Do We Over-Pathalogize?

[Therapist4Chnge]

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I was thinking about this today, and I hear a knock we often get is that we try and put a label on everything. Do you feel that we as psychologists over pathalogize?

I believe in the person and not in the label, but we as clinicians are the expert diagnosticians, and this is what we have to do. I still have to dx, even if you believe in treating the person and not just the dx.

That being said.....

I had a case today where it looked like a duck, walked like a duck, and quacked like a duck.....but it still may not be a duck. I went ahead and labeled it a duck (as a secondary dx), but then I got in a discussion with a couple of colleagues who thought it could be another animal, or not one at all. We went back and forth and there was no real conclusion, just more opinions.

It got me thinking.....are we too quick to give a dx?

(I ended up listing it as a r/o)

-t

ps. (I can't remember if this was brought up awhile back, but I figured I'd bring it back around if that is the case)

 

[Neuro-Dr]

If you want to get paid for the office visit, bill it as a duck. We have to label the clinical presentations and the indications for evaluation, not the person.

 

[Ollie123]

Short answer: Yes

Long answer:

Yes, but kind of by necessity. The problem with what we do is that there is often a tangible benefit to treatment even in the absence of actual psychopathology. In medicine, a heart transplant does little good and carries a lot of potential harm for someone with a healthy or even a not-incredibly-sick heart. Antibiotics don't help someone who doesn't have an infection.

Therapy on the other hand, can help people gain insight into their lives even in the absence of true pathology. But if you tell people "Nope you're fine" and boot them out of your office because they don't fall into the DSM criterion...that's one less patient you have coming to you, one less person who may have actually received benefit from treatment, and one more person who will likely go to their PCP and demand prozac to solve problems that don't really require drug intervention.

This, coupled with the fact that almost all psychological disorders exist on SOMEWHAT of a sliding scale rather than definitive presence or absence, sort of results in diagnosing what may still fall in the range of "normal".

So yes, I do think psychologists over-pathologize quite often. I think some potentially more interesting questions would be:
When is it good vs. bad to over-pathologize, how can we change the system to discourage sticking the label on things without discouraging people from actually seeking therapy, and where should we draw the line on what is "normal" when it can be improved with treatment?

 

[KillerDiller]

I have yet to gain experience in any sort of position where I would be asked to make a diagnosis, so take whatever scattered thoughts I have on the subject with a grain of salt. I think, though, that it is appropriate and healthy for clinicians to be reluctant to diagnose--it shows an unwillingness to overlook the client's unique situation in favor of lumping him or her in with a DSM classification. However, I also think it is important that clinicians don't allow this reluctance to prevent them from diagnosing. Although, at times, a diagnosis can make clients feel stigmatized, it can also bring relief--if what is bothering them has a name, it can't be all that abnormal. Also, insurance companies and HMOs sometimes refuse to pay for therapy without such a diagnosis (not saying that is the way it should be, just that that, from my limited knowledge, is the way it is).

That being said, I have some issues with the DSM the way it currently exists. I am also not optimisitc that my problems with the model will be addressed in the near future. It seems odd to me that each diagnosis can cover such a broad range of clients. For example, if DSM lists 10 potential symptoms for condition X, and a given client must exhibit 4 of these to receive the diagnosis, then you may wind up with two people with the same diagnosis who share exactly none of the symptoms.

Anyway, I agree that we should use a more continuum-like approach for mental illness rather than a categorical one.

 

[NYCPsych]

Definitely often a billing issue... my supervisor talks about providers needing to answer to insurance companies, and feels like sometimes people have to sacrifice their talent as a clinician. Debatable, but anyway, over-diagnosing sometimes jumps the gun, and doesn't allow for the human condition ("it's OK to feel sad once in a while.")

Therapy on the other hand, can help people gain insight into their lives even in the absence of true pathology. But if you tell people "Nope you're fine" and boot them out of your office because they don't fall into the DSM criterion...that's one less patient you have coming to you, one less person who may have actually received benefit from treatment, and one more person who will likely go to their PCP and demand prozac to solve problems that don't really require drug intervention.

On the other hand, word.

 

[amy203]

I used to work for a developmental and behavioral pediatrician who specializes in ADHD. In consultation, she prefers to focus on strengths and weaknesses, e.g. "You're child is very creative and verbal, but it having trouble focusing, which makes it difficult for him to learn. Here are the treatments that may help him focus (medication, behav. therapy)." She still uses appropriate diagnostic tools and talks to the parents about whether there children meet DSM criteria for ADHD, but the focus is much more on the child's functioning.

However, because of insurance companies and the schools, she is often pressured to give a definitive diagnosis whether she's comfortable with it or not. The special ed programs in California school districts are really under funded, so they'll only serve kids if they have a diagnosis. Parents often have to choose between labeling their child so they get the help they need or dealing with trying to explain their child's needs to a new teacher every year who may or may not cooperate.

I'm not Tom Cruise. I do think ADHD exists, and I think it is awful that so many kids go undiagnosed and untreated. On the other hand, there are negative consequences to having the diagnosis, and I think it should be diagnosed with caution. ADHD is a chronic disorder - symptoms may remit in some children but, most of time, people have to manage the symptoms for their entire lives. Having the diagnosis can impact the way parents, teachers, and peers treat a child, and how the child views himself. There is also the issue of medication. Again, I'm not Tom Cruise. I don't think Ritalin is a Nazi drug. Stimulants are the most effective short-term treatment for ADHD. On the other hand, they are a drug and they may have long-term side effects that we don't understand very well. It's just sad to think that kids get told they have a lifelong disorder, and are put on this stuff and are told that they probably need to be on it the rest of their lives, when maybe they were just having a tough year. Maybe their parents got divorced and they responded by acting out and, when there parents were filling out the diagnostic forms, they were also stressed out and didn't give an accurate description of their behavior. I think this type thing can happen pretty easily.

But again, I'm not Tom Cruise. I don't think the answer is to demonize mental health professionals or say that ADHD should never be diagnosed. Rather, we should continue trying to understand the disorder and create reliable diagnostic tools that include sections that screen for short term behavior problems with environmental causes. We should also work to inform clinicians about the potential negative effects of diagnosis and why they should be cautious when making a diagnosis.

Overall, I think this thread is a nice example of why we need thoughtful, well-trained clinicians, and why it’s so important we keep standards of training high. Psychologists have a lot of power; a mental health diagnosis can seriously impact a person’s life, in both positive and negative ways. We have to take this responsibility very seriously.

 

[psychanon]

I work as a therapist in my program's in-house clinic, in which all therapists are clinical psychology graduate students in my program. Since none of us are licensed, we cannot accept insurance. As a result, diagnoses are little more than a note in the clients' file which no one but our clinical supervisor will ever read. Given this situation, I largely think of diagnoses as heuristics. To the extent that it's helpful for me to think of a client as borderline or GAD, I use those labels. If it's not helpful, I don't bother. Along the same lines, if someone is just on the edge of meeting criteria for something (e.g., they are clearly borderline but they are under 18; they clearly have GAD but they have comorbid MDD so technically a diagnosis cannot be made; they meet 4 criteria but the cut-off is 5), I don't care. I rarely pour over the DSM making decisions. I'll treat them the same way, so what difference does it make? Clinically, I always think of psychopathology as a continuum. I realize that those who have to bill insurance companies are in a different situation.

To me, DSM diagnoses are most useful in research as operational definitions of psychopathology. Even there, though, I still will usually use continuum ratings of disorders-- after all, false dichotomization murders power.

 

[robotsahoy]

Absolutely it can be a problem. While you have to provide a dx to insurance companies to get paid, that dx can certainly have impacts on that person's life beyond your office. For example, life insurance companies will often flat out deny services to people with medical histories of depression.

 

[PsyKardinal]

Therapist4Change

I have to diagnose and triage every night in my position as an intake coordinator, and I do think that we overpathologize. Insurance will never pay for well we can improve thier quality of life. They want to know why you made a ddx, and what are the specific symptoms with a nifty little timeline to help them understand when the problems happened. *now that is my inpatient work exprience*

*outpatient practice* I try to make every effort to convert my insurance paying clients into cash clients. I use the reason that I can provide them meaningful therapy that meets thier goals, keeping a 3rd party out of it and all of the implications that insurance can bring. Then I work create payment scenario that will work for the family or client, as the always fall back to but I can just pay you the copay. I think that we need to do what is best for our clients and that keeping insurance out of it and being honest with the insurance companies even when they are demanding a dx helps keep your liability down for insurance fraud, and helps the ct in the long run.

jeff