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When I worked at a mental health center, I often found myself scratching my head as to the diagnosis that was given to a patient by a psychiatrist.  I had diagnosed one individual with an Adustment Disorder, which is anxiety and depressed mood related to a difficult situation in life.  The psychiatrist diagnosed, schizoprenia, paranoid type.  I was left utterly scratching my head as to why the psychiatrist had diagnosed schizophrenia, whereas I diagnosed an adjustment disorder.   After looking at the medications that were prescribed, I found the reason, Abilify….an antipsychotic medication.  Even though this patient did not meet the diagnostic criteria for Major Depression, let alone schizophrenia, the psychiatrist wanted to try Abilify; therefore diagnosed schizophrenia.  That was the only conclusion I could come to.  I saw this on numerous occasions.  The diagnosis didn’t fit, and the medication was an antipsychotic.  So, the diagnosis would be Bipolar Disorder, or a psychotic disorder. 

As the Last Psychiatrist noted:

“You might argue the diagnosis leads us to the treatment, but in most cases, meds are used across all diagnoses, and more often than not a diagnosis is created to justify the medication.”

I had one patient, who for 14 years, was diagnosed with depressive disorder, NOS and personality disorder, NOS, until the psychiatrist wanted to try an antipsychotic.  Suddenly, the diagnosis became schizoaffective disorder. 

You may think that the diagnosis doesn’t have implications for treatment, but it does.  If you are psychotic, you are not responsible for your behavior.  The patient diagnosed as schizoaffective, was seen as psychotic by his wife and his psychiatrist.  Therefore, he was not responsible for his Borderline, manipulative, aggressive and passive aggressive behaviors.  This was the way the psychiatrist and his wife saw his behavior.  I did not see the behavior this way because I was his psychologist.  So, this puts me in a difficult position.  I see him as responsible for the choices he makes, but the psychiatrist and wife see him as “mentally ill” when he engages in unsual behavior.  I have to set limits and tell him that I would “find him a therapist who expects less” of him when the psychiatrist and husband justifies his behavior. 

You see, I also do evaluations related to “sanity” and “fitness to stand trial.”  This particular individual would likely be seen as incompetent and insane for his inappropriate behavior by the psychiatrist, but would be seen as perfectly sane by me who sees him as having a different diagnosis.  You can say the diagnosis has no implications, but it really does in terms of personal responsibility and therapeutic issues with respect to psychotherapy. 

So, this is one reason that I see diagnostic accuracy as being an important issue for treatment.  My personality testing, interviews, and observations yield a diagnosis of a primary personality disorder, whereas, the psychiatrist’s desire to prescribe an antipsychotic yields a diagnosis of a psychotic disorder.  So, it comes down to a situation where the patient has to decide to believe a professional who believes that they have control over their decisions versus a professional who believes they have no control or responsibility for their decisions.  So far, when faced with this decision, my patients go with me, who believes that they have control and responsibility for their decisions.  When they are legitimately psychotic, that’s one thing, when they are not, that is another.  The diagnosis has real world implications in terms of personal responsibility and psychological treatment.  Fortunately for most patients, when push comes to shove, they would rather believe that they are responsible for their behavior and have a desire to make efforts towards changing their maladaptive behavior.  Unless they truly are psychotic….then the issue of personal responsibility has less meaning to them, because their reality contact is impaired.

So generally, when one of my patients is seeing a psychiatrist, the diagnosis has real world implications.  And when they are not, the diagnosis has less meaning.  Only the individual factors that contribute to the person’s difficulties are relevant.  When the psychiatrist renders a diagnosis, then there are real world implications that affect the patient and their family.