Is There a Better Way to Diagnose?

Stephen Schlein, a psychoanalytic psychologist from Lexington Mass., wrote a thougthful op-ed piece for today’s Boston Globe. In it, he discussed the trend amongst health and mental health professionals to diagnose a disorder based solely upon behavioral symptoms (and sometimes, not doing even that):

Children and adults are diagnosed with mental disorders based on their behavior in a fast-paced world, and not on their personal internal world. One much-discussed scenario occurs when a child acts up in school, and the teacher or other school personnel suggests that the child has attention-deficit disorder and needs medicine. The ADD diagnosis is so prevalent today that it’s losing its reliability as a useful diagnosis.

This sloppy labeling is arrived at from observing someone’s behavior. Yet, this process avoids any in-depth critical assessment and establishes a superficial picture of the person, ignoring the fact that every individual is a complex social being.

The same is true of the current “epidemic” of bipolar disorder. This diagnosis seems to have become another all-purpose diagnostic label, just like ADD. How could one possibly diagnose a toddler with a bipolar disorder, when there’s so much going on in the life of a 2-year-old child related to normal problems of human development and ordinary concerns of daily living?

Agreed.

Now, I was wondering where Dr. Schlein was going with this, since it’s a truism that most professionals admit is a problem, but few have a solution to it. There are very, very few professionals who think it is ever appropriate to diagnose a 2 year old child (or even a 4 year old child) with bipolar disorder.

The psychodiagnostic work performed by mental health providers in our society is deteriorating. In the past, diagnostic testing performed by psychologists emphasized “projective testing,” which was designed to look inside a person to evaluate their feelings and emotions, personality development, and life circumstances.
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A personality assessment should provide an in-depth perspective, using an analysis of self-esteem, the quality of interpersonal relationships, the impact of anxiety, and the strength of “ego functions,” such as reality testing, judgment, and thought processes.

One of the reasons why projective psychological testing generally takes a back seat to DSM-IV diagnostic criteria is because the DSM-IV has fairly strong empirical research support and projective tests, like the Rorschach inkblot test, are far more subjective and lack such reliable evidence.

Yes, there’s some research that helps to inform how to interpret projective tests like the Rorschach or TAT, but projective tests are usually just one part (and a small one at that) of a full psychological battery. Such a battery includes far more empirical measures, such as the MMPI-2, NEO PI-R, PAI, WAIS-III, etc., because those measures have more objectivity and are less reliant on a particular practitioner’s experience or theoretical background.

Are psychological tests an answer to overdiagnosis of ADHD or bipolar disorder in children?

Generally, no. A well-done psychological battery of in-depth tests can take 4-5 hours to administer, and another 3 or 4 hours to interpret. Only psychologists have the training necessary to do this, but most psychologists don’t specialize in testing when they go into practice (for many reasons, but one of which is because it’s a fairly monotonous process).

More importantly, few tests directly correlate to a specific diagnosis. While Dr. Schlein is absolutely correct that they provide a better picture of the complexities of an individual, they are overkill for most people and professionals trying to arrive at a fairly accurate diagnosis. (For instance, bipolar disorder is characterized by mood swings from depression to mania over time. Such mood swings can be self-reported fairly easily by an individual, or measured with quick self-tests, like the Beck Depression Inventory.)

While I believe Dr. Schlein’s central thesis is valid — that we are far too quick to assign labels today than we were a decade or two ago to normal child or teen behavior — I don’t see any remedy that will significantly impact this problem any time soon.

Article: When the diagnosis is part of the problem