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.
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.
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.
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.
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?
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.
Ranking of the principal diagnosis varies depending on provider. Though some systems may have “one-stop shopping” for behavioral health needs, many continuums are made up of multiple “niche” providers that may include specialties in assessment, detoxification, residential services, outpatient services and/or mental health. Clients are often re-assessed and diagnosed upon transition to a new provider. Axis I disorders, per the DSM-IV-TR, are the “focus of clinical attention.” When more than one is present, the principal or presenting problem should be listed first. Each provider in a shared continuum, having a different focus, may rank the principal diagnosis differently. The end result may involve multiple discharge summaries, generated in close proximity to one another, all carrying different primary diagnoses.
Overemphasis on Axis I, and marginalizing of Axes II, III, IV, and V. One strength of the DSM classification system is its framework for capturing both person and context on the five different axes. This allows for a comprehensive diagnostic portrait of the whole person. We are now learning that Recovery Capital has much to do with clinical prognosis, treatment planning and degree of diagnostic complication (Granville, Cloud, 1999). This capital, or lack thereof, can be captured within the Axis IV domain.
The figure illustrates the profound difference Axis IV descriptions add to a clinical picture. It outlines treatment problem areas, and aligns with several national outcome domains (employment, criminal justice, housing, social connectedness). Unfortunately, some clinicians, when faced with voluminous waiting lists and productivity mandates, see Axis IV as an afterthought and underutilize this telling scale.
Underutilizing substance-related specifier codes. In their simplicity these codes enable clinicians to describe a myriad of discrete and/or longitudinal variables. For example:
ˆ John: is symptom free for over one year while on methadone maintenance (sustained full remission/on agonist therapy).
ˆ Mark: has been clean and symptom free from all mood altering substances for five years while incarcerated (sustained full remission in controlled environment).
ˆ Susan: has been drug free for six months, but just relapsed on three beers over the weekend. She is back to attending meetings and staying clean (early partial remission).
ˆ Michael: has been sober/clean for over a year and involved in 12-Step communities and alumni associations (sustained full remission).
When a client has been in treatment and symptom free (or reduced) for greater than one month; he or she SHOULD have a remission scale added to his/her diagnosis upon discharge. This is not universally practiced. If properly completed, specifier codes have utility as a pre/post measure of treatment outcomes. If tallied and aggregated we may be able to gauge treatment effectiveness on an agency, community or state level.
Over the last several decades there has been a tremendous growth in the research supporting addiction as a brain disease (Leshner 1998, NIDA 2007). While short-term use alters brain functioning in consequential ways, chronic use causes durable changes in brain function that may last well into recovery/abstinence (Volkow et al. 1990). An ideal diagnostic setting may offer a clinician the luxury of the following resources:
Access to a battery of neurological brain scanning, and/or EEG testing, complete with expert analysis.
On site and immediate access to advanced toxicology lab services.
Access to additional information provided by loved ones, professionals or other collaterals.
Completion of standardized screening instruments [e.g., Global Appraisal of Individual Needs (GAIN), Substance Abuse Subtle Screening Inventory (SASSI), etc].
A client who is open, honest and determined to discover if he/she has a substance use disorder.
Despite advances in medical technology and a wealth of collateral information, we primarily garner substance diagnosis via interview and client self report. Most substance abuse professionals have little access to advanced medical technology. In the rare event they do, wait times for MRIs, EEGs or neuropsychological consults may take months. Moot really, as none of these high-tech resources are synchronized to diagnostic criteria anyway. Some screening tools (such as GAIN - the Global Assessment of Individual Needs) are comprehensive, long and may take hours to complete. Others, (such as SASSI - the Substance Abuse Subtle Screening Inventory) are proprietary and add costs to agencies, assessors or clients. Collateral data gathering also brings complications. Just because we know where the information is (prior treatment, physician, school, significant other), does not mean it's readily available. Personally, I've experienced four- to six-week delays between request and receipt of summaries from ancillary, historic or other healthcare providers. Family members and significant others are a good source of information; but this too has limits. Of course none of this information gathering is possible without the client giving consent, in writing, for the release of personal information. Even with consent, professionals face the bane of clinical collaboration: phone tag.
Multiple clinical licenses allow for diagnostic authority on a vast array of DSM categories (LISW, LCSW, LPCC, LPC, licensed psychologist or other professionals). Many of these professionals carry expertise within sub-diagnostic categories (for example, mood, psychosis or anxiety). Clinicians tend to hone in on specific sub-populations, illnesses or scopes. In fact, disclosure statements are required by many state licensure authorities to ensure professionals are transparent with their areas of expertise. I, for instance, have not made a diagnosis of schizophrenia over the last decade. Not because I'm license prohibited but in recognition of a self-acknowledged lack of expertise on this complicated malady. When suspecting psychosis, I refer to a practitioner best equipped to diagnose and offer service recommendations. In short, I believe clinicians tend to diagnose within their own area of expertise. Abraham Maslow once stated, “When all you have is a hammer, you see every problem as a nail.” This begs the question: How many clients are “under diagnosed” due to the limited scope of their provider?
Keeping with the belief that clinicians are more likely to diagnose within their area of expertise, the disproportionate emphasis on mental illness versus substance related disorders in higher education curricula is cause for alarm. In Ohio, for example, state standards recognize Physicians, Psychologists, Professional Counselors (LPCC), Independent Social Workers (LISW) and Independent Chemical Dependency Counselors (LICDC) as being experts capable of delivering substance treatment services, as well as having full diagnostic authority for substance disorders. Of those listed, it is only the Chemical Dependency Counselor who may have less than a master's degree. (Since 2002, new LICDC applicants are required to have a master's in a behavioral health field, and 270 chemical dependency specific training hours. The grand-parenting widow allowed for many existing non-degreed individuals to inherit this independent license). These rules carry the bold assumption that all these disciplines are infused with core knowledge of addictions. This is not true.
Requirements for the Ohio Psychology license examination require no course work relative to addictions studies (OAC, 2010); nor does the Ohio Social Work, Counselor, and Family/Marital Therapist Board. One can become a Licensed Psychologist, Licensed Independent Social Worker or Licensed Professional Counselor, all with full diagnostic authority, without having a single addictions course in his/her entire academic career. Though some universities may have addictions specific courses, these are classified as electives.
Physicians may be viewed as the ultimate authority on addictions related issues, yet medical schools do not “prioritize” addictions education. Rather than having stand-alone courses, addictions topics are often infused into behavioral medicine-otherwise known as psychiatry. Although addiction related issues are certainly mentioned by all specialties (cocaine causing heart attacks, alcohol culpable in some liver disease, for example), the main focus of medical school is on medical disease, as opposed to primary cause. Typically general practitioners may encounter their most substantial learning as an intern or resident. Per Dr. Chris Delos-Reyes, MD, Chief Clinical Officer of the Cuyahoga Alcohol and Drug Addictions and Mental Health Services Board in Cleveland:
“The lack of training leads to a vicious cycle of misunderstanding and mistrust of alcoholics and addicts and an unwillingness to deal with ‘those people.’ So they treat the symptoms (read: cirrhosis, ulcers, heart attacks, etc.) but fail to mention alcohol/drugs as the primary cause … it's 2010. Definitely better than the 70s and 80s, but still not great.”
It is my fear that addictions treatment may become mental health treatment by default in 15 years unless we aggressively address curricula and licensure.
Worthy of mention is the current argument related to diagnosis of addictive disorders even as the DSM-5 language is being drafted. Historically, the DSM has had clear distinction between what is dependence vs. what is abuse. Leading national expert Carlton Erickson, PhD, explains this as “one's a brain disease and the other is not” (Enos, 2010). The new version (still in comment stage) looks to eliminate the distinction between abuse and dependence altogether. I fret we're moving away from diagnostic clarity and demarcation into more ambiguous territory.
This brings us all back to our diagnostic realities:
A diagnosis is usually made at the first clinical contact (which lasts from 30-120 minutes).
There is insufficient time to use all resources at our disposal toward ensuring accurate diagnosis.
Clients may be motivated to filter information and present themselves in the most amiable of lights.
We have done well as a field over the last decade to more eagerly transition from science to service. Evidence-based programs such as Integrated Dual Disordered Treatment (IDDT), Motivational Interviewing, Contingency Management and Systems Therapy are being infused into some college curricula and adopted in the field. The Drug Addiction Treatment Act of 2000 served to increase the access of partial opiate agonist medications to clients in office based settings. Lacking among the plethora of new research based treatment models is a “one size fits all” treatment modality. Fact is, different models work differently for different diagnoses. For instance, methadone maintenance is contra-indicated for non-opiate related addictions. Similarly, a clinician wouldn't use the Therapeutic Community Model in an outpatient treatment setting. Fitting the right diagnosis with the right program is paramount.
This all brings us back to the urgency in adopting diagnostic practices that best ensure accuracy in our professional appraisals of clients. In brief, we can begin by advocating the following:
Prioritize diagnostics in behavioral health and primary health curricula.
State rules, or reimbursement requirements requiring full five axis diagnosis, inclusive of all indicated specifier scales, in assessments and discharge summaries.
State Licensure Boards (Psychology, Social Work, Counseling, Medical, Addictions) establishing continuing education requirements for Diagnosis of Mental Health Conditions.
Creation of Screening/Testing tools for addictions that are synchronized with DSM Criteria.
Increased coordination in communicating with ancillary and historical service providers.
By implementing these practices we can help ensure that our treatment modalities, and successes, are as enduring as our diverse clientele.John M. Ellis, MSW, LISW, LICDC, ICCS, has been involved in the addictions profession for 25 years. Presently he serves as the Director of Program Services on the ADAS Board of Lorain County (Ohio), as an Adjunct Professor of Social Work, Cleveland State University, and as the Chair of the Ohio Chemical Dependency Professionals Board.