Conceptual Frameworks and Diagnostic Judgment: How Psychiatrists Decide What Counts as a Delusion
Álvaro Cavieres, Rodrigo Arriagada, Joshua Cadima, Javiera Carrasco, Andie Palma, Pablo Lopez‐SilvaABSTRACT
Background
Diagnostic categories in psychiatry often derive from heterogeneous conceptual traditions. When applied to concrete cases, clinicians must resolve potential ambiguities between these frameworks in order to make practical diagnostic decisions. Delusion is a paradigmatic example, as it has been defined differently across phenomenological, operational (DSM‐based), and epistemic–motivational approaches. Little is known about which conceptual criteria psychiatrists rely upon in everyday diagnostic reasoning and how these frameworks affect clinical judgment.
Method
We conducted semi‐structured interviews with eight psychiatrists working in specialized psychosis services. Participants evaluated three standardized clinical vignettes designed to generate situations in which different definitional criteria for delusion could lead to different diagnostic interpretations. Interviews explored diagnostic judgments, confidence, perceived usefulness, anticipated inter‐rater agreement, and ethical considerations. Data were analyzed using descriptive qualitative analysis.
Results
A consistent gradient emerged across cases. Clinicians expressed highest diagnostic confidence and clarity when the vignette supported criteria associated with phenomenological descriptions of delusion. Operational DSM‐based criteria were often used as initial anchors but were regarded as provisional, dependent on contextual and longitudinal information. Situations compatible with epistemic–motivational interpretations generated the greatest diagnostic uncertainty, prompting requests for additional information and concerns about potential over‐pathologization. Psychiatrists did not rely on competing definitions of delusion in an interchangeable way. Instead, their diagnostic judgments reflected a preference for conceptual criteria that reduced ambiguity and supported confident, communicable, and ethically prudent decisions in practice.
Conclusions
Examining how clinicians resolve conceptual differences in real cases provides a way to assess the practical validity of diagnostic definitions in psychiatry.