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Stand up in defence of diagnostics! Or to whom does the diagnosis belong?


One of the most central assignments of health care is diagnostics, i. e. collecting and summarizing the problems presented by the patient into a well-founded working hypothesis. Careful, often time-consuming diagnostics in the beginning may save plenty of work during a treatment contact that may be several years long. By tradition, psychiatrists, i e the professional category with the most extensive education and deepest knowledge about the human body, is the profession making medical diagnoses, which is reasonable.

When we are trying to arrive at a diagnosis, plenty has to be taken into account – the patient´s narrative and behaviour, observations by people around the patient, sometimes lab data, the patient´s somatic status and in some cases imaging. All data collected in this manner is then sifted through our knowledge (what we have absorbed through studies, courses, supervision and, sometimes, research work) and our experience (a part of competence that cannot fully be replaced by anything else and to which there is no short-cut). At the best, and after differential diagnostic consideration – obviously including also somatic disease – we will eventually arrive at a plausible work hypothesis, and from there find ways to help the patient handle his/her situation. Also when choosing the treatment, the psychiatrist´s medical knowledge is indispensable – is the treatment of choice pharmacological or something else, and if pharmacological, which drug to choose?

In most cases assessment and diagnostics are made much easier if two professionals at the same time interview and assess the patient. The psychiatrist´s best partner is a psychologist, since psychologists have expert knowledge of cognitive functions. Cognitive functioning is an essential factor to consider in all assessments of patients – cognitive functions influence how the patient is affected by and present the symptoms, and psychiatric illness affects cognitive functions, at least temporarily.

Individuals with a weak theoretical ability, or borderline intellectual functioning, are very likely to be overrepresented among psychiatric patients, which is why a clinical assessment of cognitive ability – including a school history - always should be part of the diagnostic process. The patient´s cognitive function also influences, beside diagnostics, choice of treatment and compliance to be expected. Another advantage of being two professionals is obviously that four eyes see more than two, and the possibility to take turns in talking and observing, respectively. Working alone is much too common in psychiatry, and overrated as a method.

The professional assessment and diagnostic process as described above can never be replaced by questionnaires, the use of which in most cases is nothing else than an unnecessary loss of time and sometimes also misleading. Our assessment involves not only to find out what the patient answers to our questions, but even more important is HOW she answers or recounts. Some questionnaires / interview manuals contain so many unnecessary questions that they resemble a large battery of lab tests, ordered irrespective of the patient´s symptoms ”so as not to miss anything”. This is usually advised against – the choice of lab tests should be guided by the clinical assessment, and we need to think in the same way regarding psychiatric diagnostics.

Individuals with a weak theoretical ability, or borderline intellectual functioning, are very likely to be overrepresented among psychiatric patients.

Also when it comes to tests of different kinds we need to be careful in our interpretations – the only diagnosis where testing is needed (but not always possible) is intellectual disability. No other diagnostic tests exist, but a competent psychologist is able to decide when testing may be used to collect information as a support in the joint assessment.

Questionnaires and algorithms can never replace clinical common sense, but sometimes we are lead to believe that we as professionals show our highest competence if we think ”like an AI” – i e guided by algorithms and categories. There is no room for deviations, curiosity and empathy, or for in-between-states or grey areas. There is no both/and, only either/or. Diagnoses are firmly established – in spite of the fact that we psychiatrists know that our diagnoses rest on uncertain grounds, and can be changed.

A question to be asked is to whom the diagnosis belongs – is it to the patient or to the doctor? Usually the diagnosis is viewed as something belonging to the patient, maybe since diagnoses are labels on something that we believe is present inside the person. But is it not more adequate to think of psychiatric diagnoses as belonging to the diagnostician – they are our work hypotheses, or health care terms for symptom clusters. Diagnoses exist in order to facilitate communication between health care professionals. In many cases they also are of value to the patient by allowing him/her to communicate easily with health care, and sometimes with other individuals who have the same symptoms. However, psychiatric diagnoses seldom or never give an explanation to the patient´s symptoms – the diagnosis is made from the symptoms (”symptoms and signs”), but the symptoms are not there because the person ”has” a certain illness.

What I want to say with this is that we psychiatrists must stand up to defend our diagnostic competence, and not leave it to other professions – but absolutely and profitably work together with, above all, psychologists! Furthermore, we must not rely on questionnaires and interview manuals – they are often unnecessary and sometimes counterproductive, but can possibly be complementary. We must not allow algorithms, questionnaires and tests take over so that we forget (or devaluate) the art of good history-taking, a conversation which is rewarding for the doctor and her patient alike. In the end, it is our clinical competence – which we apply in the meeting with the patient, but not when we go through the answers of a questionnaire – which is the crucial factor, and which we need to cultivate, emphasize and be proud of. In addition, we need to defend our diagnostic work so that we have enough space for this in our daily working conditions. □


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