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Diagnosing Mental Disorders: Time to Lift Our Game

Friday, August 31, 2018

Getting an accurate diagnosis for problems of the mind still lags well behind the science of diagnosing problems of the body, or physical conditions. All too often, I hear that a diagnostic “label” has been given to a client on the barest of symptoms and commonly without any use of diagnostic procedures.

I don’t believe anyone would be happy with being told they “probably have liver cancer” on the sole basis of reporting abdominal pain. At the very least, we’d expect a series of questions about symptoms including pain, energy levels, appetite, digestive changes and much more. Then we’d expect to have medical tests – standardised procedures with a solid evidence base - such as an ultrasound, blood tests, even a biopsy before we accept a definitive diagnosis. We’d consider this normal before starting any form of treatment.

However, when it comes to conditions of the mind, we seem willing to accept something far less rigorous, and plunge ourselves into treatment regimes, including medications, without even asking about options.

As an example, it’s sadly still common to have a client referred with a diagnosis of, say, Bipolar Disorder on the basis of a brief clinical interview. The patient may have reported periods of low mood, hopelessness, irritability or outbursts of anger that fluctuate with periods of feeling energetic, sleeping less than usual, or having a burst of grand ideas. Depending on the mood state at the time – either low or high – they may be prescribed either antidepressants or a mood stabiliser without much, if any, other diagnostic investigation.

And the rub is that inappropriately prescribed medications for mental health problems can have a range of side effects that in themselves set off a cascade of physical and psychological changes that can be problematic, as well as masking the original symptoms, making it even harder to get to the core of the real problems (if any).

Diagnosing mental health disorders – problems of the brain and the mind – is a complex process that cannot be done properly in a single brief clinical interview.

Detailed History-Taking

A detailed history of the patient’s physical, emotional, cognitive, social and cultural experiences looking for potential triggers in each group is absolutely basic. Finding out how that person typically responds to life events helps us formulate an idea of the influence of personality, whilst getting a detailed life history of parents and grand-parents helps uncover patterns that may have a genetic basis. Understanding how their cultural background and belief systems shape the way they think and feel – or even interpret physical changes in the body – is absolutely necessary to determine whether the person is unwell.

Using Validated Psychological Tests

To help us put symptoms into perspective, psychologists have a wide range of tests we use to measure how far out of the normal range are a patient’s symptoms. At the very least, the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure is a quick-and-easy self-report profile of psychopathology based on the internationally defined criteria for all mental health disorders. Depending on the information emerging from this screening tool, patients may then complete several of the Level 2 Cross-Cutting Symptom Measures which focus in on more specific clusters of symptoms that might indicate conditions like Depression, Sleep Disorders, Mania, Substance Abuse and others.

Each of these allows the clinician to drill down to gain a deeper understanding of the patient’s mental health condition.

Investigating Severity

Then we want objective data about the severity of symptoms, and factors influencing severity, along with personality factors such as negative affect, detachment, or antagonism. These measures give us important details that help narrow down the range of possible pathologies or disorders, and the complex interactions between states (how we feel or experience ourselves and the world moment-to-moment) and traits (general patterns to our responses to experiences). Most importantly, we could use the Early Development and Home Background (EDHB) Form to investigate early-life experiences such as trauma or broken attachments that we know shape the development of the brain, and hence the mind.

Other Possible Influences

Finally, the Cultural Formulation Interview (CFI) helps the clinician find out more about the presenting clinical problem from the point of view of the person within their social network (i.e., family, friends, or others involved in the current problem). It also includes the problem’s meaning (what the person believes about their symptoms), potential sources of help they have used or might use (like herbal medicines or religious activities), and expectations about the value of services they might use for recovery.

So the next time you hear of someone being diagnosed with depression just because they told the doctor they were feeling sad or can’t sleep, or any other mental health condition without having had a comprehensive diagnostic assessment, please recommend that they seek advice from a practitioner specifically trained in drilling down to get an accurate diagnosis. And who can then follow that up with a treatment plan that tackles the real problem, not just relieves symptoms.

Dr Kate Lemerle, Psychologist

Chrysalis Counselling & Coaching, Norfolk Island


TEL: 52112 or email

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