Diagnostics and diagnosis

What is diagnostics?

Diagnostics is about the methodology of coming to a diagnosis – the “how” of reaching a diagnosis. To arrive at a diagnosis it is essential to properly address the diagnostic process – which is what this article refers to as diagnostics. This article will focus on diagnosis in relation to diagnostics. Diagnostics is an inseparable part of ‘diagnosis’. By way of analogy, a good meal usually involves the methodology of preparation, and in many but not all cases – cooking of some sort. Even a hurriedly put together sandwich needs some sort of gathering of things to make the sandwich. You ought not to expect Michelin Star quality food in mad rush at a fine restaurant!

What is diagnosis?

Diagnosis, at its core, is a conclusion or determination about what’s causing a person’s symptoms or health issues. It is basically putting a name to a set of experiences, symptoms, or test results. However, this is not a simple matter like sandwich-preparation. We’re talking about people’s lives, relieving suffering, their health, their families and loved ones. This means that the act of diagnosing is not a simple matter of looking up symptoms in a book and picking a label to match.

In many clinical situations it may appear that there are more than one diagnosis. Diagnostic systems like ICD-11 and DSM-V-TR will provide sound guidance about boundary areas between psychiatric diagnoses. Psychiatrists who pay little attention to these matters ‘diagnose everything‘ i.e. make multiple diagnoses, and then prescribe cocktails of medication to treat all. This is called the ‘buckshot’ approach. It is good for no one.

Meaning

For the patient, a diagnosis means:

1. An explanation: It provides a framework to understand what’s happening in their body or mind.
2. A predictor: It gives an idea of what might happen in the future (prognosis).
3. A guide: It suggests what actions might help (treatment options).
4. A label: For better or worse, it categorises their condition in a way that has medical, social, and personal implications.

For the doctor (or diagnostician), a diagnosis is:

1. A working hypothesis: Based on evidence, but subject to change with new information.
2. A communication tool: It allows them to convey complex medical concepts succinctly to other healthcare professionals.
3. A decision-making aid: It helps in choosing appropriate treatments and management strategies.
4. A starting point: For further investigation or monitoring.

So when someone is diagnosed with “diabetes,” it means:

• To the patient: “I have a condition where my body does not properly regulate blood sugar. This explains my symptoms. I may need to change my diet, exercise habits, and possibly take medication. I’ll need to monitor my blood sugar regularly.“
• To the doctor: “This patient’s symptoms and test results indicate diabetes. I need to educate them about the condition, consider treatment options like metformin or insulin, and set up regular check-ups to monitor their blood sugar levels and potential complications.“

From a patient’s perspective, the process is less important than what the diagnosis means for their life and health. The same applies in psychiatry, as in any other branch of medical practice.

Utility

From the patient’s perspective:

1. Understanding: A diagnosis helps patients make sense of their symptoms and experiences, providing clarity and often relief.
2. Validation: It confirms that their symptoms are real and recognised, which can be particularly important in conditions that are not visibly apparent.
3. Prognosis: It gives patients an idea of what to expect in the future, helping them plan and adjust their lives accordingly.
4. Treatment access: Many treatments, support services, and accommodations are only available with a formal diagnosis.
5. Community: A diagnosis can connect patients with others who have similar experiences, providing support and shared understanding.
6. Identity and coping: For some, especially in long-term conditions, a diagnosis becomes part of their identity and helps in developing coping strategies.
7. Insurance and benefits: A formal diagnosis is often necessary for insurance coverage or disability benefits.

From the doctor’s perspective:

1. Treatment planning: A diagnosis guides the selection of appropriate treatments, interventions, and management strategies.
2. Risk assessment: It helps in predicting potential complications and implementing preventive measures.
3. Communication: Diagnoses provide a standardised way to communicate about patient conditions with other healthcare professionals.
4. Legal and ethical obligations: Proper diagnosis is part of a doctor’s duty of care and can have legal implications.
5. Resource allocation: It helps in determining what resources (time, tests, specialists) a patient might need.
6. Monitoring and follow-up: A diagnosis provides a framework for ongoing patient care and assessment of treatment efficacy.
7. Education: It allows doctors to provide targeted information to patients about their condition.
8. Professional satisfaction: Reaching an accurate diagnosis is often a core part of a doctor’s professional role and satisfaction.
9. Research and epidemiology: Diagnoses allow for the categorisation of conditions, which is crucial for medical research and public health planning.

For both patients and doctors, a diagnosis serves as a crucial starting point. It is a shared understanding that forms the basis of the treatment relationship. However, it is important to note that the significance of a diagnosis can vary greatly depending on the condition, the individual patient, and the healthcare context.

This dual perspective highlights why diagnosis is so central to medical practice, bridging the gap between the patient’s lived experience and the doctor’s medical knowledge and responsibilities.

What happens or should happen after diagnosis?

Patient Perspective	Doctor Perspective
1. Seek understanding: Research the condition from reliable sources	1. Explain the diagnosis: Provide clear, understandable information about the condition
2. Emotional processing: Deal with feelings about the diagnosis	2. Assess patient understanding: Ensure the patient grasps the implications of the diagnosis
3. Discuss with family/friends: Share the diagnosis with support network – if they wish but with due caution.	3. Develop treatment plan: Create a comprehensive plan tailored to the patient’s needs
4. Ask questions: Prepare and ask questions about implications, treatment, etc.	4. Prescribe or organise treatment: Initiate appropriate medications or therapies
5. Consider lifestyle changes: Implement recommended diet, exercise, or other modifications	5. Refer to specialists: Connect patient with relevant specialists if needed
6. Start treatment: Begin prescribed medications or therapies	6. Schedule follow-up: Arrange for appropriate monitoring and check-ups
7. Monitor symptoms: Keep track of how symptoms change over time	7. Coordinate care: Ensure proper communication with other healthcare providers
8. Join support groups: Connect with others who have the same diagnosis	8. Offer resources: Offer information on support groups, educational materials
9. Plan for the future: Consider long-term implications (work, family planning, etc.)	9. Consider comorbidities: Assess and plan for potential related conditions
10. Learn self-management: Develop skills to manage the condition day-to-day	10. Document thoroughly: Record the diagnosis, reasoning, and plan in medical records
11. Arrange practical support: Organise any needed help at home or work	11. Manage expectations: Discuss prognosis and potential outcomes realistically
12. Review insurance/benefits: Understand coverage and apply for any available benefits	12. Consider research/clinical trials: Inform patient of relevant research opportunities

After some or all of the above, comes the work. It is quite a lot of work to assess capacity, engage patients, and plan their treatment (normally with their engagement). But it is more than that because involvement and coordination of whole teams of people needs to happen. Then there is active assessment to gauge progress or lack of it.

Factors that lead to poor dialogue

1. Time constraints: Doctors often face significant pressure to see a high volume of patients, leaving limited time for each appointment. This can make it challenging to provide thorough explanations, especially for complex diagnoses that require more time to unpack and discuss fully with patients.
2. Communication skills: Some doctors may struggle with effectively translating complex medical information into layman’s terms. This could be due to a lack of training in patient communication or difficulty in finding the right balance between accuracy and simplicity when explaining medical concepts.
3. Assumption of patient disinterest: Doctors might mistakenly believe that patients are not interested in or capable of understanding the intricacies of their diagnosis. This assumption can lead to abbreviated explanations or a focus solely on treatment plans rather than diagnostic reasoning.
4. Fear of patient anxiety: There’s often a concern among healthcare providers that detailed explanations might cause unnecessary worry or confusion. This fear can lead to withholding information, especially regarding uncertain aspects of a diagnosis, in an attempt to protect patients from distress.
5. Diagnostic uncertainty: When faced with ambiguous cases, doctors might hesitate to fully explain their reasoning. The fear of being wrong or having to revise a diagnosis later can lead to vague or incomplete explanations, as they try to maintain credibility and patient trust.
6. Paternalistic attitudes: Some doctors may still harbor outdated beliefs that patients don’t need or shouldn’t be burdened with understanding the details of their diagnosis. This “doctor knows best” mentality can result in a lack of transparency and shared decision-making.
7. Cultural and language barriers: Explaining complex medical concepts across cultural or linguistic differences can be challenging. Without appropriate translation services or cultural competency, doctors may struggle to convey nuanced information effectively, leading to incomplete or misunderstood explanations.
8. Lack of patient engagement: If patients appear passive or don’t ask questions, doctors might interpret this as a lack of interest or understanding. This misinterpretation can lead to abbreviated explanations, as doctors may not realise the need for more detailed information.
9. Overconfidence: Some doctors might believe their diagnosis is self-evident and does not require a detailed explanation. This overconfidence can stem from overestimating the patient’s medical knowledge or understanding, resulting in insufficient information being shared.
10. System pressures: Healthcare systems that prioritise efficiency and throughput over patient education can inadvertently discourage thorough explanations. Lack of institutional support or incentives for patient education can further exacerbate this issue.
11. Emotional fatigue: Burnout and compassion fatigue are significant issues in healthcare. When doctors are emotionally exhausted, they may put less effort into patient communication, leading to cursory explanations of diagnoses.
12. Legal concerns: In an increasingly litigious healthcare environment, some doctors may worry that detailed explanations could be used against them in potential malpractice cases. This fear can lead to guarded communication and less thorough explanations of diagnostic reasoning.

Diagnostics across Physical and Mental Conditions

In the proper practice of psychiatry, it is well known that symptoms and signs may overlap into several diagnostic categories. For example, anxiety as a symptom can occur in every mental disorder. Anxiety is not a diagnosis but anxiety disorder is. Delusions and hallucinations may also be found is several mental disorders. So, it is not delusions plus hallucinations therefore it is schizophrenia. In some instances schizophrenia can be diagnosed without the presence of delusions and hallucinations.

Diagnostics means a sound gathering of evidence about the nature of mental symptoms, excluding organic or other contributing factors, considering cultural and religious context – and much more. Diagnosis is about the thought processes that bear on the evidence in context.

Aspect	Physical Conditions	Mental Health Conditions
DIAGNOSTICS
Objective Tests	Abundant (blood tests, imaging, biopsies, etc.)	Limited (mainly to rule out organic causes)
Tools	Primarily technology and laboratory based	Primarily observational and interview based
Reliability	Generally high inter-rater reliability	Variable inter-rater reliability
Time Frame	Often can be done in single visit/admission	Usually requires longitudinal observation
Cultural Impact	Relatively less influenced by cultural factors	Heavily influenced by cultural interpretation
Documentation	Largely quantitative data	Largely qualitative descriptions
Cost	Often expensive, equipment-dependent	Generally lower cost, less equipment-dependent
DIAGNOSIS
Basis	Often tied to clear pathophysiology	Based on symptom clusters and patterns
Certainty	Usually more definitive	Often more tentative/”working” diagnosis
Aetiology	Generally clearly identifiable	Usually multifactorial/complex
Validity	Generally high construct validity	Variable construct validity
Boundaries	Usually clear disease boundaries	Often overlapping syndromes
Classification	Based on pathology/aetiology	Based on phenomenology/presentation
Comorbidity	More easily separated	High levels of comorbidity common
Verification	Often possible through tests	Primarily through clinical consensus
Treatment Link	Often direct link between diagnosis and treatment	Unclear treatment links and more difficult to match treatments to conditions.

Conclusions

‘Clenching the diagnosis’ means very little in psychiatry. Why? Because diagnosis does not mean a person will be treated ‘appropriately’. The latter may be the legitimate expectation but it is not guaranteed to happen in the current cash-strangled NHS of the last 5 years (at least).

The aggregate of all activities related to diagnostics and diagnosis means there is a heavy volume of work for individual psychiatrists and their multidisciplinary teams. There is meant to be a lot of energy involved in the thinking process of diagnostics, and then considering the evidence in order to come to the best diagnosis.

Considerable time and effort ought to be spent by psychiatrists in diagnostics and diagnoses. Production-line services that push mental health teams for rapid turnover – in the face of heavy bed pressures – risk patients being wrongly diagnosed and getting the wrong treatments or supervision. The outcomes could be catastrophic as seen many a Public Inquiry or Coroner’s inquest.