Diagnosis in (clinical) psychology is defined as the identification of a disease, disorder, syndrome, condition etc. – whereby categorisation and classification are the central concerns (Reber, Allen and Reber, 2009). Diagnosis has been based on the disease entity concept used in medicine. Within this orientation, clinical diagnosis is of paramount importance, for appropriate treatment depends on the correct diagnosis. This ‘disease entity model’ has previously proven to be successful in a wide array of health-related disciplines: biochemistry, genetics, and microbiology (Sutker and Adams, 2004).
There are an estimated 850,000 people with dementia living in the UK, and this figure is set to rise to 1 million by 2025. The total cost to society for looking after those diagnosed is estimated to be £26.3billion (£32,250/person); Alzheimer’s Disease (AD) being the most common cause of dementia, with an estimated 62% prevalence rate (Alzheimer’s Society, 2014). Early detection of changes, with regards to AD, appears to be one of the most demanding challenges right now. This is made increasingly difficult due to the nature of changes, which are elusive, and our ability to distinguish them from changes we know occur in normal ageing (Devlin, 2017). An early diagnosis can be key in several ways. From a clinical perspective, appropriate treatment can slow down or even prevent the rate of further decline. In addition, the diagnosis is likely to be more accurate if it’s made earlier on in the disease process (before the brain gets damaged further). From a patient’s outlook, it may empower the individual, allow better and more thoughtful choices to be made, as well as generally help one’s family and themselves in the process (Alzwisc.org, n.d.).
Post-traumatic stress disorder (PTSD) entered the Diagnostic and Statistical Manual of Mental Disorders (DSM) in the 3rd edition which was released in 1980 by the American Psychiatric Association (APA). This was due to the increasing intensity of (political) pressures that were being placed on the mental health field in recognition of the psychological effects which were observed among veterans of the Vietnam War. An analysis by Isaac Galatzer-Levy and Richard Bryant (2013) calculated that there are now 636,120 (an eightfold increase from DSM-4’s 79,794) ways to be diagnosed with PTSD based on all the possible combinations of symptoms that would fulfil a diagnosis for this condition. The authors suggest using statistical techniques resulting in empirical data to help us better understand and describe mental health problems. However, a wider implication of this study adds on to the general criticism of the DSM-5. For example, the British Psychological Society (BPS) suggested ‘mental disorders are better explored as part of a spectrum shared with normality’ and changing the diagnostic framework that is currently deployed (BPS, 2011). Alternative criticism was mentioned in Thomas Insel’s (2013) blog post, writing on behalf of the National Institute of Mental Health (NIMH), whereby his interpretation of the DSM-5 is that the strength of the manual is its reliability and the weakness is its lack of validity.
It may seem that there can only be advantages of diagnosing in a clinical setting i.e. the appropriate treatment, and the subsequent patient and family counselling, is dependent on an accurate diagnosis. Diagnostic labels can be useful, in the sense that they lead to more empathetic understandings and more effective responses relating to a condition. These labels classify individuals for treatment and research purposes, but can also act as cues that generate stigma and stereotypes (Garand et al., 2009). In more longitudinal cases, these stigmas may affect the quality of care provided to a patient, their willingness to seek care, as well as family and patient’s endeavours associated with the diagnosis (of the disease etc.). In relation to dementia, the disorder inherently carries its own diagnostic label, but one that is of a significant use in a healthcare or research setting.
A timely study (Teresi et al., 2012) found evidence to support the notion that clinical diagnoses of AD may be affected by self-reported race. This finding, that knowledge of race may influence the diagnostic process in some unestablished way, parallels the necessity of information and standardisation with regards to the diagnostic process. Misdiagnosis and overdiagnosis are usually side effects of early screening (for a disease), and because most people are treated based on their diagnosis, there can only be harmful consequences as a result. These can be: physical effects (via medical interventions), psychological effects (labelling and increased sense of vulnerability), and an economic burden (cost of healthcare and/or associated costs of treatment). The BMJ claims that the ‘political drive’ in the UK towards early diagnosis lacks succinct evidence and pointlessly worsens the ‘war against dementia’ as opposed to defending against it by helping those patients at risk of developing the condition (Campbell, 2013).
A government mandate to the NHS aims to maintain a diagnosis rate of at least two thirds, as well as increase the numbers of people receiving a dementia diagnosis by 2020 (Department of Health, 2015). However, these objectives, which are further outlined in a recent government briefing (Parkin and Baker, 2016), may prove difficult, especially when the wider picture is consolidated with the antecedent research, and applied amidst the pros and cons of diagnosis wholly.
When looking at diagnosis in a clinical psychology picture frame, there are arguments supporting the concept, but also a backlash from the psychological community, with some fields within the area already abandoning diagnosis in theory and in practice. At a surface level, diagnosis is useful to: define clinical entities, determine treatment, and differentiate problems. On the other hand, a diagnosis is: imposed by an ‘expert’ and not by the client, shown to lead to self-fulfilling prophecies and despair, and tends to ignore sociodemographic factors. Despite there being supporting evidence (from clinical studies) and opposing evidence (from psychological studies), the purpose of diagnosis remains a grey area for most involved within the field. Aside from dementia, and neurodegenerative disorders affecting (mainly) the elderly population, the appropriateness of diagnosis can vary when applied in a psychiatric setting e.g. mental health where jargon such as ‘diagnostic labelling’ may be more prominent than (say) personality disorders.
With regards to the wider literature, diagnosis tends to show ubiquity within psychiatry and whilst it does yield positive support, inauspicious effects of ‘labelling’ are not unheard of. For example, a recent study (Lam, Salkovskis and Hogg, 2015) found borderline personality disorder (BPS) labelling to be associated with more negative ratings of a woman’s problems and her prognosis. However, conflicting evidence suggests that the effect of labelling depends on what the label implies (Huibers and Wesseley, 2006). Their study on chronic fatigue syndrome (CFS) concluded that the act of diagnosis is a trade-off between: empowerment, group support, and illness validation juxtaposed with the risk of ‘diagnosis as self-fulfilling prophecy of non-recovery’. Together with assessment and treatment, the evidence suggests that there is an unequivocal demand for diagnosis, especially in the clinical branch of psychology. However, it is a combination of both objective and subjective reasoning that ultimately leads to and maintains their use within these disciplines.
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