All of my new patients undergo an initial one-hour diagnostic evaluation.
Like most other psychiatrists, I approach these evaluations from what is known as a “biopsychosocial” perspective. That is, I take into consideration biological factors, psychological factors and social factors when arriving at a diagnostic formulation. I usually am able to arrive at a DSM-V-5-TR diagnosis (American Psychiatric Association Diagnostic and Statistical Manual) in the initial intake evaluation, though sometimes it may take a few visits to do so. That diagnosis helps me decide on a medication regimen that is likely to alleviate so-called “target symptoms”, though sometimes no medication treatment is indicated (i.e., psychotherapy may be the treatment of choice).
In the field of Medicine, descriptive diagnostic labels are usually used when the symptoms of a condition can be adequately characterized, but the underlying causes have yet to be scientifically proven. That is, the name of the condition refers only to its hallmark symptoms. Such a condition is called a “syndrome” rather than a “disease”. Thus, diagnoses like “chronic fatigue syndrome” and “irritable bowel syndrome” describe co-occurring symptoms without implying a definitive cause or causes. If scientific progress leads to the discovery of specific biological causes of a given syndrome, the name is changed to a “disease”. However, if the causes are not limited to biological causes (i.e., some of the causes are psychological or social), the condition usually is still called a “syndrome”. Interestingly many medical diagnoses that have unclear causes are believed to have significant psychological and social causal contributions.
In psychiatry, we call syndromes, “disorders”. Most, if not all disorders, have complex mixtures of biological, psychological and social causes. Thus, while eventually some disorders such as “Bipolar I Disorder” may be shown to be a primarily biologically based, neurochemically mediated brain disease, at this point in time it still is more accurately conceptualized as one of several mood disorders. Even though research suggests genetic predispositions may be the primary causal factor, so far that research fails to discriminate how the phenotypic expression of the genes leads to the illness. Some researchers suggest that Bipolar Disorder is best thought of as a spectrum of mood disorders ,some more biologically based and some having significant psychological and social causal factors. In my view, it is important to remember that two different people with the same symptoms may have two very different reasons for having those symptoms (i.e., headaches can have different causes in different people).
Having a syndromal diagnosis is helpful to psychiatrists because the medications they prescribe help manage symptoms. However, treating symptoms with medication is not the same as treating the causes of those symptoms. It is important that patients and clinicians alike explore for possible underlying psychological and social causes of their symptoms because often there is one or more environmental contributions to the illness that, when treated, leads to more lasting and beneficial changes. For example, a patient complaining of symptoms of Major Depression may respond only minimally to antidepressant treatment because he or she is in an abusive relationship and requires psychotherapy or counseling in addition to medication.