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Be Patient.
With some people, things are so clear-cut that the diagnosis jumps out in
five minutes. But with others, it may take 5 hours. With still others, it may
require five months or even five years. Diagnostic impressions are useful
hypotheses to be tested, not blinders that can cause you to miss newer
information or the bigger picture. If you rush into a diagnosis, serious
mistakes can be made.
Psychiatry has many shades of gray that are lost with black-and-white
thinking. Using the Unspecified label reflects and announces that there is an
appreciable level of diagnostic uncertainty — a useful thing when the
simple, fast answer is so often wrong and harmful. Uncertainty can arise
when there is insufficient information, or when a patient has an atypical or
subthreshold presentation, or when it is unclear whether substances or
medical illnesses are causing the symptoms. The Unspecified designation
implies that we will need to extend the evaluation and learn much more
before committing ourselves. Admitting uncertainty is a good first step to
accurate diagnosis. Pseudoprecision is no precision, and premature
certainty brings no certainty; instead, both lead to the dangerous
unintended consequences of unnecessary stigma and excessive medication
treatment.
Suppose that a patient has an apparent depression, but it is not yet clear
whether the symptoms constitute a primary Depressive Disorder, are
secondary to alcohol use or to a medical illness, are medication side effects,
or are some combination of these. Until the picture comes into clearer
focus, Unspecified Depressive Disorder is just the ticket. Or suppose that a
teenager presents with a first onset of psychotic symptoms, and it is too
soon to tell whether this is a Bipolar Disorder, Brief Psychotic Disorder, or
the result of multiple secret LSD trips. Stick with Unspecified Psychotic
Disorder until time (ideally) tells all. Don’t “ready, fire, aim.”