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.