The result of the exploration of the clinical condition in the context of a patient's life cannot, for the time being, be replaced by laboratory findings nor by neuroimaging and electroencephalographic recordings. The summary of the observations of a skillful clinician—including a diagnosis and a mention of the syndrome that has been observed—remains one of the main tools of work in psychiatry, and its preparation should be given priority because it can be the best guide for the treatment of mental illness, for decisions about directions of research, and for the organization of education of all categories of health personnel.
The answer to the editors' question is therefore not diagnosis, nor syndrome, but both, as well as other information about the patient's life and illness relevant to the understanding of the mental disorder and of the individual who suffers from it.
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In-person and telehealth appointments available. These discussions present an opportunity for patients to explain their cultural and personal position regarding the utility and implications of a diagnosis, and enables clinicians to negotiate with the patient why a particular diagnosis might be useful or helpful. Diagnosis focuses on pathologies and weaknesses, yet recovery is strengths based. Being misdiagnosed with a disorder can lead to iatrogenic harm from inappropriate treatments, but it can also preclude access to more helpful interventions, such as trauma-focused care.
Therefore, diagnosis always has an ethical dimension. GPs will care for patients who have experienced considerable harm from misdiagnosis, and they can play a critical role in establishing a good therapeutic alliance.
One consumer, Inigo Daya, writes about her experience where diagnostic harm outweighed benefit. Prior to that understanding, she had experienced involuntary hospitalisation, multiple medications and electroconvulsive therapy, each treatment associated with significant iatrogenic harm. She notes that the biggest cost was the threat to her identity and agency, describing a sense of hopelessness as she adapted to a future with chronic treatment-resistant mental illness.
Her story emphasises the importance of formulations and the dangers of premature closure. For Aditya, there are significant ethical concerns. The GP must make a psychiatric classification that has merit and integrity: the diagnosis should be accurate. Coupled with this is the issue of justice. This needs to be carefully managed. The benefits of the diagnosis — including access to services, treatments and support — must outweigh the harms.
There is also a harm in seeing Aditya as the problem rather than understanding that he is part of a dysfunctional family system. A good formulation may be helpful if the GP is able to acknowledge any trauma Aditya has experienced growing up in a high-conflict home.
Psychiatric diagnosis is not a simple act of classification. As Sadler would say, we are not botanists. GPs have a responsibility to make their diagnosis as complete and clinically useful as possible, and that involves systematically exploring the science, art and ethics of mental illness experience.
Did you know you can now log your CPD with a click of a button? Diagnosis General practice Mental disorders Mental health Social stigma. Making a good mental health diagnosis: Science, art and ethics. Background There are limitations to psychiatric classification, which affects the utility of diagnosis in general practice.
Objective The aim of this article is to explore the principles of science, art and ethics to create clinically useful psychiatric diagnoses in general practice. Discussion Psychiatric classification systems provide useful constructs for clinical practice and research.
Case Aditya is boy aged 10 years who presents with his mother, Nisha. Science: The accurate diagnosis Science is embedded in the work of medicine, and because it is an integral part of the culture of clinical care, it can be difficult to recognise and acknowledge its limitations.
Making an accurate psychiatric diagnosis 52 Psychiatric diagnosis is complex and involves history-taking and evaluation. Screening: It is not uncommon for patients to have completed a screening tool prior to the assessment. Remember that screening tools are not diagnostic, so the GP needs to do a complete assessment before committing to a diagnosis.
Current concerns: This includes exploring specific symptoms, the context including events leading up to this presentation , the time frame and whether symptoms fluctuate, the factors that exacerbate or reduce symptoms and the history of past treatments. Remember to ask specifically about symptoms that may be difficult to discuss, including suicidal thinking.
Developmental history: 53 This involves exploring childhood experiences, environment and relationships, and includes trauma histories, interpersonal relationship challenges and physical health issues, such as chronic illness. Remember that the impact of adverse childhood experiences is cumulative, so although GPs do not need to know exactly what occurred in childhood, patients who recount multiple instances of trauma are more at risk than those who have experienced a single incident.
Trauma histories need to be explored sensitively, because the risk of re-traumatisation is high. In general, it is more important to understand that trauma occurred than to ask a patient to recount the nature of that trauma in detail. Family history Past medical and psychiatric history Drug and alcohol history Premorbid personality: In order to facilitate recovery, it is important to understand who the person experiencing the illness really is.
Current social situation: Remember to ask about dependents, safe housing, exposure to ongoing violence and financial concerns, as these will impact recovery and capacity to access treatments. Mental state examination: A mental state examination contains observations relating to appearance, behaviour and rapport speech eg rate, dysphasia or problems with articulation mood the internal feeling as described and affect the observed emotional response thought disorders including abnormal content — such as delusions, overvalued ideas, suicidal thoughts, obsessions or phobias — and thought process — such as disorders of the form, stream or possession of thoughts perception eg hallucinations cognition often measured by a mini-mental state examination intelligence judgement insight.
Physical examination and investigations: It is important to detect and manage comorbidities in patients with a mental health concern, especially if organic cerebral pathology is suspected. Art: The comprehensive diagnosis Psychiatry has a long history of narrative diagnosis, understanding why people are the way they are by exploring their life histories.
Box 2. General practitioners GPs might consider family history of mental illness; personality issues; social context, such as long-term and intergenerational unemployment; and interpersonal history, including trauma. Precipitating factors These are subacute factors that drive the current presentation.
GPs might consider recent issues, such as physical illness, medication side effects, substance abuse, life events and stressors, workplace issues, discrimination or harassment and social circumstances.
Perpetuating factors These factors are ongoing and may need to be addressed in psychological therapy or through other psychosocial interventions, such as financial support or housing. GPs might consider chronic illness, relationship issues, responsibilities for children or aged relatives, loneliness, financial problems and unstable housing.
GPs might consider ongoing treatment, existing coping skills, personality traits, social connections and a sense of meaning and purpose. Box 3. Understanding bias: Is mental health assessment and management really based on objective criteria? Garb 41 performed a meta-analysis of studies examining social expectations and stereotypes eg racial bias, social class bias and gender bias in clinical judgment and found trends for bias in some specific tasks but not others.
Most studies presented clinicians with written vignettes, manipulating only the social characteristics ie their ethnicity, gender or socioeconomic status. The difference in clinical judgment between conditions indicates potential bias that cannot be accounted for by differences in cultural expression.
The following clinical decisions were affected. Box 4. Ethical principles in psychiatric diagnosis 54 There is a framework of moral principles that underpin mental health practice, including diagnosis.
Autonomy Respect for autonomy recognises that patients have their own views, capacities and perspectives, and they have a right to exercise that autonomy by making informed decisions.
Psychiatry is unique in that it can restrict personal liberty. General practitioners need to manage the fear of loss of autonomy thoughtfully and support the patient when restriction of liberty is required eg with high-risk suicidality. A new study, published in Psychiatry Research , has concluded that psychiatric diagnoses are scientifically worthless as tools to identify discrete mental health disorders.
The study, led by researchers from the University of Liverpool, involved a detailed analysis of five key chapters of the latest edition of the widely used Diagnostic and Statistical Manual DSM , on 'schizophrenia', 'bipolar disorder', 'depressive disorders', 'anxiety disorders' and 'trauma-related disorders'.
Diagnostic manuals such as the DSM were created to provide a common diagnostic language for mental health professionals and attempt to provide a definitive list of mental health problems, including their symptoms. Lead researcher Dr Kate Allsopp, University of Liverpool, said: "Although diagnostic labels create the illusion of an explanation they are scientifically meaningless and can create stigma and prejudice.
I hope these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences. Professor Peter Kinderman, University of Liverpool, said: "This study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose. Diagnoses frequently and uncritically reported as 'real illnesses' are in fact made on the basis of internally inconsistent, confused and contradictory patterns of largely arbitrary criteria.
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