The ICD guidelines have been useful in assisting clinicians in understanding diagnosis and applying them in clinical setting, to communicate clinical information, select effective treatment, and for the prediction of future clinical management needs.[1
The process of making a diagnosis in psychiatry is dynamic and usually requires a series of interviews and assessments before a stable, valid diagnosis is made. This process may be compromised in clinical settings, more so in areas where psychiatrists are overloaded and have limited time to spend on each patient. With 0.4 psychiatrists per 100,000 population,[10
] this situation exists in most parts of India. The main purpose of the study was to find the applicability of ICD-10 in busy clinical settings as well as to explore the causes that hinder in making confident diagnosis according to the guidelines.
The findings from our study indicate that in 67% of cases there was a very good match between the initial “provisional diagnoses” on which the treatment was started with the “final diagnosis.” Further, 17.69% had “almost match” and 1.5% had “significant match.” Therefore, for the majority of the patients, there was no change in diagnosis after extensive assessments.
Among the individual diagnosis , “Depression” had poor concordance with the final diagnosis. The “depressive symptoms” were therefore overdiagnosed as a disorder. On more thorough assessments, the patients did not fulfill the criteria as laid down in the ICD-10. The possible reason could be lower threshold for diagnosis of “depression” where the distress may be due to other reasons, which are not discovered on the first assessment.
Matching of the “Provisional Diagnosis” with “Final Diagnosis”
The other diagnosis where 33.33% had “almost match” was dissociative disorder. In order to make a diagnosis on ICD-10, the “evidence for psychological causation in the form of clear association in time with stressful events and problems or disturbed relationship (even if denied by the individual)” should be present. Further, it states that “In the absence of evidence for psychological causation, the diagnosis should remain provisional and enquiry into both physical and psychological aspects should continue.” Here, the difficulty was in clearly delineating a temporal relationship with a psychological causation in a crowded OPD in short duration.
In OPDs, it is believed that due to paucity of time, proper rapport could not be established, and this is the main reason that patients are unable to share their personal matters in crowded surroundings. In most cases, the level of dissociation has been found to be related to reported overwhelming sexual and physical abuse.[11
] Chu et al
. (1999) reported that child abuse, especially chronic abuse starting at early ages,[12
] was related to high levels of dissociative symptoms in clinical samples.[13
Besides, it has been also found that in the long term, dissociation is associated with decreased psychological functioning and adjustment.[14
] Although stressor is the main cause of dissociation, yet the suggestion is that for the purpose of making diagnosis in clinical setting this criteria should be reviewed and diagnosis can be made on the suspicion of the stressor.
Patient with somatoform disorder often attribute their symptoms to organic cause and that is why they seek medical help. They also have a tendency to disbelieve the doctor when they are told that there was no physical cause of the problem. In ICD-10, the reassurance provided by a doctor that the patient had no physical problem has been considered as an essential criterion to make a diagnosis of somatoform disorder. In 25% of cases, it has been noticed that the patient did not fulfill this criterion, as they had never been reassured by the physician although they fulfilled other criteria.
The discordance in the final diagnoses in “Adjustment Disorder” was recorded as the onset of symptoms occurred 3 months after the stressful situation. Thus, a temporal correlation between the problem and stressor was not established.
Nearly 33% patients with dysthymia were found moderately depressed at the time of further assessment, revealing a greater possibility of having clear cut episode of depression in dysthymia. The ICD-10 states that the depressive symptoms are “never or very rarely severe enough to fulfill the criteria for recurrent depressive disorder mild or moderate severity.” Therefore, a precise diagnosis of dysthymia could not be made. Considering the possibility of depression in dysthymia, a category of Double Depression may be worth considering in the future.
The criteria for diagnosis of Recurrent Depression in ICD-10 required that “the criteria for Recurrent Depressive Disorder should be fulfilled, and the current episode should fulfill the criteria for depressive episode – mild or moderate severity” for definite diagnosis. It was observed in 33% of the cases that the patient came to OPD in the beginning of depression, eg, 3-4 days of disturbed sleep, poor appetite, and loss of interest. From their earlier experience of illness, the patients were able detect the symptom early and seek medical help.
In such cases, doctors’ assessment was that the illness was recurring but diagnosis was not possible on ICD-10 due to the criteria related to duration. Several general population surveys have demonstrated that quite minor differences in the definition of individual syndrome such as major depression may result in large differences in recorded prevalence.[15
] Probably, the future version of ICD may take this into consideration and allow a relaxation in duration criteria for relapse episodes.
The approach to diagnosis and management of psychiatric disorder varies worldwide. These local variations are due to the variation in social and cultural norms, availability of resources, training of healthcare workers, and the modality of treatment that are available. Most of the psychiatrists in India are overloaded and have limited time for assessment of an individual patient. The focus of the psychiatrist in such a condition is to choose the best treatment and record accurate diagnosis according to the guidelines may be ignored. The patients may continue to receive treatment on the “provisional diagnosis” they are labeled with, especially if they show improvement on treatment.