With mental health problems being more openly discussed in public, and individuals with mental health issues becoming an increasingly important and sometimes critical voice in mental health care, the way psychiatrists practice their craft has also become an object of deeper interest for a broader audience. One central aspect of psychiatric practice is diagnostic reasoning.
When you visit a psychiatrist because you are suffering,
you expect them, among other things, to determine whether you suffer from a
mental disorder and, if so, which one. While it's crucial to recognize that
this is part of a psychiatrist's job description, what is not trivial is the
further question: how exactly does a psychiatrist arrive at the diagnostic
conclusions they write in their reports and communicate to their patients? How
does the psychiatrist know what the patient’s mental disorder is?
A swift response that someone at least vaguely familiar with psychiatry might give is, “Well, they ask the patients for their symptoms and compare these to the list of mental disorders in the DSM/ICD, which tells them what the diagnosis is,” or something along those lines. Though tempting to close the matter here, it is not that easy. Criteria and symptom lists do not apply themselves to patients; it has to be judged whether they apply to the patient. Furthermore, patients are imperfect sources of information. Imperfect in the sense that they will not automatically and correctly tell you all their symptoms, and sometimes they may claim to have symptoms but misjudge their problems.
For example, some patients think it is normal to be socially
isolated as they have been so for many years, so they will not mention social
isolation as one of their problems. On the other hand, patients may say they
ruminate about something, while the pattern of cognition that constitutes their
“rumination” is more accurately classified as generalized worrying, in the
language of psychopathology. These cases show that the process of psychiatric
diagnostic reasoning implies more complicated patterns of reasoning and
information gathering. A truism for any clinician supporting this is: You can't
just pick up a DSM and be good at diagnostics; diagnosing is a skill to learn.
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Just picking up the DSM isn't enough; diagnosing is a skill! |
If this is so, how does proper psychiatric
diagnostic reasoning work? Not many philosophers of psychiatry have attempted
to provide a theory of this practical aspect of the epistemology of psychiatry.
Some work can be found among scholars committed to the Phenomenological
Tradition of psychiatry, some in the works of those focusing on the
interpersonal quasi-hermeneutic sense-making processes between clinicians and
patients, and finally, some thoughts are to be found among philosophers of
psychiatry approaching the field from the perspective of philosophy of science.
In my recent book “How Does The Psychiatrist Know?”, the first book-length treatment of psychiatric diagnostic reasoning, I side
with those approaching it from a philosophy of science perspective. I argue we should consider how the procedures of clinical psychiatric
diagnostics typically look, i.e., what is taught in many of the
central textbooks on psychiatric diagnostics and the standards of
the leading psychiatric expert communities. Based on this, psychiatric
diagnostic reasoning can largely be seen as a cognitive modelling process, quite
similar to the procedures we see in scientific modelling.
For clinicians, philosophers, and anyone else
willing to dig through an academic textbook to get an idea of the whole story I
put forward, the book is available open access.
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