So much of psychiatry is opinion. While there can be general agreement that something is amiss with an individual, sometimes gravely so, there can also be a lot of debate as to what that actually is. The discussion about their potential mental disorder may be stimulating and interesting for the clinician; perhaps rather less so for the patient.
There has been an expansion in people receiving psychiatric diagnoses recently, and I’m not going to talk about whether this is right or wrong, because that would only be my opinion, based on my experience, which will inevitably be flawed. What does concern me are the dichotomies in different clinicians’ opinions about illness and treatment, and how they reach these. I suspect it may be based on an experience of seeing someone diagnosed or treated for something resulting in a eureka moment and subsequent generalisation. People have told me that they believe in ECT as a treatment after seeing me get better. Well, I’m delighted to get better, and it may well be ECT – but of course it may not be. Apparent response to any treatment does not necessarily prove a diagnosis, perhaps especially in psychiatry.
My own diagnosis of bipolar disorder may, or may not, be correct, depending on what correct means. I’ll never have complete ‘belief’, but it matches up to diagnostic criteria. My partner seems more certain of this than I do, but maybe it’s easier for him, not being trained in the art of psychiatry. He also observes and remembers, where I experience and forget.
What I do feel strongly about is the game of changing diagnoses, and I use the word game as it does sometimes seem like that. My own experience of a changing label from depression to bipolar disorder, back to depression, and then back to bipolar does seem fairly representative, and hasn’t been too bad, I suppose. I know from speaking to people, and, increasingly, reading people’s experiences online that many struggle with diagnoses being given, diagnoses being changed and even just removed. I think this might more manageable if more of us had the same clinician caring for us over the years (I’ve been lucky in this), as someone changing a diagnosis that they’ve made themselves is far more understandable, and hopefully they would give a good reason. However, if you see a new psychiatrist, and they say – well, I know so-and-so said you have such-and-such a diagnosis, but I don’t agree, I think you have something quite different – it can be very difficult indeed.
My personal experience is that it can take a long time to accept a diagnosis, and when someone changes it I think – well, they clearly don’t agree with each other, so quite likely they’re both wrong. Now, I know that getting a diagnosis ‘right’ can be very difficult, and it’s also very important, both to get the right treatment and to minimise iatrogenic harm. But I also know that diagnoses can sometimes be changed on the basis of one appointment, and if the change is to, for example, personality disorder that can be devastating.
I’m also aware that some clinicians have a reputation for making particular diagnoses more often than others. As a psychiatrist myself, I can think of at least two who are reputed to diagnose bipolar disorder in very many of their patients. This is a problem, because some of these patients may not have bipolar disorder, and may be treated with medications like antipsychotics which can cause harm, which is unacceptable if unnecessary. They may also have other problems which are not being treated. However, given the population prevalence, some of their patients will indeed have bipolar disorder, and this may also be a problem, as there can be an assumption by others that they don’t. I like to think that another clinician would quickly realise that they did; but the credibility of any diagnosis should not depend on the individual psychiatrist.
Perhaps this is why I like to work in addictions, as things can seem more straightforward. But even in addictions they aren’t, not really. When someone is clearly dependent on alcohol, for example, and detoxing, my task can seem fairly clear. But actually it is often extremely hard to know how much someone is drinking, or using, and why. They may tell me they are drinking less, so as not to lose their driving licence; or using more drugs, so I will prescribe for them. And, of course, they, too, will often have other mental illnesses. Which comes first, the anxiety or the drinking, and how can I be sure? Sometimes the addiction diagnosis is seen as more stigmatising, but this doesn’t mean we should pretend it is something else; instead we need to address stigma.
Ultimately it’s all about communication. No-one should have a diagnosis given, or changed, without a clear explanation. And if the patient disagrees, this must be heard with an open mind (A genuine open mind. The patient sees more of themselves than you do). If a second psychiatrist later disagrees with the first, maybe they need to speak to each other, as, regrettably, the changing diagnosis game can sometimes have a feeling of point-scoring. There are lots of horrible diagnoses, in both physical and mental health, and most of them we wouldn’t want to have. But I think we are more able to accept a diagnosis that has been explained to us, and that we ourselves can recognise.
There is also a lot said about diagnoses of mental disorder being less convincing than their physical counterparts. Well, that may well be true, we have less diagnostic tests. But psychiatric disorders have patterns of symptoms that re-present throughout the generations. Melancholia, for example, is fairly consistent, and definitely not new. Classifications will change, hopefully treatments will improve, and we need to be open to this. Shades of grey are often better than black and white, but, to my mind, the most dangerous thing in psychiatry is belief.