In my goal to illustrate how psychiatric diagnosis really works - I came up with this preliminary drawing. It was a very rough sketch of various the various requirements in the areas of perception, data acquisition, pattern matching, and reasoning during the diagnostic process. I decided to send it out to psychiatrists who I knew were excellent clinicians to get feedback for further modifications. In my emails I was careful to specify that the diagram did not imply a temporal relationship - that is there were no stages or discrete steps from left to right. The stages on the left did not have to precede the stages on the right.
So far I have received feedback from 3 people but even before that occurred I found myself making 6 additional modifications of the diagram. I am currently on the diagram you see below (click on any graphic to enlarge).
The features added include a connection of all of the diagnostic areas to indicate there are all in superposition. The term here basically means that they all exist at the same time - independent of any passage of time. I have also added hypothesis testing at various point in the diagram. In some cases this hypothesis testing is rapid - like recognition of of life threatening condition. In others it may takes days or weeks like trying to determine whether a person has a mood or anxiety disorder and/or a personality disorder. The ancillary determinations about safety and medical stability also require additional time.
In an interesting trade-off some information content has very high actionable quality and that can result in action in a very short period of time. For example, aphasia in a patient who is being seen for agitation would generally mean that there is a high probability that the patient needs acute medical and neurological care rather than psychiatric care as soon as possible. On the other hand, insomnia is less likely to require acute care or urgent treatment.
I am posting these graphics here for two reasons. First, just to describe my process. The graphic as made with my usual tool Microsoft Visio. I save each iteration as a *.vsdx file and generally snip these drawing to *.jpg/jpeg or *.png for posting. Second for feedback. If you have ideas about how to improve these graphics especially if you are a psychiatrist who has been making these assessments for a while - feel free to post your suggestions here or just email me. If you want me to email you graphics that are in the works - just let me know what you email address is and I will send it along when I solicit feedback. I do not anticipate that will be more than 4 or 5 times a year.
George Dawson, MD, DFAPA
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