1. Getting the right diagnosis
According to basic medical principles, making an accurate diagnosis is the first step in developing a rational, evidence-based and personalized treatment plan. Because psychiatric diagnosis is not yet based on clear biomarkers in most cases (though this is beginning to shift), but is instead based largely on clinical presentation, there are unfortunately many reasons why diagnosis may be delayed or inaccurate.
One reason for difficulty making an accurate diagnosis is inadequate history. Getting a good clinical history requires a lot of time and a good connection between clinician and patient. Time may be limited because of managed care in the case of insurance-based care, or because of difficulty committing financial resources and scheduling enough time. It’s important to gather past history as well, and doing so includes obtaining prior medical records as well as, at times, speaking with family members or reviewing school records to get accurate information. These and other reasons interfere with diagnosis when important information is missed.
Clinicians may also be inclined to make rapid diagnoses based on insufficient history, leading to errors in diagnosis especially if the decision is not reviewed periodically, either as a matter of routine good care or when treatment is not working. When a particular diagnosis is popular, as ADHD currently is, clinicians may be quick to notice difficulties consistent with ADHD, and fail to recognized other issues. Many conditions are associated with distractibility, agitation and inattention, including post traumaticconditions, bipolar disorder, depression and anxiety, and others. When diagnosis is unclear, or treatment isn’t helping after a reasonable period of time, getting a second opinion and obtaining formal psychological testing may be useful
2. Accuracy of medical history
Taking a comprehensive history can be difficulty for both patient and clinician. In addition to the amount of time, there are so many possible factors to consider it is hard to cover all of them, though the use of self-report instruments can be helpful. Furthermore, there are important factors which people may not want to talk about, or may not understand are important, including substance and alcohol use, developmental adversity and trauma, and periods of time which didn’t seem problematic, but may be key information, a good example being hypomanic episodes which feel good, and aren’t necessarily seen as problematic by patients if they haven’t cause problems. Hypomanic episodes would suggest a diagnosis of bipolar disorder, rather than major depressive disorder, and the approach to care is very different. Issues like this lead to delays in diagnosis and effective care.
3. Diagnostic “chameleons”
Complex Developmental Trauma (cPTSD)
Post-traumatic consequences can present in many different ways, and in the absence of careful evaluation may easily be mistaken for other problems. For example, cPTSD (Complex Post Traumatic Stress Disorder) may appear to be a basic anxiety disorder (such as generalized anxiety disorder or panic disorder), a mood disorder, anger management issues, attention deficitdisorder, and may also present with alcohol and substance use, eating disorders, and interpersonal issues. Focusing on one facet of the presentation without seeing the big picture can be very misleading.
Well-intentioned clinicians will often take the path of least resistance, or may not be properly trained to identify more complex issues, rather than risking confrontation with patients and families about more troubling and far-reaching problems, including hidden abuse and addiction within the family. Under these circumstances, the child—referred to here as “the identified patient”—may become the sole focus of concern within a dysfunctional family. The identified patient becomes an unwitting victim of pathological family dynamics designed to cover up problems behind the guise of concern and care. This often is the case with conditions beyond ADHD, including eating disorders and behavioral problems.
When trauma hasn’t been identified, and may be omitted due to avoidance or lack of understanding of its importance, people may end up with multiple diagnoses and treatments which don’t seem to be working. On top of all this, people often have more than one condition, including both medical and psychiatric disorders which present with emotional and psychological problems. In addition, the diagnostic system itself is evolving, and is periodically revised. As we understand the brain better, and the relationship among various biological and social factors, the way we view diagnosis may change almost completely in the future.
Attention-Deficit Hyperactivity Disorder
In contrast to developmental trauma, ADHD is often more acceptable to people than other causes for difficulty with concentration and focus. It’s psychologically easier for many people to say they have ADHD. It’s not unusual for patients (or their parents) to suggest a diagnosis of ADHD, which can cover up other issues.
On the other hand, ADHD is also under-diagnosed, and often dramatically effective treatment can be delayed for far too long. This highlights the importance of diagnostic accuracy and comprehensive evaluation.