Trigger warning – suicide, death, discrimination.
“Listen to your patient, they are telling you the diagnosis.”
– William Osler.
Each disorder is like a puzzle. The pieces that make up each puzzle varies from person to person. But, more often than not, one piece does not fit correctly, leaving the puzzle incomplete, a misdiagnosis. It is the practitioners’ duty to accurately diagnose their clients and design a plan of treatment best suited for the said diagnosis. As terrifying as it is, misdiagnosis is a prevalent phenomenon. It will do more harm than good for a client. It may not be as easy as it sounds, but actively listening to your client is the most basic and crucial step in trying to evaluate and achieve diagnostic clarity. The consequence of error is much higher in some jobs as compared to other jobs. All current and aspiring mental health professionals are well aware of this. Hence, a misdiagnosis is extremely dangerous.
At 16, Carls (adhadult – Instagram handle), attempted to end their life and even after a day in the hospital they received no mental health follow up. For 4 years, their mental health continued to fluctuate and at 20 they were misdiagnosed with Panic Disorder and Major Depressive Disorder, which did not help the situation. Their doubts were cleared when they were correctly diagnosed with Attention Deficit Hyperactivity Disorder. Last month, they received an additional diagnosis of Borderline Personality Disorder. They said and I quote, “With this final piece to the puzzle I really started healing. I am now working towards becoming a therapist to help people through their mental health journey.” Carls and many others have experienced a misdiagnosis that has delayed their journey to mental wellness, the reasons are multifold.
Mental health professionals just like everyone else are prone to make mistakes, while this cannot be used as an excuse for misdiagnosing their clients, they must be self-aware of their biases. Infallibility does not come with a medical license or a piece of paper. It can only be achieved with years of experience, constant research and relying not only on the knowledge one possesses but also on one’s intuition in various situations. Many times it is not only the professional fault for a misdiagnosis. Sometimes clients do not recognise certain behaviours and emotions of mental illness and therefore do not report them. Such as, in the case of Magda, a patient who received a misdiagnosis of Major Depressive Disorder, as she failed to report the times during which she felt most alive, had elevated energy and her thoughts raced with excitement. Her psychiatrist was only treating her for the constant sense of dread, lethargy and recurring sadness which she did report. In addition to this, the psychiatrist failed to ask the right questions. Hence, her Bipolar Disorder went unrecognised (Kvarnstrom, 2017). In the end, however, the responsibility for a misdiagnosis will always lie with the expert.
A study conducted by Rutgers University, which looked at 599 Blacks and 1,058 Non-Latino Whites, found that clinicians failed to effectively weigh mood symptoms when diagnosing schizophrenia among African-Americans. The findings suggested that clinicians put more emphasis on psychotic than depressive symptoms in African-Americans, which skewed diagnoses towards schizophrenia even when these patients showed similar depressive and manic symptoms as white patients (Gara, 2019). The misdiagnosed patients were at a greater risk of diabetes and weight gain as the side effects of medication taken for Schizophrenia.
Also, while the rates of mental illness in Asian-Americans do not differ significantly from those found in other groups, mental health professionals may hold the stereotype that they are ‘mentally healthier,’ a bias that contributes to inadequate treatment and prevention (Goode, 2001). Misdiagnosis among Asian-Americans can perpetuate the stereotype that this group does not struggle with mental illness, particularly severe mental illness, at the rate of the general population. This may solidify the damaging stigmas that keep people from identifying their own distress and seeking care.
This clearly shows the dire consequences of misdiagnosis due to racial and cultural biases.
A study published on 2 February 2021, titled ‘Misdiagnosis, detection rate, and associated factors of severe psychiatric disorders in specialized psychiatry centres in Ethiopia determined the prevalence of misdiagnosis and detection rates of severe psychiatric disorders including schizophrenia, schizoaffective, bipolar, and depressive disorders in a specialized psychiatric setting. In this study, roughly four out of ten patients with severe psychiatric disorders were misdiagnosed. The commonly misdiagnosed disorders were schizoaffective disorder (75%) followed by major depressive disorder (54.72%), schizophrenia (23.71%), and bipolar disorder (17.78%). A possible reason for misdiagnosis was the failure in comprehensively noting down the psychiatric history of the patient. The average length of time to register and evaluate a patient’s history must be approximately 45 minutes. However, the length of time for psychiatric assessment in Ethiopia was only 5 minutes. This study can be generalised to therapeutic settings in which it is the duty of the counsellor to accurately note down the medical history of their client in the initial stages of counselling itself. It acts as a basis for the treatment process in the future. A complete absence of, or incomplete information regarding the medical history can derail the diagnosis before it is even made.
Providing a diagnosis is an extremely tedious and important part of a mental health professionals job. The effects of a misdiagnosis are drastic, ranging from the development of another mental or physical illness to even death. It can lead to the questioning of the validity and reliability of the mental health profession, which already has a shaky foundation due to the stigma related to it in many countries. A negative experience with a particular counsellor in relation to misdiagnosis will make the person hesitant to reach out to other counsellor’s who may be more dedicated. It can lead to the fear of therapists. Diagnosis and treatment planning are now such standard components of counselling practice that a failure to diagnose on some level or a lack of professional diagnostic training may be construed as unethical (Sommers-Flanagan & SommersFlanagan, 1998). While it may not be easy, an accurate and helpful diagnosis is achievable. Cooperation, Communication and Conscientiousness while making a diagnosis can aid in its faultlessness. There must be complete cooperation between the professional and their client/patient to be able to share all the relevant information. Communication should be reciprocal and honest in nature. The professional must structure the diagnosis with due diligence. A client/patient can only move on to the next puzzle for healing, if the previous one is complete, with all the pieces fitting soundly with each other.
– Urveez Kakalia & Ferangiz Hozdar.