The Checklist Problem: OverDiagnosing Mental Health Disorders

The Checklist Problem: 
Over Diagnosing Mental Health Disorders

Diagnosis can be a tricky thing.  Two errors always haunt the process- diagnosing a problem that is not there, and not diagnosing a problem that is there.  For any problem, both these errors are always possible, and happen often.

In the realm of mental illness, one approach has led to an explosion of the first sort of error, diagnosing a problem that is not there.  I call this problem the checklist problem, and the trouble comes from a very simple mistake that is very hard to detect.

The checklist problem occurs when someone concludes that a person has a diagnosis based on a list of symptoms that could be caused by more than one problem.  An easy example that is somewhat silly is the mistake that would occur if we told everyone who came to our office with a fever that they had malaria, since everyone with malaria has fever.

This example dramatizes the fact that diagnoses are really subsets. What we mean by that is that if we look at everyone in the world who has a fever right now, a subset of those people will have the condition malaria.

Our brains have a great deal of trouble with subsets.  We tend to think that subsets and the main set are the same.   A good example of this trouble comes when we think about another symptom, strep throat.  Now most people with who are sick with strep throat have a sore throat, so most people who are sick with a sore throat really wonder if they have strep throat.  But only about 30% of people with sore throat have strep, and if you have no fever, and have a cough, that number drops quite a bit.  Even so, if you have a sore throat, it is hard not to think you have strep, because everyone with strep has a sore throat.

When it comes to mental health issues, the checklist problem really takes off.  That is because in the 1970's Robert Spitzer took over the creation of the new edition of the DSM and in 1980 the third edition, or the DSM III, was published.  Dr. Spitzer was an avid advocate for the use of checklists, and the publication of the DSM-III marked an historic shift towards the use of checklists in the diagnosis of all mental health problems.  Since 1980, the DSM has served as the reference for defining all mental health disorders in the United States.

Here is where such an approach gets into real trouble: cause.  Notice that no checklist can address the question of what is causing the symptom.   The DSM may list 20 or so symptoms for a condition, and require you have 8 of them to qualify, but it says nothing about finding a cause for the symptoms.  We do not operate this way in physical illnesses.  To return to strep throat, just because sore throat is a symptom of strep, we do not tell people they have strep throat solely on the basis of having a sore throat.  We look for the cause by testing for the presence of strep germs in the throat using a throat swab.  No strep, no strep cause, no strep throat.

For children, no diagnosis has suffered more from the problem with checklists without looking for actual causes of symptoms than AD/HD.  The DSM lists a little over 20 symptoms seen in AD/HD, some to do with inattention others with hyperactivity/impulsivity.  If you have more than a certain number, you have AD/HD.
The DSM always provides a waiver, concluding every diagnostic definition with the caveat that you do not have this problem if some other cause is found.

But wait a minute.  It turns out there are many, many causes of these symptoms.  Another silly example.  Let's say I have excellent attentional abilities, and am reading a book very intently and successfully.  But suddenly a branch snaps and falls on my foot shattering my bones.  I will no longer be able to pay attention to my book.  If I looked at my symptoms at that moment, I would be very inattentive, likely hyperactive, and appear impulsive as I howl and jump around in pain.  I would, technically, meet many criteria of the DSM and some, just hearing my symptoms might wonder of I have AD/HD.   Even without trees falling, other causes can create the symptoms of AD/HD besides AD/HD.

A short list would include a host of cognitive dysfunctions such as working memory deficits, slow processing speed, dyslexia, math learning disorders, writing learning disorders, anxiety disorders, depression, conflicts with teachers and/or parents, personality disorders, and many, many more.  Each can create just the right mix of symptoms to clearly meet the DSM definition of AD/HD, but one would never know another problem is causing it besides AD/HD without looking.

And so, this is the heart of the checklist problem- you can be positive by checking off symptoms on a checklist for a condition, and not have the condition.  Why?  Because checklists cannot prove cause.

Bottom Line:
Whenever a mental health condition is being considered for your child(ren), be sure that a diagnosis is never made solely on the basis of a checklist, make sure qualified professionals have helped you determine the real cause of the symptoms before you diagnose.

Dr. Arthur Lavin

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1 comment:

  1. Indeed! True blog. One of the major problems with mental health illnesses is that most people who are affected by mental problems are refusing to talk about the problem and sometimes refusing to seek professional medical help due to the gross misunderstandings and misconceptions from the general society concerning mental health problems.

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