The diagnostic process – a translation where it is easy to get lost
- Lena Nylander
- Jun 7
- 4 min read
The psychiatric diagnostic process is very different from diagnosis in other areas in medicine – it is a lot more difficult, since we have no biomarkers of any kind, only our translation into diagnostic categories of what we see and hear when we meet the patient. We are trying to find ways to validate our assessments with questionnaires and standardized interviews, but the difficulties remain. To make a psychiatric diagnosis is a question of very competent and empathic translation, and to extract the important issues in all the so-called noise. Thus I think we are heading the wrong way if we try to find easier ways to do this – as long as we don’t have reliable biomarkers, and those still seem to be far away in the future.
Making a useful and adequate psychiatric diagnosis is a craft, or an applied art, that to a great extent is not learned by reading or listening to lectures. Diagnosing is best learnt by apprenticeship – listening to and learning from a master in a practical work setting. It is a dynamic detective work, and neverending – each time the doctor sees the patient there are new translations to make and new details to try to understand – or to dismiss. Becoming an expert takes time, and expertise in its subtlest forms can not be expressed or explained verbally. It has to do with seeing and taking in the entire situation – what the patient says, how she says it, what she doesn´t say, her life situation, relations and experiences, her cognitive function, emotional stress, behaviour in the doctor´s office and much more. This extremely complicated entirety is then translated into a working hypothesis in the form of a psychiatric diagnosis (or sometimes no psychiatric diagnosis).
Many things can be lost in this translation, and a lot can be misunderstood or falsely added. The patient is also translating, trying to find words to express the suffering or impairment that brought her to the clinic. This translation may be harder for some patients than for others, or can be influenced by the impression the psychiatrist makes and his/her ability to quickly establish a good rapport. When the patient has translated her thoughts and feelings into spoken language and behaviour, the psychiatrist translates what he hears and sees. The bottom line for almost all patients is to be understood, correctly translated, by the doctor. Sometimes, but not always, a diagnosis can be translated as an understanding.
A common mis-translation, also in DSM-5 and maybe therefore by many clinicians, of a psychiatric diagnosis is that the diagnosis provides an explanation to the patient´s symptoms. With a few exceptions, psychiatric diagnoses are made because the patient presents with a group of symptoms commonly seen together – the diagnosis is a name of a symptom cluster but does not explain why the patient has the symptoms. The patient gets the diagnosis because she has the symptoms, not the other way around. And, since the symptoms may be changing or ambiguous, the diagnosis is always a working hypothesis that could, and should, be changed when another diagnosis, or none at all, would be more helpful.
Psychiatric diagnoses are changing over time, they are translated into so-called criteria with ambitions to make the symptom clusters more easily recognizable and the diagnostic process thus easier. But in this simplification, important issues are lost in translation. One example is that the symptoms of anomalous self experience have been lost from the description of schizotypy, which has also been translated as a personality disorder in DSM-5 and not a schizophrenia spectrum disorder. Another example is that the diagnosis of autism in the last 10 years in a large number of cases has been translated as more “light”, “high-functioning” or even “masked”, and thus much more common, than earlier. This way the meaning of “pervasive developmental disorders”, the ICD-10 term for autism spectrum disorders, has been lost.
To summarize, in making a psychiatric diagnosis much can, and probably will, be lost in translation. For us clinicians, this means that we need to have an open and humble mind, and remember that making a psychiatric diagnosis is a craft, not simply applying an algorithm to the answers to a questionnaire, a craft that can be beautiful and very helpful. We must also remember what a diagnosis really is – not a fact that is definitely established, but a working hypothesis that can be changed whenever a change is needed. If this makes us feel lost, we are in good company with Hippocrates who at times may also have felt lost in translation as he said “Life is short and long, opportunity fleeting, experience treacherous, judgment difficult”. However, another quote from Hippocrates may help us, also in the difficult diagnostic process, namely: “First, do no harm”. □
