Findings and disorder inconsistencies in the domain of Phobias

Paul,

We'll add this to the agenda for the Feb 17 meeting. I just this week put together a list of candidate sub-hierarchies for the group to tackle next - so the timing is perfect. 

Best,

Piper

What time is the meeting on the 17th?

Hi Piper Allyn Ranallo,

That's great.

Many thanks indeed.

Regards

Paul

Paul Amos, 

Attaching a couple of documents here enumerating the concepts listed as a direct child of concept phobia (finding). I'm not sure why the SNOMED concepts are organized the way they are... we have noticed that many, many of the concept hierarchies are a little "off" when it comes to mental health. 

Michael First, Laura Fochtmann, and Darrel Regier can speak more specifically to this, but my understanding is that the idea of a phobia implies more than just the existence of fear of an object or situation (e.g., by associated cognitive and behavioral phenomena like actively avoiding the feared object or situation).

What is less clear to me is whether a phobia is always and necessarily a disorder, or whether it can be a simple finding (analogous to depression the finding and depression the disorder).  I'll leave it to the SMEs on the thread to address this issue. 

This problem of findings vs disorder isn't unique to the mental health content. Keith Campbell, Jim Case and I discussed this (general distinction) a while back. (Though I think progress stalled).

Anyway, my argument was that they're all "conditions or clinical states", and remove any judgement about being a disorder or not. 

So in this case, whether it's a "phobia" or some other 'flavor of fear' - is a decision for diagnosing clinician.
Whether or not the condition (e.g. Fear) is considered a disorder might depend on the context - e.g. some fears are reasonable. - so also up to the clinician.

To me, Findings - are objective outcomes of a specific test/evaluation/question. e.g. "Does respond to X" "Does not respond to X"

I've also struggled to consistently make sense of the distinction, and hence my current view (which I'll qualify as just my opinion ).
It's hard to find/agree on the right words (especially when some are "loaded"), but hopefully, my intent is apparent.

So categorising something as a "disorder" - implies it is a negative, or undesirable.

• There's no contention that something like "Open fracture of fibula (disorder)" would be a bad thing.
• Then there are concepts like "Ephelis (disorder)", aka "freckle". Is that really a disorder? Some people might feel they have too many (subjective), and that causes problems, but the freckles themselves aren't necessarily "bad".
• Then there are those things that may have historically had a negative perception (or still do), often based on social values. The sexual behaviour/function content is the most obvious example.

I'm not sure what value categorising things as "disorders" within the terminology brings. And having them creates confusion.

I think there's very subtle language (at least in english) that sometimes might differentiate what could be considered a finding vs diagnosis? E.g. Anxious vs Anxiety; Fear or phobic vs phobia. Complicated by lay person usage. ie. traits vs named conditions

As for differentiating a "diagnosis" and "finding", I don't think that's the role of SNOMED CT; The information model should support the recording of both findings and diagnosis.
A diagnosis (or clinical conclusion?) is not inherently bad e.g. Pregnant (finding), Leukemia in remission (disorder), Fit and well (finding), Synesthesia (finding)

If diagnosis is exclusively for "named disorders". Some of the findings to reach that diagnosis, could also be "named disorders".

As we can see from the discussion, this differentiation between "finding" and "disorder" has been problematic for decades. There are those that feel that the distinction is important enough to specifically instantiate within the terminology and others that think it is in the eye of the beholder(i.e. clinician).  I think there is general consensus that these both represent a clinical "condition" of the patient, but the question is how much context do we want to put around these explicitly in the terminology.  A single blood glucose measurement above the normal reference range is certainly of interest, but it does not imply necessarily that the patient has diabetes.  A fear of spiders, or heights, or snakes may have reasonable foundations, but do not really represent a "phobia disorder".  There are lots of contextual knowledge needed to make that determination. 

SNOMED provides the atoms for clinicians to record both objective observations (findings) and summary interpretation of the clinical condition of a patient (disease).  A "diagnosis" is really the summary of the clinical interpretation of the supporting facts and gives it a reference to a named disease.  However, it might not be correct (presumptive diagnosis), or the only one (differential diagnosis) or a subtype (i.e. pathological diagnosis, laboratory diagnosis, clinical diagnosis).  This why I like to stay away from the use of the term "diagnosis" as a synonym of "Disease".

Having said all that, it is important that we are able to make the distinction between an objective finding at a point in time and an actual disease.  Both need to be followed up and managed.  Unfortunately, SNOMED CT has been rather undisciplined in assigning things as findings or disorders due to both the lack of clarity of the distinction and historical modeling (thus a freckle becomes a disorder because it has an ASSOCIATED MORPHOLOGY).  We are continuing to discuss this at the EAG, but as Matt stated, it has become stalled as we try to decide how much churn any change to the current structure would have on members, and how much they might be able to tolerate.