Shirah Vollmer MD

The Musings of Dr. Vollmer

How Important Is A Diagnosis?

Posted by Dr. Vollmer on July 11, 2013

Who can/should diagnose a psychiatric illness and after all, why is this necessary? The latter is easy to understand. Without a proper diagnosis, there cannot be the appropriate intervention. Yet, is psychiatry that simple? Of course  not. Many therapists do not think in terms of diagnosis, but rather in terms of psychic pain, and as such, they try to alleviate suffering, without too much concern for the category of illness. Sure, a diagnosis has to be written on an insurance claim form, but “depression” seems to serve that purpose for almost all. Yet, what if they miss something? What if they think someone is schizophrenic, when, in fact, they are looking at a drug-induced psychosis? What if they miss that someone’s enthusiasm, is really mania, requiring immediate intervention? What if the person needs to be treated against their will, and yet the therapist is mostly comfortable dealing with patients who consent? What about primary care physicians, who are becoming more and more responsible for managing mental illness? How much training do they get? Who trains them? Do they know when they have hit their limits, or does tragedy ensue? What about psychiatrists who attempt to train primary care physicians, or non-MD mental health professionals how to recognize serious mental illness? Are they adding to the problem of mis-diagnosis or are they part of the solution to help more of the mentally ill have access to care? If a middle-aged female is suffering because her husband left her for a younger woman, does she need to be seen by a psychiatrist, when the cause of her suffering appears to be straight-forward? Should she be triaged before being sent off to a therapist, or should she self-refer to a clinician she heard was good from her neighbor? That psychiatrists, through refined listening skills, and thorough history taking, can come to a diagnosis, is yet another skill set which seems to be trivialized and devalued. Systems of care look to psychiatrists to prescribe, but not to diagnose. “This person needs meds,” is often the reason for referral, as opposed to “this person needs an assessment.” Looking for an assessment is looking for a deeper understanding of the patient, whereas looking for “meds” is looking for the patient to be contained so the psychotherapy can proceed. Once again, it is clear to me, that with the excitement of our psychopharmacology boom of the early 1990’s, we lost sight of how valuable our diagnostic skills are. We neglected to trumpet that clinicians need to refer to us to help them understand what is going on, and not necessarily to prescribe medication. This nuanced issue is how we lost our way. We offer the mentally ill understanding, in ways that other clinicians, because of their limited training, cannot. We have been through medical school, learning pharmacology, physiology, anatomy and the pathophysiology of disease. We have been through residencies where we spent years in mental hospitals, working with the chronically mentally ill, day in and day out. We have worked in emergency rooms with violent and non-consenting patients, who are both frightened and frightening. We have worked in medical hospitals with patients who have recently tried to harm themselves in drastic and terrifying ways. We have seen the suffering in families trying to deal with a mentally ill relative, with all of the frustrations and despair that go along with this illness. This training, unlike other clinicians, has given us a way to say to people with psychic troubles, that we have seen this before and we understand, even if we do not have the best tools to help them cope. Understanding, even under these dire circumstances goes a long, long way. I never tire of saying that. I taught medical students that yesterday, and in a way, they seemed to understand their training deficits, if they did not undertake a psychiatric residency. Group by group, post by post, I hope to continue on with this message.

4 Responses to “How Important Is A Diagnosis?”

  1. Commenting on your statement: “That psychiatrists, through refined listening skills, and thorough history taking, can come to a diagnosis, is yet another skill set which seems to be trivialized and devalued.” I agree entirely with your comment that diagnosis is extraordinarily important prerequisite for treatment…However, my concern is that without training and education in “refined listening skills” and “thorough history taking”, these skills of a psychiatrist or other mental health provider will continue to be devalued and lost…My worry is that many are not receiving this kind of psychiatric education, nor are they utilizing skill sets beyond a ‘checklist’ of questions…
    In my teaching at the med school (my first academic post), I worked with residents on their interviewing skills, the process of eliciting the information necessary for good diagnostic work. A further concern is that psychiatrists have been relegated to the ‘quick in and out’ necessary for managed care of patients, allowing little time for thoroughness or listening…I’m sharing my concern…but always optimistic that the culture may be changing…

    • Thank you so much for chiming in. I think that discussions like ours, are the first step towards change. We need to expose the issue in order to generate energy to revamp the training. Thank you again!!!’

  2. Shelly said

    I am constantly confused between all the sets of therapists which exist today who do therapy. Except for the psychiatrist, do social workers and psychologists deal with the mentally ill? Yes. Do they do a thorough history taking–yes, may have refined listening skills (perhaps, depending on their training), and can come to a diagnosis with practice–yes?. Can MFCCs and the myriad of other practitioners? If so, then why is there the need for psychiatrists, other than to prescribe meds and train family doctors to prescribe meds? I see your point, Shirah about the loss of the psychiatrists’ place in society, but I still think that psychiatrists do it best. And lets not forget that there is a huge stigma with going to a psychiatrist to get meds, but less so in going to your family doctor to get them.

    • Thank you, Shelly, for articulating the confusion. Yes, there are many ways in which people can become psychotherapists, and the public is often not aware of these differences. The training is so varied, with some mental health professionals, never having the experience in a psychiatric hospital, whereas others have spent years dealing with the spectrum of mental illness. Again, there is no way for the public to know the difference, and hence one agenda of my blog is to bring awareness to the many different types of psychotherapies and psychotherapists. Psychiatrists, in my mind, have taken a poorly conceived strategic move by marketing themselves, as predominantly psychopharmacologists. In the heyday, in the early 90s, there was a great need to explore this new frontier of psychiatric medications. However, as time has passed, we have come to have greater perspective about how medications fit into the overall treatment of mental illness. However, psychiatrists have now lost their way as they forgot to remind the public that we are not only skilled with medication, we are also skilled with diagnostic tools and deep understanding. We need to have a public relations campaign so that people like you are no longer confused. If nothing else, rest assured, I will keep talking about this. Some ideas need repeating.

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