Mental Health Diagnosis Ridgewood, NJ

The Rationale for Diagnosis

To some, diagnosis seems an unnecessary activity. A diagnosis after all cannot capture the uniqueness of the person, some say. Also, many complain that a diagnosis obscures the person. Such views stem from misunderstanding. The diagnosis is not the person; it merely tells something about the person. A diagnosis tells, in a routinized format, how a person is functioning at a particular moment in time. We are all individual, but at the same time we are all human. In a real sense, there are commonalities across persons. To a great degree, humans have a shared experience whether of function or dysfunction. When used appropriately, diagnosis captures this shared experience of dysfunction without overshadowing the unique experience of the person diagnosed.

Diagnosis is functional, suggesting how the diagnosed disorder might be treated. Illustrating this point, Michael A. Fauman, author of the study guide to the Diagnostic and Statistical Manual of Mental Disorders, writes that many of his medical students ask him why they must diagnose. They want to know why they can’t simply treat the psychotic patient with antipsychotics and the depressed patient with antidepressants. His answer is as follows: “These illnesses may look alike on a superficial level but each has a different etiology and prognosis and each may require a different treatment approach.”

Elegant Explanations

When formally diagnosing, one should hold to the ideal of elegance.  Elegance in a scientific sense means the ability to simply and singularly explain a problem.  Newton’s gravitational laws elegantly explain the motions of celestial bodies…Darwin’s Evolutionary theory elegantly explains the diversity of life.  Consequently, elegance in diagnosis entails explaining a cluster of signs and symptoms with the fewest number of possible diagnostic categories. The concept of elegance is related to the concept of parsimony.  When you are generally parsimonious you conserve resources; when you are diagnostically parsimonious you conserve diagnoses.  In other words, the ideal of elegance and parsimony is to find, if possible, a single explanation that fits the entire presentation.  It was William of Occam, the thirteenth century Franciscan Friar, who first fully articulated these ideals; ever since they have become a mainstay of logic, science and diagnosis.   Of course, some people present with more than one disorder and it is appropriate to accept and record more than one disorder in such cases…this is comorbidity. 

Signs, Symptoms and Syndromes

These three words are often used informally, their definitions becoming so lax as to lose meaning. Though they often blend into one another, these terms have decidedly different meanings. Signs are observable features. Signs can be seen; they don’t have to be told. A sign of depression is psychomotor retardation or the slowing of movement. In contrast, symptoms are gained by patient report. A symptom of depression is sadness. Effective diagnosis combines observable signs and covert symptoms. It is important, in other words, that the clinician both observes and asks. Furthermore, understanding the syndrome is most important. A syndrome is a collection of signs and symptoms. Isolated signs and symptoms are of little use in understanding patients and their problems. Alternatively, it is important to try to understand the overall picture; to try to look at all signs and symptoms and see if there is a single explanation…see if there is a single syndrome to which they all belong. (Read about the technicalities of diagnostic decision making)

In 2013, the American Psychiatric Association transitioned to the fifth edition of their Diagnostic and Statistical Manual of Mental Disorders. If a diagnosis is pursued at the end of an assessment, it will appear using the terminology and numerical coding provided in that most recent psychiatric compendium. Nevertheless, it is conceptually useful to recall the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders for its use of multi-axial assessment methods, and example of which can be seen below:

  • Axis I: All transient mental illness; this axis contains all forms of mental illness that one commonly calls to mind
  • Axis II: Personality disorders and mental retardation; these are lasting disorders that are part of the person and inseparable from them
  • Axis III: General medical conditions; especially those impacting psychological functioning
  • Axis IV: Psychosocial and environmental factors contributing to the disorder
  • Axis V: Global Assessment of Functioning; more or less a numerical grade of psychological health

Using multiple axes allows for a more complete description of the person that takes into account, not only the disorder proper, but associated features. Here are some actual examples of formal psychiatric diagnoses according to the American Psychiatric Association’s multi-axial system

Example I:
Axis I:309.28 Adjustment Disorder with Depressed and Anxious Mood 309.81 Post Traumatic Stress Disorder
Axis II:Features of Narcissistic Personality Disorder
Axis III:Back Injuries
Axis IV:Severe Stressors
Axis V:GAF = 54 (Current)
Example II: Axis I:296.21 Major Depression
Axis II:Deferred
Axis III: None
Axis IV:Moderate psychosocial stressors
Axis V:GAF = 64 (Current)

Dr. Steven C. Hertler
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Ho Ho Kus, New Jersey 07423

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