Diagnosis Code Debate

June 18, 2012

was recently asked the following question:

There always seems to be an on-going debate in the market as it relates to Diagnosis. There is debate is between DSM-IV and DSM-V and in other instances, I hear people in the behavioral health industry lash out against ICD-9 vs. DSM. But what I do not understand is why the code set used to define the diagnosis is focused upon as the source of frustration. In my mind, these code sets are just a language used to describe/identify a diagnosis and rather than debate the issue of whether you can truly ever accurately diagnose a client with mental illness, it seems that people debate the language. In my mind, it is as though someone called me an “idiot” in French. Frankly, I do not rally against the French language, I take umbrage with the assessment that I am an “idiot.” I am sure I am missing something, but can you explain why the language used (DSM-V, ICD-9, DSM-V) makes such a difference to people in the market?

I thought that was a great question and one that others may also be wondering about. Here’s my response. There’s an old saying: “if you ask 10 therapists about anything, you’ll get 15 opinions”. (As a “recovering” therapist, I can get away with saying that.) But there is a nugget of truth in that a lot of what we do as clinicians is theory-based and so, if the diagnosis language doesn’t fit with the way I see the world, I will argue that the language is wrong. There are still some clinicians that believe the very idea of diagnosing is wrong, whatever the taxonomy. They often aren’t at odds with the particular language used as they are concerned about

    1. The process of diagnosing is in fact labeling and it is at least judgmental and at worst stigmatizing. There is a kernel of truth in this in that a mental health diagnosis carries baggage with it that other medical diagnoses don’t.
    1. That a simple diagnosis can’t possibly accurately capture the true nature and complexity of a person’s problem/suffering. They also fear, sometimes with good cause, that clinicians will “treat the diagnosis” instead of treating the person.
  1. The use of diagnosis is essentially a device borrowed from a “medical model” which traditionally meant physician-driven, an idea that doesn’t sit well with a lot of psychologists and social workers who, like physicians, are also licensed to practice independently. However, omitting diagnosis altogether is a “baby with the bathwater” solution. The upside of diagnosing is, as the writer pointed out, that it provides a common language between professionals. If I say someone is depressed, or more specifically, suffering from Major Depressive Disorder, I’ll likely be understood pretty well by my peers.

The rub comes from three sources:

    1. Consistency of diagnosis – can I be assured that the clinician who is referring someone to me for treatment of Major Depressive Disorder really followed the DSM-x guidelines to get to that diagnosis or did they slap that diagnosis on the person when in fact, the person is suffering from something much less intense such as Uncomplicated Bereavement.
    1. Lack of clarity about what I’m actually treating – assume the diagnosis is correct, am I going to treat depression or the problems caused by depression like sleeplessness, lack of energy etc.
    2. The nature of diagnosis itself – when you look at the DSM series, the diagnoses described therein are really just a set of mutually agreed upon conventions, usually a constellation of symptoms, that we’ve agreed to call “Schizophrenia” or “Bipolar Disorder”.

That helps with the aforementioned “common language” problem but, at the end of the day, it’s pretty unlikely that a thing like “Schizophrenia” actually exists to the extent that one could find it anatomically or genetically. That’s part of the reason that thelast 10 years of research looking for the genetic underpinnings of Schizophrenia has produced nothing. “Schizophrenia” is a term that’s an agreed-upon collection of symptoms, so it shouldn’t be too surprising that we can’t find the gene or genes that cause it. There are probably a whole lot of clusters of symptoms that look like schizophrenia and would be diagnosed as such but are really different things genetically. The same is true for addictions. There isn’t one thing called alcoholism. There are many “alcoholisms” that all deal with various problems related to alcohol and might even met the diagnostic criteria for alcoholism but they are very different. For some people, it is obvious that what happens when they take a drink is very different than when I take a drink.