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30.07.2015

Mental diagnosis, what causes noise in your ears - For Begninners

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When one sits down with consumer groups, families, or patient advocates one of the most common complaints that we hear voiced today is that "every time someone sees a new psychiatrist they get a new diagnosis." It is easy to see why this could be a bit disconcerting.
A shifting approach to diagnosis can hardly be expected to build confidence in one's psychiatrist. We like to think that the diagnosis that we make will also help to predict what sorts of treatments will or will not be effective for the condition.
A few of the people in our little group of diagnosed "Bipolars" would actually turn out to have schizophrenia if more details about their history were available. Strangely enough, a couple of the patients in that collection of "Bipolars" may not even have a mental illness at all. So a common diagnostic label such as Bipolar Disorder can mean a wide variety of things in actual practice. We are now faced with a situation where nearly every conceivable human problem has been given an official diagnosis and a five-digit diagnostic code. Busy psychiatrists often don't take the time to read or understand the changing diagnostic criteria. These days there is no guarantee that the psychiatrist will even make the actual diagnosis. Of course those were times in which a psychiatrist would typically spend at least a couple hours performing diagnostic interviews on new patients, then see them several times per week for fifty minutes. One problem inherent in modern psychiatric diagnosis is that it's typically based on answers to a series of "yes or no" questions, usually about the presence or absence of various key symptoms.
The opposing view would say that we must have clear, objective diagnostic criteria that don't require a lot of intuition or psychodynamic understanding if these diagnostic criteria are to be reproducible across many clinical settings. One main weakness in the current approach to diagnosis is that it usually depends on the patient to provide the answers about whether various symptoms have been present, and for how long. Strangely enough, some patients exaggerate symptoms of their illness during diagnostic interviews.
Chemically Dependent people now have to have the diagnosis of a mental illness to continue receiving disability benefits.
Few would now question the fact that predictions about Chemically Dependent people flooding the existing mental health programs have proven accurate. This candid appraisal of what people will sometime do to get benefit checks or hospital beds may seem a little too cynical for some advocates of the mentally ill.
When we diagnose schizophrenia psychiatrists are also supposed to specify which subtype of the illness the person suffers from. At any rate, the intention of the committees that define these disorders was to create a diagnostic category for a type of schizophrenia that was different than the rest in its symptoms and prognosis. The real implications here have to do with the fact that the important criteria that research committees use in forming these diagnoses are not known or appreciated by the clinicians. In other disorders the mismatch between clinical disorder and diagnosis carries greater weight. A very common mistake in the public sector is the practice of adding "Axis II (meaning Personality Disorder) diagnoses to people with schizophrenia.
In many cases the only ways to tell if these symptoms are related to drugs rather than an underlying mental illness are a) to get good historical information about whether the symptoms arose in the setting of continued stimulant abuse or b) to treat the symptoms, then observe to see if they ever recur in the absence of stimulant abuse. The return to substance abuse eventually leads to another psychiatric decompensation, more medications, and even further confusion about whether the person would really have a mental disorder in the absence of stimulants.
It's impossible to get a clear look at our diagnostic practices if we can't filter in the effects of race and poverty. So it's clear that the numerous problems with psychiatric diagnosis today have more than just academic implications. Several systems changes may have to take place before the declining standards of psychiatric diagnosis are reversed. The changes in the Doctor-patient relationship that have been outlined elsewhere will go a long way towards improving diagnosis too. When we use shoddy diagnostic practices like calling everyone "schizoaffective", adding countless "rule out" diagnoses without actually doing anything to rule them out or confirm them, or neglecting the diagnostic criteria that we've all ostensibly agreed to use, we give other professional the wrong ideas about diagnosis. There are some computerized diagnostic programs available now and some of them aren't too bad.
Of course many of us are waiting for the day when our diagnoses will be determined by improved technology in the brain sciences. Perhaps in our lifetimes there will be sufficient technological advances in neurobiology and genetics to provide definitive diagnoses for each and every patient.
Others consider psychiatric diagnoses to be no more than labels, which lack scientific and predictive validity and serve only to stigmatise and objectify those who suffer from mental disorders.
About DinaMy name is Dina Poursanidou - I am Greek, I am a researcher, I have been using mental health services since 2008, and I am a member of the Asylum Collective. Darryl Cunningham worked as a nursing assistant in a psychiatric ward and witnessed the realities of mental illnesses and their symptoms. When cartoonist Ellen Forney was diagnosed with bipolar disorder, she was in a manic phase and not eager to seek treatment, fearing that medication would impair her creativity. Mental illness isn't a straight line from diagnosis to recovery, and sometimes even nailing down a diagnosis can be harder than it appears. Unlike the other comics on this list, Look Straight Ahead is a work of narrative fiction, although it was inspired by Elaine Will's own experience with what she describes as a mental breakdown. Rather than focus on any one particular mental illness, The Next Day explores the persistant suicidal thoughts that can accompany mental disorders.
Many patients carry each of the diagnoses of Schizophrenia, Major Depression, Bipolar illness, and Schizoaffective Disorder at some points in their lives. People, rightfully, expect that their Doctors will make a clear, reasoned diagnosis of their condition and that treatment will follow accordingly. They want to trust and believe in their Doctor and don't really know much about how diagnoses are made.


People who had the same diagnosis were supposed to be suffering from pretty much the same constellation of symptoms and problems. It's pretty easy to argue that our current approach to psychiatric diagnosis falls far short in each of those areas. A wide range of opinions exist among psychiatrists as to which groups of symptoms should trigger this diagnosis. These days if one were to take a representative sample of public sector patients who have been diagnosed with Bipolar Disorder it will become clear that a wide variety of problems have lead to the application of that label.
Depressions are common and occasional patients will have brief episodes of mania that don't qualify for the actual diagnosis.
There are nearly 300 separate mental disorders defined in the latest Diagnostic and Statistical Manual. In practice, most of us only use several favorites from the hundreds of diagnoses available. Nurses or social workers may provide the diagnosis after their intake assessments and the psychiatrist then signs off on it for billing purposes. In these meetings there was so much emphasis placed on making sure that the patient had been given the correct diagnosis that sometimes we had little time to discuss anything else. Some of the older, more psychotherapy - oriented psychiatrists have protested that diagnosis has been reduced to a "Chinese menu" or "comic book" approach.
But regardless of one's views on the subject, it's increasingly clear that a great many things can go wrong with our diagnostic process today. Briefly stated, the idea is that the mental illness itself prohibits the person from realizing that he is ill.
It is a sad state of affairs when our mentally ill people have to go to these lengths to get treatment (or more commonly food and shelter) but this is the reality that we currently must deal with. For example, the diagnosis of Major Depression is a common current justification for receiving Social Security Disability checks. Back in the 1990's it was decided that people with primary Chemical Dependency diagnoses would no longer be able to receive Social Security Disability checks on the basis of their addictions.
But we shrinks sometimes hear about how patients will even go to the library or the Internet to see what symptoms they need to endorse to get a particular diagnosis. Let's look at just a few common examples to see how these problems with diagnosis get translated into modern psychiatric practice. Any or all of those symptoms that prohibit the diagnosis may be present but the Paranoid Type specifier is still given.
We don't really understand how or why the experts determine these differences in diagnosis. People are given labels such as "antisocial", "dependent" or "borderline" in addition to the schizophrenia diagnosis. An enormously important diagnosis in our culture is that of "Cocaine-Induced Mood Disorder" but that is one that we almost never see utilized in our public mental health systems. Anyone who works in public mental health has seen innumerable people that exhibit this pattern for years on end.
Research has shown that the same symptom profile is much more likely to result in the diagnosis of schizophrenia if a person is black than if he's white. While the psychiatric profession has expanded its list of diagnoses to almost 300 disorders, in the public sector there has been an evolving movement to give everyone the same one. Simply putting an emphasis on allowing people to stay in their homes and adjusting the degree of services brought in to fit their changing clinical conditions will have a pronounced impact on diagnosis.
As the treatment relationship becomes more symmetrical, the process of diagnosis becomes more of a cooperative venture. And when systems of care actually use nurses or other professionals to provide the diagnoses they should be honest about that. Their strength is that they ensure that all of the right questions necessary to make a sound diagnosis are asked about in a systematic fashion. If we can do specific tests that will tell us exactly what sort of disorder a person suffers from that would immediately clear up many of the problems around diagnosis. If we get to the point where every patient can be given the optimal diagnosis and treatment through technology, the psychiatrist's role will change dramatically.
I experience profound ambivalence towards my mental health service use and my mental illness (for want of a better term) experiences with their catastrophic consequences for every aspect of my life. Tell us more want to know about your work- Saturday Aug 15 - 8:52pmResearcher is looking for people who have been given a diagnosis of #schizophrenia and disagree with it. Psychiatric Tales combines science, history, and anecdotes to demystify and destigmatize mental illness, and Cunningham's stark artwork can be deeply affecting. A recent review of the case of a woman who had committed suicide found that her psychiatrist had diagnosed her with all of these disorders within the past year. Even some psychiatrists are beginning to publicly speculate about whether the severe mental disorders might exist on a spectrum rather than as discrete clinical entities. Some psychiatrists will, understandably, always error on the side of calling people "Bipolar" rather than diagnosing schizophrenia though. When historical information is inquired about they may endorse a history of a lot of different symptoms in order to bolster their claim of mental illness. If it's true that we humans exist as either "lumpers or splitters" it's pretty clear which group has won out when it comes to psychiatric diagnosis. Of course we tend to diagnose conditions that we think that we understand and that we feel comfortable treating. Busy clinics can provide care to more people - and increase revenues - if scarce psychiatric time is not tied up with diagnostic interviews. For example, people with Paranoid Schizophrenia are often quite adept at presenting as "sane" during diagnostic interviews or even psychological testing. While true Major Depression is typically a self-limited illness - one that usually got better on its own even before the days of widespread antidepressants - many clients will literally receive disability benefits for decades because they have been diagnosed with Major Depression.


A big part of this diagnostic mismatch results from the fact that many busy psychiatrists just don't read the new manuals or use the information within them in their day to day practice. In the "Emerging model of mental illness" chapter we looked at the connections between a lower place on the social ladder, crowded living conditions, and a biological propensity for cocaine abuse. This is getting harder to access as budgets devoted to public mental health are being slashed throughout the country. And these are just a few examples of the many diagnostic problems that we are struggling with these days. Schizoaffective Disorder has become a diagnosis that almost everyone with a severe mental disorder seems to get at some point in their life.
The Doctor helps to educate the patient about the key symptoms that are involved in diagnosis and they try to determine together which label provides the best diagnostic fit. If these people are going to do the diagnosing we should train them specifically in the art of diagnosis rather than pretending that the psychiatrist is doing the work. But, like any approach to diagnosis, they depend on the patient's willingness and ability to provide accurate and honest answers. We may be surprised, however, to see that many of our current basic assumptions about diagnostic categories don't hold up well when accurate tests become available. Talking to people, helping them to better understand themselves, and trying to help them find optimal ways of living will be what's left for us to do once the machines can diagnose the disorders and determine the treatments. There are, however, other, often personal, comics that can open your eyes to real human experiences with mental disorders.
A sound diagnosis is also intended to provide information about the prognosis that a patient suffering from any given disorder is likely to have- what course the illness is likely to take, whether it's likely to get better or worse over time, the likelihood that it will run in families, and so on. The quick witted patients with the giddy moods appear to have been replaced by the "irritable manics" that were more recently admitted to the diagnostic grouping.
But some psychiatrists won't even diagnose personality disorders anymore, at least as the primary diagnosis.
And we favor making diagnoses that trigger ready reimbursement from insurance companies and government programs.
The obvious problem is that many of the professionals who end up doing the actual diagnosing have not had much training or experience in the process. Attaching the wrong diagnostic label would certainly lead to far-reaching negative consequences.
A number of factors make psychiatric diagnosis a much more uncertain undertaking these days. Losing jobs, housing, or custody of one's children are always realistic possibilities for people with severe mental illnesses too.
Yet some psychiatrists never diagnose any other type of schizophrenia except for paranoid type. The fact that it is wrong, and again reflects an inadequate understanding of the diagnoses involved, is only a small part of the problem (The DSM's do provide for the addition of a Personality Disorder diagnosis in cases where the person clearly had a personality disorder before the onset of schizophrenia - in that case we're supposed to specify that it was a "Premorbid" diagnosis). The current diagnostic practices involving Schizoaffective Disorder are so pervasive and important that the next chapter will be devoted to that issue alone. So at each stop on the circuit there is a new conceptualization of the patient's problems and opportunities for a new diagnosis - or misdiagnosis. Topics generally focus on issues that have a direct impact on mental health services, service users and mental health professionals. Of course these patients are very likely to have depressive episodes too, although those aren't technically required for the Bipolar diagnosis. Professionals years down the line may see that manic symptoms were documented or Bipolar Disorder was diagnosed and those "facts" get carried on into the current diagnostic formulation without much question. We've had four successive diagnostic manuals released since 1980 and the criteria and names for many of the disorders have changed with each new edition. The catch is that psychiatric diagnosis is based on a longitudinal perspective of the person's life and symptoms of mental illness. Plus, the diagnosis of Major Depression today requires only that you answer "yes" to five of nine questions about whether various depressive symptoms are present. This may not have a huge impact on the person's treatment (since we give everyone the same medications anyway) but the reasons for this diagnostic mismatch are informative.
Most people with schizophrenia do have one or more of those exclusionary criteria and are not eligible for the Paranoid Type diagnosis.
And now the closely related problem of severe mental disorders arising from methamphetamine abuse is moving from rural America to urban areas as well.
Psychiatrists are understandably reluctant to attribute someone's mental health problems to substance abuse unless they are very certain of the connection, especially if we know that it may result in the person becoming homeless. A new "treatment plan" must be created, complete with new "goals" that the professionals must document for the patient (in truth, severely mentally ill people rarely think in terms of "goals and objectives"- this is another well-intended creation of administrators that may be far removed from clinical realities).
It's always amazing to see how many patients in our present system do not have any idea what their diagnosis is or why their Doctor thinks they have a particular disorder. So they diagnose Bipolar Disorder based on assumptions about symptoms that they think the person will have in the future. And the bipolar diagnosis may be much more palatable to the clients than being called "personality disordered". That may add to our mystique but fuzzy communication does not help to create clear diagnoses. Even basic mental tasks such as those allowing the person to have "will" or a sense of future may break down. Since a single diagnosis can usually be made in an hour or less that month leaves plenty of time for diagnosing friends and family.



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