QUESTION: Patients sent to a psychiatrist or some other therapists often receive a formal diagnosis (known as a DSM-IV or  DSM-5 or an ICD diagnosis) - which can be helpful in determining disability eligibility and medication regimes. Do you use such diagnoses?

QUESTION: This answer is also available as a print-out - HERE

ANSWER: While formal diagnosis like Borderline Personality Disorder or bipolar disorder can be helpful in forging an understanding between healthcare providers of the nature of the problem with which they are each involved – mostly people who share such diagnosis are rendered better off working from the same page. While we retain a tendency to use these terms with patients who have been diagnosed in this way elsewhere ( and may have), we are not going to be involved with the patient's medication in any way, we are not going to be relied upon to provide evidence of disability. But beyond this we have an overarching reason for using a different system of understanding and classification of patients.

We too are wanting to be on the same page, firstly with each other, as the patient will be seeing both the physician in charge and session facilitators who are important mediators of treatment as well. it is good to have multiple people involved working from the same understanding of the patient, and in our system, it is good for the patient themselves to be increasingly aware of the factors in play in their recovery. we involve them in creating descriptions. Our methodology addresses the rigidities of behavior which we might well call temperaments or personality traits. No one is without a personality, so the system we use is different from a diagnostic system, in that everyone could be described as having a certain tendency in their personality, while in a diagnostic system only those who deviate from what we consider normal merit diagnoses. Increasingly we see personality tendencies as inherited. We see trends showing up in the perinatal period, suggesting that they appear before they could possibly have been learned. Dr. Karen Horney, psychoanalyst in the 40s and 50s came up with a system of categorizing all people into 1.) Aggressives (those who move against stress, and others) 2.)Complaints (those who engage the interests of others under stressful conditions) and Detacheds (those who move away from stress when it occurs.”

Over time, it became possible to quantify these personality traits and the Horney-Coolidge Tridimensional Inventory came into existence as a self-administered questionnaire which assesses the patient's tendencies in each of these three directions. This test has stood the test of time and is considered to be valid and reliable by such authorities as UCLA psychiatrist, Dr. Daniel Siegel, today's major proponent of mindfulness. Why would a mindfulness oriented practitioner have an interest in rigidifying personality structures? Because mindfulness is a freeing up from the rigidity, a capacity which is new. Previously, it has been thought that very intensive psychotherapy could sometimes be brought to bear on a personality structure, but it was thought unlikely that much more than minor adjustments could be made.

Since our aim and our experience suggests that our deliverable is in the realm of spontaneity flexibility and resilience, and since we have learned that our patients are taking some new mindfulness skills and neuroplasticity tools on the road with them, it helps greatly that the patient is engaged in the identification/ determination of their personality structure. We want them to be able to see with some clarity their own emerging maturity in some kind of tangible way. Thus we have described what would amount to the antithesis of each of the three Horney structures, to which we have arbitrarily assigned colours to create any ease in talking about them. Since relief from the rigidity of a lifelong personality can often be seen during the month the treatment is going on, we have developed an easy way for the patients to contribute to their understanding and our understanding of their process. Those who discover compassion arising, are often but not always Horneyvian Aggressives, those discovering flexibility and focus, are often but not always Horneyvian Compliants, and those who find themselves more spontaneous are often but not always Horneyvian Detacheds.

We can quantify the progression towards freedom from rigidity by a combination of early and late measurement of Mindfulness Scores, using the same measurement instrument as the mindfulness meditation Kabat-Zinn teachers use, by measuring the Horney-Coolidge Tridimensional Inventory at the onset and, if major change is not obvious, again at 6 months. While the Mindfulness Scores can measure of progressive freedom from rigidity, the HCTI scores only measure rigidity itself, and not the freedom from it. It has long been held that HCTI scores do not change over a lifetime, and so when we get a patient whose score has changed considerably over six months, we can reach the conclusion that sufficient loosening of rigidity has happened. So this diagnostic duo works well for us, but more than working well for us, it is a way for the patient to see their own progress, and to assume responsibility for it.

For other people's purposes, particularly when medications are being considered, other forms of diagnosis may be preferable. But it is no small matter that such diagnoses, once made public, may have the opposite effect from helping the patient - they may actually prevent the patient from getting insurance for certain jobs. Finally, many of the people who come to see us, come simply because they want to increase their ability to manage stress. Many of them would have no formal diagnosis at all and we don't want to add to their problems by creating one.

My 12 Best Tips on Psychiatric Diagnosis

Allen Frances Professor Emeritus, Duke University

We already had a crisis in psychiatric diagnosis before DSM-5. It is a sure sign of excess that 25 percent of us qualify for a mental disorder and that 20 percent are on psychiatric medication. Unless checked, DSM-5 will open the floodgates and may turn current diagnostic inflation into future hyperinflation.

Below are my 12 best tips on how best to ensure accurate and safe diagnosis.

1.The less severe the presentation, the more difficult it is to diagnose. There is no bright line demarcating the very heavily populated boundary between mental disorder and normality. Milder problems often resolve spontaneously with time and without need for diagnosis or treatment.

2.When in doubt, it is safer and more accurate to under-diagnose. It's easier to step up to a more severe diagnosis than to step down from it.

3.Children and teenagers are especially hard to diagnose. They have a short track record, varying rates of maturation, may be using drugs, and are reactive to family and environmental stresses. The initial diagnosis is likely to be unstable and inappropriate.

4.The elderly are also hard to diagnose. Their psychiatric symptoms may be caused by medical and neurological illness and they are prone to drug side effects, interactions, and overdose.

5.Take the time and make the effort. It takes time to make the right diagnosis -- adequate time for each interview and often multiple interviews over time to see how things are evolving. Except for classic presentations. quick diagnosis is usually wrong diagnosis.

6.Get all the information you can. No one source is ever complete. Triangulation of data from multiple information sources leads to a more reliable diagnosis.

7.Consider previous diagnoses -- but don't blindly believe them. Based on their tenure, incorrect diagnoses tend to have a long half-life and unfortunate staying power. Always do your own careful evaluation of the person's entire longitudinal course.

8.Constantly revisit the diagnosis. This is especially true when someone is not benefiting from a treatment that is based on it. Clinicians can get tunnel vision once they've fixed on a diagnosis, become too married to it, and are blinded to contradictory data.

9.Hippocrates said that knowing the patient is just as important as knowing the disease. Don't get so caught-up in the details of the symptoms that you miss the context in which they occur.

10.If you hear hoof-beats on Broadway, think horses, not zebras! When in doubt, go with the odds. Exotic diagnoses may be fun to think about -- but you almost never see them. Stick with the bread and butter.

11.Accurate diagnosis can bring great benefits; inaccurate diagnosis can bring disaster.

12.Remember the other enduring dictum from Hippocrates: First, Do No Harm.

(Excerpted from  my book, 'The Essentials of Psychiatric Diagnosis' by permission of Guilford Press).


Putting The Mind And Soul Back Into Psychiatry

All medicine should be bio/psycho/social. Illness is never just a biological phenomenon -- more than 80 percent of health outcomes are determined by economic, social, and behavioral factors.

And the psychosocial part is especially important in psychiatry. As Hippocrates pointed out 2,500 years ago, it is more important to know the patient who has the disease than the disease the patient has.

In recent years, psychiatry has embraced what a former president of the American Psychiatric Association has despairingly called a "bio/bio/bio" model. The enormous research budget of the National Institute Of Mental Health has been totally invested in biologically reductionist brain and genomic research.

Pat Bracken is an Irish psychiatrist and philosopher who would like to put the mind and soul back into psychiatry. Pat writes:

"I believe that psychiatry finds itself in a pernicious position. Pharma has used its financial power to mould psychiatry into something that serves corporate needs, not the best interests of patients. And the massive investment in genetic and neuroscience research has yielded practically nothing of clinical value for our patients.

In fact, we have gone backwards. The narrow focus on biological research has led to a profound neglect of the social, cultural and psychological dimensions of mental illness. In the United States, where Pharma has had most influence and the perverse payment system has operated, there is evidence that, to a large extent, psychiatric care has become equated with the provision of a DSM diagnosis and a prescription.

The New York Times carried a story in 2011 in which a psychiatrist spoke of having to train himself not to get too close to his patients and 'not to get too interested in their problems'. His role was simply to check the diagnosis and adjust meds.

The reductionism that now dominates psychiatric theory and practice is ideological in nature: it does not stand up to conceptual challenge and is not supported by the results of empirical investigation. Its dominance is sustained through finance from Pharma allied to a professional quest to be more 'medical' than the rest of medicine.

What we have to grasp is that when we put the word 'mental' in front of the word illness, we are doing something important. We are delineating a territory of human suffering that is primarily about relationships, meanings and values. And, while we cannot experience anything without a functioning nervous system, a knowledge of the brain will not help us a great deal in understanding the nature of this territory.

The brain is a necessary, but not a sufficient cause of human experience. We are embodied beings but we are also encultured. We grow to become human in the midst of language, culture, history and relationships with others. These shape the way we experience ourselves and how we encounter the world around us and cannot be reductively explained in biological terms. The demand that psychiatry should simply become a 'clinical neuroscience' is nothing more than an assertion of dogma and is not based on a genuinely questioning scientific approach to the sort of problems that face us.

We need to nurture the development of a psychiatry that sees relationships, meanings and values as its primary focus. I have used the word 'hermeneutic' to describe this.

Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life Hardcover – May 6 2013 How to get there is the challenge. Evidence-based medicine (EBM), with its focus on controlled studies and meta-analyses, has not proved robust enough in protecting psychiatry, and medicine in general, from corruption. It has been said that EBM itself is 'broken.'

With our colleagues from other medical disciplines we will need to develop a much deeper form of critical appraisal. I believe that any profession that has power in the lives of ordinary people should seek to critically reflect on its own history, assumptions, values and practices in an organized and sustained way. A mature profession should not be afraid of this. We need practitioners who are trained to question and to doubt, to challenge their teachers and to see financial ties to third parties as an aberration.

On a more positive note, our discipline has a rich history of grappling with conceptual issues before the rise of 'neuromania' and the DSM. The work of Karl Jaspers stands out in this area but many of our predecessors struggled to develop a theory and a practice of psychiatry that was not reductionist. The great Swiss psychiatrist, Medard Boss, for example, sought to develop a specifically hermeneutic psychiatry in the post World War II era. We do not have to re-invent the wheel. A growing movement of critical psychiatry is now emerging as a positive force for change within the profession (www.criticalpsychiatry.co.uk).

I believe that we need to develop a practice that is centered on relationships and we need to acknowledge the limitations of a diagnosis-guided practice in our field. This is not anti-medical but simply an acceptance that mental health work demands something different. We need to nurture negotiation skills in our trainees and encourage them to engage with the growing consumer movement in a positive and non-defensive way. We need to accept that psychiatry has done a great deal of harm to many of its patients and professional arrogance should be stigmatized and fought against. We need to nurture doubt, questioning and critical reflection in our academic and clinical practice. A hermeneutic psychiatry would be one where doctors, patients, carers and other professionals struggle together to determine what research, teaching and service models are appropriate. I also believe that we should struggle to shed the power to order coercive interventions. This is not to say that sometimes people need to be cared for safely and even against their will, but there is no scientific or moral reason why the medical profession should be in charge of this.

I do not claim to have an answer to all the problems of psychiatry but the following moves will be essential if we are to find a cure for our current ills: 1) collaborate with other doctors who are struggling to free medicine of Pharma corruption, 2) find ways of working positively with, and learning from, the growing international consumer movement, 3) balance our involvement with the biological sciences with an equal involvement with the humanities and social sciences, 4) nurture the development of a clinical discourse that is centered on relationships, meanings and values, 5) seek to shed the coercive powers that are now invested in us and promote an open debate about how people can be looked after safely through times of crisis."

Thanks, Pat. We must get back to treating the whole person, not just his brain circuits. The brain is involved in all we do and what we are, but it is also itself influenced by our psychology and social context.And we must equally counter those who err in recommending an opposite and equally extreme psychosocial reductionism. Mindless psychiatry and brainless psychiatry are equally misguided and harmful.