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. And some of those crafting and drafting criteria have never worked face to face with a patient – ever. What those of us toiling away day to day in the trenches need is a diagnostic bible that we can easily get our heads around and decipher quickly.

There’s no such thing as diagnostic or treatment 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 criteria for each disorder discriminately, focusing on those within the sphere of your expertise. Just familiarize yourself with them and make notes that help you remember the key points. Then, after you begin 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 — match up your session notes with those that you’ve made about the criteria for disorder A ,B, C, etc. Mesh these with your impression of the client. Decide what to call it, and then proceed with treating it. 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.

Seek out collateral sources of information which 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 assessment and diagnostic process because lying, minimizing, rationalizing, denying and omission are common to some clients to varying extents.

All of the above is pursuant to advancing to the next step — developing a customized, individualized treatment plan with established behavioral objectives that can be measured in terms of progress. Be prescriptive and not solely diagnostic by telling people what will help them; don’t strive to merely achieve consensus with the client. You’re the thought leader in the room. And this assumes the client wants to be helped, otherwise all bets are off.

We are expected to guide a client toward unburdening themselves as part of assessment, diagnostic and treatment protocols; the heavier lifting though — the change process — is theirs to own or not.

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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

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