Saturday, October 02, 2010

Guest Blogger Dr. Mitchell Newmark: The Relative Unimportance of Diagnosis in Psychiatry


Look, he came back! Guest blogger Mitchell Newmark, M.D. put on his armor and came to blog with us again.


The Relative Unimportance of Diagnosis in Psychiatry

As we will soon be witness to the emergence of DSM-V, the new rule book for psychiatric diagnosis, I am reminded of all the pitfalls of diagnosis in psychiatry. In other fields of medicine, diagnosis is based primarily on etiology, with objective findings, rather than on symptoms alone, as it is in psychiatry. When you go to your internist with stomach pain, there’s an endoscopy to look for ulcers, a sonogram to look for gall stones, a blood test to look for hepatitis. But in psychiatry, there is no CT scan to check for Bipolar Disorder, no blood test to assess if the patient has Schizophrenia, no spinal tap to check for Major Depression.

For the psychiatric community at large, diagnosis is important for many reasons. It helps doctors sort out patients so that clinical trials can be conducted on similar groups of patients. It enhances communication among psychiatrists when behavioral, affective and cognitive symptoms can be categorized. But for the individual patient, it is less useful. Some patients fit nicely into DSM categories, and others don’t. There are many patients who have unique combinations of symptoms across several diagnostic criteria. This leads to assigning multiple diagnoses, and confusing the treatment picture. Since diagnosis is based on symptomatology, treatment should also be based, more often than not, on symptoms, regardless of the “official diagnosis.” Latching on to a diagnosis may often limit the treatment options because medicines or psychotherapies designed to treat one disorder are considered inappropriate for treating another disorder. Flexibility is essential for coming up with the best treatment plan for an individual, especially those patients who do not fall neatly into a diagnostic box.

I am always happy to discuss diagnosis with patients, but even this can cause difficulties. For example, when I see a patient in their late teens or early twenties with protracted psychotic symptoms, not due to drug abuse or medical issues, and without the mood changes seen in depression or mania, I am asked “Is this schizophrenia?” According to the DSM, the answer is yes, but many patients recover from these episodes completely. The psychiatric answer is “this seemed like schizophrenia, but it must have been something else.” Meanwhile, the patient has had to cope with being labeled with a devastating diagnosis. I would prefer to answer, “these are the symptoms you have, so let’s treat them with the appropriate medicines. We may discover over time that you have schizophrenia, or an illness like schizophrenia, an illness that does not have a clear cut diagnosis, or this episode may resolve completely and indefinitely.” And that’s the truth.

Someday I may be able to send a patient for a PET scan and get a report back stating “Impression: Bipolar Disorder, Type !!.” By then the DSM will be a thing of the past.

12 comments:

Sarebear said...

When docs don't want to get specific about a diagnosis, I really wish they'd go into WHY, like you explain here about the younger person with the "perhaps schizophrenia, perhaps not." Because that really helps explain the WHY of not to get too specific.

My psychologist, who, granted, is not a medical doctor, but has to I assume diagnose for his own insurance forms, doesn't like to really get too specific with diagnoses with the patients, lest they label themselves; he's learned that they get stuck in the labels, and crap. Problem is, if I'm paying to see someone, I want ANSWERS, lol.

As well, when he recommended the book on OCD, Brain Lock, part of the methodology in it for countering the thought patterns and other things I get trapped in involves telling yourself that it's just the OCD.

Well, if I don't know that I have the OCD, ie, if the psychologist or psychiatrist hasn't "officially" told me, I can't fully believe in it enough for the methodology in this book to work for me. That's just how my brain works. I'm not trying to lock myself in to some particular label for the hell of it, but it is sort of a catch-22 with this book - if you want it to help you, you kind of have to know if you have OCD or not.

To me, it's obvious without any kind of official diagnosis that I do - I could list reams of things that would make it obvious to anyone. But for me to be able to believe the methodology in the book, I have to have an official diagnosis, I have to have been officially told that I have it, and that is probably psychologically something to explore. It may not be anything deeper than, well, we've been raised that professionals are the ones to give the diagnoses, not ourselves, so I can't fully trust my own opinion on it despite the reams of examples I have, lol. It might be as simple as that, heh.

Eventually I got him to say it, since I just could not make myself read the book anymore without knowing "officially" if I had it or not, because what's the point of using the method if you can't BELIEVE the method?

It felt dragged out of him, though, and I really resented him for that. I felt like, if you were a psychiatrist, you wouldn't have near this much problem giving me a diagnosis, but because you are a psychologist you are over-thinking what I'm going to do with "a label" or that I might pigeonhole myself into categories, something he's said about giving diagnoses in the past.

It's not like he hasn't given his opinion on the bipolar thing, especially given his difference of opinion on the matter with my first psychiatrist, but there's been no discussion of type this or that. So I have no idea there, not even from any of my psychiatrists.

If my first psychiatrist hadn't ignored the evidence of mania, I might have taken his theory a bit more seriously. He picked and chose what he listened to, though, which is, in the end, what doomed us.

Major said...

Agree with this post. Although I don't think the specific diagnosis matters a ton for me with treatment(though really it would feel amazing to have a simple label that summed up my problems. Sometimes it can make me feel even crazier when I'm outside the categories) it does tell a lot in terms of seeing how the treater perceives me. If our perceptions are too out of sync it doesn't bode well for working with that provider.

The Oracle at D said...

Daniel Amen, M.D., double boarded in psychiatry and nuclear medicine, prolific author, media phenomenon (PBS, Oprah I think), multiple clinics round the country, is using spect scan technology to, amazingly, show the brain at work in real time, sort of like a video, rather than still photo (CT, MRI) to identify specific parts of the brain with specific psychiatric symptoms. Namely, increased circulation in anterior cingulate gyrus associated with OCD sx; underactive prefrontal cortex associated with ADD, etc. Here is a concrete test to assess the brain at work with regard to behavior, mood, psych sx. A method to accumulate evidence. To enable us to generate a diagnosis based on actual data. You'd think our profession would be all over it. Yet, I'm not encountering articles about him, or his work, in the major journals. Not even opinion papers. Granted, I haven't exhausted myself looking. But, that you don't bring him up with reference to the frustrations of using the DSM to generate diagnoses surprises me. I've followed this awesome blog (I am insanely jealous) for several years now. You three are not shy about sharing opinions on current trends. He's a current trend. Don't think he's legit? Waiting for more data to emerge before expressing an opinion? The mere possibility of evidence based diagnosis thrills me. Wouldn't treatment based on logic be sweet? Thoughts?

Major said...

@the oracle at d

There's good reason why you're not seeing a lot of people talking about Dr. Amen and that is because his claims are way overstated.
The research he uses to base his diagnoses are based on average differences between two groups. Averages can't tell you about a specific individual. There is also a huge problem of false positives in bain imaging studies and frequent failure to replicate findings. Dr. Amen takes these studies and tries to generalize them in ways that the evidence simply does not support at all.

Dan Carlat has written a wonderful article explaining the problems with this method http://www.wired.com/medtech/health/magazine/16-06/mf_neurohacks?currentPage=all&showAllComments=true

moviedoc said...

Psychiatry doesn't really look that bad compared to general medicine. Alcohol intoxication is caused by alcohol, for example. Look at fibromyalgia. Diagnosed with criteria just like our DSM. And who knows what causes diabetes? We have to do the best we can with what we have if we want to help with the very real suffering, and to do that we must create categories. Take our drug categories with a grain of salt, too. Most of the drugs we call antidepressants we might better classify as anti-anxiety drugs. Maybe someday we'll treat synaptic cleff serotonin deficiency disorder. We're just not there yet. Dr. Amen? Quite a showman, but I saw his work and was not impressed. Was he the one who said, "There's a sucker born every minute?" I recommend a visit to quackwatch.com whenever you hear something about psychiatry that seems to good to be true. Sarebear, your psychologist sounds... honest. Make him read your comment.

Sunny CA said...

I agree with you, and it's the same philosophy my psychiatrist has. Largely I think it is better to not discuss diagnoses with patients unless it might help in some way. Oddly my psychiatrist volunteers "diagnoses" of people in my family or others in my life, then gives a rundown of symptoms that make up those diagnoses, so that I can put these people into proper perspective and see how their behaviors relate to their psychology. This helped me understand a lot in my life.

Sarebear said...

Moviedoc, he is, quite, and I really appreciate that about him, even if this is one of the very few things about which we disagree.

I've discussed most all of what I said in the comment with him in the past; I'll take a look at it to note those things that I may not have, like my lingering resentment and things like that.

I appreciate your kind words to me about it.

I also, in re-reading my comment, see that perhaps my OCD made me too rigid in obsessing about getting a diagnosis before proceeding with the work in the book, ironically. That's also an insight I can share with him now, heh.

Mitchell Newmark, M.D. said...

Thanks for the comments. I am very hopeful about the strides researchers are making in finding etiologies for the major illnesses. And this is why diagnosis IS important. But it is not so important for the individual who suffers today, in my office. The latest advances in SPECT scanning will not, for now, lead to any important treatment ramifications. I don't have a policy of not discussing diagnosis unless forced to; I just discuss how it may not be the most important factor in helping someone get better.

I became a psychiatrist in the first place because the presentation of psychiatric illness is as varied as people are--no two are alike. Lumping people together often does as much damage as it does good.

For example, some OCD patients feel empowereed reading about OCD. Some find that the reading makes them anxious. Some join the International OCD Foundation. Some find that the tidal wave of information they provide upsetting. Some OCD patients have thoughts that spill over into the psychotic range, others find all their thoughts are uncomfortably false. I have patients whose OCD spills over into panic attacks. I have patients whose OCD leads to depression, and whose OCD is confounded by ADHD. I recently have been treating a spate of patients with OCD during pregnancy and severe post-partum OCD. The point is, even in an illness as clearly neurologically based as OCD, the diagnostic label is not nearly as important as the individual and his or her symptoms

Sarebear said...

I see your point, Mitchell, and I would say that it's also and how to treat those symptoms; in my case, the how involved this book, and the method involved telling yourself "it's just the OCD". If I couldn't believe that I had it, since no one had diagnosed me with it, the method wouldn't work for me, so my particular situation was kind of a problem given the method that was being "prescribed" for me. If some other method that didn't require believing that you had OCD to treat it was tried, I wouldn't have had that problem.

I do see where you, and perhaps now he, are coming from on the issue, though.

It just seems to me that the particular solution that I was being told to use, and yet a diagnosis being withheld from me, was kind of it being wanted both ways on the psychologist's part, and I just couldn't juggle that. Not in the specifics of what the solution being offered in my specific situation was requiring of me. It required me to fully know and believe, so I could 100% invest in the method, or I wasn't going to be able to do it. In fact, I still haven't made it very far into the book, perhaps because of the lingering resentment that I didn't realize I still had until this blog conversation came up . . . . so ironically, in the end I guess it didn't matter that I eventually got it out of him. I REALLY need to bring this up, this week, it's clear to me more than ever.

I thank you for that, that this post and resulting discussion has helped clarify some issues for me that I didn't realize I had, that were blocking me from working on some important things.

jessa said...

Dr. Newmark, I now declare my love for you. Seriously. You have taken a good, sensible approach to the concept of diagnosis that acknowledges both the benefits and drawbacks (in my ever so humble patient opinion). In my experience, this is a rarity, despite the fact that I seek out mental health care professionals capable to nuance.

Is it that hard when a patient asks about diagnosis, yet as a Dr. you feel the pull to downplay diagnosis, to explain, even briefly, the pros and cons and give a cautious, qualified diagnosis? It doesn't seem like it should be. Although, my experience of doctors and diagnosis is much the opposite; I have had doctors all too eager to diagnose me. When those diagnoses are passed on to the rest of the care team, outpatient or inpatient, that's where the real trouble starts. I've been given a diagnosis of Borderline PD, which wasn't ever accurate, which made everyone else on the care team view everything I did within that frame. Confirmation bias meant they noticed things that "confirmed" the diagnosis rather than noticing that said diagnosis was entirely inappropriate. If these people took a nuanced and balanced view of diagnosis as the illustrious Dr. Newmark, I would have been viewed more accurately, as a person rather than as a walking diagnosis.

Maggie said...

I reacted rather strongly to this post, and was going to write a nice long comment. Then Jessa got to most of what I was going to say first! So first let me say that I wholeheartedly agree with everything that Jessa said and would have made similar points if they weren't already in a comment right above mine. So rock on, I love you're logic, all the stuff in the post above mine. :-) (Assuming Jessa's comment is still the last one by the time I hit the "publish" button.)
Like Jessa, I've been accused of being borderline and manipulative based on (professionals') logical fallacies. Unlike Jessa (I mentioned this to her in a comment on her blog about the similarities of our experiences,) I'm almost completely sure autism is the only truly logical explanation for my symptoms. Whether I'll ever know "officially" is up in the air, since most general psychiatrists don't know much about autism and there may not be much advantage in seeing a specialist as an adult. (When I mentioned autism to my psychiatrist, her response was that she's not a developmental psychiatrist, so she'd have no idea.) So for now I have to be satisfied that I meet the criteria and that I seem to have autistic causes behind those criteria. An official "no, you're not manipulative, you just sometimes seem that way because you're autistic" would be nice, but I'm already aware of my own motivations (I think) so really, such a thing would really only serve as "proof" to others.

Moviedoc, I greatly appreciate the concept of "synaptic cleft serotonin deficiency disorder," and truly look forward to the day when that may be a diagnosis. You made the point that I frequently try to make and don't usually succeed at too well-- that the meaningful labels define cause rather than symptom. Whether it manifests as as anxiety or depression or something else (like fibromialgia?,) if the problem is with serotonin, it's useless to try to adjust something else. And likewise, if someone is depressed but doesn't have a serotonin imbalance, adjusting serotonin won't help.

Anonymous said...

I am glad to hear it acknowledged that diagnoses can be devastating. I haven't received enough recognition for the devastation and exacerbation of my symptoms that the trauma of diagnosis has caused me. If someone had taken a more cautious and less labeling approach I am pretty sure I would be coping much better than I am at the moment.