What we’ve said about Psychiatric diagnosis

“Any DSM diagnosis simply serves to capture one slice of a patient's presentation of pathology. This is also another problem with a lot of anti-psychiatry people”

“You can see the limitation in using DSM diagnoses. Do not take diagnosis and use that to extrapolate to the facts. Take the facts and use that to extrapolate to a diagnosis”

“a core component of the work I do is I'm trying to develop a diagnosis or at least a formulation if I can't get a specific diagnosis and get on the same page with the patient”

“a formulation to me is much deeper and richer and actually gives you an idea of what's going on with a person”

“Two people of the same DSM diagnosis will have radically different behaviors and lives. And I don't know if people understand that diagnosis is not destiny”

“We think about things as diseases because we want to be better. We want things to be better. We want to prevent things from getting worse”

“You don't lower a fever and say, okay, problem solved. or cure a skin rash and not be interested in what it's telling you about what's going on in the body. And you can describe a limp in terms of present versus absent criteria, but you're not you're not saying that it is the disorder”

“we should be talking about traits versus disorder. We should be saying people can have certain traits, certain behaviors, and certain problems, but those are present to a greater or lesser degree across the whole population”

“whether or not something is part of a mental disorder or a diagnosis is different from whether or not someone does it willfully or that they don't have control over it. And even that is a separate question from whether or not someone should be responsible for it in some way”

“For me, and maybe this is because I was trained in a medical setting, you go from diagnosis to treatment. You have to identify what's going on before you move to how do we help this person”

“The categories are social constructions. We've developed these to try to capture real aspects of the real world. And sometimes a patient may meet the criteria for multiple diagnoses, and they really only have one disease”

“simple names that we use to guide and kind of better understand people and categorize them quickly. But it's still that narrative experience of what people are going through. That's the fundamental thing”

“particular diagnoses carry real implications in terms of understanding transference and countertransference. And this is where the psychoanalytic side of me comes out, where if you're not thinking in this sort of way, you may really miss what's going on right before your eyes”

“a psychiatrist any diagnostician in mental health needs to recognize that their questions are the exam your questions and the interview every moment of it has its own positive predictive value and negative predictive value and sensitivity and specificity”

“a syndrome or a disease itself is not an arbitrary collection of symptoms that a patient reports. Our diagnosis relies more than on plain reported symptoms. We have to look at how the patient relates to and describes the symptoms themselves”

“You should be adjusting your, quote, pre-interview probability of a certain disorder throughout the interview. But to have an accurate view of this, you need clinical experience and you also need basically crystallized knowledge about different conditions”

“What I think is important for a clinician to do is to have a real sense of what is the life course and disease course of people who most psychiatrists would agree has certain diagnoses”

“output is not the same as underlying process. Oh, okay. What someone is doing in front of you, what they talk about, what they tell you is or is not happening is not the same as whatever is going on inside of them that's producing that”

“People think they can exclude something in 50 minutes, and it takes much longer to exclude a diagnosis than it takes to recognize a diagnosis”

“the presence of one disorder does not exclude the presence of another. And I know a lot of practitioners don't like that because they care about parsimony”

“If this is a true pattern, I want to see it more than twice. I like to say twice is a coincidence, three times is a pattern. That's a little conservative, but I want to see more”

“the way you solve that is first off time and seeing them progress and see how those symptoms progress. And second, collateral”

“when you don't have collateral, you cannot imagine that a person has presented because this is normal for them. It's always possible. I would say that that's a minority of the cases. You have to then start comparing them to an ordinary, regular person”

“even when I'm quite sure that a primary mood or psychotic disorder is not present and I want to take someone off of medication, I will still say, I don't know for certain what happened before or what's going to happen in the future”

“there are no set standards about when you call something or not. It's all clinical judgment. So, you know, diagnoses are not lifelong”

“when you give an opinion, when you have a conclusion, a clinical conclusion for a patient, you better have that on a good basis that you can explain to a neutral audience”

“Ideally, what should happen on the inpatient ward should be diagnosis. Okay. should be diagnosis okay if i can diagnose or if i'm expected to diagnose within one and a half to two hours on outpatient, somebody living there should be diagnosable, right”

“Don't just stick to DSM. There's been so much written in this field for over 100 years that we really limit ourselves if we simply read the DSM in the latest edition of our favorite psychiatry textbook”

“Don't be afraid to diagnose personality. You're not doing it. You shouldn't be doing it to punish patients. You're doing it because you want to be a good clinician and you want to correctly identify which things should be treated with psychotherapy and which things should be treated with medications”

“I think it's very important to make sure that you're utilizing data from both the state in front of you in visits and also the course based on the history, and particularly the course. Because, again, a personality disorder is supposed to be something that is present across settings and with different people”

“We want to first listen carefully in a way that's more sensitive but not specific for signs of personality pathology within the visit, within interaction, and also in the history. And then once enough of those signs have been marked as present, In our minds, we go to something more specific”

“any diagnosis that you reach with short time you have to know that you're doing that with a lower degree of certainty than one that you've reached over time and from testing and retesting so just keep that in mind your diagnosis is only as good as the database that you're working with”

“The internal process is extremely important in identifying how people function in their interpersonal element, basically their level of personality functioning. OK, but it doesn't give you a diagnosis”

“if your problems with concentration are happening because of a stressor of fear over losing an unfortunate relationship or all these fights that keep happening over and over in your relationship, then the method of successfully treating that is not going to be Zoloft”

“So much danger in over-interpreting things as Axis 1. And when you start thinking in terms of personality, you have more control. You have more ability to change your surroundings”

“you never feel a pressure to make a diagnosis. And I think, and something that was really helpful in, in, my treating of patients was not feeling a pressure to make a diagnosis at the end of a first appointment and, and communicating to the patient, you know, like these things are on my differential”

“i said you know i don't know what you have i don't know if you have anything at all you could have something you might not there's definitely some stuff we are seeing here uh in the past from you that suggests there's something but i can't tell you what it is”

“let's not use any diagnostic labels. That's just a way we organize our ideas so we know if we're talking about the same thing. So I want you to tell me without using any jargon, without any big terms, what's been going on in your life and what are you noticing and what do you want to be different”

“There's no use giving a diagnosis to a patient that they don't understand. OK, or that they can't explain in their own words based on what's happened in their lives”

“naming a condition can reorganize a person's narrative and that reorganization can reduce stress. So labels can help or harm depending on the accuracy and the fit and the person”

“I basically explain what diagnosis is for. Diagnosis is really for us to guide specific treatments under medical evidence. And I don't have a diagnosis for you at this time”

“every single time I've had this conversation of whether I say you have borderline personality disorder or I say there absolutely are traits, the conversation has gone really well. Most patients really just want help”

“once you have the assessment that you feel like it's more of a borderline personality disorder than, say, ADHD or depression, And framing those symptoms in the context that they are secondary to interpersonal dysfunction is crucial”

“I think denigrating your formulation is not helpful to the patient. What you can do is say, and I've done this a million times with patients on intakes, as I say, maybe not intakes, because you need to build some rapport and gauge whether you think the patient will accept it”

“the purpose of a diagnosis is to further the treatment. So if disclosing a confirmed diagnosis, even one that you believe, would definitively and you know would hurt the treatment process or the patient or interrupt it in some unrepairable way, that is a reason to at least temporarily withhold it”

“Nowadays, people come in and they say, I have disorder X, disorder Y, disorder Z, and I heard about it on TikTok and this is exactly who I am. And when you try to take that away from them, you're going to face a lot of resistance”

“ideally, that would be a process that's Done over a course of time, when there's a good working alliance, when the patient feels comfortable with you, when the patient trusts your judgment, when the patient has a sense that you actually know what you're talking about”

“I blame society and the practice of medicine and mental health because we've given sort of an impression to the layperson that they are the expert in their diagnosis. They are the expert in their lives. They are the expert of their experiences, and we need to respect and understand that and get that out of them”

“First is you have the wrong diagnosis. There's so many times that I'm supervising someone and they say, what medication should I add? And I go, what's their diagnosis? And they're like, I'm not really sure”

“trying to medicalize human behavior that falls within the range of normal even when it's an extreme in the range of normal or human behavior that's rationally driven Turning that into a medical diagnosis is a mistake because then there's this implicit philosophical understanding or belief that it's out of control”

“diagnostic labels initially can kind of help people understand themselves better because it's putting words to experience that before they didn't have words to. And what we've seen more and more is that the The diagnostic label is actually allowing less insight and less self-understanding”

“there is quite a trend in the community of diagnosing off vibes only, off countertransference only. Probably what I mostly see is that they ignore personality”

“be very careful about the possibility of any diagnosis, but particularly culturally laden or emotionally invested diagnoses in functioning as a form of resistance to appropriate treatment, consciously or unconsciously for patients”

“a lot of people out there in the community have a habit of diagnosing post-traumatic stress disorder without Actually going through the criteria. They can identify that someone is in a persistent fear or mood problem and that they have a criteria in a trauma and they say, well, they've got that”

“A lot of people come in with a very, very strong, almost culturally embedded idea of what they have. And sometimes that's wrong”

“it's not uncommon for people with bipolar who haven't fully accepted their diagnosis to, after a long period of time, find a psychiatrist and think that they were misdiagnosed”

“Often they come off the inpatient floor with a completely definite diagnosis, which was never talked to with the patient. Like it'll say schizophrenia. And then on the intake, you'll go like, okay, so you were diagnosed with schizophrenia. And authentically they go, oh, I didn't know that”

“I think we're just tempted to believe this idea that If there is a diagnosis in the DSM and the patient meets the criteria for the diagnosis, we give the diagnosis. I think it's actually a very harmful way of thinking that's really philosophically and scientifically flawed”

“a diagnosis can obscure if we simply call it generalized anxiety disorder or PTSD. And then we ignore the personality components, the developmental components, all kinds of components that should belong in that formulation. Then the diagnosis robs us of vision rather than gives us clarity”