tag:blogger.com,1999:blog-8489009971732520747.post1984283226665208622..comments2024-03-24T07:19:28.136+00:00Comments on Lake Cocytus: DiagnosisThe Shrinkhttp://www.blogger.com/profile/10009039342346247138noreply@blogger.comBlogger3125tag:blogger.com,1999:blog-8489009971732520747.post-7284958644196747112008-09-24T10:21:00.000+01:002008-09-24T10:21:00.000+01:00Great post, and relevant to mine today about case ...Great post, and relevant to mine today about case formulation!<BR/>I don't like 'diagnosis' particularly because I think it leaves us without possible explanations for individual unique presentations - and diagnoses might help you and I talk about what is going on (as a sort of verbal shorthand), but it doesn't unpack the various factors that may need to be addressed during intervention. <BR/>I wonder whether a diagnosis is so helpful when we start looking at a biopsychosocial model - or when it's disability we're looking at rather than impairment.<BR/>Perhaps diagnoses are great in certain settings (eg research, or where a clear mechanism has been identified, or where clinicians need to communicate with each other) - but less useful during the process of therapy, or where the impact of a problem starts to affect the life of a person.<BR/>Bronnie, Adiemusfree<BR/>http://healthskills.wordpress.comAdiemushttps://www.blogger.com/profile/10916409292989654972noreply@blogger.comtag:blogger.com,1999:blog-8489009971732520747.post-85018595988366951982008-09-22T23:32:00.000+01:002008-09-22T23:32:00.000+01:00(Apologies in advance for the long comment)Regardi...(Apologies in advance for the long comment)<BR/><BR/>Regarding diagnosis, you make a very strong case for the absolute importance of this approach in physical health care.<BR/><BR/>However applying these arguments to mental health without some qualification is problematic in my view. Here are two things which trouble me when thinking about this:<BR/><BR/>1. The interaction problem<BR/><BR/>(This one is only going to be an issue for you if you believe, as I do, that psychological factors (beliefs, values, emotions, volition etc) have some role to play in the aetiology and / or maintenance of MH problems.)<BR/><BR/>The problem in MH (and to some extent in physical health) is that the very condition being diagnosed can improve or worsen in response to being told one's diagnosis. For example, panic attacks can become panic disorder when a person appraises normal psychological and physical phenomena (e.g., thoughts racing, pulse racing) as evidence for impending mental or physical catastrophe (e.g., ‘I’m going mad’ or ‘I’m having a heart attack’). Conversely, being informed you simply have ‘panic disorder’ can reduce your conviction that you are not 'going mad' or having a heart attack. If you have faith in this being the correct diagnosis, then this will reduce your anxiety and reduce the frequency of your panic attacks. There is a beneficial interaction between the diagnois and the condition being diagnosed.<BR/><BR/>It can go the other way too though. Imagine the following:<BR/><BR/>Someone comes to you saying that they have started hearing voices and they worry this means they are going mad. Assessment suggests the voices are much more frequent and intense whenever the person gets really anxious. The person only gets really anxious whenever they find themselves worrying that the voices mean they are developing a psychotic illness (such as schizophrenia). <BR/><BR/>Given the above, we might reasonably predict that diagnosing that person with a psychotic illness is likely to increase their anxiety and in turn increase the frequency and intensity of the voice hearing (notably, risk of suicide also increases following a diagnosis of major mental illness and if fears of mental disintegration are present). This is an example of a detrimental interaction between diagnosis and the condition being diagnosed. <BR/><BR/>I suppose we could also predict that the less 'psychological' a problem is, the less there is an interaction effect (beneficial or detrimental) Clearly, diagnosing a person with dementia does not cause them to develop dementia.<BR/><BR/>Whether the interaction effect is an argument against diagnosis in MH, or an argument against telling people their diagnosis is not clear to me. Follow the link to an interesting response by philosopher Thomas Pogge to this very problem:<BR/><BR/>http://www.askphilosophers.org/question/2061<BR/><BR/>You’ll note from his response that complete honesty may not always be the most ethical policy.<BR/><BR/>2. Values<BR/><BR/>Consideration of values is much more relevant in MH than in physical health. In physical health, it's fairly uncontroversial to refer to problems encountered as 'illnesses' and 'diseases'. We don't disagree over the negative value of cancer, for example. <BR/><BR/>But in mental health, controversy reigns supreme - whether professionals or service users like it or not. In such a climate, 'objective' diagnoses are a hard call. This is why I think distress (subjectively defined) and impaired capacity are the only decent justifications for psychiatric input. That is, diagnosis on it’s own is not enough. I think this argument holds true across constructs like 'delusions' and 'personality disorder' and so on. <BR/><BR/>If a client is distressed and asking for help and / or has impaired capacity I agree the benefits of an accurate, comprehensive, reliable and valid diagnosis are immense. Not harming the client with inappropriate treatment, the planning of effective interventions, the prediction and prevention of future distress / impairment and developing better treatments are all very good reasons for retaining some sort of classification system. <BR/><BR/>However I agree with the view that the ICD-10 / DSM-IV systems DO NOT provide reliable or valid diagnostic categories when it comes to things like depression, anxiety, ‘personality disorder’ or psychosis – primarily because of reification of social norms, astonishingly high levels of comorbidity (i.e., a lack of the desired symptom clusters) and poor reliability. <BR/><BR/>I may be wrong but for these and some other problems I agree with those who argue the solution is likely to be a dimensional symptom focused approach where the cut-off point between ‘health’ and ‘illness’ is driven by considerations of distress, help-seeking, impaired decision-making capacity and available resources. <BR/><BR/>Judgements of ‘mental illness’ should no longer be talked about as if they were objective and value free. Instead we should make the value judgements explicit and we should get them right, as far as we can. <BR/><BR/>The best way to get the values right, in my view, is to promote service user involvement as far as possible.Paulhttps://www.blogger.com/profile/04254403035647731234noreply@blogger.comtag:blogger.com,1999:blog-8489009971732520747.post-85738100005705826062008-09-22T15:23:00.000+01:002008-09-22T15:23:00.000+01:00Your point is a good one in the situation you cite...Your point is a good one in the situation you cite, where the same symptoms can come from different diagnoses. What worries me is when those symptom clusters have not been fully differentiated and varying symptom clusters are lumped under one diagnosis. My son has ADD with some autistic features, but I have avoided the Asperger's diagnosis because I think that will lead not to more appropriate treatment but to less appropriate treatment. He doesn't fit the standard pattern of Aspergers. <BR/><BR/>The other interesting case is very early stages. My husband has been diagnosed with Lewy Body Dementia. He is currently in Washington DC doing research at the Library of Congress and staying with an aunt. I am, in the balance, glad I know and can prepare for the future, and Aricept has helped him. But it is hard knowledge to live with, particularly when almost everyone says "He seems fine."Pemhttps://www.blogger.com/profile/15013673393201944341noreply@blogger.com