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Order of Diagnoses May Impact Treatment

Mental health issues are often more than a singular problem as individuals may be bothered by a cluster of symptoms that represent several related, although distinct disorders.

A new study discovers that the order in which the diagnoses are listed appears to influence the care we receive.

Currently, the diagnostic system used by many mental health practitioners in the United States — known as the Diagnostic and Statistical Manual of Mental Disorders — assumes that symptoms of two disorders that occur at the same time are additive and that the order in which the disorders are presented doesn’t matter.

In a new study, published in the journal Clinical Psychological Science , researchers discovered that order actually plays a significant role in determining how clinicians think about psychiatric disorders.

For the investigation, researchers Jared Keeley, Chafen DeLao, and Claire Kirk of Mississippi State University reviewed existing research on conceptual combination to determine how clinicians diagnose psychiatric disorders that occur together.

They predicted that for disorders with overlapping symptoms — such as major depressive disorder (MDD) and generalized anxiety disorder (GAD) — clinicians would describe the disorders pretty much the same way, regardless of which disorder was presented first.

But for two disorders that are quite different — such as generalized anxiety disorder (GAD) and antisocial personality disorder (ASPD) — the researchers predicted that the order in which symptoms are presented would significantly influence clinicians’ descriptions of the disorders.

Keeley and colleagues also predicted that the features of one disorder would overshadow the features of another, providing evidence for a “dominance” effect.

In two different studies, the researchers asked clinicians to identify the symptoms that would describe each of three disorders individually (MDD, GAD, ASPD) and the symptoms that would describe paired combinations of the three disorders.

In both studies, the clinicians were inconsistent in their descriptions of disorder pairs — for example, the symptoms they identified for a combination of MDD + ASPD were not necessarily the same as those identified for a combination of ASPD + MDD.

And in one of the two studies, the researchers found that the order of symptoms mattered more for clinicians’ descriptions of disorders that were different than for disorders that overlapped, partially confirming their original hypothesis.

Together, these results seem to contradict the assumption that order doesn’t matter in psychiatric diagnoses.

Findings from a third study indicated that clinicians’ descriptions of the symptoms involved in GAD were dominated by their descriptions of both MDD and ASPD, while symptoms of ASPD and MDD had equal weight.

Keeley and colleagues believe these findings may be the result of several factors.

First, clinicians could be straying from the additive guidelines of the Diagnostic and Statistical Manual of Mental Disorders. Alternatively, their clinical experiences may have led to “rater drift,” such that the criteria that they use to evaluate symptoms have drifted over time.

Another possibility is that practitioners are actually ahead of the curve with clinicians “accurately modeling an aspect of psychopathology that our current diagnostic system has yet to accommodate.”

Although the jury is still out on whether these findings have implications for the actual treatment of psychiatric disorders, Keeley and colleagues believe that the studies may help researchers and practitioners bring the classification of psychiatric disorders and actual clinical practice closer together.

Source: Association for Psychological Science

Order of Diagnoses May Impact Treatment

Rick Nauert PhD

Rick Nauert, PhDDr. Rick Nauert has over 25 years experience in clinical, administrative and academic healthcare. He is currently an associate professor for Rocky Mountain University of Health Professionals doctoral program in health promotion and wellness. Dr. Nauert began his career as a clinical physical therapist and served as a regional manager for a publicly traded multidisciplinary rehabilitation agency for 12 years. He has masters degrees in health-fitness management and healthcare administration and a doctoral degree from The University of Texas at Austin focused on health care informatics, health administration, health education and health policy. His research efforts included the area of telehealth with a specialty in disease management.

APA Reference
Nauert PhD, R. (2018). Order of Diagnoses May Impact Treatment. Psych Central. Retrieved on September 28, 2020, from
Scientifically Reviewed
Last updated: 8 Aug 2018 (Originally: 30 Nov 2012)
Last reviewed: By a member of our scientific advisory board on 8 Aug 2018
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