The diagnostic process disorders and diagnoses

Psychiatrists learn during their general medical training that the search for a diagnosis underlying the presenting symptoms is one of the central purposes of medical assessment. This is because if an underlying cause can be found, powerful and logically based treatments may be available. But even in general medicine, as Scadding pointed out 'the diagnostic process and the meaning of the diagnosis which emerges are subject to great variation ... the diagnosis which is the end-point of the process may state no more than the resemblance of the symptoms and signs to a previously recognised pattern'. (!1.) In psychiatry, 'may' becomes 'usually', and this has been recognized by the compilers of both ICD-10 and DSM-IV, in that these are presented not as classifications of diagnoses, but of disorders. These classifications use similar definitions of a disorder; the key phrases in ICD-10 are 'the existence of a clinically recognisable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions', and in DSM-IV 'a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability...'.

The use of such broad definitions is necessary because of the present limited knowledge of the causes of most psychiatric disorders, and a similarly limited understanding of processes that underlie their constituent symptoms. To avoid overoptimistic assumptions, there is much to be said for psychiatrists avoiding the use of the term 'diagnosis' except for the comparatively small minority of instances in which it can be used in the strict sense of indicating knowledge of something underlying the symptoms. A consequence of this viewpoint is that the currently used 'diagnostic criteria' in both these classifications should be relabelled as 'criteria for the identification of disorders'.

In spite of this, it must be accepted that the patient and family are likely to expect statements to be made about the cause of their distress and symptoms. The members of all human groups expect their healers to discover the causes of their misfortunes (i.e. to make a diagnosis), and to provide remedies. This is so whether the group is a sophisticated and scientifically oriented modern society, or a non-industrialized society that relies on ethnic healers and folk remedies. The obvious relief of a patient or family on the pronouncement of an 'official' diagnosis is often evident in any type of healing activity, even though the diagnostic terms themselves mean very little. The pronouncement of an official diagnosis is taken to show that the doctor knows what is wrong, and therefore will be able to provide successful treatment or advice. If the diagnosis is expressed in terms that the patient can understand, it will have additional power as an explanatory force.

The readiness of ethnic healers and practitioners of complementary (or alternative) medicine to provide a diagnosis and treatment in terms that have a meaning and therefore a powerful appeal to their customers is probably one of the main reasons for their continued survival and popularity alongside scientifically based medicine. This is a separate issue from the question of whether or not the treatments of complementary practitioners are successful in the sense of having effects that could be demonstrated by means of a controlled clinical trial.

Within psychiatry and clinical psychology, the medical habit of searching for a diagnosis has at times been misunderstood as an unjustified preoccupation with the presence of physical disease as a cause of mental disorders. This was most marked in the United States during the 1950s and 1960s, expressed particularly in the writings of Menninger in which the diagnostic process and attempts to classify patients were dismissed as a waste of time. (23) This viewpoint ignores two points made here and by many others; first, the choice of a diagnostic term is only one part of the overall process of assessment that leads also to a personal formulation. Second, any assessment of a person, whether made as statements about psychodynamic processes, as statements about structural and biochemical abnormalities, or as statements about interference with activities, is unavoidably an act of classification of some sort.

More detailed discussions about the importance of diagnosis have been provided by Scadding (!1) as a general physician, and by Kendell(24) as a psychiatrist. A detailed analysis of the diagnostic process in psychiatry and its close relationship with classification and formulation is also given by Cooper. (25)

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