Hi XXXXXXX

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

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