I am immersed in my new position as a clinical interviewer at The Menninger Clinic. Leaving behind my previous career as a vocational rehabilitation counselor, I never imagined finding a job that would provide the ideal platform for furthering my interest in psychiatric diagnoses. As a clinical interviewer, I administer the Structured Clinical Interview for DSM-IV disorders (SCID) to adult patients at The Clinic. The SCID covers a variety of symptoms and behaviors culminating in clinical diagnoses for a wide range of psychiatric disorders. The purpose of using the SCID at Menninger is to document diagnoses for research purposes, as well as to provide diagnostic information to treatment providers.
My position provides a unique experience with patients in that I enter the interview unbiased by previous interactions and with minimal history. Thus I am in a good position to assess patients’ symptoms from their point of view. The work is fascinating as it challenges me to decipher symptoms, using my previous clinical experience and knowledge of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to help determine appropriate diagnoses. My curiosity about diagnostic criteria is piqued as I learn how to fit patients’ unstructured experiences into a structured set of diagnoses.
Since starting these interviews, I have received considerable feedback from patients regarding their DSM diagnoses. Their reactions fall into two opposing views:
- those who accept and appreciate their diagnosis as well founded and informative and
- those who object to their diagnosis, feeling as though it strips them of their personal experience and lumps them into a stigmatizing category.
My interest in these viewpoints was sparked by a patient who expressed loathing for the DSM. She asked why I was using the manual, explaining that in her opinion the idea of a diagnosis was too subjective, stigmatizing and counter to a therapeutic experience. The patient even asked if I could pass this information on to the people who created the DSM as a means to discontinue its use. I explained I had no direct contact with the writers of the DSM; however, I could appreciate her concern regarding diagnoses. I shared my opinion that diagnoses actually can be helpful in presenting clinicians with an understanding, on a quantifiable level, of a patient’s symptoms and behaviors. In essence, diagnoses provide a mental image that can help clinicians focus their efforts in a particular direction, leading to a more efficient approach to treatment. This was the first of many conversations that I would have with various patients who were concerned for their wellbeing, the focus of their treatment and the potentially stigmatizing effects of their diagnoses.
Not all patients express disdain for their DSM diagnoses. Some patients take the opposite extreme, that is, they over-identify with their diagnosis. Some can get so caught up in the diagnostic label that they even adjust their own behaviors to better match those of the diagnosis-specific symptoms. For example, I met with a patient who remarked that her entire identity surrounded her diagnosis of borderline personality disorder. “I’m a borderline,” she reported, describing how she has been told this and believes it to be true to the extent that it defines who she is as a person. During our interview, she frequently referred to the diagnosis, often letting me know that her behavior “is typical of borderlines.” Subsequently, the patient seemed to match each of her examples of poor decision making with behaviors found in other people with the same diagnosis. After our meeting, I couldn’t help but wonder: Were her behaviors truly a “by-the-book” coincidence or, having learned more about the diagnosis, was she unwittingly aligning her behavior to be more like what was described in the DSM?
Another patient reported she had been depressed her entire life, noting the many experiences that resulted in her current dismal state. She had become so accustomed to discussing her depression as something that was outside of herself, yet so much a part of her life, that when asked about who she was apart from the depression, she could not recall. It occurred to me that this chronic depression may no longer be distinguishable from her personality.
Such excessive identifications with diagnoses can rob the patient of agency, externalizing responsibility onto a diagnosis as if it were an impersonal force in control of the person’s behavior. No doubt, patients can feel that their illness has control over their behavior. However, the goal of treatment is to help patients develop a greater responsibility for their illness, and the goal of diagnostic understanding is to help patients feel more knowledgeable and empowered.
Impact of a changed diagnosis
Yet another problem with over-identification: When a diagnosis becomes assimilated into one’s self-image, it can cause marked confusion if the diagnosis is ever changed. For example, one patient reported he had been told he was depressed his entire life and had therefore adopted the idea of depression as part of who he was. He had extensive knowledge about depression and the various anti-depressant medications available. He identified so much with his diagnosis that when it was recently changed to bipolar disorder, he became upset, feeling that his personal schema had been turned upside down. He now struggled with an image of being “disturbed,” having a diagnosis that in his opinion brought to mind an agitated, “crazy” person. He reported, with dismay, “They’re saying I’m bipolar now.” In a similar example, another patient, formerly diagnosed with depression, reported going to great lengths to keep her newly diagnosed bipolar disorder a secret, driving many miles to a remote pharmacy to pick up her prescriptions. She reported discontent, fear and shame over her new diagnosis. For both patients, the cost of identifying with a diagnosis was internalized stigma.
Both of these perspectives – for and against diagnoses – have validity. On the one hand, the collection of symptoms is helpful in categorizing behaviors into an objective DSM diagnosis, which can facilitate understanding and inform treatment. On the other hand, there is a limit to objectivity. The symptoms are subjective and must be interpreted twice: once by the patient and again by the clinician. Sometimes symptoms are vague and apply to a number of different diagnoses, while at other times patients lack awareness into subtle symptoms that can make a significant difference in a diagnosis. Moreover, clinicians filter their patients’ descriptions of symptoms through their own subjective understanding of a diagnosis.
Each patient’s initial diagnosis is tentative at best and is refined over the course of treatment and through the collaborative effort of the treatment team. Most important, a diagnosis is only one facet of the understanding that goes into an individual’s treatment.
So how much weight does a diagnosis hold? You be the judge.