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As any doctor can tell you, the most crucial step toward healing is having the right diagnosis. If the disease is precisely identified, a good resolution is far more likely. Conversely, a bad diagnosis usually means a bad outcome, no matter how skilled the physician. —Andrew Weil
The first step in any treatment plan is getting the right diagnosis—but it’s not always as straightforward as one would hope. There are a number of mitigating factors that can interfere and, because psychiatric diagnosis is not yet based on clear biomarkers in most cases (though this is beginning to shift) but is instead based largely on clinical presentation, there are unfortunately many reasons why diagnosis may be delayed or inaccurate. Here are a few of the most common ones.
1. Inadequate or Incorrect Patient History
Getting a good clinical history requires a lot of time and a good connection between clinician and patient—and both of those are not always available at the outset of treatment. Time may be limited because of managed care in the case of insurance-based care or because of difficulty committing financial resources and scheduling enough time. It’s important to gather past history as well, and doing so includes obtaining prior medical records as well as, at times, speaking with family members or reviewing school records to get accurate information. These and other reasons interfere with diagnosis when important information is missed.
Clinicians may also be inclined to make rapid diagnoses based on insufficient history, leading to errors in diagnosis especially if the decision is not reviewed periodically, either as a matter of routine good care or when treatment is not working.
Additionally, there are important factors which people may not want to talk about or may not understand are important, including substance and alcohol use, developmental adversity and trauma, and periods of time which didn’t seem problematic but may actually be key information. A good example would be hypomanic episodes which feel good to a patient and aren’t necessarily seen as problematic by patients if they haven’t caused problems. However, hypomanic episodes would suggest a diagnosis of bipolar disorder rather than major depressive disorder, and the approach to care is very different. Issues like this lead to delays in diagnosis and effective care.
2. Misdiagnosis
When a particular diagnosis is popular, as ADHD currently is, clinicians may be quick to notice difficulties consistent with ADHD and fail to recognize other issues. Many other conditions—including bipolar disorder, depression, anxiety, and post-traumatic conditions—are also associated with the main symptoms of ADHD such as distractibility, agitation and inattention. When diagnosis is unclear or treatment isn’t helping after a reasonable period of time, getting a second opinion and obtaining formal psychological testing may be useful.
3. Diagnostic "Chameleons"
Complex Developmental Trauma
Some issues can present in many different ways and, in the absence of careful evaluation, may easily be mistaken for other problems. For example, post-traumatic consequences—Complex Post Traumatic Stress Disorder, or cPTSD—may appear to be a basic anxiety disorder (such as generalized anxiety disorder or panic disorder), a mood disorder, anger management issues, attention deficit disorder. They, may also present with alcohol and substance use, eating disorders, and interpersonal issues. Focusing on one facet of the presentation without seeing the big picture can be very misleading.
Well-intentioned clinicians will often take the path of least resistance or may not be properly trained to identify more complex issues, rather than risking confrontation with patients and families about more troubling and far-reaching problems, including hidden abuse and addiction within the family. Under these circumstances, the child—referred to here as "the identified patient"—may become the sole focus of concern within a dysfunctional family. The identified patient becomes an unwitting victim of pathological family dynamics designed to cover up problems behind the guise of concern and care. This often is the case with conditions beyond ADHD, including eating disorders and behavioral problems.
When trauma hasn’t been identified and may be omitted due to avoidance or lack of understanding of its importance, people may end up with multiple diagnoses and treatments which don’t seem to be working.
In contrast to developmental trauma, ADHD is often more acceptable to people than other causes for difficulty with concentration and focus. It's psychologically easier for many people to say they have ADHD. It’s not unusual for patients (or their parents) to suggest a diagnosis of ADHD, which can cover up other issues.
On the other hand, ADHD is also under-diagnosed and often dramatically effective treatment can be delayed for far too long. This highlights the importance of diagnostic accuracy and comprehensive evaluation.
4. Doctor’s Discretion
At times, clinicians may hesitate to discuss mental health diagnoses with patients. This is especially true with conditions associated with even greater stigma than the considerable stigma attached to common psychiatric disorders at baseline, including very common anxiety and depressive disorders. Higher stigma diagnoses include trauma-related issues, personality disorders, substance and alcohol-related disorders, and bipolar disorder, among others. Typically clinicians with more medical training will view proper evaluation and diagnosis as the first steps in proper care.
There are ethical arguments for exercising caution when discussing diagnosis, treatment and prognosis for psychiatric conditions if there is valid concern providing diagnostic information may do more harm than good. In an ideal world, discussions of diagnosis are conducted in such a manner as to be part of good treatment, delivered with tact and sensitivity to assist patients and their families to become informed collaborators in planning effective care.
Sharing diagnostic impressions may take place over a few meetings to allow for sufficient time to process challenging information. In addition, diagnostic possibilities are not always clear-cut, and if additional evaluation is required, diagnosis may be presented as possibilities to be investigated. Many patients with a history of treatment-resistant mental health problems have had a series of different diagnoses, resulting in regrettable confusion. While there are substantial cross-cultural differences, the American medical system preferences patients' autonomy and rights over more paternalistic models in which patients may be kept more or less in the dark about their own care.
5. You May Have More Than One Diagnosis
It may sometimes be difficult to get a single diagnosis for the simple fact that patients often have more than one condition, including both medical and psychiatric disorders which present with emotional and psychological problems. In addition, the diagnostic system itself is evolving and is periodically revised. As we understand the brain better and the relationship among various biological and social factors, the way we view diagnosis may change almost completely in the future.
6. You May Have No Diagnosis At All
The last answer for why it’s difficult to get a diagnosis may be the fact that there may not in fact be anything "wrong" with you. Some clinicians and schools of thought view therapy not as a clinical endeavor but rather as a kind of enlightened dialogue of self-examination. There are plenty of situations where people seeking help may not want or benefit from a clinical approach, preferring a form of deep personal inquiry. For those seeking to understand themselves more fully, address developmental issues in adulthood, make sense of existential issues, or simply have an experienced sounding-board to sort out common problems in living, there may not be significant medical pathology per se.
Clinicians have variable philosophies about diagnostic terminology and the utility of medically-oriented treatment. Some may not “believe” in diagnosis or may object to using “labels,” or may not agree with evidence-based care when it comes to therapy or medication. People seeking expert help have a right to know what is being offered—and what is not being offered—as part of informed consent.
Conclusion
The numerous factors that go into treatment and recovery when it comes to mental health and addictive disorders make it hard to get clarity on diagnosis. Clinicians and patients alike may have difficulty accepting and adjusting to challenges when it comes to mental health issues and many patients find relief in understanding what they are dealing with, helping them to get on with intentional and informed treatment.
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