Diagnosis of Exclusion


I was sitting in the passenger seat of an ambulance driving back from a call when all of a sudden, my face went numb. I started touching my cheeks excessively and flipped down the visor-mirror to see if I had facial droop. There is no way I could be having a stroke at the age of twenty-two, right? I asked my partner to pull over the ambulance so I could jump in the back and take my vitals. My heart rate and blood pressure were sky-high. Maybe this is my sugar? I mean I haven’t eaten anything all day because of the back-to-back assignments. I grabbed the glucometer and poked my finger; my glucose was on lower end of normal. My partner, a 55-year-old man, said, “ Tyler, you are having an anxiety attack.” My first thought was that an anxiety attack was always the last thing we were taught to assume as first responders. Think of the consequences that could arise if a paramedic arrives on scene to someone having a heart attack, and assumes it is just an “anxiety attack.” Knowing this was formerly taught as a diagnosis of exclusion, my brain refused to accept that this was not the case for me. This began my passion and obsession with psychology.


While the patient assessment is salient in all aspects of healthcare, the tools we use to build diagnostic momentum in clinical medicine are largely tangible. An electrocardiogram (ECG) may influence you that a patient is having a myocardial infarction and findings on a chest x-ray may lead you to believe that the patient’s chest pain is actually pneumonia and not cardiac in origin. However, when it comes to making a psychological diagnosis, the tools are less objective. So how exactly is a psychological disorder diagnosed?


The Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The DSM-5 is the Bible of of clinical psychology. Each chapter is referred to as a “diagnostic category.” Within those categories are similar mental disorders and symptoms in which they may exhibit (American Psychiatric Association, 2013).

In order for a person to meet clinical criteria of a diagnosis, they must have a prespecified amount of the listed symptoms. For example, if someone only met three out of six criteria for a certain disorder, they would not qualify for that diagnosis.


The number of symptoms needed to receive a diagnosis are decided and voted on by the DSM committee (James Davies, 2017). A client may have a broad spectrum of symptoms that do not fit under one particular diagnosis, in this case there are unspecified disorders (Kring & Johnson, 2018). With now over three hundred psychological disorders, our approach to psychology allows for nuances and a broader spectrum of cultural considerations.


An additional diagnostic tool that can be used to identify discreet details and context of symptoms, is the clinical interview. The clinician may begin the interview with a few structured questions, but the goal is to get the client comfortable enough to open up and lead the conversation. While the spoken information is important, the body language and inflection can often lead a clinician to identify areas in which they can zoom in and extrapolate more detail for further context.


Perhaps before a clinical interview is performed, the client will take a survey that asks a series of questions in which the response will be screened and pre-test probability of psychological disorders. This information may guide the interviewer to approach the evaluation differently, depending on the results.


So how did my story end? I went through three years of denying that my symptoms were related to anxiety, I missed weeks of work at a time, and racked up more emergency room bills than Johnny Knoxville. I finally decided to see a psychologist and was diagnosed with general anxiety disorder. I was put on a medication called sertraline and saw a therapist for a few years. To this day I still take this medication, and honestly, I am scared to come off of it. Just as someone who has diabetes needs insulin, a person with mental illness may need to take a medication to maintain a healthy life. When I look back at the history of psychology, who knows how different my life would have been.


My only regret is the fact that I ignored the fact that anxiety was just as much of a diagnosis as anything else. In the field of emergency medicine, psychological manifestations are taught as a diagnosis of exclusion, and without resources like the DSM-5, diagnosis would be largely left to interpretation.


The field of psychology has come a long way since the belief that abnormal behaviors were supernatural in origin. With over 347 individual diagnosis in the fifth version of the DSM (American Psychiatric Association, 2013), it is hopeful that early diagnosis and treatment can be initiated to help individuals fight mental illness and return to an improved quality of life.


Just remember that when it comes to you as a person, anxiety and depression should not be a diagnosis of exclusion. If you think you may be struggling with anxiety or depression, our team is always available to talk.



References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.


James Davies (2017) How Voting and Consensus Created the Diagnostic and Statistical Manual of Mental Disorders (DSM-III),Anthropology & Medicine, 24:1, 32-46, DOI: 10.1080/13648470.2016.1226684


Kring, A. M., & Johnson, S. L. (2018). Abnormal psychology: The science and treatment of psychological disorders (14th ed.). Hoboken, NJ: Wiley.