5 Signs That a Previous Psychiatric Diagnosis Could Be Inaccurate

It might seem convenient, as discussed in Part 1, for a patient to come to us pre-diagnosed. This doesn't give a clinician license, however, to unquestionably accept the inherited diagnosis.

Source: Jeremy Lishner/Unsplash

Given the considerable psychiatric misdiagnosis rates (e.g., Glazier et al., 2015; Rakofsky & Boadie, 2015; Beatson et al., 2019; Fresson et al., 2019), if you don't yet know the patient, and automatically accept their historical diagnosis, which could have been cursorily applied, it becomes a case of the blind leading the blind, which likely won't help the patient ever see the light.

Thinking of your encounter as a second opinion can lead to a world of improvement for the patient. Consider Jacques (identifying information and other details disguised):

12-year-old Jacques was involved with the court due to threats towards a teacher. It was documented in the referral for evaluation that, for about a year, he had been experiencing increasing trouble focusing, struggled with irritability, was often restless, impulsive, and easily distracted. Sometimes Jacques appeared to be daydreaming. During that time, Jacques began treatment for ADHD and was on his second therapist in 8 months. The court requested a diagnostic evaluation to better understand the youth and to see if he was receiving proper care.

After interviewing the family, I began contacting collateral resources for data. This incuded Jacques’ then-therapist, Anna, a long-standing member of a particular therapy practice. I asked what diagnosis and symptoms they were working on. “ADHD,” said Anna. "I’ve seen that in other documents and the family reports it, too,” I replied, furthering, “What evidence of the condition have you observed? What specifically are you addressing in the sessions?” Anna explained, “That’s the diagnosis he arrived with.” I pressed, “I know it’s in his history, but do you think it’s accurate?” “That’s the diagnosis he came to us with,” Anna repeated, adding, “I’m working on helping him focus.” I asked if there was any discussion about family dynamics, knowing there was a separation happening. “Yeah, the stress has definitely made his ADHD worse,” she finished.

I often joke that my job is to disprove that all court-involved youth have ADHD. It seems the bulk of the population we evaluate have the diagnosis in their charts. Not unusually, ADHD turns out to be inaccurate. Sometimes there is indeed ADHD, along with other conditions, the symptoms of which were historically assumed to be accounted for by the ADHD.

Numerous other conditions can masquerade as ADHD. These include trauma, dissociative disorders, generalized anxiety, and depression, each requiring a different and/or additional treatment approach. ADHD is a “popular” diagnosis and even a cursory look at literature reveals concerns of over-diagnosis (e.g., Bruchmuller et al., 2012; Schwarz, 2017). Unfortunately, if it is an inattentive, restless boy, the knee-jerk response tends to be ADHD, and it sticks.

What's going on?

As I checked the math, so to speak, the variables just weren't adding up:

• He had no early developmental history typical of ADHD, such as the surfacing of inattentiveness and hyperactivity by kindergarten or thereabouts.
• There was no family history of the condition.
• Jacques' mother had no prenatal concerns correlated to ADHD, like smoking, alcohol use, preeclampsia, or gestational diabetes.
• Jacques had a clean bill of physical health and did not take any prescriptions that might encourage ADHD-like symptoms.
• He had no history of mental health concerns until middle school, and it would be extremely unusual for someone with ADHD to spontaneously burgeon at that point.
• Jacques also didn’t have a history of educational difficulties up until 6th grade.

What was going on was that when Jacques was 10, his parents began having problems, which they thought they kept quiet. By the time Jacques was 11, in 6th grade, his parents were living in separate parts of the house and often fighting after he went to bed. Now, when Jacques was 12, his father was preparing to move out. It’s no coincidence that Jacques’ difficulties skyrocketed at this time.

Indeed, when I asked Jacques how the family situation had been on him, he admitted he was very angry at both parents and worried about what life was going to be like. Picking at his cuticles and bouncing his leg, Jacques’ anxiety was palpable as he explained how his parents hated each other. His ultimate fear was that his mother was going to keep him from seeing his father.

It seemed as if, were Jacques' historical diagnosis a math problem, a sum was calculated with only one variable, and no one ever checked the math.

Some minor detective work went a long way. While Jacques indeed was inattentive, irritable, and restless, the symptoms developed as his parents’ relationship deteriorated in front of him. A more accurate diagnosis was Adjustment Disorder With Mixed Disturbance of Emotions and Conduct.

No matter how hard a therapist might try to get Jacques to calm down and focus with interventions for ADHD, nothing was going to change until he processed the separation and, ideally, family therapy also took place.

Keeping it real

When inheriting a client with a previous diagnosis, even if it is from someone whose opinion you trust, it can’t hurt to review the diagnosis/diagnoses and see for yourself. Check the math!

ADHD Essential Reads

The New Amphetamine Crisis

Adult ADHD and Perfectionism

Its good practice to learn to raise an eyebrow at any of the following five items and be extra careful in your diagnostic investigation:

1. The patient has a long history of the same diagnosis, yet despite being invested in their psychotherapy, they have shown little to no improvement.
2. It's a popular/knee-jerk diagnosis such as ADHD, bipolar disorder, or autism (especially in the absence of specialized evaluations for autism spectrum conditions).
3. The diagnosis is from a non-mental health specialist, such as their primary care provider.
4. Historical documentation does not include a thoughtful diagnostic formulation and is missing information like symptom context, duration, and only focuses on a symptom or two. As addressed here, it isn't unusual for a diagnosis to be provided based on one chief item.
5. The patient diagnosed themselves.

To expand on the final item, with online diagnostic checklists, media portrayals, and pharnaceutical commercials, it is easy for a patient to quickly take to what they assume are accurate depictions of particular mental illnesses. Desperately wanting to identify the problem so they can obtain treatment, they may convince themselves, and thus try to convince providers, "This is me (or my kid/spouse, etc.)!" While they may ostensibly appear to have symptoms of X or Y, patients don't understand that a diagnosis isn't a mere checklist of symptoms. As noted on page 19 of the DSM-5:

The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis.

The above does not mean your patient could not very well experience the diagnosis being reviewed, but they do leave more room for error. Considering that upwards of 40% of people in mental health care are misdiagnosed (Buffington, 2015), erring on the side of caution is never a bad thing. Your patients are more likely to improve, and you'll feel more confidence and enjoyment from your work.