem okay with it (“You can’t really expect a therapist to diagnose well”) or express that it was their fault for not doing the entire diagnostic assessment themselves, when that’s not their job. It’s so frustrating to me and makes me think more and more that psychologists should maybe directly supervise masters-level clinicians.

SO. MUCH. THIS.

I am nit-picky about diagnostic assessment and as a result have carved out a niche for doing differential diagnosis, which led to some nice IME work. It's amazing how many times I see PTSD, bipolar, mild cognitive impairment, and a few others that are SO OVERLY DIAGNOSED without a clear rationale or proof of presentation.

 

[cara susanna]

Or you could be my clinic and refer EVERYONE to psychologists for diagnostic testing. There has to be some happy medium.

 

[futureapppsy2]

Or you could be my clinic and refer EVERYONE to psychologists for diagnostic testing. There has to be some happy medium.

That's why I think supervision of masters-level therapists might be a happy medium (also, ugh at people thinking testing is needed for every psychological diagnostic question).

 

[psych.meout]

Or you could be my clinic and refer EVERYONE to psychologists for diagnostic testing. There has to be some happy medium.

That's why I think supervision of masters-level therapists might be a happy medium (also, ugh at people thinking testing is needed for every psychological diagnostic question).

This is such a big one. A friend from another program told me that their program often sends practicum students to this private practice where they do extensive testing for what seems to be virtually every patient. The clinic apparently did a full WAIS for a patient "just to be sure that there weren't any cognitive problems that could get in the way of therapy," not because it was for any specific purpose or concern.

 

[chicandtoughness]

Masters level clinician here. It is scary how little training we get on diagnosis (and indeed, the prevailing idea in masters programs nowadays is that diagnosis is demeaning/detrimental and we shouldn't do it because it ruins "holistic" treatment, whatever that means /eyeroll). We get one class in psychopathology that is more like, "Let's read over the diagnostic criteria together and discuss!" instead of "let's actually practice differential diagnosis". In my practicum (in house counseling center) I watched my colleagues diagnose ALL sorts of disorders after only having met their patients once or twice. (Meanwhile I stuck to my go-to, F43.23 with a nice helping of r/o's hahaha). In internship, unless you were working in a busy af community clinic where they treated you as free independent labor, you most likely weren't practicing assessment and diagnosis either. (Actually, in my internship I didn't diagnose a single person 😀) If it weren't for me specifically going out of my way to seek out jobs and trainings, I would have started my first post-grad job with next to no training at all.

I'm all for doctoral level practitioners (psychiatrists, psychologists) supervising the masters folks for their provisional/associate/prelicensure years. Beyond that, I think it would depend on the level of care/facility/population whether further supervision is needed.

So yeah. We're wildly unprepared, and it is so damaging. I work in eating disorders and substance use. Ooooof the number of colleagues who can't diagnose eating disorders properly when that is THE ONLY THING THEY'RE DIAGNOSING.

 

[conky124]

Yeah people who aren't us suck at diagnosis! Jk you kinda right...

 

[Sanman]

This is what happens when payment is in no way attached to quality of work and, in fact, discouraged in complex cases due to paperwork and limited reimbursement for diagnostic work.

One of the major reasons I quit my old job was my boss hiring cheaper and cheaper labor and sending me to "fix" them later. No thanks.

 

[BuckeyeLove]

bipolar

This is the one out of all of them that I will never understand. Maybe because I see it every. single. day. and that's why I get so frustrated when I read evaluations and people conflate "anger/frustration/aggression" with a manic episode. If you can't spot mania and differentiate, get out off the field. You don't deserve to play.

 

[Fan_of_Meehl]

This is the one out of all of them that I will never understand. Maybe because I see it every. single. day. and that's why I get so frustrated when I read evaluations and people conflate "anger/frustration/aggress" with a manic episode. If you can't spot mania and differentiate, get out off the field. You don't deserve to play.

Agreed. And it's relatively straightforward to rule in/out if the person has ever experienced a true manic or hypomanic (or mixed) episode...there are symptoms that are pathognomonic (e.g., reduced NEED for sleep, hypersexuality, grandiosity, increased drive) for mania occurring over days/weeks at a time and indicative of a clear and distinct change over baseline mood/functioning. With focused interviewing, this could be accomplished easily in 15-30 mins (esp. if these pathognomonic sxs are denied).

I've seen cases of patients carrying a 'rule-out biplolar d/o' dx in their chart through multiple inpatient stays and even 2-3 month long residential program stays. The fact that not ONE clinician during all that time bothered to rule in/out hx of mania (with MAJOR treatment implications) is ridiculous.

 

[Indiana_Jane]

This is the one out of all of them that I will never understand. Maybe because I see it every. single. day. and that's why I get so frustrated when I read evaluations and people conflate "anger/frustration/aggression" with a manic episode. If you can't spot mania and differentiate, get out off the field. You don't deserve to play.

I agree. Applying for internship this year and still a student, but I feel like I spend more time reversing diagnoses from previous providers than I thought I would. Worked inpatient before grad school and had an inkling then but whew... if I had a dime for every time I had to explain why Bipolar doesn’t fit...

 

[borne_before]

On the child side: autism. Teenage girl spends two hours doing make up for youtube -->autism. Child with "sensory" and parents who let the kid run feral issues --> autism. Kid with severe ID who stims and is nonverbal ---> autism.

 

[futureapppsy2]

On the child side: autism. Teenage girl spends two hours doing make up for youtube -->autism. Child with "sensory" and parents who let the kid run feral issues --> autism. Kid with severe ID who stims and is nonverbal ---> autism.

Also, “kid is shy—> autism”, “parents asked me if the kid might have autism with no other information given—> autism”, “adult self-diagnosed themselves with autism after reading tumblr post or watching YouTube video—> autism”

 

[borne_before]

Also, “kid is shy—> autism”, “parents asked me if the kid might have autism with no other information given—> autism”, “adult self-diagnosed themselves with autism after reading tumblr post or watching YouTube video—> autism”

I remember seeing a (serious) meme on tumblr claiming that self-diagnosis was valid because not everyone had the privilege accessing psych testing. If you want to rage, check this out:

 

[Mindfulpsych22]

Clinicians are also terrible about remembering to rule out whether symptoms are not due to a medical condition, substance use, or medication changes.

I’ve had multiple patients who have been diagnosed with fairly serious conditions with major tx implications (bipolar, psychotic disorders, panic disorder) only to learn that they had no history of these symptoms prior to starting a medication and the onset of sxs coincided perfectly with starting the medication. No one had bothered to even consult with the psychiatrist and report this information. Low and behold once they discontinue the medication, these symptoms disappear. It also amazing how many symptoms of “bipolar” disappear when someone is no longer actively abusing substances🙄

 

[R. Matey]

This is what happens when payment is in no way attached to quality of work and, in fact, discouraged in complex cases due to paperwork and limited reimbursement for diagnostic work.

One of the major reasons I quit my old job was my boss hiring cheaper and cheaper labor and sending me to "fix" them later. No thanks.

This.

I've worked with many master's level providers as a master's level provider and very much agree that the training is completely inadequate for the tasks required of them. I remember a social worker telling me that they didn't have a single class in diagnosis and now were expected to diagnose and, us, LPCs usually only had one class. I also want to point out, like @Sanman is saying, that this problem is in equal parts the settings master's level clinicians find themselves in. Many centers do not allow sufficient time for a full diagnostic interview and actively discourage diagnostic complexity through passive-aggressive means such as overloading clinician caseloads, limiting time for diagnosis, and fear-based paperwork policies. Other places (*looks at university counseling centers) have a pretty "devil may care" attitude towards diagnosis. It's fine for the center because they aren't billing insurance, but what happens when an outside provider requests those records? So it's poor diagnostic training in setting that do not incentivize good diagnostic practice. Supervision would help, but system change is also very necessary.

 

[sloh]

Clinicians are also terrible about remembering to rule out whether symptoms are not due to a medical condition, substance use, or medication changes.

I’ve had multiple patients who have been diagnosed with fairly serious conditions with major tx implications (bipolar, psychotic disorders, panic disorder) only to learn that they had no history of these symptoms prior to starting a medication and the onset of sxs coincided perfectly with starting the medication. No one had bothered to even consult with the psychiatrist and report this information. Low and behold once they discontinue the medication, these symptoms disappear. It also amazing how many symptoms of “bipolar” disappear when someone is no longer actively abusing substances🙄

Patient on gabapentin —> Dementia

 

[PsyDr]

This is the one out of all of them that I will never understand. Maybe because I see it every. single. day. and that's why I get so frustrated when I read evaluations and people conflate "anger/frustration/aggression" with a manic episode. If you can't spot mania and differentiate, get out off the field. You don't deserve to play.

Some of this was from that study in the late 1990s, where a pediatric psychiatrist wrote a paper in a major journal , which said that mania in children presented as irritability, and not grandiosity/euphoria. Suddenly, the reverse was true: angry kid=bipolar kid. Being able to give a psychiatric diagnosis that insurance would pay for, opened the door to hospitalizing kids with physical aggression. And then you could use sedating medications when some pissed off kid is raising hell.

Then some people saw that mood stabilizers kinda worked in personality disorders with an affective instability component. Because what are you gonna do when you when you got someone in your office who is labile but not manic and really all you do is prescribe stuff? But insurance is a tricky game, and they won't approve those meds for a personality disorder. So you dx bipolar, and get it done.

 

[Justanothergrad]

I've seen good MA level providers, and bad ones. I've seen the same thing true in doctoral level providers. The issue comes down to a focus on diagnostic practice during training, and sadly it tends to be more cursory than anything else. As a result, higher level conceptualizations about diagnoses are entirely missed and people don't understand presentation patterns. Sadly, some doctoral programs approach it the same way. Assessment just isn't 'fun' or 'cool' in modern practice, despite it leading directly to appropriate treatments and good clinical care decisions.... This is such a peeve of mine.

 

[cara susanna]

I get a lot of patients labelled as having borderline personality disorder and I refuse to believe they all have it. Some, yeah. But some I think just have PTSD.

Honestly, it feels like in the VA if you're a woman and have PTSD secondary to MST, you're probably going to get a BPD diagnosis at some point.

 

[Fan_of_Meehl]

Some of this was from that study in the late 1990s, where a pediatric psychiatrist wrote a paper in a major journal , which said that mania in children presented as irritability, and not grandiosity/euphoria. Suddenly, the reverse was true: angry kid=bipolar kid. Being able to give a psychiatric diagnosis that insurance would pay for, opened the door to hospitalizing kids with physical aggression. And then you could use sedating medications when some pissed off kid is raising hell.

Then some people saw that mood stabilizers kinda worked in personality disorders with an affective instability component. Because what are you gonna do when you when you got someone in your office who is labile but not manic and really all you do is prescribe stuff? But insurance is a tricky game, and they won't approve those meds for a personality disorder. So you dx bipolar, and get it done.

I think that a little training in the philosophy of science (or just logical fallacies) would go a long way.

The 'irritability/aggression' = mania is a perfect example of the fallacy of affirming the consequent (If A, then B; B, therefore A).

Just because manic people often display irritability/aggression, it does not follow that someone displaying irritability/aggression is necessarily manic. Obviously, there are many other alternative causes/explanations for irritable/aggressive behavior.

Edit: and base rates are important (though often ignored)

 

[R. Matey]

I've seen good MA level providers, and bad ones. I've seen the same thing true in doctoral level providers. The issue comes down to a focus on diagnostic practice during training, and sadly it tends to be more cursory than anything else. As a result, higher level conceptualizations about diagnoses are entirely missed and people don't understand presentation patterns. Sadly, some doctoral programs approach it the same way. Assessment just isn't 'fun' or 'cool' in modern practice, despite it leading directly to appropriate treatments and good clinical care decisions.... This is such a peeve of mine.

I'm glad you brought that up. I've seen the same thing with some of my peers in graduate school and on internship who "refuse to diagnose" due to their personal issues with the DSM. Granted, I have my own issues with categorical thinking, but will do my due diligence until another system supplants it.

 

[futureapppsy2]

I've seen good MA level providers, and bad ones. I've seen the same thing true in doctoral level providers. The issue comes down to a focus on diagnostic practice during training, and sadly it tends to be more cursory than anything else. As a result, higher level conceptualizations about diagnoses are entirely missed and people don't understand presentation patterns. Sadly, some doctoral programs approach it the same way. Assessment just isn't 'fun' or 'cool' in modern practice, despite it leading directly to appropriate treatments and good clinical care decisions.... This is such a peeve of mine.

I agree that there’s a lot of variability under each curve, but I think the lack of training on diagnosis and assessment in masters-level programs makes it harder for them to “beat the odds,” and develop competency in diagnosis, though some do.

 

[cara susanna]

I think that time is another issue. Like I've said in other threads, a lot of the diagnostic clarification testing referrals I get could be answered just by a good, thorough chart review. The thing is, I'm actually given enough time to do chart review in my testing clinic, whereas other providers aren't.

Ditto ADHD testing referrals.

 

[BuckeyeLove]

I've seen the same thing with some of my peers in graduate school and on internship who "refuse to diagnose" due to their personal issues with the DSM.

I may be projecting, but I've always felt that this line of thinking is just such pure vanity/narcissism in students/trainees/docs. Had quite a few that fell into this boat that I went to school with in my cohort.

 

[WisNeuro]

I may be projecting, but I've always felt that this line of thinking is just such pure vanity/narcissism in students/trainees/docs. Had quite a few that fell into this boat that I went to school with in my cohort.

I do recall one class in graduate school where a classmate vehemently argued against the alcohol abuse diagnostic criteria, mainly because he met a good deal of them and did not think he had a problem...

 

[jdawg2017]

Along with psychological assessment, even as an advanced PhD student now I am baffled at how neuropsychological assessment get jumbled, too. I cannot count the number of patients I have seen who got a diagnosis of minor or major NCD due to AD based off of a MOCA alone, plus maybe a few memory questions (usually coming to our clinic from neurology or outside PCP). Or there are "providers" who use neuropsychological tests without proper training (violating ethical codes) and clearly do not know how to interpret results, resulting in some astonishing diagnoses.

Maybe it's my training, but especially with mild/major NCD I am extremely cautious and double check how the clinical criteria I mention for the etiology align with the presenting problem. Iatrogenic effects are some real ****.

 

[WisNeuro]

diagnosis of minor or major NCD due to AD based off of a MOCA alone,

We call this the "OT method" of assessing cognition.

 

[deleted343839]

Maybe it's my training, but especially with mild/major NCD I am extremely cautious and double check how the clinical criteria I mention for the etiology align with the presenting problem. Iatrogenic effects are some real ****.

Agree. And in a system where a diagnosis is easy to just cut and paste, indefinitely, until someone stops to ask questions, it can have real consequences.

I was evaluating a surgical candidate who had a diagnosis of schizophrenia in their record. I'm no expert on psychosis but I found nothing remotely suggestive of that diagnosis in the patient's history or behavior. I referred the patient to a psychiatrist for a second opinion since the person was "supposed to be" on antipsychotics and I wanted to cover all bases. The psychiatrist's diagnosis was... no diagnosis. No need for those meds after all.

 

[WisNeuro]

Agree. And in a system where a diagnosis is easy to just cut and paste, indefinitely, until someone stops to ask questions, it can have real consequences.

I was evaluating a surgical candidate who had a diagnosis of schizophrenia in their record. I'm no expert on psychosis but I found nothing remotely suggestive of that diagnosis in the patient's history or behavior. I referred the patient to a psychiatrist for a second opinion since the person was "supposed to be" on antipsychotics and I wanted to cover all bases. The psychiatrist's diagnosis was... no diagnosis. No need for those meds after all.

I've seen diagnoses of Bipolar based purely on irritability and patient saying that they "don't sleep at all." 1 or 2 simple follow up questions clears up this diagnostic enigma most of the time. People are either lazy, or incompetent. In the mid-levels, it's more of the latter because they haven't been trained well in many of these things. In doctoral providers it's a mix of the two.

 

[Ollie123]

I may be projecting, but I've always felt that this line of thinking is just such pure vanity/narcissism in students/trainees/docs. Had quite a few that fell into this boat that I went to school with in my cohort.

Its funny. I've met a fair number of the <actual> DSM critics (i.e. the folks whose papers you would likely reference if you were asked why the DSM was bad). Not a one of them refuses to diagnose. Literally not one. Its always some random person who briefly skimmed and half-understood one of their articles, then got excited because it reinforced their preconceived notion that "all labels are bad n' stuff" when the critics are usually just advocating for replacing one labeling system with a better one.

All that said, I think this goes both ways as I certainly see tons of clinicians (especially students) spend eons trying to differentiate MDD vs adjustment disorder when it fundamentally doesn't matter. I actually think this is a part of where the problem comes from...for most of the psychology "bread & butter" outpatient cases, diagnosis has pretty minimal impact on treatment. There are exceptions (bipolar vs MDD, bipolar vs borderline vs ptsd, adhd vs not, etc.), but I can also see how it is easy to get lazy if you mostly see some combo of GAD/MDD/adjustment dx where the differential isn't going to impact much beyond (and will end up being "all of the above" a fair chunk of the time anyways). Doesn't excuse it, but I do think its a contributing factor.

 

[Therapist4Chnge]

Ollie...agree with 95% of your post, though I would argue that there are "real world" implications of diagnosing an Adjustment Disorder v. MDD or similar. The primary implication relates to justifying the # of treatment sessions needed to treat whatever you diagnose. Obviously an adjustment disorder is viewed as less severe than MDD, so I can see an insurance company pushing back trying to treat an adjustment disorder for longer than a handful of months.

 

[futureapppsy2]

Ollie...agree with 95% of your post, though I would argue that there are "real world" implications of diagnosing an Adjustment Disorder v. MDD or similar. The primary implication relates to justifying the # of treatment sessions needed to treat whatever you diagnose. Obviously an adjustment disorder is viewed as less severe than MDD, so I can see an insurance company pushing back trying to treat an adjustment disorder for longer than a handful of months.

Issues with what's a reportable versus non-reportable diagnosis to things like licensing boards may come into play here, too.

 

[BuckeyeLove]

Issues with what's a reportable versus non-reportable diagnosis to things like licensing boards may come into play here, too.

Can you expound on this?

 

[futureapppsy2]

Can you expound on this?

An adjustment disorder is by nature time-limited, and it would be more difficult to argue that it would constitute a reportable (mental) health condition because of that, versus something like MDD, which is more likely to be chronic, seen as needing to be monitored/controlled, etc. I also don't think an adjustment disorder would qualify as a disability under the ADA (the ADA specifically excludes protections for conditions that are expected to be temporary in nature) versus MDD (again, more likely to be chronic/recurrent in nature and viewed that way in legal interpretation), so that could come into play with legal protections/rights as well.

 

[Ollie123]

Oh, I'm in no way denying that there are occasional circumstances where these things can come up. And to be clear - I do full diagnostic interviews at every intake (or at least did before we created a separate intake team). I'm just making the case that in a typical clinical scenario, knowing if someone has MDD vs adj dx w/depressed mood has virtually zero impact on the treatment plan, so its not terribly surprising to me that clinicians may not invest the time/effort in figuring that out. Yes, they still probably should (and its an interesting ethical question on where to draw the line on additional assessment/diagnosis vs beginning treatment), but if our reasons for the latter are largely bureaucratic vs clinical I can't say it shocks me that people aren't as invested in it.

On futureapp's point - I'm actually curious if adjusment dx is actually less chronic. I mean, I know that's the intent but I haven't seen any solid evidence for it. My anecdotal experience is that its actually more chronic (or at least more frequently lapsing/remitting) since ****ty life experiences beget future ****ty life experiences and my adj dx folks are actually more likely to return than my MDD ones. That said, my vague recollections of the past few years of cases is far from solid evidence either.

 

[Fan_of_Meehl]

An adjustment disorder is by nature time-limited, and it would be more difficult to argue that it would constitute a reportable (mental) health condition because of that, versus something like MDD, which is more likely to be chronic, seen as needing to be monitored/controlled, etc. I also don't think an adjustment disorder would qualify as a disability under the ADA (the ADA specifically excludes protections for conditions that are expected to be temporary in nature) versus MDD (again, more likely to be chronic/recurrent in nature and viewed that way in legal interpretation), so that could come into play with legal protections/rights as well.

Maybe I'm misunderstanding your post. Are you saying that a therapist has a 'duty to report' the fact that a licensed provider has clinical depression (and has sought treatment) against their will to their licensing board? I apologize if I'm way off base.

 

[Fan_of_Meehl]

Oh, I'm in no way denying that there are occasional circumstances where these things can come up. I'm just making the case that in a typical clinical scenario, knowing if someone has MDD vs adj dx w/depressed mood has virtually zero impact on the treatment plan, so its not terribly surprising to me that clinicians may not invest the time/effort in figuring that out. Yes, they still probably should, but if our reasons are largely bureaucratic vs clinical I can't say it shocks me that it often doesn't happen.

Right. I was also thinking about it in terms of time/effort in vs. incremental treatment utility out. In everyday practice, this is a constant balancing act. I certainly don't have the time to give structured clinical interviews (SCID, ADIS, PDE) routinely. "What difference will this differential make in the treatment approach?' is a valid consideration.

 

[futureapppsy2]

I remember seeing a (serious) meme on tumblr claiming that self-diagnosis was valid because not everyone had the privilege accessing psych testing. If you want to rage, check this out:

I think the issues around self-diagnosis come down to a difference in seeing autism as a medical/developmental/mental health condition versus seeing it as an identity/benign trait group, and the autistic self-advocacy community has largely moved to endorse the latter view ("If you identify as autistic, you are--welcome, we have cookies!"), which is also a core idea behind the anti-treatment views of the autistic self-advocacy community--that autism is an identity/trait, not something that really needs to be diagnosed or treated. I was in a Facebook group for both healthcare providers and autistic people to promote dialogue between the two about autism diagnosis, and it was not uncommon for people to post in the group saying "I got an assessment/evaluation and my provider wouldn't diagnose me with autism," only for the autistic members to respond with "if you think you're autistic, you can still identify that way and be part of the autistic community."

 

[Sanman]

Some of this was from that study in the late 1990s, where a pediatric psychiatrist wrote a paper in a major journal , which said that mania in children presented as irritability, and not grandiosity/euphoria. Suddenly, the reverse was true: angry kid=bipolar kid. Being able to give a psychiatric diagnosis that insurance would pay for, opened the door to hospitalizing kids with physical aggression. And then you could use sedating medications when some pissed off kid is raising hell.

Then some people saw that mood stabilizers kinda worked in personality disorders with an affective instability component. Because what are you gonna do when you when you got someone in your office who is labile but not manic and really all you do is prescribe stuff? But insurance is a tricky game, and they won't approve those meds for a personality disorder. So you dx bipolar, and get it done.

The geriatrics version of this is ER docs dxing schizophrenia when in reality it is dementia or delirium in the setting of dementia. However the dx allows them to prescribe an antipsychotic, sedate them, and ship them out to the SNF rather than paying for a 1:1 sitter and risk the SNF refusing transfer. I had to educate nearly every clinician we hired on this so they understood about being skeptical of such a dx.

 

[futureapppsy2]

Maybe I'm misunderstanding your post. Are you saying that a therapist has a 'duty to report' the fact that a licensed provider has clinical depression (and has sought treatment) against their will to their licensing board? I apologize if I'm way off base.

Diagnosing providers typically wouldn't report (unless they felt like there was a real and immediate risk of harm to patients), but it may come up in licensing renewal ("Have you been diagnosed with a physical or mental health condition that could potentially impair or limit your ability to practice in [field]?"). There's a lot of debate over what meets that criteria and what exactly license holders need to report, but failing to report an MDD diagnosis would likely look more sketchy in court than failing to report an adjustment disorder diagnosis.

 

[WisNeuro]

Diagnosing providers typically wouldn't report (unless they felt like there was a real and immediate risk of harm to patients), but it may come up in licensing renewal ("Have you been diagnosed with a physical or mental health condition that could potentially impair or limit your ability to practice in [field]?"). There's a lot of debate over what meets that criteria and what exactly license holders need to report, but failing to report an MDD diagnosis would likely look more sketchy in court than failing to report an adjustment disorder diagnosis.

Not only sketchy in court, but I imagine that the hospitals liability insurer would look at failure to self-report that diagnosis as a way to void the liability contract and put the financial burden on the provider. Definitely a messy issue that stigmatizes MH in the population that is tasked with treating MH issues in patients.

 

[BuckeyeLove]

Diagnosing providers typically wouldn't report (unless they felt like there was a real and immediate risk of harm to patients), but it may come up in licensing renewal ("Have you been diagnosed with a physical or mental health condition that could potentially impair or limit your ability to practice in [field]?"). There's a lot of debate over what meets that criteria and what exactly license holders need to report, but failing to report an MDD diagnosis would likely look more sketchy in court than failing to report an adjustment disorder diagnosis.

This is what I was wondering about. I just got curious. Nowhere in my state bylaws, code, or on renewal does it ask about if you have a mental health condition that could preclude practice, like a declarable.

 

[Fan_of_Meehl]

This is what I was wondering about. I just got curious. Nowhere in my state bylaws, code, or on renewal does it ask about if you have a mental health condition that could preclude practice, like a declarable.

Yeah. Such a rule would--on its face--heavily discourage providers with treatable MH conditions from seeking help.

 

[WisNeuro]

This is what I was wondering about. I just got curious. Nowhere in my state bylaws, code, or on renewal does it ask about if you have a mental health condition that could preclude practice, like a declarable.

Depends on the provider type, I've been licensed in a few states, one did ask. I do believe that this is much more standard say, in the physician world.

 

[futureapppsy2]

Yeah. Such a rule would--on its face--heavily discourage providers with treatable MH conditions from seeking help.

Oh, it definitely does. It's a big problem in aviation.

 

[futureapppsy2]

This is what I was wondering about. I just got curious. Nowhere in my state bylaws, code, or on renewal does it ask about if you have a mental health condition that could preclude practice, like a declarable.

Varies by state for psychology (and somewhat for other fields). Here's a study that was published on it a couple years back, specifically for psychology licensing boards: APA PsycNet