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The modern industry of Western psychiatry has secured a range of advances in the care of people who are experiencing mental distress. Today, there is a variety of pharmacotherapies and psychotherapies targeted at managing and understanding the symptoms of distress as well as find new methods of dealing with them. The past model of treating patients with psychological conditions has become obsolete, with community care offering more and more services to support crisis management and early intervention. Besides, the academic community has grown both in numbers and complexity of research, which is another worthy achievement.
Nevertheless, it is imperative to mention that psychiatric theory and practice, including diagnosis practices, have become to a halt. The diagnoses listed in the majority of large manuals on psychiatric diagnoses have not yet been associated with physical tests and biological markers. Therefore, unlike the rest of medicine, the large majority of psychiatric diagnoses are not based on pathophysiological explanations, and no independent data is available to practitioners to support their subjective diagnoses.
Thus, this paper will focus on exploring the view that diagnosis is of limited use for modern clinical psychologists. Despite the fact that the reliability in making diagnoses has enhanced for some purposes of research, the clinical practice has not been improved as the issue of validity persists. However, psychological diagnoses that are made today are as reliable as they can be currently despite the fact that they have no observable organic base. Practitioners monitor the behaviors of their patients as well as what they report about themselves (Randall-James and Coles 2018: 451). Therefore, since there is no other method of diagnosing mental distress in patients, the current procedures are the best (but not enough) that they can be.
Current methods of diagnosing patients are not considered enough for effective treatment due to issues with validity. If one was to apply the standards found in the rest of medicine, then the validity of diagnostic constructs relies on the degree to which it represents a naturally occurring category. The inability of basic science research to discuss specific psychological markers for psychiatric diagnoses means that the existing systems do not have the desired level of research security. With controversies surrounding the diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, it is essential to evaluate the range of diagnostic concepts within the sphere of mental health. Traditionally, psychiatrists have underlined the role of establishing diagnostic categories, implying that they provide a reliable method of treating the identified conditions.
Nevertheless, in everyday practice, diagnosis, independent of other identification methods, does not tell practitioners about the causation of mental health disorders. Also, diagnosis may be ineffective in instructing psychiatrists regarding the forms of interventions that must be undertaken or provide evidence about the experiences of patients with diagnosed disorders. As mentioned by Macneil, Hasty, Conus, and Berk (2012: 1), while diagnosis “may be helpful working concepts for clinicians, many are not valid in the sense that they are not discrete entities with natural boundaries that separate them from other disorders.” Besides, the diagnoses listed in the International Classification of Diseases may not address the case of each patient as patients may be diagnosed with the same condition while having few common symptoms.
In instances of categorical diagnosis, it is essential for psychiatrists to understand the characteristics of conditions with greater homogeneity. Such diagnoses show some demonstrable patterns as well as points in which categorical diagnoses guide the accuracy of treatment. However, very few mental health disorders in psychiatry can match the description of categorical diagnoses. Mood and personality disorders, anxiety, psychosis, and others are linked to a wide variety of etiological factors such as early childhood experiences, family, social stressors, lifestyle choices, medical factors, and other characteristics that contribute to the well-being of individuals (Bystritsky, Khalsa, Cameron and Schiffman 2013: 30). Therefore, it is imperative to incorporate the mentioned categories into individualized treatment plans as an essential quality of care, “with failure to do so not only risking an ineffective outcome, but potentially impacting negatively on the therapeutic relationships and resulting in exacerbation of the person’s symptomatology” (Macneil et al. 2012: 2). Since the mental health of each patient depends not only on the physical manifestations of distress but also on the emotional background as well as experiences that they as people have undergone.
Thus, when it comes to mentioning the causes of psychiatric diagnosis unreliability, it is important to understand the correlation between patient factors and their psychological state. For instance, some individuals may be in a state that will be beneficial for them to offer both reliable and useful information to their psychiatrists (Timimi 2014: 208). Others may not be as willing or able to do so as they may be disorganized in their thoughts due to psychosis or other mental heal issues. Some patients may hide some information from their healthcare providers because of denial, shame, or even fear of legal consequences. Patients with personality disorders may also manipulate the data given to their psychiatrists, and the reasons behind their actions may not always be available. The range of mentioned factors is not always under clinicians’ control despite the fact that they are the ones tasked with the assignment of eliciting the information from their patients and make a rational judgment of psychiatric diagnosis.
Apart from a patient’s psychological state, it is also essential to consider the use of proxy information. As mentioned by Aboraya, Rankin, France, El-Missionary, and John (2006: 43), for individuals who cannot provide reliable information, clinicians should, when possible, use proxy data that may often be distorted and incomplete. Usually, proxy information results from patients exaggerating some elements of stories or minimizing them based on their vested interests. Munchausen Syndrome by Proxy (MSP) is the most important example of dependence on proxy information. It refers to behavioral patterns exhibited by caretakers who deliberately fabricate, exaggerate, and may even induce both psychological and physical health problems in others. In this case, it is expected that information by the proxy would obstruct the formulation of a reliable diagnosis (Hall, Prochazka, and Fink 2012: 533). In instances such as dementia, psychiatrists are challenged by collecting the information provided by the patient’s family, which can also lead to an unreliable diagnosis. Overall, when proxy information is given to psychiatrists, it is essential to evaluate its quality for determining relative utility in diagnosis formulation.
Psychiatric diagnoses are also greatly challenged by the reliance on observations. The utilization of clinical data that has been derived from direct observations is at the center of examinations on mental status (Surís, Holliday and North 2016: 5). Regardless of the methods used for making a diagnosis, there is the potential that the standardized methods that clinicians use for soliciting information can result in bias data. In addition, performance-based measurements of functional abilities have been created for allowing clinicians to observe activities of daily living (ADL). The reliance on these instruments of observation introduces possibilities of systematic bias that may adversely affect the formulation of diagnoses. Most importantly, the increased likelihood of false negatives does not provide a reliable basis for making conclusions about patients’ mental health conditions, which means that reliance on observational data makes psychiatric diagnosis not enough for most practitioners.
The clinician interview is another aspect included in the process of diagnosis formulation. As psychiatrists practice interviewing, they develop their personal styles and methods. Those who have effective interviewing skills can establish a positive rapport with their patients and make them feel comfortable when sharing information about their emotional state and experiences. Most practitioners implement open-form interviews when evaluating the mental well-being of their patients (Williams, Olfson, and Galanter 2015: 303). Although, the reliability of diagnoses in psychiatry that is based on this type of interview has been identified to be low (Aboraya et al. 2006: 45). There are several reasons that explain the unsatisfactory quality of diagnosis made with the help of open-ended interviews.
First, psychiatrists tend to give the most attention to the most significant and pressing symptoms thus failing to consider other manifestations that tend to be less acute. Second, clinicians experience pressure from a range of institutional requirements and various financial incentives to make a diagnosis that would get reimbursed at a higher rate. While it is desirable for practitioners to make diagnoses that can facilitate patients’ receiving insurance coverage or governmental assistance, such diagnoses may not be reliable. Third, unstructured interviews increase the changes in important areas of an inquiry being lost or overlooked (Jamshed 2014: 88). Therefore, it is essential to approach the structure of open-form interviews with a high degree of scrutiny since they are challenged for not being adequate enough for good clinical practice.
Another important aspect that limits the reliability and validity of psychiatric diagnoses is associated with the atypical representation of patients’ mental health disorders. Because the majority of psychiatrists use the criteria of the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual of mental disorders (DSM), the typical presentation of disorders needs to align with these guidelines. For instance, according to DSM-5 criteria, an individual exhibiting a major depressive symptom should experience fatigue, either insomnia or hypersomnia, the loss of focus, and the presence of suicidal thoughts over the period of at least two weeks (Tolentino and Schmidt 2018: 450). Despite this classification, some patients may not have the typical manifestation of depressive symptoms. Even those individuals that require severe clinical treatment for depression may not present the textbook definition. In some cases, physiology-related changes can influence the manifestation of mental health disorders later in their lives. Therefore, patients with atypical representations of psychiatric disorders can represent a challenge to even the most experienced professionals and cause unreliability in their diagnoses. This means that it is essential for diagnosticians to consider that the large majority of patients do not fit classic psychiatric diagnoses.
The formulation can be used as an alternative to current procedures of diagnosis. It refers to the process of formulating a hypothesis regarding the causes and maintaining influences on an individual’s psychological and behavioral issues (Eels 2007: 37). Thus, instead of developing a diagnosis based on observations, interviews, clinical guidelines, or self-reported data that contribute to bias and the loss of reliability, it can be beneficial for clinicians to use the Five P’s approach to formulations. The first aspect refers to presenting a problem, which goes beyond regular diagnoses and also includes the components that both the clinician and a patient find difficult (Macneil et al. 2012: 3). The second aspect is predisposing factors that represent possible genetic issues, biological factors, personality, and psychological problems, environmental conditions, and other characteristics that may limit one’s ability to develop good mental health.
The third aspect of the formulation is precipitating factors that represent events that have occurred prior to the onset of a mental health disorder and can include anything from financial stressors to substance abuse (Clark, Cuthbert, Lewis-Fernandez, Narrow and Reed 2017: 72). The fourth aspect refers to perpetuating factors that maintain the occurrence of current difficulties that patients experience. For example, these can include repeated behavioral issues or biological factors that prevent patients from maintaining a healthy and balanced mental state. The last aspect is the protective or positive factors which involve the identification of strengths or supports that reduce the adverse influence of psychiatric disorders.
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In summary, the formulation may represent a more flexible method of gathering and synthesizing information about patients’ mental health state. In contrast to the standardised diagnosis methods that are limited by hidden information, biases and reliability, formulation is a beneficial alternative that will allow clinicians to assess and treat patients’ mental health states. Most importantly, diagnostic procedures must include better rapport and positive relationships between psychiatrists and their patients, and formulation can offer such an improvement. Further research is needed not only to identify the limitations of psychiatric diagnosis but also for formulating methods for the effective identification of mental health conditions and interventions for their management. A focus should be placed on studying relationships between psychiatrists and their patients.
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