Growing up with a mentally ill family member is a surefire way to see the good, bad and the ugly of psychiatric care. In fact, early on, I developed a healthy skepticism toward any M.D., PH.D. or M.S.W. who wanted to slap a label on my dad's head and hand out a handful of pills or a piece of insight. By the time I had my first child, he'd received enough labels to wrap around half the prescription bottles at your local pharmacy.
It's not that he was treated by a bunch of bozos. The vast majority of his mental health practitioners were good-hearted, well-credentialed people who truly wanted to figure out what was wrong. It's just that the accuracy of a psychiatric diagnosis is influenced by so many factors - some of which make sense and some of which don't:
Your diagnosis will be influenced by the quality of the information your therapist seeks. Research consistently suggests using a structured interview format significantly increase the odds that a mental health professional's diagnosis will be right. By using a set of prescribed questions that cover each criterion for a variety of mental illnesses specified in the DSM-IV-TR (or ICD-10 outside the United States), including symptoms that are not initially mentioned by the client, the clinician diagnostic decisions are made based upon the systematic review of the client's symptoms as laid out by the structured interview protocol.
Unfortunately, if you have ever received treatment for a mental illness, your interaction with your clinician did not likely involve a structured diagnostic interview. Instead, the clinician likely asked you what brought you into see him or her, asked a few pointed questions about symptoms that often go along with the ones you presented with, and made a quick judgment regarding a diagnosis.
Your diagnosis may be influenced by your race. For example, scientist John Zeber found that blacks in the United States were more than four times as likely to be diagnosed with schizophrenia, and Hispanics were more than three times as likely, despite the fact that schizophrenia appears to affect all ethnic groups at the same rate.
Your diagnosis may be influenced by your gender. Consciously or not, our idea of how men and women "should" behave is likely to influence our perceptions of them once they enter our office. To wit: gender bias has been reported in the diagnosis and treatment of a wide variety of medical illnesses. While few studies have actually examined whether or not this influences a psychiatric diagnosis, we do know that both male and female psychiatrists are more likely to hand a female patient a prescription for Prozac and that women are over-represented in personality diagnoses such as Borderline Personality Disorder and Histrionic Disorder
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Your diagnosis may be influenced by the theoretical orientation of your therapist. A 2009 study by Bruchmuller and Meyer found that, when given fictional clients who met the criterion for bipolar disorder, cognitive behavioral therapists were less likely to be distracted by diagnostically irrelevant information (and therefore less likely to misdiagnose) than psychodynamic therapists were.
Your diagnosis may be influenced by your therapist's ethnicity, particularly if it doesn't match your own. If not recognized as such, culturally sanctioned behaviors can be misinterpreted as psychopathology. Lack of eye contact, for example, can be viewed as a sign of disturbed interpersonal relationships in a therapist's office while, in the client's community, it may be a sign of respect. Similarly, a very religious client matched with a very secular therapist who thinks hearing the voice of God is abnormal, you have a situation ripe for misinterpretation.
If you have more than one diagnosis, your mental health professional will probably miss one. Most patients with a psychiatric illness meet criteria for more than one diagnosis (for example, depressed clients are also more likely to suffer from anxiety), but comorbidity is frequently overlooked. The good news is that, from a medication standpoint, antidepressants such as Zoloft, Paxil, and other SSRIs are effective with a variety of disorders, increasing the odds that overlooked symptoms will respond to a drug prescribed for another diagnosis. The bad news; missing coexisting problems may make it harder to predict treatment outcome or leave out powerful adjunct treatments (such as AA for alcohol dependence).
I've never been a fan of psychiatric labels. They can so easily force a person into a diagnostic box; every depressed person has a different story to tell. They can also create, or reinforce, stereotypes (She is anorexic? Oh, she must be a white, rich, spoiled little girl).
At the same time, different diagnoses respond differently to different treatments. Misdiagnosis can condemn someone to incorrect treatment for a condition they don't have, or it can cause someone to lose valuable years of their life due to incorrect, unhelpful treatment. I've also come to appreciate the relief clients can feel once they realize that they are neither alone in their symptoms or freaks for having them, but rather one of many individuals who have encountered symptoms for which we have well-supported treatments.
As far as my family story goes, my dad was (finally) accurately diagnosed and is about as content most days as those of us who haven't had a mental health cross to bear. And, as for those misdiagnoses, that brings me to the topic of my next post: Once you've gotten your diagnosis, how do you know if it's the right one?
