Diagnosis is often the easy part

Some psychiatric diagnoses are very difficult. There can be several possible conditions with overlapping symptoms; the presence or absence of these symptoms may be very subjective. Some people have very atypical symptoms for a given condition and some people are not very good at describing how they feel or may not be very good observers of their own behaviour.

On the other hand, diagnosis is sometimes very simple. I often hear patients express scepticism that a diagnosis could be made after a brief encounter. Sometimes the diagnosis can be made in the first few minutes of an interview. If the symptoms are very clear, unequivocal and typical for a particular disorder, there may not be much question.

Bipolar disorder illustrates both of these extremes. On the one hand, if symptoms are mild there can sometimes be a question of ADHD, Borderline Personality Disorder or bipolar disorder. It may not be possible to make a definitive decision at the initial interview. One may have to wait to see the response to treatment or until the condition declares itself more clearly over time. If, however, the patient arrives in a manic state the diagnosis may be obvious in the waiting room or from the referral letter that precedes their arrival. It may remain only to make sure they are not abusing drugs, or taking some medication that could cause a similar presentation. If a brief interview reveals a family history of bipolar disorder, the diagnosis is even more certain.

Of course the diagnosis may not be the hard part in this case. Having a clear idea what one is dealing with is a good place to start but it does not necessarily lead to an immediate solution. There may be personality issues, lack of insight or cooperation, social or financial problems and a host of other complications that stand between a diagnosis and a successful treatment.

One would be quite justified to say that a brief interview and the prescription of medication are not sufficient even if both are correct. It would be quite correct to conclude that one does not know everything one needs to know about a person just because the diagnosis has been made and the broad outlines of treatment are known. Psychiatry is not a matter of simply applying treatment guidelines. There is an art to therapy that is much more ephemeral.

Sometimes even if you know all the facts and have the necessary treatment methods, you can't succeed because the patient is indecisive, doesn't believe what you say or is surrounded by people and circumstances that interfere with therapy. Maybe the therapist reminds them of someone from the past, a past partner or parent with whom they had issues. This phenomenon of reacting to someone on the basis of past experiences is known as transference. Therapists too can react to patients on the basis of their past experiences counter-transference.

Whether the diagnosis is quick and easy or slow and difficult, successful therapy requires a therapeutic relationship based on trust. It is a partnership with each party having to give the other the benefit of the doubt and working through difficult issues in trying to understand what is going on and often going through difficult times until treatment eventually begins to work. Communication is central to the process. Sometimes the message has to be repeated in many different ways before that understanding dawns, sometimes in a flash of insight.


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