The Nuts and Bolts of Diagnosis

Have you ever sat at your desk, or work space, opened the DSM IV and seriously attempted to digest the criteria? What do you make of the exclusionary criteria, riders, modifiers, specifiers, or whatever these are called nowadays? And if you think it’s a challenge now, just wait for what DSM-5 has in store for you. So why the complexity, why is there seemingly so much for us to have to wade through? Here’s why:

The more complex a disorder seems to be, the more its criteria will be dressed up with nuances and extraneous data that attempt to cover entirely too many bases. Many of those crafting and drafting criteria spend the majority of their time – if not exclusively – operating in the academic world. Some have never worked face to face with a patient – ever. And that’s fine, it’s just that most of us toiling away day to day in the trenches aren’t academics and are in need of a diagnostic bible that we can easily get our heads around and decipher quickly. There’s no such thing as diagnostic perfection, it is success that we’re seeking. And success is defined this way: Has the client’s position (or condition if you’d rather) improved as a result of coming to us. Nothing else really matters.

So if wading through criteria has proven to be a conundrum for you, here’s how to proceed: Read the disorder criteria for each classification discriminately; don’t try and memorize it, just familiarize yourself with it and make notes that help you remember the key points. Do this because you first need an understanding of what might be coming at you when you’re in session. Then, after working with the client, ask yourself what your clinical expertise, judgment, intuition, insight and common sense are telling you about this person and their presenting (or ongoing) problem list. Assuming you’re taking notes in session – and if you’re not, you’d better be able to trust your memory – go back and match up your session notes with those that you’ve made about the criteria for diagnosis A or B. Then mesh these with your impression of the client. Decide what to call it, and then proceed with treating it, as best you can. And understand that diagnosis is a moving target, not an endpoint. It will wax and wane with the rhythm of the client’s life.

Diagnosis isn’t all that complicated when you’re asking the right questions, observing appropriately and listening intently.

And finally, seek out collateral sources of information that are supportive of the client’s efforts to get better. There’s no better way to confirm your findings, so explain to the client that having them sign a consent permitting you to obtain outside input is in their best interest. If they refuse, consider that a red flag. Collateral sources are important to the diagnostic process because lying, lying by omission, minimizing, rationalizing and denying are all common, in spite of evidence to the contrary.

All of the above is pursuant to advancing to the next step – developing a customized, individualized treatment plan with established behavioral objectives that can measured in terms of progress. And this assumes the client wants to be helped, otherwise all bets are off. It is amazing to me how many people come to my office and want to fork over their money just to hear me tell them that they’re fine, the world’s against them and that their problems are all their mother’s fault. Accepting money for doing that would be reprehensible on my part.

Joseph Wegmann, R.Ph., LCSW is a licensed clinical pharmacist and a clinical social worker with more than thirty years of experience in the field of psychopharmacology. His diverse professional background in psychopharmacology and counseling affords him a unique perspective on medication management issues. In addition to consulting with numerous psychiatric facilities, he has presented psychopharmacology seminars to thousands of clinicians in 46 states.

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