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What is your personal opinion being a psychiatrist?

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Practicing since : 2003
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Since you have been a Psychiatrist, how has your personal opinion about diagnosis changed since you began in the field?

What position do you see diagnosis occupying in the larger social or political context?

What measures might you take to strike a balance between engaging the DSM fully enough to use it well and with precision, yet maintaining an intelligently critical stance toward it?

Posted Mon, 31 Dec 2012 in Mental Health
Answered by Dr. Jonas Sundarakumar 12 hours later

Well, my perception and personal opinion about psychiatric diagnosis has undergone significant changes since I began in this field.

Initially, my perception of psychiatry and psychiatric diagnosis was that it was that it was vague, abstract and even confusing. When starting of as a resident, I used to wonder why there were so many classifications, diagnostic categories and criteria. Over the years, seeing patients and gaining more clinical exposure has modified this perception to a state where I have understood that though psychiatric diagnoses may be complex, yet there are well-defined syndromes and fairly clear-cut diagnostic categories.

My approach to diagnosis has also undergone evolution. During the initial stages, my approach was narrow and more of a “check-list” approach – where I would “search” for symptoms matching the diagnostic criteria and see if I could give a diagnosis. As time went by, my diagnostic approach broadened, where I am able to get a holistic picture of the problem – where I first sieve through the symptoms, correlate them and try to find out if they can be fitting or representative of a typical psychiatric syndrome or diagnosis.

“From disease-centered to patient-centered”: Over the years, I feel that psychiatric diagnosis has evolved from being “disease-centered” to being “patient-centered”. I have been able to gradually realise that the diagnosis which we give to a patient is actually not to “label” a disease, but rather to identify the patients’ problems better and help them more effectively. This is why the social and cultural contexts of a person’s problems are extremely important to understand. For example, if a lady presents with symptoms of feeling sad, low, social withdrawal, crying, negative thoughts, despair, etc. and I diagnose her to have a major depression without taking into consideration her social context, I would probably be missing out important information which could even change my diagnosis. This lady could have had a major stressor like the loss of a job or a major financial loss or an abusive husband, which could have been the cause of her depressive symptoms, and in such a case a diagnosis of an adjustment disorder with a depressive reaction would be more appropriate. So, taking a patient-centered approach is more appropriate and useful that a disease-centred approach. That is why, over the years, I have learnt to modify my diagnostic approach to a "bio-psycho-social" approach, which looks at a patient as a whole and not at his / her disease alone.

Now, coming to the position of psychiatric diagnosis in the social political context, like I had mentioned earlier, psychiatric diagnosis has XXXXXXX social and cultural roots. Social stigma regarding psychiatric diagnosis is something which has been prevalent since a very long time. Though this concept is slowly changing, still, people given a psychiatric diagnosis are viewed by the society in negative light. In addition to this negative attitude, once a person is given a psychiatric diagnosis, there are also other social implications like difficulty in finding jobs, difficulty in marriage and social life, and even difficulty in re-integration into the society. This is the reason many social activists and critics argue that the label of a psychiatric diagnosis often ends up de-moralizing a person, more due to these social implications, than due to the illness itself. Also, there is still a widespread belief that all psychiatric illnesses are chronic, incurable diseases and any person with a psychiatric diagnosis is deemed incapable of normal social functioning.

There are also political underpinnings to a psychiatric diagnosis. Diagnoses such as homosexuality, gulf war syndrome, etc. can stir a lot of political controversies. One more psychiatric diagnosis which has stirred political debate is that of personality disorders. Whether personality problems, especially those with socially disruptive behaviours like anti-social personality disorder should come under the realms of psychiatry or law / criminality has been debated for ages.

I think that the DSM is a good tool in the hands of a psychiatrist with regard to psychiatric diagnosis. However, it has to be used judiciously and always combining it with a sound clinical judgement. A psychiatrist should not forget the fact that every psychiatric diagnosis is a “clinical” diagnosis – and so, it largely depends on the psychiatrist’s clinical skills and abilities. Tools like the DSM are just guidelines which aid in making a systematic diagnosis and streamlining the diagnostic process. It can never replace a psychiatrist’s clinical experience and skills. So, I would refrain from blindly following a check-list approach using the DSM, but rather strike a healthy balance between the well-structured diagnostic criteria as well as my personalized clinical judgement in everu case. I would also be culturally sensitive and patient-centered in my diagnostic approach.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
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