Treatment of a mental health disorder begins with an assessment and a diagnosis. Unfortunately, there are no foolproof tests for mental illness.
A CAT scan might alert doctors to a neurological problem that allows them to rule out schizophrenia. But schizophrenia itself will not turn up in a CAT scan, blood test, x-ray, or any other medical test or instrument.
For the most part, clinicians use direct observation, self-report, and the report of those close to the patient to identify symptoms and make a diagnosis. As our Associate Editor Veronique pointed out in her post Bipolar Disorder vs. Borderline Personality Disorder: Knowing the Difference , many mental health disorders look the same to the untrained eye. Even experts can have a hard time making the right diagnosis.
Some of things that make it hard to diagnose a mental health disorder include:
- Lack of insight (often referred to as “anosognosia”) or unreliable information from the patient.
- Family members’ fear of stigma, shame or denial about a loved one’s problems.
- Age of patient (children and adolescents can be especially hard to diagnose due to the many changes which normally occur during this period of life).
- Other behaviors that either mask or aggravate the mental health symptoms, such as substance use, or undiagnosed or untreated medical conditions.
Sometimes a clinician isn’t sure and observes a patient’s reaction to treatment to confirm the diagnosis: treat for depression and if the patient responds positively, that’s the diagnosis. The problem with this approach is that the treatment for depression can be catastrophic for someone who actually has bipolar disorder.
This happened to my family when we first brought my daughter to the care of a professional. She was prescribed a medication for ADHD and within a matter of days her problems had magnified. We discovered she didn’t have ADHD. But our family trip to visit out-of-state friends that weekend was a disaster (see my post on Family Vacations for advice on how to avoid such situations).
It’s been said that to a hammer every problem looks like a nail. Take your child to a pediatric neurologist and you might come away with a diagnosis of ADHD, Tourette Syndrome, or Nonverbal Learning Disability. Take the same child to a psychiatrist specializing in mood disorders and he gets diagnosed with Mood Disorder NOS. One therapist who sees a lot of kids with autism spectrum disorders thinks it’s Asperger’s Syndrome, while the CBT-trained therapist who specializes in anxiety treats for – guess what? Anxiety.
Many of the families I speak with have experienced the same pattern of confusion and uncertainty. Ultimately, you learn to trust results over diagnoses and assessments. But when I think of the many years we wasted with professionals who treated for the wrong thing or went about it in the wrong way, I realize how important it is to get it right the first time.
This is the reason rtor.org with its Resource Directory of Family-Endorsed Providers exists. Most families dealing with a serious mental health problem for the first time encounter what I call the “cycle of discovery”: the time it takes to put together the right combination of services, treatments and caregivers. rtor.org seeks to shorten the cycle of discovery to get it right the first time.
Many types of professionals are qualified to make a mental health diagnosis. The most common are:
- Clinical Psychologists
- Clinical Social Workers
- Psychiatric Nurse Practitioners
- Psychiatrists
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Hi Jay,
Thank you for the helpful article about the trouble we have obtaining a diagnosis (Mental Health Diagnosis: Getting It Right the First Time, July 30, 2015), and especially for the link to rtor’s Resource Directory of Family-Endorsed Providers. As a volunteer with the Southwest CT affiliate of the National Alliance on Mental Illness (NAMI), I keep an ongoing list of resources for use by other local NAMI volunteers who get calls from families and individuals in crisis. I will add your link to it.
With respect to your list of reasons why getting a correct diagnosis can be difficult, you included the patient’s lack of insight into his own illness. You called this lack of insight “agnosia,” which is the psychiatric term for the partial or total lack of ability to recognize things using one’s senses. I have also heard the patient’s lack of insight referred to as “anosognosia.” That term has been used for example by Xavier Amador, PhD, the clinical professor of psychiatry at Columbia University, in his book, “I’m Not Sick, I Don’t Need Help.” The program outline for a talk he gave at the NAMI national convention in 2011 described anosognosia as “the inability to perceive that one is ill due to impairment to the brain’s ability to see oneself accurately.” They called it “the single biggest reason why more than 50 percent of people living with schizophrenia and bipolar disorder refuse treatment.”
Peter Case
Hi Peter.
Thanks for the clarification on anosognosia. I’ve edited my original post accordingly.
Families often encounter this “lack of insight” in their loved ones with schizophrenia and other psychotic disorders. It can be very frustrating. But I have found that it is almost never fruitful to directly challenge a person’s beliefs about whether they have a mental illness. Sometimes I wonder if a cognitive approach such as Cognitive Behavior Therapy might be helpful in such situations.
Thanks for commenting.
Looking back, I have suffered with bp2 and bpd for over 60years. I am tired of all the emtional upheavals that always come back. is there no end to this?