Critical Values Based Practice Network

C-VBP-N

Difficulties with Diagnosis

Written by Steven Coles on . Posted in Clinical Psychology Bite-Size

Difficulties with Diagnosis

Issue 06 – September 2008

Key points

  • There appears to be a continuum between what is deemed ‘psychotic’ and so-called normality, rather than distinct diagnostic categories.
  • Unlike medical diagnosis in physical health, psychiatric diagnosis lacks clear physical markers (signs) and is reliant on what clients say and do (symptoms).
  • Psychiatric diagnosis does not appear to reflect real or meaningful categories.
  • Diagnosis of “schizophrenia” is a poor predictor of outcome (symptomatically and socially) and does not indicate response to specific psychiatric medications.
 Implications for research and practice
  • Clinically an alternative to diagnosis would be understanding service users’ experiences in relation to their life experiences and social world.
  • It is argued that mental health research should focus on understanding specific difficulties (e.g. hearing voices) rather than use diagnostic categories.
Diagnosis is a common and everyday part of mental health practice, however, diagnosis has not been beyond criticism. Some of these critiques of diagnosis in the realm of the “psychoses” will be summarised. Psychiatric diagnosis is based on medical diagnosis in physical health, however it is questionable whether psychiatric diagnosis shares much in common with medical diagnosis. Unlike diagnosis in physical health, psychiatric diagnosis lacks physical signs (e.g. a blood test) and is reliant solely upon symptoms (what people say and do). In addition, early research showed that clinicians often disagreed about what psychiatric diagnosis to give someone. Whilst diagnostic manuals such as DSM-IV mean there is greater agreement, such improvements have only been modest1,2.   Category or Continuum? Within a psychiatric diagnostic system a person is placed as either having or not having a specific illness e.g. “schizophrenia”. However, research suggests different diagnoses overlap extensively and that there is a continuum between experiences deemed ‘psychotic’ and those experienced within the general population1,2. Further, some experiences diagnosed as ‘mental illness’ might be found to be positive and adaptive, such as having a positive spiritual interpretation of hearing a voice.

Meaningful Patterns?

Historically when the diagnosis of ‘schizophrenia’ was first created, its formation should have been based on the discovery of a meaningful pattern between different symptoms3. However, there is no evidence of any meaningful pattern being discovered between the different behaviours and experiences observed in patients3,4. Currently, research using ‘cluster analysis’ does not support the use of psychiatric diagnoses such as ‘schizophrenia’1. Overall, research suggests that diagnostic categories do not reflect any real or meaningful categories, for example there is extensive overlap of symptoms between different diagnostic categories. Boyle (2007)5 points out that it is not really surprising that a system (medical diagnosis) created to study body parts does not work when applied to psychological experience and behaviour, she notes body parts “…..don’t have language or emotions, form beliefs, make relationships, create symbols, search for meaning, or plan for the future” (p 290).

Does it Predict Prognosis and Treatment Response?

For diagnosis to be useful it should be able to predict outcome and suggest what treatments will be helpful. However, research has highlighted that there is great variability in the outcome of people given a diagnosis of “schizophrenia” (symptomatically and socially)1,2. Also, research highlights that response to psychiatric drugs is better predicted by specific difficulties (e.g. voices, mood) rather than by psychiatric diagnoses such as ‘schizophrenia’ or ‘bipolar’1, 2.

What are the Alternatives?

If diagnosis is not a meaningful way to understand people with very distressing experiences and life circumstances, what are the alternatives? Clinically, several authors have put the case forward for collaboratively working with people who use services to make sense of their experiences. This would involve negotiating a shared meaning of their difficulties and wherever possible a way forward. This would often involve understanding people’s experiences in relation to their social world and life history. Pilgrim (2000)7 notes an understanding of a person’s context and world is more likely to help us understand their needs than the label of “schizophrenia”. In terms of research, Richard Bentall has strongly advocated for focussing on specific difficulties or ‘symptoms’ (e.g. hearing voices, low mood etc) and argues that this approach is advancing far quicker than approaches based on diagnosis6.  

Conclusion

The evidence suggests that the distinctions made between diagnostic categories are not conceptually meaningful or useful.  It is recognised that people have significantly distressing experiences and circumstances and finding an alternative to diagnosis does not undermine these difficulties and experiences, rather it hopes to create more meaningful and personally informed ways of helping and providing support.

REFERENCES

  1. British Psychological Society. (2000). Recent advances in understanding mental illness and psychotic experiences. A report by the British Psychological Society Division of Clinical Psychology. Leicester: British Psychological Society.
  2. Bentall, R. P. (2003). Madness explained: Psychosis and human nature. London: Penguin Books.
  3. Boyle, M. (1999). Diagnosis. In C. Newnes, C. Dunn & G. Holmes (Eds.), This is madness: A critical look at psychiatry and the future of mental health services (pp. 75 – 90). Herefordshire: PCCS Books.
  4. Boyle, M. (2002). Schizophrenia: A scientific delusion? (2nd Edition). London: Routledge.
  5. Boyle, M. (2007). The problem with diagnosis. The Psychologist, 20 (5), 290 – 292.
  6.  Bentall, R. P. (2007). Researching psychotic complaints. The Psychologist, 20 (5), 293 – 295.
  7.  Pligrim, D. (2000). Psychiatric diagnosis: More questions than answers. The Psychologist, 13, 302 – 305.
     

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