By Eda Gorbis, Ph.D., LMFT, and Alex Gorbis, MA (The Westwood Institute for Anxiety Disorders, CA)
Throughout time, assessment and diagnosis in medicine have been key in the determination and identification of treatment for medical illnesses. No course of treatment will begin without diagnosis and understanding of the origin of the illness. As far back as the invention of traditional Chinese medicine millennia ago, tools have existed that are used to identify medical illnesses. In today's world of medicine, we have all kinds of tests: scientific tests, blood tests, urine tests, neurological tests, MRIs, and CT scans. In the medical field, people cannot move on to treatment without a proper diagnosis. It would be illogical, wrong, and considered malpractice. So why is it that, in the mental health field, it happens far too often?
At the beginning of the 20th century, no scientifically or empirically proven methods were able to determine psychiatric and psychological illnesses and separate them from medical illnesses. However, over the past three decades, an enormous amount of empirically proven assessment tests have been developed that are shown to be accurate in diagnostic tests. These are used to inform scientifically proven tools that are used to treat people following the precise diagnoses they offer based on the attestation of diagnostic criteria and have been disseminated by and for mental health professionals. These diagnostic assessments are taught at most academic institutions and are available online. And yet, far too often, they are not being applied in practice.
Globally, for centuries, there has been a stigma associated with psychological and neurological ailments. People who suffer from a medical illness can identify an organ that hurts and separate themselves from that organ. A person with a headache can identify that their head causes the pain. However, those with mental illnesses often have a blurred line and cannot separate themselves from the problem. Rather than treating it like any other affliction, they believe that something is wrong with their personality, and often blame themselves.
Although the symptoms of obsessive-compulsive disorder (OCD) are serious and debilitating on their own, it is a condition that often does not occur alone. It is common for people with OCD to have one, two, and or more different OCD spectrum disorders/comorbidities (such as body dysmorphic disorder, eating disorders, etc.), depression disorders, and anxiety disorders such as panic disorder, generalized anxiety disorder, social phobia, PTSD, and simple phobias.
In September 2022 — in a nod to the nation’s pressing mental health crisis — a US task force made up of a group of influential medical experts recommended, for the first time, that all adults under the age of 65 get screened for anxiety. The draft recommendation is designed to help primary health clinicians identify early signs of anxiety using screening methods.
However, our disbelief stems from how specialists who reside on the boards of major national and international conferences have fallen into a pattern of failing to administer diagnostic tests and subsequently misdiagnosing their patients. These individuals have been extensively trained to use various diagnostic assessments, which are based on empirical evidence, so why still are they failing to properly assess the patient? The only assumption we can form, is they are not using the tools given to them to their fullest capacity, instead opting to haphazardly administer and diagnose.
The importance of proper assessment rather than assumption in diagnoses can be illustrated by the following cases:
Case 1:
The patient was treated by a very reputable institute, but the assessments were sent via the Internet to be filled out by the patient who was initially unaware of their fear structures and their comorbidities. A scale to assess panic disorder was not included, and panic disorder was therefore missed in the diagnosis. It is well known that panic disorder must be treated first when it is presented with OCD so that it does not later impede on the gains made once OCD is treated. Because the panic attacks were not treated, the progress made in OCD treatment was erased, and the patient's progress regressed. It remained unclear as to why the patient was continuously dysfunctional.
Case 2:
Necessary assessments were administered to a patient, again via the Internet and through self-report. All diagnoses and comorbidities were properly diagnosed, but the patient continued to be unaware of the fear structures they presented with. The patient was only treated for a fear structure of contamination, so their fear structure for completion was never detected and therefore, never treated. During three weeks of treatment, the patient maintained all of their symptomology and proceeded to get worse (i.e., the patient’s daily shower time increased to 6 hours a day).
Contrasting these two cases, here are two cases that illustrate proper assessment which were successfully carried out at the Westwood Institute for Anxiety Disorders:
Case 1:
Our team provided a comprehensive and detailed assessment of the patient. The patient had been previously diagnosed with OCD and high-functioning autism spectrum disorder (ASD); however, extensive treatment via exposure and response prevention (ERP) therapy was not helping to reduce her Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score or improve her ability to speak, read, and write without anxiety. After the WIAD team conducted a 4-hour long assessment, including questionnaires that totaled 500 questions, they were able to determine that panic disorder had been interfering with her OCD treatment. This was a significant revelation that had not been previously identified by multiple therapists and psychiatrists over the last 5 years. In addition, the comprehensive diagnosis fully explained the “constellation” of mental health disorders that must all be treated to improve her quality of life. The patient is now working with a therapist to address the panic disorder so that she can eventually manage OCD with reduced levels of fear and anxiety.
Case 2:
The patient had a diagnosis of post-traumatic stress disorder (PTSD) and social phobia that was completely missed. The patient was tested and treated for OCD alone, and the diagnostic tests were administered via the Internet. Diagnostic tests for PTSD and social phobia were never sent to the patient, and thus never had a chance to be diagnosed. At the Westwood Institute, the team administered all these tests with the MINI-International Diagnostic Neuropsychiatric Interview, and both disorders were properly detected and diagnosed. During the patient’s treatment, their OCD, PTSD, and social phobia were all addressed, treated, and resolved. Now, the patient has been in complete remission for the past 6 months. This demonstrates why it is crucial to conduct these empirically qualified diagnostic tests in person rather than online.
This issue of not using proper diagnostic methods should be prioritized because of the need for the administration of accurate and effective treatments, and of the general importance of public mental health. Our previous recommendations have centered on treating severe OCD refractory treatment and anxiety and applying various scientifically proven research methodologies in the treatment of adolescents and adults. Our question does not intend to separate the medical from the mental, as they are intertwined. Rather, we advocate for the initial assessment to consist of a vast set of questionnaires that total about 500 questions, to be extremely thorough, and to last two to five hours. This specific testing should be done to determine the diagnosis and eliminate the chances of misdiagnosis. One of the many assessments we recommend is the MINI-International Diagnostic Neuropsychiatric Interview, which goes through various criteria to ultimately rule in or rule out mental health disorders and aids in determining a precise diagnosis. We also recommend the use of the Structured Clinical Interview for DSM Disorders (SCID) and the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) as assessment tools. A multitude of questionnaires that together total about 500 questions is ideal because they are done to find common denominators of all fear structures that exist; without this variation, a clinician cannot target the exact fears. We recommend all of this to take place in person, under the supervision of a licensed professional — not over the Internet and via self-report questionnaires. This is because the patients may not be aware of their fear structures or the severity of their condition. An example of the importance of in-person assessments can be demonstrated by the following: we asked a patient we were treating to fill out a self-report questionnaire, which we then also administered in-person. We found many discrepancies between these two types of administration surrounding the patient’s fear structures; the in-person administration showed much greater severity than the self-report. Many are aware that the Westwood Institute has been advocating for and administering an extensive initial assessment throughout the past three decades. Our use of a large questionnaire battery that includes the MINI-International Diagnostic Neuropsychiatric Interview, the SCID, and the ADIS-5 is not the only factor that results in accurate assessment; other positive factors include detailed in-person sessions done by professionals and the thorough and precise nature of these sessions.
In conclusion: Remember — assess, assess, assess!
Eda Gorbis, Ph.D., LMFT, is a world-renowned authority on the treatment and research of Obsessive-Compulsive Disorder (OCD). From 1999 to 2014 Dr. Gorbis held an appointment of Assistant Clinical Professor in the Department of Psychiatry at the USC School of Medicine and the Adult Department of Psychiatry at the USC School of Medicine from 2015 to 2023. Since 1996 Dr. Gorbis has been the founder and director of the Westwood Institute for Anxiety Disorders, which treats refractory cases of multidimensional OCD-spectrum disorders with multidisciplinary teams. Dr. Gorbis is the author of almost two hundred articles and presentations on OCD-spectrum disorders.
Alexander Gorbis, AMFT, obtained his master’s degree in Clinical Psychology with an emphasis in Marriage and Family Therapy from Pepperdine University. Since graduating from Pepperdine, Alex has been working at the Westwood Institute for Anxiety Disorders, gaining clinical experience with extreme cases of OCD and comorbid disorders. His responsibilities as an associate therapist are administering supervised assessments to new patients and providing support in developing and executing exposures with patients. Presently, he is a doctorate candidate at the Chicago School for Professional Psychology.
For additional information, please visit: hope4ocd.com