In the Trenches

Understanding the adolescent mind.

The Art of Diagnosing

The Art of Diagnosing

What would it be like without the Diagnostic and Statistical Manual of Mental Disorders?

How do mental health professionals make a psychiatric diagnosis? Most use the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association and currently in its fourth edition. The definitions and criteria for mental disorders have changed from edition to edition of the DSM, usually due to advances in research, input from pharmaceutical companies, psychiatrists' opposing views, and changes in societal and cultural norms.

A notable change was the elimination of homosexuality as a mental disorder in the DSM II (1972). This was in response to protests by gay activists at the American Psychiatric Association's annual conferences in the early 1970s, as well as new research data from Alfred Kinsey and Evelyn Hooker. The diagnosis was replaced by "sexual orientation disturbance." A new revision of the DSM, due to be published in 2013, may include as many as twenty major changes. If you are interested in learning more, go to DSM5.org.

How do mental health professionals diagnosis children and adolescents? Diagnosing children is very different from diagnosing adults because of the ongoing maturational changes. How can a professional feel confident that his or her diagnosis is correct? Behaviors you see today may not be the same behaviors you will see tomorrow.

It takes twenty-six years for a child to reach full cognitive and emotional maturity. The process is unique for each child and is determined by many factors, including genetics, parenting, life experiences, and environment. Professionals may decide to change a diagnosis depending on changes in development, additional information, or the expression of different symptoms.

Diagnosing is an art. Some practitioners are better at it than others. A good diagnostician uses knowledge, experience, and, most importantly, intuition when diagnosing a case. In "Gut Almighty," her May 1, 2007, blog entry on Psychology Today.com, Carlin Flora wrote, "Intuition . . . is best used as the first step in solving a problem or deciding what to do. The more experience you have in a particular domain, the more reliable your intuitions, because they arise out of the richest array of collected patterns of experience. But even in your area of expertise, it's wisest to test out your hunches-you could easily have latched on to the wrong detail and pulled up the wrong web of associations in your brain." http://www.psychologytoday.com/articles/200704/gut-almighty

Flora's eloquent definition resonates with how I come to a diagnosis. The following steps may shed some light on the process:

First, I use my intuition: "Yes, I have seen this before. It feels familiar." The next step is to ask myself the following questions: If it is not what I think, than what else might it be? Have I gone through this child's history with a fine-tooth comb? Do my feelings, knowledge, and judgment correlate with what I am being told? Am I missing any piece of information? Have I subjectively overemphasized or misinterpreted a piece of information? Have I considered the norm? Is this something a child could outgrow? How serious are these symptoms?

When I feel confident about my diagnosis, I will discuss it with the parents. I want their feedback. I want to know if this diagnosis makes sense to them. Does this sound like their child, and if it doesn't, why not? What diagnosis would better suit their child? If I feel uncertain about the diagnosis, I will discuss my uncertainties with the parents.

As professionals, we should never minimize the narcissistic injury that can occur when parents are informed that something is wrong with their child. The narcissistic injury can be equivalent to the death of a loved one. A parent's dreams, hopes, and fantasies can be demolished. I want to protect the parents emotionally and at the same time inform them of my findings. The last thing I want to do is scare the parents out the door, possibly resulting in the child not receiving treatment.

In some ways diagnosing without using the Diagnostic and Statistical Manual of Mental Disorders might be easier. We could use everyday words to describe the behaviors we observe. We could replace scientific, intimating words like depression, bipolar, attention deficit disorder, or conduct disorder with words like edgy, quirky, precocious, moody, temperamental, sensitive, domineering, or loquacious.

Don't get the impression that I am saying the DSM doesn't have value, but sometimes you have to wonder: Will the diagnosis you rendered today even be in the next rendition?

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Wanda Behrens-Horrell, L.C.S.W., N.C.Psy.A, is a child developmental psychoanalyst in Scarsdale, NY.

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