Say “no” to diagnosis soup!
Psychology/Medical Student Syndrome - you’ve heard of it, right? It occurs when students are introduced to various diagnostic criteria/symptoms and diagnose themselves with a ton of really terrible sounding diseases. Unfortunately this error of assuming that a symptom checklist equals a diagnosis happens not only with student healthcare providers but also with experienced providers and actual real life patients. Student syndrome quickly leads to the more nefarious condition I call “diagnosis soup.”
In real life practice, it looks like a patient reporting, “I have depression, social anxiety, agoraphobia, OCD, borderline personality disorder, and bipolar disorder.” While a given client might meet the symptom checklists for all of those disorders, in the vast majority of cases, they probably only have one or two underlying conditions that explain ALL of the symptoms. Diagnosis soup is dangerous because if we don’t know what the true underlying diagnosis is, we don’t (always) know how to target treatment appropriately at the real cause. I say this as a practitioner of ACT, which doesn’t always require that we target specific diagnoses since the general target is psychological flexibility. Even for me, finding the root diagnosis is vital to conceptualization and treatment.
How did THIS PERSON get here?
In most cases, clients accumulate these diagnoses over many years. They may be diagnosed with major depressive disorder by a primary care doctor. When they eventually seek a therapist, they get a generalized anxiety disorder diagnosis. Then they see another therapist who says they have social phobia. When they try medication for depression or anxiety, they may have a paradoxical reaction and respond better to medication used for bipolar depression, resulting in a bipolar II diagnosis. Then after years of treating their symptoms like bipolar II, they discover that they actually are autistic and their supposed mood undulations were actually a cycle of autistic burnout and recovery, mimicking bipolar II. Over the changes of providers, no professional stopped to explain to this client that they have one diagnosis: “Autism Spectrum Disorder,” which we colloquially (and more sensitively) call “being Autistic” now. ONE DIAGNOSIS. The others were based on the best information each provider had at the time they knew this client but in the end, being Autistic in a neurotypical world explains each of their mental health struggles over the years. They do not have five “disorders.”
How did OUR INDUSTRY get here?
How, as an industry, did we end up getting so sloppy about giving out diagnoses without explaining them?
Parity is part of it
Treating mental health conditions like any other health condition is vital. Treating mental health conditions like any other health conditions is a mess. In an effort to legitimize mental health diagnosis and care, various mental health professionals have worked hard to advocate for mental health conditions being just as valid as any physical health condition. On principle, they’re totally correct. Mental health issues can be every bit as life threatening as any other medical condition. But if we treat them like any other health condition, we have to diagnose, code, and bill them like any other condition in the medical field.
Laws have been passed to ensure parity of insurance coverage for mental health conditions, just as any other health condition (thank goodness). The dark side of parity, however, is that insurance companies took expectations of medical necessity straight from the medical guidelines and slapped those onto mental health. More diagnoses and procedures = more reimbursement. There isn't any incentive for clear diagnoses of underlying causes, cleaning up charts, and explaining to patients that their past diagnoses are better explained (and therefore replaced) by new diagnoses. There’s no incentive against “diagnosis soup.”
Clarity (or lack thereof) is part of it too
In addition to payers offering no incentives for good “problem list” management, there is also more disagreement between practitioners on evaluation, diagnosis, and treatment of mental health conditions. We have two major sources of mental health disease definitions In the United States: The Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases (ICD). ICD's development is global, multidisciplinary and multilingual; the primary constituency of the DSM is U.S. psychiatrists. Both resources were built with research and shared vocabulary in mind. While the DSM does offer really important textual explanations of each disorder, what’s best known about both the DSM and ICD are the symptom checklists (yes we’re back to those).
In actual clinical practice, the DSM is simply a resource we use to describe a client’s pattern of symptoms in an abbreviated format and the ICD, to communicate reimbursement requests to payers like insurance companies. Diagnoses aren’t meant to be comprehensive guides to treatment targeting. For that, we need conceptualization, which is essentially “How this person’s suffering developed and therefore, how we think we can fix it.”
My request of you all
First, for the clinicians reading this: Please take a look at your clients’ lists of diagnoses and explain to them which you think best explain(s) their presentation and what you’re targeting. Share your conceptualization with them and bring them onto the treatment team as your partner. Your clients will not break under the weight of this information. Besides, it’s their chart and they’re entitled to all of the information anyway. You may as well let them know what you see and what you’re doing to support them and clear up any misconceptions they came to treatment with in terms of the thousands of diagnoses they’ve received int he past.
For clients: Don’t be afraid to ask “what have you diagnosed me with and what do you think of how this process is working in me?” Dig into your chart and ask for it to be cleaned up and accurate (this goes for your medical charts too). Ask to have removed misdiagnoses and things not relevant to your current treatment. If you and the clinician disagree, please note that clinicians have to chart accurately according to their genuine impressions of your case. This accuracy is integral to our ethical codes. So if the clinician thinks you have a disorder you disagree with, ask them to document your disagreement if they can’t remove it.
With clinicians and patients partnered, we can fight diagnosis soup!