By: Peter
Tyrer and Kenneth R. Silk
Why, you may well ask, has a book about treatment found it necessary to begin with a section on diagnosis? Since the introduction of DSM–III (American Psychiatric Association, 1980), diagnosis has seemed to become the ‘holy grail’ of psychiatry. Yet currently, diagnosis is in the doghouse, as the quotations above, spanning nearly a hundred years, illustrate. But, even though we despair at regular intervals, we continue to want a nice clean system that allows psychiatric patients to be pigeon-holed by clever clinicians who then have both an explanation of a disorder and its solution. For the hope has always been that if a specific diagnosis is made correctly, that the proper and best treatment will follow almost automatically.
If only psychiatry were that easy! If it was, then that book would not be necessary, for
from the proper diagnosis would flow the essential
treatment. But in psychiatry, and we would venture to say in most other specialties as
well (though perhaps not so
readily acknowledged by other practising physicians as in psychiatry), the diagnosis
not only does not point
directly towards treatment but can become a source of major conflict between clinicians
and patients, and lead to
allegations of the generation of stigma, labelling and other counter-productive arguments.
Then why do we persist with trying to refine and rework diagnoses and diagnostic
manuals, and furthermore, why give it pride? In
psychiatry, the path
from correct diagnosis to correct explicit treatment is neither straight nor
unambiguous and probably depends upon a number of different factors. The first factor
might be
the way diagnoses have evolved or developed in psychiatry, especially since,
but not solely because of, the development of the editions of the DSM or the ICD that
were advanced in the mid
1970s and became established as the DSM–III in 1980 (American Psychiatric
Association, 1980)
and the ICD–9 (World Health Organization, 1975, 1978) in 1975 with its clinical
modification in 1978.
Both of these then new iterations of prior diagnostic
manuals profoundly
changed the way psychiatrists approached diagnosis on both sides of the Atlantic. Rather than
making a
diagnosis based upon a number of different factors that included not only the ‘chief’
or presenting complaint, the specific symptoms that surrounded or accompanied the
chief complaint, and the
associated physiological and somatic concerns and complaints, while also
considering the
patient’s capacity for empathy, the nature of his rapport or stance or
‘posture’ in relationship to the interviewing physician, the congruence of his
affect with the content
of his speech, and his ability to step back and view and comment on his own behaviour,
the psychiatrist using
the ‘new’ post 1980s approach basically needed to consider only the chief
complaint with its accompanying symptoms, since together they were thought to be part
of the
package of the patient’s overall psychophysiological, i.e. biologically determined,
disorder. Empathy, relationship to the interviewer or to other people, capacity
for insight, even
motivation to change took on less significance, if any at all, as the new psychiatry,
determined to look and feel like the rest of medicine, moved rapidly down the one
diagnosis-one treatment road. If you got the diagnosis right, the choice of treatment would
be, as
they say, a ‘no-brainer’.
This process can be compared with travelling on an expanding limited-access
highway system where all you needed to know was what
exit to take. Get on the correct road and take the correct exit and you would speedily
be led to your desired
destination. Get on the right diagnostic road and you will soon arrive at your destination, the
right treatment.
If the things that you needed at a specific exit were not that close by and to
make things even clearer and more precise with less chance for error, more exits
leading to
more highways could be built (or more diagnostic entities created) so that you
could arrive at your destination even more rapidly and efficiently. Of course, one of
the problems
with the interstate highway system, at least in the USA, is that, from the
highway, all the roads look the same; and even when you get off the highway, the
interchanges, with their almost standardized or perhaps operationalized
conglomeration of fast food chains and service stations (symptoms and
checklists), all, at least from some distance, look the same as well. You get little
impression of the
people who live and work in that particular area. But venture perhaps no more than a
mile from the interstate, and you will find towns and cities and country roads
that carry with them the
specific distinction, flavour, and even peculiarity of the people and the geographical
areas that
you are passing through. Such a diversion from the interstate may not get you to
your destination sooner, and it may not even appear initially to lend any valuable
information to the journey. Yet it may convey a completely different and more complex
sense experience and, in turn, appreciation of the trip that the shorter,
faster, more direct
route, the route the map searches on the computer produce when queried, places
little or no value upon. The second factor is related to other specific ideas
about psychiatry,
diagnosis and biology that developed throughout the 1970s. There evolved a number of ideas
that took hold beginning
in the late 1960s that were to change psychiatry and the diagnostic process
profoundly.
There developed the belief that we could, with enough expertise and diagnostic
rigidity, isolate very specific diagnostic entities in psychiatry; and further
that these specific entities were separate and distinct from other
diagnostic entities.
For example, there evolved the idea that depression, i.e. mood disorders, could
clearly, in many cases, be distinguished from anxiety disorders. There was even a
specific test developed,
the dexamethasone suppression test (DST), that was purported to be able to
distinguish true
melancholic depression from other entities. The title of that seminal paper in 1979,
‘A specific laboratory test for the diagnosis of melancholia’ conveys a good deal more
about the wishes, not
only of the authors, but of psychiatry in general, that there be specific laboratory tests
that could help
psychiatrists determine which patients had which diagnoses (Carroll et
al., 1981). If there was a biological or laboratory test that could
help support that distinction, then psychiatry could have ‘real’ rather than imagined
diagnoses (even though in most of medicine, there are actually very few diseases that have
specific or pathognomonic tests that support their existence unequivocally).
This is in no way to deny that the DST has gone on to become an
important and useful measure of hypothalamic-pituitary-adrenal (HPA) activity and has led to many
important areas of research and explorations into brain neurochemistry.
And while
the HPA axis is still thought to be overactive in some mood-disordered states, we now
know that HPA overactivity may be a more general measure of an individual’s
reaction to stress and
stressors rather than a specific laboratory test that reveals the presence of a
specific mood disorder, or a mood disorder at all. What was originally
proposed to be a
specific laboratory test for a specific diagnostic entity turned out to be a
laboratory test that cut across many of these so-called specific diagnostic
groupings and appeared to be disordered across a number of conditions that all seemed to
be linked together because of their relationship and reaction to stress. Stress
certainly plays
a role in many disorders, psychiatric as well as more purely medical.
References
Peter
Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in
Psychiatry, Cambridge University Press 2008.
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