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Tuesday, May 27, 2014

"Why is Misdiagnosis of Mental Illness so Very Common?"

     This question is from a client who has done some "internet research" after having received several different diagnosis over the course of a couple years. This is a very common problem. Last year, I worked with two different parents of children who had over eight different diagnosis in about a 5 year period. They were looking for another opinion, but also wanted an explanation for their child's behavior problems. In mental health, a diagnosis is not an explanation, it's just a description.

Accurately diagnosing mental illness remains
difficult. Second and third opinions
should be sought, especially if you are
told that you have a severe diagnosis, like
Schizophrenia, Bipolar, or OCD.
      In studies of reliability, researchers use a Kappa score to determine if diagnosis are consistent from one provider to another for the same patient (inter-rater reliability). A diagnostic category is considered to be reliable if it has a Kappa score of at least .70. With regards to the DSM, only a couple diagnosis have a Kappa score of .70 or higher. So, nearly all mental illnesses are considered unreliable with regards to getting an accurate diagnosis from one provider to another. In fact. you can almost be certain that if you have been diagnosed by a mental health provider, the diagnosis is incorrect or incomplete.
     Misdiagnosis is a serious problem because it leads to mistreatment, and this can be, in the least, frustrating, but it has the potential to be fatal.** Also, being labeled with a serious mental illness is to be stigmatized, and this can lead to problems with employment, joining the armed forces, and other social and economic issues.

          There are many reasons why misdiagnosis is so common in the field of mental health. To start with, there are no medical tests for mental illnesses, so, mental health providers rely on self-reports of clients in the form of "clinical interviews," with clients and family members, questionnaires, and observations made in the practitioner's setting (e.g., office, hospital). The lack of concrete medical tests with reference ranges that define a normal range, leaves providers with subjective information; this subjective information is open to a very wide-range of interpretation from one provider to another.

     The criteria for mental illness are written in
vague language. Phrases like "extreme irritability" means something different from one provider to the next. There are hundreds of symptoms of mental illness and nearly all of them are vague. This is probably why mental illnesses are "co-morbid" (occur at the same time) with each other; for example, 50% of children diagnosed with ADHD are thought to have ODD. The same behaviors can be categorized under different labels instead of reserved for one.

During the time of phrenology (1810-1840)
simplistic hypothesis lead to misdiagnosis.
Today, Psychiatry continues to use
faulty and artificial syndrome constructs.
     Another factor is that the symptoms are mostly descriptions of behaviors. For example, one symptom for ADHD is: "Often does not seem to listen when spoken to directly." For Bipolar: "Doing things that have a high potential for painful consequences, for example, unrestrained buying sprees... foolish business investments." Another is, "unusual talkativeness." The behaviors may sound specific, but how providers measure the frequency, duration, and intensity of behaviors varies from one to another. The cause of each of these behaviors may be different, and clients tend not to keep track of any particular symptom. The level of tolerability from one person to the next, for a specific symptom, varies. 

     Self-diagnosis and confirmation bias are two factors that contribute to misdiagnosis. Many patients think that their minimal and infrequent behavior or emotional problems are symptoms of a serious mental illness, when in fact, they are not. I've known many patients to think that the presence of a symptom equals the presence of the disorder. Providers often take patients at face-value, not asking for specific examples of what they are reporting as a symptom. Some patients are convinced that they have a mental illness and will seek out a provider who will agree with their beliefs; although, of all the factors, this is probably the least common.

     Cultural issues play a large role in misdiagnosis. For example, Psychiatrists who are Asian (from India, Philippines, etc...) may interpret a volatile or expressive temperament as being symptomatic of bipolar disorder. I have witnessed this occur first hand when I used to do rounds with psychiatrists. Temperamental differences between the psychiatrist and the patient can lead to problems with arriving at a correct diagnosis.

     Economic status has been studied as a factor. It is clear that lower income people are much more likely to be diagnosed with severe mental illnesses. Also, less attractive people and minorities are more likely to be diagnosed with severe mental illness.

     Mental illnesses are very easy to fake. Sometimes people want to be misdiagnosed. I've actually known some people who have faked symptoms of ADHD or anxiety in order to acquire the prescription drugs for nefarious reasons. The fact that symptoms of mental illness are so easy to fake makes reveals the non-scientific nature of mental illness symptoms. The Rosenhan experiments, in the 1970's, are excellent examples of how fallible the diagnostic process can be: .

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     Behavioral-based diagnosis, like ADHD, are very subjective. This is because no single behavior, let alone a set of behaviors like in ADHD, have many potential causes. Different types of providers may spend more time trying to figure out the cause of a behavior, whereas psychiatrists will assume one of two things: 
1) the cause of the problems are biological, therefore I will treat it with chemicals, or 
2) regardless of the cause of the problems, I will treat it with chemicals, and possibly refer the patient for "supportive therapy."
      Psychiatrists will assume that biological factors (genetics or neurotransmitters) are the primary cause and anything else is secondary to that or a "complicating factor," not a cause, but something that makes the genetic problem worse. Whereas, social workers, psychologists, and counselors will see biology as a relatively insignificant factor compared to other factors, like trauma, life stress, relationship problems, and problems with how and what people think about themselves, others, and life.
      Because of these differences in the underlying cause of mental illness, psychiatrists have less interest in exploring the many factors that contribute to mental health problems; as a result, there may be a more discrepancies in diagnosis between a psychiatrist and social worker. However, with regards to diagnosis and treatment, each type of provider is consider equal to the other with regards to the provision of mental health services.

** If you are diagnosed with a serious mental illness and prescribed psychotropic drugs, the chronic use of many of these drugs can lead to disease, disability or early death, especially with chronic use of neuroleptics like Seroquel, Haldol, Risperdal, Zyprexa, or others. Also, for example, misdiagnosis of major depression or generalized anxiety disorder can lead to under-treatment of suicide ideation.

Mental Health Advice Disclaimer: The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.

1 comment:

  1. Well written. This is something that I have been thinking about a lot lately because of experiences I have had.