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Diagnosis of Substance Related Disorders

November 1, 2010
by John M. Ellis, LISW, LICDC, ICCS
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Complicating Factors Within the Continuum of Mental Health Disorders

This is the second in a series on the treatment of diagnostic practices and co-occurring disorders.

“Sticks and stones can break my bones, but words can never hurt me.”

Great quote, but self-comforting mantras can only insulate one's psyche so far. Simple fact is … words, and more specifically names, can hurt. Nicknames, formal monikers, titles, even diagnoses, can create an aura around an individual; a power. This power ranges from cathartic to noxious, confidence boosting to emotionally crippling. Names reflect a judgment and carry a consequence-sometimes positive, sometimes negative; but never inert. This is a truth that we, as clinicians, must always remember.

More evolved than simple name calling, diagnosis is the clinician's tool for capturing a cluster of signs, symptoms or behaviors, and placing them into an understandable framework. Sounds simple, right? Let's consider but a sliver of factors that complicate definitive and consistent results:

  • Accuracy of client self report.

  • Avoidance of stigma.

  • Diagnosis for disability benefit.

  • Inequality of reimbusement between diagnoses.

  • Malingering.

  • Lack of a historical record.

  • Lack of communication between healthcare providers.

  • Client coached by a legal defense strategist.

  • The magnitude of shared symptoms among a multitude of varying diagnostic categories.

  • Limits of diagnostic scope between varying clinical disciplines or the leaning of individual clinicians or entities toward specific maladies.

  • Most diagnostic tools are malady specific (BDI- Depression, HAM-7- Anxiety, SASSI- Substance Involvement).

  • Disconnect between primary health and behavioral health.

The exponential assortment of complicating factors involved in the effective and consistent diagnosis of mental illness is too much to be addressed here. This article will explore systemic and clinician-specific barriers to consistent diagnostic practices involving substance use disorders.

The Diagnostic and Statistical Manual (IV-TR)

Before venturing too far into the diagnostic abyss, we must look at the common diagnostic platform available to us. The American Psychiatric Association (APA)-published Diagnostic and Statistical Manual series (DSM-IV TR- current) is far and away the most recognized manual in behavioral health. The purpose of this manual, and others like it (See International Classification of Disease (ICD) series endorsed by the World Health Organization), is to categorize clusters of symptoms, and disseminate them in such a way as to synchronize clinical judgments among professionals. In essence, it aims to (a) offer a common language to describe a client, and (b) get us all on the same page.

John M. Ellis, LISW, LICDC, ICCS
John M. Ellis, LISW, LICDC, ICCS


As a tool, the DSM remains largely underutilized, despite its capacity to define and classify diagnosis. This happens for a variety of reasons, including but not limited to:

  1. Caseload volume and productivity requirements do not lend to comprehensive differential diagnosis. During the insurance-rich 1980s Glenbeigh Hospital in Cleveland offered a 10-day inpatient assessment period prior to a standard 28-day treatment stay. Certainly a well-equipped facility could garner a differential diagnosis, utilizing multiple sources, within that amount of time. No such luxury exists today. In our current financial climate it's not unheard of for a clinician to assess and diagnose 30 individuals per week. Not having time to gain prior treatment records, physician's reports or even interviews with significant others, many diagnoses are made entirely on client self report. Private-practice clinicians may not even get reimbursed for a non-diagnostic visit. Our current climate weighs the speed of the diagnosis more favorably than accuracy.

  2. Clinicians may “cherry pick” diagnoses within their own area of expertise or within the agency's scope. While there is a plethora of clinicians with expertise in a variety of maladies (disorders of mood, psychosis, substance use, personality, child and adolescent specific), few (if any) are experts on all the listed diagnoses within the DSM. How can a true differential diagnosis be made lest we look into all the variables available? Could client volume, in addition to limited diagnostic expertise, lend to the retrofitting of clients into criteria clinicians are most familiar with?

  3. Diagnosis may be limited by clinician or agency scope. Many states have different departments for mental health, developmental disabilities, and substance disorders; with different certification requirements and funding streams for each. Assessments in a single scope certified entity may utilize diagnostically limiting tools. Clients aren't viewed through lenses capturing the entire continuum of possibilities; rather they are viewed as being inside or outside the agency's niche service.

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