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By Caroline Fleck

About this blog: I am a clinical psychologist, mother, and wife committed to using my life to help the lives of those around me. In addition to seeing clients in my private practice, I contribute to various training and research initiatives in cli...  (More)

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Mental Health Diagnoses: A Second Opinion

Uploaded: Apr 25, 2015
I was sick for several years before finally being diagnosed with multiple sclerosis (MS). My main symptom was nausea, so I worked closely with a gastroenterologist to try to determine the cause. I had countless blood tests, several endoscopies, and two colonoscopies, which all came back normal. A doctor removed my gallbladder, giving that a 50% chance of fixing my problems (it didn't do anything except leave a permanent scar). Then I developed vertigo, what most doctors consider a neurological symptom. I had an MRI, which revealed brain lesions consistent with MS, and then a spinal tap, which showed an abnormal autoimmune response within the brain. The results of these last few tests, in addition to the symptoms I was experiencing, finally confirmed the correct diagnosis.

I am quite confident that my doctors would not have arrived at the diagnosis of MS without the physiological data provided by the MRI and spinal tap. None of the various experts with whom I consulted during this time ever suggested MS. The neurologist who ordered that first MRI said he did not expect to find anything in it that would explain my symptoms, except for maybe a tumor. He wanted to rule out this extreme, but improbable, case scenario.

Unfortunately, the field of psychology is far behind the field of medicine when it comes to assessment and diagnosis. Mental health diagnoses are typically determined through self-report (the client describes their symptoms) and observation (the therapist observes a client's mood, presentation, attention-span, etc.), rather than physiological data like blood tests or brain scans.

In determining a psychiatric diagnosis, therapists typically refer to the Diagnostic and Statistical Manual (DSM), now in its 5th edition. This manual lists the diagnostic criteria for all of the recognized psychiatric disorders. Generally speaking, to be diagnosed with a disorder, a patient must have a certain number of symptoms, within a specified period of time, alongside significant distress or impairment. These symptoms cannot be better accounted for by some other condition, and it is often up to the therapist to determine if the client is manifesting symptoms (such as distractibility, feigning symptoms, etc.) that they may not be aware of or endorse.

Now, there are a couple of obvious problems with this current method of diagnosing psychiatric disorders. Here are just a few:

Problem 1: It suggests that you either have a disorder or you don't. If you have 6 out of a possible 8 symptoms you have the disorder, if you only have 5 you don't. This not only feels arbitrary, but it can make disorders and diagnoses seem much more black and white than they actually are. Many argue that most mental health disorders would be better represented along a spectrum. Where a person falls on the depression spectrum, for instance, might vary overtime.

Problem 2: If it's not in the DSM, it's not a disorder. Conversely, if it is in the DSM, it is a disorder. This has significant social, political, and treatment implications. For instance, homosexuality was included as a disorder in the DSM from 1952- 1974. This obviously implied that, from the perspective of the American Psychological Association (APA), homosexuality was a disease that could potentially be treated.

Problem 3: There is considerable overlap between diagnoses. Disorders like major depressive disorder and generalized anxiety disorder share many of the same symptoms including difficulty concentrating, fatigue, sleep disturbances, and psychomotor agitation. In determining whether you have anxiety or depression, a clinician will consider factors such as how long you've been experiencing symptoms, the primary symptoms with which you identify, and which symptoms most negatively affect your quality of life. As you might imagine, this determination is often incredibly subjective.

So what does all of this mean for you? For starters, if you go to a psychologist, psychiatrist, or therapist expect or request a thorough assessment. If you came to the ER after falling down a flight of stairs and told the doctor you thought you broke your arm, you would expect them to examine your arm, in addition to probably giving you an x-ray. You would not expect them to nod and say, "ok, let's put a cast on it and see if it heals."

Because the field of psychology lacks the equivalent of x-rays for mental health disorders, the assessment becomes even more important. A thorough assessment means that your clinician should ask a lot of questions regarding the onset, nature, and course of your symptoms.

In addition to a thorough assessment, you should consider getting a second opinion if you have concerns about your diagnosis or treatment. A client was once referred to me with a diagnosis of borderline personality disorder. She had already been in treatment for 8 months and was not improving. Upon further assessment, it appeared that her symptoms were more consistent with major depressive disorder. The changes in sleep and appetite that she reported also had us wondering if there wasn't something else going on. We referred her for a physical and it was revealed that she had a thyroid condition. Her symptoms of depression all but disappeared once the thyroid condition was treated.

My feelings on mental health diagnoses are mixed: on the one hand, I encourage my clients to hold them lightly given the shortcomings of our current diagnostic tools and resources; on the other hand, I believe that we should acknowledge the value of an accurate diagnosis. Although the process is far from perfect, psychiatric diagnoses often determine the treatment we receive, how it will be covered by insurance, and the availability of various academic and job accommodations. We do not yet have blood tests or brain scans to aid in the diagnosis of most psychiatric disorders; in my opinion, this is all the more reason why we should be diligent, thorough, and cautious in arriving at these diagnoses.
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 +   2 people like this
Posted by Frank, a resident of Old Mountain View,
on Apr 26, 2015 at 6:45 am

I obviously agree with your observations, but do you expect any backlash from the DSM community? If you do, stand up and confront them with the courage that you have always had!

 +   2 people like this
Posted by Caroline Fleck, a Mountain View Online blogger,
on Apr 26, 2015 at 2:52 pm

Caroline Fleck is a registered user.

Thanks Frank! To their credit, I think the DSM community has been pretty open to feedback, especially with the latest edition of the DSM, published in 2013. I'm not even that opposed to the DSM; I think it does a fair job of integrating current research to establish the criteria for various disorders. I think where therapists get into trouble is in clinging to the diagnoses they provide, rather than holding them lightly. Because self-report and observation are all we have to work with right now, I think we need to be even more careful in making psychiatric diagnoses and quicker to re-evaluate our assumptions.

 +  Like this comment
Posted by Ashley, a resident of Bailey Park,
on Jun 10, 2015 at 11:08 am

I would suggest everyone to get a second opinion just to be safe. I have used a second opinion service a few times and will continue to do so. For the time and price its well worth it. Very professional and saved me a bunch of money.

 +   1 person likes this
Posted by Blakeley Southern, a resident of another community,
on Jun 26, 2015 at 2:32 pm

I agree with you caroline that psychological disorders are often not black and white but that there exist many gray areas. There are many shortcomings in our current diagnostic tools and resources, as you mentioned. However, I have heard that psychological testing is constantly approving and becoming more reliable. Do you agree with this?

Web Link

 +   2 people like this
Posted by Caroline Fleck, a Mountain View Online blogger,
on Jun 26, 2015 at 4:18 pm

Caroline Fleck is a registered user.

I definitely agree that psychological assessments are improving. And I really, really value thorough assessments. The testing done at the site to which you linked is top notch and could go a long way in helping determine a correct diagnosis and thus effective treatment. I think psychologists find themselves in trouble when they do shoddy assessments and then draw diagnostic conclusions from these shoddy assessments. Again, even at its best, psychological assessments are far behind those seen in traditional medicine. In my opinion, this is all the more reason why patients should request and seek a thorough assessment and/or consider seeking second opinions if the diagnosis or recommended treatment approach seems off.

Thanks for your thoughtful comment Blakeley!

 +  Like this comment
Posted by anuja, a resident of Jackson Park,
on Oct 9, 2017 at 3:06 am

I appreciate you for share this information with us. This post is very helpful to who are suffering like. In some situations, to get suggestions from other are helpful or not. Whatever, We need to take corrective action before taking any step regarding health or anything.

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