diagnosing?

[The2abraxis]

i have had this concern for a while, and it is this: Is diagnosing for emotional disorders really that important? Im thinking you can find out the problems and even find solutions w/o knowing if a person is manic, bi polar, depressive, anxious, etc... Also, the requirements for certain disorders just seem to overlap so much, and many of the symptoms might not be because of the disorder itself! It just seems like a waste to dictate what type of classification there is, and to instead focus on the main problems and find solutions to them

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[Ollie123]

I'd say it depends a great deal on the situation.

I'd agree that as far as treatment is concerned, differentiating between MDD or sub-threshold depression that ends up getting labeled as adjustment disorder is not going to result in drastically different treatment plans.

In other cases, it can make a massive difference. Knowing whether someone who presents with depressive symptoms is really bipolar and could flip to manic before the next session is hugely important. For one because we are often assessing for psychiatrists, and it may make a difference in terms of medication. But also because the appropriate behavioral treatments are very different.

Its also important to know what is "primary". For example, if the depression didn't start until AFTER they started drowning themselves in whiskey, it can drastically change your focus.

We have far from a perfect diagnostic system, that's certainly true. Its far from useless though. If anything, any limitations to utility come from the fact that we don't know enough about behavioral disorders yet, so it will likely become even more important in the future.

 

[erg923]

Diagnosis is tricky, and no, it does not fit neatly into discreet categories no matter how much we want them to. However, I would argue that diagnosis is extemely important for several reasons.

1. Diagnosis was really developed so professionals could communicate symptoms presentations to one another. When you get a referral from another physician or psychologist, the first thing everyone asks is, whats the (do they have) a diagnosis? This will immediately clue us in on what to expect and provides second opinions and collateral info that we might overlook. Diagnosis also informs us statistically about about prognosis, risk for suicide, and a host of other factors. It also informs us about what approach and method of psychotherapy may be most appropriate. Some psychotherapeutic techniques (i.e., guided imagery) are contraindicated in those who are susceptible to or who are currently psychotic. Extremely directive interventions are contraindicated in those who have certain Axis II conditions, and paradoxical interventions are contraindicated in those with hx of psychosis, severe clinical depressions, and past suicidal gestures. Similarly, I would treat a person who is suffering from subclinical issues, or existential problems, with more insight oriented techniques, vs. a chronically depressed individual with long standing diagnosable depression moth more directive CBT techniques. It is true that many psychotherapeutic interventions are symptoms focused, but one can not ignore the bigger picture. Symptom clusters often run together, an indicate underlying commonality and pathology. Often many symptoms are the consequence of just one underlying condition/issue. Treating each symptoms in isolation, as its own little problem, ignores the complex, evolving, and interactional nature of psychopathology. Everything and every symptom feeds from and is influenced by others symptoms.

2. Another big one that OLLIE mentioned is psychopharm treatment. For example, a patient who presents with depression. Knowing that a patient has a hx or family hx of mania will impact treatment, as SSRIs can throw these people into a manic cycle if they are bipolar. Even if they are not presenting with mania at the time, adding an anticovulsant to prevent this possibility is indicated in this situation. More energizing antidepressants would be indicated in someone with an atypical depression vs a more typical clinical depression. The distinction between schizoaffective DO vs. bipolar DO with severe and psychotic manic phases is important for knowing which mood stabilizer and antipsychotics would be most effective and in what doses, and which problem (the psychosis or the mood symptoms) are influencing which (i.e., which is primary). Differentiating a major depression from a prolonged period of grief is important for the proposed time period of pharmacological treatment, as well as the psychotherapeutic interventions employed (focus on goal adjustment and feelings toward lost loved one for a reactive grief depression, or CBT and challenging depressive shematas for more endogenous chronic depression) . Getting too caught up in treating individual symptoms can be dangerous. For example, I have seen PC docs prescribe elderly patients one drug for their insomnia, one drug for anxiety, one drug for low energy, one drug for mood. Looking carefully at a patient with difficultly sleeping, restlessness, low energy, and low mood, we see that these are the vegetative signs of clinical depression. All the symptoms are likely related to one underlying problem (i.e.,depression). Often, by treating the underlying psych DO (in this case depression) the other problems begin to dissipate as well. This avoids the unnecessary risk that polypharmacy presents.

3. Research on the etiology of certain disorders requires a strict definition of the disorder so that the disorder can be study in its purest conceptualized form.

 

[cara susanna]

Patient insight is another benefit. Sometimes just putting a name to something can really help. If a patient is diagnosed as bipolar, not only can he/she describe what is going on better, but he/she can also research it on his/her own.

 

[The2abraxis]

i agree on what you are saying. just to clarify, I wasn't suggesting treating each symptom individually w/o looking for the big picture, that would just be terrible :-D

it seems like in a sense diagnosing could be doing a few bad things like: simplifying reality and causing a self fufilling prophecy. Some of the symptoms that are described in some disorders (ex: fatigue in depression) may not even be part of the depression, but because of something else (maybe poor sleep habits, no exersice, poor diet), and then a person could get treated for it (like medication) when they need something else (a better diet, better sleep habits, etc...).

The main thing im kinda concerned about is how the diagnoses is given. Because of the potential problems in the diagnoses process, it seems like it would need a good amount of time/interviewing to understand the diagnoses fully. I am not sure how true it is, but I have read/heard alot about how diagnoses are given in one session (along with prescriptions) when itseems like it would need a lot more time to find out what is causing what, why something is causing something, etc... before going into treatment.

Overall, I believe it would be better/more effective to the patient to spend time and find out the main problems rather than slap on a diagnoses very quickly and deal with it from there

 

[erg923]

You are correct on some of your points. However, diagnoses are not made lightly. Sloppy and snap diagnoses are typically only apparent on acute inpatient psychiatric units, where a diagnostic code upon admission is needed for billing purposes. An intake interview, even an extensive one, will give a clinician a "diagnostic impression." The disorders to most likely be in the running in other words. Further exposure to the patient and utilization of psychometric tests help to shape the picture over time. However, there certainly are diagnosis that will pop out readily in clinical interviews. Some diagnosis really are pretty visible upon interview. It's hard not see paranoid schizophrenia when the patient spends the entire interview talking about his delusions of government control. However, seeing patients for ongoing psychotherpay allows for the freedom of not settling on a working diagnosis for the first 3,4,5 sessions. Not many places, except acute inpatient facilities, slap on a diagnosis too quick. And remember, diagnosis alone does not dictate treatment choices. Clinicians are always free to modify the treatment plan as additional issues/possible diagnoses pop up during the course of treatment. Diagnosis is evolving, its not written in stone. Psych diagnosis is not like having cancer, where you either have it or don't. In reality, psych disorders are clusters of symptoms that run on a continuum, but the medical model of categorical diagnosis still prevails. DSM-V and its further successors will likely work on this problem in the future.

Neuropsych is a different animal in this regard, and many neurological/neurodegnerative diseases have well established patterns of cognitve deficits that can be elicited with extensive testing. For example, the pattern of neuropsychological deficits seen in Alzheimer's disease is pretty easy to recognize for neuropsychologists. As long as the neuropsycholgist has access to medical records that have ruled out medical causes for the cognitive decline, this diagnosis ("probable dementia of the Alzheimer type") can be made after one extensive day of interview and psychometric evaluation.

As far as deciphering what symptoms are due to what, this of course is tricky. Of course a person's fatigue might not be totally due to depression. For example, the literature suggests the early morning awakening often seen in clinical depression is highly likely to be due to the depression itself. But obviously diet exercise, sleep habits, all influences energy level as well. These issues are also explored in a clinical interview. The art of good clinical interviewing aims to tease out these issues the best we can. If there other symptoms of depression lift, and apathy or lethargy still continue, treatment will be augmented accordingly.

 

[Ollie123]

In the interest of keeping this thread collegial I'll just say this was one of the factors that made me choose psychology over med-school. That's not a comment on the actual capabilities or knowledge of people in either profession, rather a function of the system each is forced to operate in. Its not ideal for anyone.

It doesn't sound like your problem is with diagnosis, so much as with people using diagnoses incorrectly. That's actually more the fault of individual laziness and/or a broken system than diagnosis not mattering. What you are describing "Spending time and finding out the main problems" pretty much IS clinical assessment. A host of tools are available to simplify collecting that information (SCID/MINI/MMPI/PAI/WAIS) and that's just barely scratching the surface. Or complicate it in the case of the SCID, whose copyeditor need a swift kick in the behind

To arrive comfortably at a diagnosis should take quite awhile. I'm not sure I can think of a situation in which anyone should be 100% confident in a diagnosis. I doubt you'll find anyone here disagreeing with that. Slapping on a diagnosis is a bad idea. That doesn't mean diagnosing is bad, just that doing a bad job of diagnosing is bad

You make a good point about symptoms often being mistaken for a part of the disorder when they may not be. I actually think the lack of training in how to spot things like this is one of the biggest flaws in psychology training - we focused too much on separating ourselves from medicine, and let in too many biology-phobic individuals.

 

[The2abraxis]

ah, well its good to hear that places don't take them lightly. I guess I thought some practices took it lightly, but they may not :-D It does seem bad though in some inpatient places (the few I visited/volunteered in) like you said, but it may be hard to spend so much time to get a full picture with a patient.

what do you have to say about the self fufilling prophecy aspect of the diagnoses process? I am not particulalry talking about what a therapist/psychiatrist tells a patient, but what a person hears and sees on the internet/tv/paper/etc... They may be misattributing certain symptoms as a certain disorder, or even see that they have only a few generic symptoms and feel they have a full blown case. If the self fufilling prophecy aspect is true, how does one prevent it from happening? (besides telling people not to self diagnose :-D)

 

[The2abraxis]

ollie you are right once again :-D. Its not really that diagnoses is bad, but the labeling aspect just seems so rigid and easy. Like I mentioned in my post above me ( i dont know if someone posted yet or not :-D), the labeling can be taken completly out of context. What sparked this was my friend said he thinks his friend is a form a bipolar (i dont remember the name) and he showed me how he was anxious, sad, happy, etc..etc.. I think almost every symptom on the list, the person had. I looked at these, but they seemed like completly normal symptoms that every person has in a given period of time, yet it made him that type of bipolar? It just seemed crazy because when I looked at it, I would have been diagnosed as well!

edit- im not bipolar by the way haha

 

[erg923]

I guess all I can say about that is that people should be wary about self- diagnosis. Most lay people don't understand psych diagnosis, or how it is made. I'm sure many people use their diagnosis as a means of attempting to escape responsibility or self handicapping. Actually I have seen it first hand. But such is life. People do it with tons of other things as well. I just stress that it might not be your fault that your down, but it your responsibility to get back up again. I can help, but no one can do it all for you.

On the flip side, the majority of people I have seen find psychotherpay empowering, and are happy to know that people care and relieved to be informed that mental illness does not mean you are "weak" person.

PS: The DSM is not a cookbook and should not be such as such. Unless your friend is in the mental health profession, he is dabbling in something he doesn't fully understand the nuances of. All of us will have symptoms of things. The key is do we reach the clinical threshold for "disorder?" This is why the DSM has so many specifiers in terms of time frames of symptoms and symptom onset, and if these symptoms cause significant impairment in social or occupational functioning (this is a criteria of almost all psych diagnoses). All of these judgments require a knowledge of psychopathology, it patterns and nuances, and informed clinical judgment.

 

[WannaBeDrMe]

I don't recall seeing anyone mention the relationship between diagnosis and billing/reimbursement other than on an inpatient unit. (For clarification, in my state, there are FAR more sloppy dx in outpatient. Billing codes per specific diagnosis are only needed in outpatient settings to pre-approve care. Inpatient care only has to prove that someone meets criteria for continued care.)

I have a pet peeve about people who do not take the time to distinguish between the different diagnoses and basically just give everyone a mix of MDD/PTSD/GAD to cover their initial billing. The fact is that a lot of worried well are receiving insurance-supplemented treatment under those codes even though they do NOT meet criteria for the disorder. If someone wants to be a hero, and not adhere to the DSM, be my guest. However, our healthcare finance system is in crisis and if you are going to take the money, you need to play by the rules.

I'm not speaking to the OP here as I share your concerns. My personal theory has always been... "why does it matter what it's called if it's still happening anyway?" However, by choosing to work within this system and accept Medicaid/Medicare/3rd Party monies, I feel really obligated to work from that framing of ideas.

There is not an unlimited pot of money. The money coming out of insurance to pay for little Sally's sadness over her not getting a BMW for her 16th birthday might raise insurance costs too high for Sally's teacher to be able to afford treatment for diabetes. Then, Sally's teacher gets an infected foot, dies, and it's a sad story for all involved.

So, I guess to answer the original question. Not all diagnoses are covered by insurance. Different diagnoses mandate different lengths of treatment. etc, etc, etc. So, with regard to you getting reimbursed for your services, it will matter whether or not someone has an adjustment disorder or MDD.

Good topic.

 

[PsyDr]

IMHO not wanting to diagnose for fear of "labelling" someone is buying into and therefore propogating the stigma of mental illness.

 

[The2abraxis]

Actually I think the labeling itself is what makes a stigma, because someone can see that they have the label on them and then they may become a stigma in their minds or others minds :-D. If they feel they just have certain problems that they can deal with instead of bipolar disorder and schizophrenia, they may feel a bit better about their situation :-D

 

[erg923]

Actually I think the labeling itself is what makes a stigma, because someone can see that they have the label on them and then they may become a stigma in their minds or others minds :-D. If they feel they just have certain problems that they can deal with instead of bipolar disorder and schizophrenia, they may feel a bit better about their situation :-D

Then what would you suggest we do instead? You would have to replace with something that still provides everything I mentioned in my first post (informative communication between professionals, prognosis, treatment guide, research on etiology, etc.) or else things would be even worse, right.

 

[PsyDr]

let me begin by stating, I believe that this bias may be the result of you caring for your patients a great deal. I laud this compassion. However:

Having acurate dx with known treatment responses is incredibly reassuring to patients. Pubmed it, there is research. It also separates us from the non-trained or non-professionals. Taken outside of mentlal health, patients want to know 1) what is wrong with them, 2) what can be done to treat it, and 3) how effective said treatment is.


I know i would be less than comforted if a physician told me that my cells were dividing in an unusual pattern and he was going to expose me to to things he knew about. I would much prefer to hear I have a pancoast carcinoma in my left lung which would be surgically resected and then treated with X rads X number of times, which would yield a 45% increase in my 12 month survival rate.

I think it is beyond hubris to avoid telling patients what the objective evidence states because a clinician feels that the patient cannot handle it.

I also believe that this type of thinking is ultimately detrimental to the field. Without dx, the psychological treatment is classified as "experimental" (as no known response rate can be known) in insurance (read non-reimbursable). Keeping that in mind, if in your best clinical judgement there is nothing wrong with the patient then you should not assign a DSM/ICD code to the insurance slip. Writing a dx you do not believe and asking for monies from a third party payor is called INSURANCE FRAUD in this country. IMHO this concept also stinks of rank amateurism to other fields. Try to explain to a physician that you don't dx and don't know how effective treatment is. Our profession is held to the exact standards that medicine is, and to think that we should be treated as equals, but not subject to the same standards is IMHO a logical fallacy that absolutely shames me.

 

[The2abraxis]

Then what would you suggest we do instead? You would have to replace with something that still provides everything I mentioned in my first post (informative communication between professionals, prognosis, treatment guide, research on etiology, etc.) or else things would be even worse, right.

haha i have no idea (as of now) what could be done, besides labeling and grouping the problems together, and finding out which effect the patient (ex: behavioral, affective, motivational, physiological, cognitive, etc...), finding themes in the problems, and then working out the problem. Kind of just like typical problem solving :-D

But I am not saying to get rid of diagnosing. It seems to serve its purposes of outlining typical symptoms and problems in a certain disorders, but these disorders are not like the type of diseases that physicians and medical doctors deal with. The process seems to be a lot more compicated than finding out what biologcal problem there is and fixing it, because there are so many other factors going on. The diagnoses is useful in providing a good backbone of "what is to be expected," but (like you mentioned before) it really shouldn't be followed so strictly. People may think a diagnoses has a certain cure that would work for everyone, but in the case of emotional disorders this is not the case, as each person/situation varies a great deal, and stick a label (although it serves it pourpose) just seems to easy.

 

[The2abraxis]

let me begin by stating, I believe that this bias may be the result of you caring for your patients a great deal. I laud this compassion. However:

Having acurate dx with known treatment responses is incredibly reassuring to patients. Pubmed it, there is research. It also separates us from the non-trained or non-professionals. Taken outside of mentlal health, patients want to know 1) what is wrong with them, 2) what can be done to treat it, and 3) how effective said treatment is.


I know i would be less than comforted if a physician told me that my cells were dividing in an unusual pattern and he was going to expose me to to things he knew about. I would much prefer to hear I have a pancoast carcinoma in my left lung which would be surgically resected and then treated with X rads X number of times, which would yield a 45% increase in my 12 month survival rate.

I think it is beyond hubris to avoid telling patients what the objective evidence states because a clinician feels that the patient cannot handle it.

I also believe that this type of thinking is ultimately detrimental to the field. Without dx, the psychological treatment is classified as "experimental" (as no known response rate can be known) in insurance (read non-reimbursable). Keeping that in mind, if in your best clinical judgement there is nothing wrong with the patient then you should not assign a DSM/ICD code to the insurance slip. Writing a dx you do not believe and asking for monies from a third party payor is called INSURANCE FRAUD in this country. IMHO this concept also stinks of rank amateurism to other fields. Try to explain to a physician that you don't dx and don't know how effective treatment is. Our profession is held to the exact standards that medicine is, and to think that we should be treated as equals, but not subject to the same standards is IMHO a logical fallacy that absolutely shames me.

As i stated before, the diagnoses in defenite biologcial problems holds a much stronger "value" (you can debate this as well ) because it gives a very strong view of the problem and the treatment. The same is a bit iffy on emotional disorders (I am not talking about the ones that have a known biologcial cause), because it would take alot more work and a lot more of getting to know the patient. Like I said before, they are helpful in understanding where to start (a backbone), but to lump the people in a category that may have completly different problems and not fully understanding why or what to do right away (sometimes not even for a long time, or ever!), seems to be tough.

I know it's important for the field, but it is very experimental (as with most other professions!). It seems like some of the most useful therapies/interventions are based on theories/philosophy! I am not saying the field is useless (no point into going into a useless field :-D) because it has helped many and continues to get stronger and stonger.

When you said

"I think it is beyond hubris to avoid telling patients what the objective evidence states because a clinician feels that the patient cannot handle it. "

that is not what I was getting at (I was just speculating on the self diagnoses and self fufilling prophecy). I was mainly expressing the though that the diagnoses serves merely as a backbone, and probably most of the objective evidence would not even really relate to the diagnoses (in some cases).

It's not that I don't believe in the diagnoses (sometimes they are right on!), but they don't always seem as applicable and even as useful as they should be (seems to simplify reality). WHen you said

" Our profession is held to the exact standards that medicine is, and to think that we should be treated as equals, but not subject to the same standards is IMHO a logical fallacy that absolutely shames me."

it seems strange that we would want to have the same standards when the types of problems/solutions/practices are completly different because the origin of the problems are deeply rooted in something we may never fully comprehend. It's hard to be seen as equals when everything is so much different. We may want to be on the same level as terms of respect, but trying to copy/imitate their procedures/standards/procedures,etc... for the sake of pride seems to be a conflict of interest for what the field wants and the most effective ways for treatment. Once again I am not saying it is pointless (serves a good backbone, and the other things erg923 said such as going from therapist to therapist, insurance, etc...), but it does not seem to have the same effect as it does in medicine.

 

[PsyDr]

To begin, I would say that self diagnosis should never be undertaken. I feel somewhat unable to respond to most of your statements as some appear to refer to personal experience rather than explaining that to which it refers. I woudl also state that while I wish you the best with dealing with a friend who self dx's, I have no interest in discussing your personal life in a message board about professioanl matters. I would prefer to keep this professional.


i would contend that there are no pure "biological problems" in mental illness. There is not 100% penetrance in monozygotic twins for ANY mental disorder, including schizophrenia. While there are undoubtedly biomarkers for suseptibility for mental illness, environmetnal factors play a key role in expression. Please see Nobel prize winner Eric Kandel's early work for more information regarding this. Kandel later contended that the exact same mechanism of protein synthesis in response to environmental factors was the same mechanism that made psychotherapy effective. Fascinating reads. I will agree that there are some conditions that are primarily biolgically determined such as MR. However, we also know that mild progress can be made with behavioral tx.


I agree that dx provides a "backbone" for therapeutic intervention, as even manualized therapy fails to dictate exactly what is said. All EVTs allow room for slight deviations from the tx. However, with PROPER dx and appropriate tx, response rates are known. Failure to gain objective evidence for dx may resutl in inproper tx. For example, the proper tx for MDD and normal grieving are exceptionally different. However, many idiots easily confuse these dx's on a daily basis harming untold #s of individuals in dire need.

As for tx's being "experimental", I agree that there are a legion of experimental tx modailities. However, I believe it is unethical to provide experimental tx to a pt without explaining the nature of the tx. AMA & APA tend to agree with me (please see ethics codes for more info, APA 10.01 (b) specifically). However, some conditions do not have a proper dx (e.g., a CC of "i want to learn about myself"). This is fine, but the tx is experimental. If the pt is fine with this, then no ethical breech has been used. and insurance will not pay. fine. psychoanalysts do this all the time, and many of their patients report the experience to be extremely helpful.

If the objective evidence does not support the dx, then you have what is called a "misdiagnosis". IQ=100, ADLs= WNL? No MR. period. There are many great textbooks about this, Lezak being my preference. Our history is in OBJECTIVE MEASURES OF COGNITIVE PHENOMENON, like it or not. Psychotherapy was not and never will be the unique feature of psychology. there are a legion of history of psychology books that will explain this in better terms than i am capable of. refer to any of them.

As for your presumptive statement that this is not "what the field wants", I would refer you to the NIMH blueprint, APA's educational standards and current propositions, NAN's PAIC, Medicare, the federal and state insurance commisions, APA preseidential addresses, pretty much any edition of the Monitor, American Psychologist, any APA journal, AMA journal, etc and ask you to support your statement with evidence. Our field is incredibly supportive of empirically supported diagnoses and treatments. APA is currently implementing new educational guidelines regarding this. There was exceptional expense undertaken to fight for RxP last month for just such equality. Also such a goal was undertaken in DC for Mental Health parity this year. In this same line, our actual livelihood depends on playing the game. Insurance reads research just as much as we do (or should in some cases) and dictates payment through this. This is what separates us from the quacks. You see any RCTs supporting "oriental medicine". Nope! However, they have ideas on why it works. Insurance sure isn't going to pay for that though. Don't want to use insurance? Fine. I hope you are super charismatic and live in a very wealthy area, or are willing to work for peanuts.


In closing i will state that I understand that you are saying that there are within dx variations , and therapy needs to be customized for said variations. There is extensive literature in all fields that agres with this proposition. However, the majority of let's say MDDs respond to CBT in a predictable fashion. Some pts are nonresponders and second line interventions must be used (e.g., interpersonal therapy, tricyclics, etc). However, IMHO to utlimately discard dx as a whole because of these within disorder variations is simply lazy and not the purview of true science. While some psychologists feel this is fine, I belive that they are acting unethically.

 

[The2abraxis]

I agree on what you are saying. We are actually basically saying the same things, except it seems you think I believe it is pointless and they should not be used, which I don't really think. I am merely questioing the importance/useage of it as a whole when finding out problems and treatment, and seeing if they should be taken as seriously as they are. Everything else we are basically on the same lines :-D

edit: it seems like you are taking some things I posted out of context. Some points you are arguing I wasn't even talking about or even considered talking about!

 

[cara susanna]

Even medical diagnosis can be shady. For instance, a person is told that she has IBS. She was found to have IBS not by any physical abnormality, but by the process of elimination, because she was tested for Crohns, Celiacs, etc, and did not. As one may know, there are no known cures for IBS, so really all she has now is just a label for her terrible stomach pain, and methods to take to reduce the symptoms so that they are controllable. These methods are not as simple as just taking a pill. Furthermore, there are still many doctors out there who do not even believe that IBS exists. She also may have endometriosis--are her symptoms caused by that? Endometriosis is often misdiagnosed as IBS.

In my philosophy of science class we discussed whether or not medicine is even really a science.

 

[Therapist4Chnge]

One of the challenges of the clinician is to work with the patient and help them understand their Dx, while also helping them differentiate between themselves and their Dx. Some people believe that they are their Dx, as opposed to an individual with something that has been diagnosed. I often run into this in the world of EDs. The pt. with the ED believes they are their Dx as a whole, and it isn't merely a part of something they do...and/or an affliction to the person/self, and not the actual self.

 

[pingouin]

One of the challenges of the clinician is to work with the patient and help them understand their Dx, while also helping them differentiate between themselves and their Dx. Some people believe that they are their Dx, as opposed to an individual with something that has been diagnosed. I often run into this in the world of EDs. The pt. with the ED believes they are their Dx as a whole, and it isn't merely a part of something they do...and/or an affliction to the person/self, and not the actual self.

I was just thinking that.. Had that exact situation come up with one of my ED kids yesterday and had that conversation about medical disease being an affliction rather than defining self. I used our hospital's cancer patients as an example: They are not "leukemic", rather, they "have leukemia".

Exploration and education of diagnosis is particularly helpful with people who suffer drastic mood swings, whether related to an affective disorder or personality disorder (or both). It provides a framework to discuss perceptions of how "most people" (not "normal" people) experience moods and react to them, allows the patient to explain how they feel they differ from "most people", and that helps guide therapy goals to make the changes that the patient wants.

 

[PsyDr]

if i took somethign out of context, i apologize. I can see some errors i made in that as we were posting at the same time earlier. Again, i apologize for said errors.


I am clearly a firm believer in diagnosis and EVTs.

To your OP: "is diagnosising for emotional problems really that important?"


My answer is a firm yes. As is the APA's.

In your 2nd post, you mentioned the need for in depth investigation for accurate dx, which I agree with.


In your 3rd post, you expressed concern that indviduals would begin to atribute all symptoms to his/her diagnosis and questioned how to prevent this. My answer is patient education. Other clinicians will say therapeutic rapport. I know there is research in this area, but it is not my speciality so i will leave it to you to familiazre yourself with the literature.

In your 4th post, you stated that a friend of yours mentioned someone who had several symptoms of bipolar disorder. You stated that ppl expereince these symptoms in the course of normal life. My answer to this: the DSM requires the symptoms to cause significant distress or impairment in social occuptaional, or other areas of functioning. While we all experience mood swings from time to time, few of us experince significant impairment from said labile episiodes. This is what separates pathology from non-pathology. I do not feel comfortable discussing family, friends, etc in a professional discussion so i made no mention of your friend or yourself.


in your 5th post (i am losing count, but i belive this is right), you advocated for finding out the problem rather than labelling as you believed patients would feel better abotu this. I replied in firm opposition to this, as this prevents insurance reimbursment, makes our profession look like quakery, implies a lack of trust in the pt's ability to handle ideas, prevents accurate research, etc.

in your post at 2:36PM you backed off your position of not labelling/diagnosing patients but treating their symptoms instead and contended that it may actually be alright. Then you stated "We may want to be on the same level as terms of respect, but trying to copy/imitate their procedures/standards/procedures,etc... for the sake of pride seems to be a conflict of interest for what the field wants and the most effective ways for treatment.". I heartily disagreed based upon my support of EVTs, concerns regarding professional appearance, concerns regarding 3rd party payors, etc. I then stated that your presumption that the field of psychology would find equality with medicine "to be a conflict of interest for what the field wants" was misguided. I backed my postiion by referring to several large national organizations that have position papers that express a desire to have parity and utilize standards of research and care modelled by medicine.


In regards to your most recent post, i agree that on some level we share some viewpoints. However I believe that you are not considering the implications of this line fo reasoning. So i agree when you stated, " Some points you are arguing I wasn't even talking about or even considered talking about!", I agree. I expressed concern in two key areas: 1) that i did not feel comfortable using the analogy of your friend as i wished to keep this discussion professional and 2) the implications of this line of thinking on the macro level. So while you never stated that you would fake a dx on insurance, i questioned how someone who did not believe in the utility of the construct ,or the construct therof, of dx would be able to truthfully write a DSM code for insurance reimbursment. I then stated that if you truly did not belive that someone's problems could not be descrribed by diagnostic language, that coding for insuranve would represent fraud in all states.

I understand what you are saying, and i once held that point of view. However, i now see that there are significant problems that this line of reasoning cause for not only the patietn but for the field at large as well.

 

[biogirl215]

I was just thinking that.. Had that exact situation come up with one of my ED kids yesterday and had that conversation about medical disease being an affliction rather than defining self. I used our hospital's cancer patients as an example: They are not "leukemic", rather, they "have leukemia".

Exploration and education of diagnosis is particularly helpful with people who suffer drastic mood swings, whether related to an affective disorder or personality disorder (or both). It provides a framework to discuss perceptions of how "most people" (not "normal" people) experience moods and react to them, allows the patient to explain how they feel they differ from "most people", and that helps guide therapy goals to make the changes that the patient wants.

This is slightly off-topice, but I'm curious... Is there much evidence that "person first" language (i.e., "person with schizophrenia" vs. "schizophrenic") really improves patient preception, outcome?

I have a physical disability, and I know some people perfer "person with a disability" over "disabled person," though I've always used the latter myself, and I have even referred to myself as a "cripple," even though I would hate it if a non-disabled person used the term. OTOH, I've known other people with physical disabilites who were very, very picky about using "person first" language.

Obviously, this is different from psych dx's in that psych dx's tend to be much more stigmatized and, perhaps, more "encompassing" (...? That's probably the wrong word) to an individual, but it did make me wonder about how/why this is used in the field...

Sorry for the slight detour from the topic--this just caught my eye.

 

[The2abraxis]

One of the challenges of the clinician is to work with the patient and help them understand their Dx, while also helping them differentiate between themselves and their Dx. Some people believe that they are their Dx, as opposed to an individual with something that has been diagnosed. I often run into this in the world of EDs. The pt. with the ED believes they are their Dx as a whole, and it isn't merely a part of something they do...and/or an affliction to the person/self, and not the actual self.

indeed. Would it really effect their treatment/problem if they did not know their general Dx, and instead spent time figuring out the underlying problem (they think the world should be perfect, they have brain damage, etc...)?

 

[myelin]

This is slightly off-topice, but I'm curious... Is there much evidence that "person first" language (i.e., "person with schizophrenia" vs. "schizophrenic") really improves patient preception, outcome?

I have a physical disability, and I know some people perfer "person with a disability" over "disabled person," though I've always used the latter myself, and I have even referred to myself as a "cripple," even though I would hate it if a non-disabled person used the term. OTOH, I've known other people with physical disabilites who were very, very picky about using "person first" language.

Obviously, this is different from psych dx's in that psych dx's tend to be much more stigmatized and, perhaps, more "encompassing" (...? That's probably the wrong word) to an individual, but it did make me wonder about how/why this is used in the field...

Sorry for the slight detour from the topic--this just caught my eye.

This language comes from the humanist movement that sought to think of the client (not patient) in terms of the person and thier disorder. This is accomplished by saying "the person with autism" versus "the autistic child." To me, the former statement shows respect for the person.

I'm not sure about what the literature says on this, but I'd think that it would create less of a self-fulfilling prophecy by using person first language rather than the person second. It is much easier to fit the role of a paranoid schizophrenic by saying to yourself "i'm a paranoid schizophrenic" rather than "i'm a person with paranoid schizophrenia."

 

[The2abraxis]

if i took somethign out of context, i apologize. I can see some errors i made in that as we were posting at the same time earlier. Again, i apologize for said errors.


I am clearly a firm believer in diagnosis and EVTs.

To your OP: "is diagnosising for emotional problems really that important?"


My answer is a firm yes. As is the APA's.

In your 2nd post, you mentioned the need for in depth investigation for accurate dx, which I agree with.


In your 3rd post, you expressed concern that indviduals would begin to atribute all symptoms to his/her diagnosis and questioned how to prevent this. My answer is patient education. Other clinicians will say therapeutic rapport. I know there is research in this area, but it is not my speciality so i will leave it to you to familiazre yourself with the literature.

In your 4th post, you stated that a friend of yours mentioned someone who had several symptoms of bipolar disorder. You stated that ppl expereince these symptoms in the course of normal life. My answer to this: the DSM requires the symptoms to cause significant distress or impairment in social occuptaional, or other areas of functioning. While we all experience mood swings from time to time, few of us experince significant impairment from said labile episiodes. This is what separates pathology from non-pathology. I do not feel comfortable discussing family, friends, etc in a professional discussion so i made no mention of your friend or yourself.


in your 5th post (i am losing count, but i belive this is right), you advocated for finding out the problem rather than labelling as you believed patients would feel better abotu this. I replied in firm opposition to this, as this prevents insurance reimbursment, makes our profession look like quakery, implies a lack of trust in the pt's ability to handle ideas, prevents accurate research, etc.

in your post at 2:36PM you backed off your position of not labelling/diagnosing patients but treating their symptoms instead and contended that it may actually be alright. Then you stated "We may want to be on the same level as terms of respect, but trying to copy/imitate their procedures/standards/procedures,etc... for the sake of pride seems to be a conflict of interest for what the field wants and the most effective ways for treatment.". I heartily disagreed based upon my support of EVTs, concerns regarding professional appearance, concerns regarding 3rd party payors, etc. I then stated that your presumption that the field of psychology would find equality with medicine "to be a conflict of interest for what the field wants" was misguided. I backed my postiion by referring to several large national organizations that have position papers that express a desire to have parity and utilize standards of research and care modelled by medicine.


In regards to your most recent post, i agree that on some level we share some viewpoints. However I believe that you are not considering the implications of this line fo reasoning. So i agree when you stated, " Some points you are arguing I wasn't even talking about or even considered talking about!", I agree. I expressed concern in two key areas: 1) that i did not feel comfortable using the analogy of your friend as i wished to keep this discussion professional and 2) the implications of this line of thinking on the macro level. So while you never stated that you would fake a dx on insurance, i questioned how someone who did not believe in the utility of the construct ,or the construct therof, of dx would be able to truthfully write a DSM code for insurance reimbursment. I then stated that if you truly did not belive that someone's problems could not be descrribed by diagnostic language, that coding for insuranve would represent fraud in all states.

I understand what you are saying, and i once held that point of view. However, i now see that there are significant problems that this line of reasoning cause for not only the patietn but for the field at large as well.

well there is alot of respoding, so forgive me if i miss it all

with regard to the 4th post that you mentioned: I was concerned that time may not be taken to differentiate between a symptom of the disorder of a symptom of something else (its hard because some people get medication after 1 session!)

with regard to the 5th post: I am not saying pateints will feel better about this, I am just wondering if time is being taken away from what is really important (there are always procedures for everything though, so its understandable)

at 2:36 PM: I may have made a typo, or forgot a few words, but defenitly treating the symptoms alone would be awful (I dont remember mentioning that?)

yes the analogy was quite pointless, I was just stating where the curiousity came. He was seeing the list of symptoms and was believing he had them all because he had the disorder, when the symptoms may have been from something else!

 

[Therapist4Chnge]

I try and be respectful of the person and not imply that they are their Dx, but it is tough sometimes to be consistent. It is nuanced, but I think important.