Sunday, February 26, 2012

Nothing Really Matters To Me....

The title of this post is a line from Bohemian Rhapsody by Queen.

A reader wrote in and asked us to comment on the necessity of diagnosis and referenced a post by a medical student:

Just read a blog by I Am Not House at and it struck me as a great show topic for you guys.  Obviously in forensic psychiatry a diagnosis is the goal but what about in other treatment settings?

This is a good question, and recently I was consulted by an on older and wiser psychiatrist who asked me to consult on her patient, in part to figure out the diagnosis.  Wait, she's been seeing the patient and can't figure out the diagnosis and thinks I can?  And the patient has been treated with medications and she's well now, so I'm consulting on an asymptomatic patient to figure out the diagnosis.  "What difference does it make?"  I ask.  "She deserves a prognosis," I'm told.  Let me tell you, this is a very good psychiatrist with a lot of experience, and if she can't figure it out, I'm not going to be able to either.  And people may "deserve" a prognosis, but my crystal ball doesn't work so well, and personally, I'd like my own prognosis...for life in general...never mind a mental illness.

I have a secret to confess.  Please don't tell anyone because I think what I'm about to say is obvious and every one knows it, but it's total taboo to admit it.  This may be it for my psychiatric career, but at least I'll go out in a flame of honesty.  With very few exceptions, I could care less about psychiatric diagnoses.  I don't care what they put in the DSM-V.  I stick a code somewhere because I have to, but getting to an accurate diagnosis in psychiatry tells you next to nothing about prognosis, and diagnostic criteria are formed by a bunch of guys (not in even all in suits, I bet) arguing, and asking for public website input, it's not like looking for that hidden little tumor behind the kidney, where if you get the right piece and stick in under a microscope you can say "Ah, ha, high grade malignancy we need chemotherapeutic agent X."  

Treatment in psychiatry focuses on symptoms.  And hey, all our symptoms, with the exception of hallucinations and delusions (and even there...) and suicidality, are variants of normal states.  Where is the exact point at which someone who is a productive, energetic, & exuberant stops being a productive fast-tracker and becomes an mentally ill hypomanic?  At what point precisely does someone cross the line from creative, marvelous, and wonderful, to histrionic, melodramatic, and sick?  Find me that point. And find me that point so that it makes sense every single day, not just on Tuesdays or days when the stars line up right or when the patient is in the middle of a divorce. 

The truth is that if someone comes in complaining that they are sad and irritable and not enjoying anything and they have stresses that might explain this, but maybe not, and they really think there is something wrong, I don't sit there with a check list saying, nope, your Beck Depression Inventory is two points too low for you to meet criteria, you're not depressed.  And I don't keep a DSM in the office.  If someone complains of depression and I don't know how biologically based it is, I go through the options and if the person wants to try a medication, I'm fine with that.  If they come back and say "I didn't like that stuff,"  that's fine, too.  If I feel strongly that they need medicine, I say so.  

Prognosis, from what I can tell, doesn't depend very much on the diagnosis.  People who get sick at young ages and never pull lives together to work and to love, don't tend to do as well.  Some people get horribly sick and can't function, but then they get better.  Even if they show up really, really ill, people with episodic illnesses have episodes: they get better. until the next episode and the work of treatment becomes preventing the episodes or catching them early.  People with chronic illnesses don't do as well as people with episodic illnesses.  And some people have chronic symptoms but function just fine in the world anyway.  By my count, they do well, too.  I tend to be an optimist.  And some of the people I feel more pessimistic about prove me wrong and they do fine, too.

I guess the one place where diagnosis matters is with regard to giving a person an anti-depressant who has clear cut bipolar disorder.  But you've heard my thoughts on the Bipolar Diagnosis.  Antidepressants can destabilize people and they do better on mood stabilizers, if it is bipolar disorder.  But figuring out if someone is hypomanic, versus anxious, versus having attentional problems, versus being a fast-talking, high energy soul is hard.  And I'm always a bit worried when I stop an anti-psychotic agent on someone who has been psychotic, but if they want to try stopping, and the last episode didn't endanger anyone, then I may decide it's worth a risk.  I suppose the shrinky world would have us think that this is safer if they have a mood disorder then if they have schizophrenia, but since we seem to have trouble making that distinction, who knows.

Yup, I stick something on the form so people can get reimbursed by their insurance, and if they actually meet criteria for a diagnosis, it might even be the right diagnosis.  But is there a law somewhere that says every single person who presents in distress to a psychiatrist must have symptoms that come in a matter that neatly fits into one of our diagnostic entities?  To hear people talk, you'd think that everyone simply must make it into one of those boxes and if they don't, there is something wrong that the clinician didn't get the right diagnosis, not the possibility that the patient's symptoms just don't get explained by our artificial criteria.  

You can fire me now.


Anonymous said...

Since you would like it, here is your very own prognosis for life in general: It's fatal.

Otherwise, you make good points. Most private practice shrinks I know would say the same, so I don't think any of it is radical.

Anonymous said...

I'd be a prime example of that. I've had more diagnoses than you can shake a stick at and none of them are quite right--or entirely wrong. There's dysthymia, MDD, some BPD or is that ADHD?, avoidant or is that social phobia? or is it schizoid or schizotypal or maybe a little Asperger's?, delusional disorder maybe? but I do seem to be a mind reader so maybe not? maybe it's the BPD sensitivity? Or maybe I'm just gifted and eccentric and depressed because I don't fit in? Have fun trying to diagnose me, lol.

Marie Gronley MD said...

Yes often an illness defined by the DSM can be seen as an issue of taxonomy since psychiatry lacks the bio-markers as do other medical fields. Often most clients have a bundle of symptoms that don't fit the this textbook criteria. During the initial evaluation, a short discussion about the field of psychiatry "not having any bio-markets" will sometimes diffuse the blow-back when a client doesn't respond or when they go for a second opinion and are diagnosed with something other than my diagnosis. When we are at the mercy of the client providing us with the diagnostic criteria...these issues are part of our daily lives.

Enjoyed the article and a very good topic

Annaliesa said...

After diagnosis number five, I started snickering at the DSM codes on the receipts I submitted to my FSA company.

I've seen three psychiatrists, and they've all agreed it's Bipolar something or other, but which form seems to change with the alignment of Mars and whatever random constellation. The NOS format seems to be what they end up settling on.

As long as they give me my pills and are polite when I see them, I don't particularly care. They've all been pretty fun - first psychiatrist and I talked about French literature, second CMH issues, and current talks to me about advances in neuroscience. Second shrink was a bit pesty about a medication in addition to lamotrigine as I was somewhat stable - failed third antipsychotic, really - so I got a second opinion. Current shrink gives me pills sans antipsychotic. All is well.

Favorite diagnoses in the DSM -

Adjustment Disorders of all sorts
Diagnosis Deferred
Anything ending in NOS - especially Mood Disorder NOS and Personality Disorder NOS (Personality Disorder NOS is a riot)

Liz said...

i, too, have received a few diagnoses: depression, obsessive compulsive disorder, borderline personality disorder, bipolar disorder, anxiety disorder, attention deficit disorder...

some of them never stuck (ocd, from a hospitalization as a teenager), and some of them stuck for a while.

in some ways, a diagnosis is a comfort, but too many people, in my opinion, identify too strongly with their diagnosis-- they become their illness instead of their diagnosis describing some of their issues.

dialectical behavioral therapy has been a god send to me. mentally, i have re-framed my issues from a "mental illness" to a "skill deficit." before, i didn't have an emotional pressure gauge, so i felt fine, until i "blew up". now i do have an emotional pressure gauge, and i have the skills to monitor that pressure and make sure it stays at a healthy, manageable level.

Kimberly said...

I have been given labels all my life also. From Bipolar II, OCD, GAD, Major Depressive Disorder, Borderline Personality Disorder(fit seven of the criteria for it)... with overlaping personality traits (avoident, dependant ect) let's see also attention deficit disorder... eating disorders... I had a self harm problem also. I have been on a lot of meds including, Zoloft, Lexapro, Prozac, Risperdol, Seroquel, Depakote, Adderall and some others.

I recently have been introduced to DBT also, keeping my fingers crossed.

Jane said...

something tells me ur not alone. i used to see a psychologist who felt much the same way

rob lindeman said...

The New Yorker Cartoonist, Bruce Eric Kaplan, was a junior high and high school classmate of mine. Bruce sat in the back and doodled. I sat in front and took notes. Now look who's getting paid!

Noel Bell Psychotherapist said...

yes interesting as others have already pointed out that psychiatry lacks the bio-markers as do other medical fields.

rob lindeman said...

"Treatment in psychiatry focuses on symptoms."

That's a fair statement. The problem is that we have no idea what we're treating. Are we treating a chemical imbalance, as Dr. Gormley tells her patients?

No, we're treating phenomenology.

Like the somatic treatments that went before them (e.g., Insulin, Metrazol shock, ECT, pre-frontal leucotomy), pharmacotherapy is used today because, well, the treatment appears to alter the phenomenology.

We then construct a scenario that appears to explain why the phenomenology changes. Then the current theory obsolesces from lack of evidence and we move on to another treatment and another theory.

Hey, you can call that medical science if you want. But like Joan Cusack said to Melanie Griffith in "Working Girl" (1988):

"Sometimes I dance in my underwear in front of the mirror … it don’t make me Madonna, nevah will"

Anonymous said...

Sorry, Marie, I meant Dr. GRONLEY

I am not a robot

Dinah said...

Anon who reminded me that I'm going to die: Gee, Thanks.

Rob, fine to dance in your underwear in front of the mirror. Since I don't know you, not sure if you should be dancing in your underwear in front of the window. Probably the only way to know is to try it and see if good things happen or bad things happen or if nothing happens.

rob lindeman said...

I shouldn't have dissed pre-frontal leucotomy. It was enormously effective. If the first 'treatment' didn't make the phenomenology go away, you could repeatedly operate until you got achieved the desired effect.

DBT-Fan said...

"People who get sick at young ages and never pull lives together to work and to love, don't tend to do as well"

That line knocked the wind out of me. I was sick young and almost missed love (and work.) Nowadays I could not imagine fighting the good fight without love. Some days I forget how bad it could be.

Oh and as far as Anons fatal prognosis - my favorite version of that perspective was from another medical blogger Doctor D - "The human body is a low-down Judas that will eventually screw you over then kill you!"

Dinah said...

Oh, and some people look really sick when they are young and then outgrow whatever it was and do fine.

I think you know the prognosis after it's been had.

Not House said...

Figured since I indirectly contributed to this post, I could offer my $0.02.

What I realized (actually at work today) is that the difficulty in psychiatry is that unlike every other walk of medicine, the symptoms ARE the disease. In cardiology, for example, you don't say someone is or isn't having a heart attack based on whether they have chest pain or palpitations - the symptoms of the disease are variable, and it is through further diagnostic testing that the true disease is unmasked. In psychiatry, however, the symptoms themselves are essential to the "formal" diagnosis of the disease. Hence, you can have two patients present with entirely different symptoms and get diagnosed with the same disease, and you can have two people show up with the same "symptoms" and, depending on what the interview unearths and/or how it is interpreted by the examiner, get two different diagnosis.

I hope my initial post didn't make me seem as though I was rallying against the whole idea of psychology as some people here seem to do (Dr. Lindeman has shown up at my blog too to similarly decry psychiatry). I can certainly appreciate these patients are ill, but it seemed counterintuitive to try and pigeonhole these patients into rigid categories. It's very reassuring to hear practicing psychiatrists reject this ideology and show a more fluid appreciation of their patients needs and aims.

Good stuff!

Liz said...

I will never forget when I read my hospital records at sixteen: prognosis: poor. Also, at a size sixteen(then), I was described as morbidly obese. R/O BPD.

It was just the info necessary to share with a depressed teenager.

I'm so proud to have survived, to have a wonderful, healthy family, and to be working hard on my emotional health. I just found out I was accepted for grad school w. a full ride. That doctor was wrong.

DBT-Fan said...



East Coaster said...

Recognizing that we all die isn't necessarily pessimistic. It can focus you to make the most of the brief time one does have.

My favorite diagnosis in a client's chart is schizoaffective disorder. I dont' that I've seen in the public system a diagnosis of psychotic depression. Don't know what to say: it's schizoaffective.

Anonymous said...

How do you know when you (or anyone else) has "figured it out"?

Anonymous said...

How do you know when you (or anyone else) have "figured it out"?

Anonymous said...

How do you know when you (or anyone else) have "figured it out"?

Anonymous said...

How do you know when you (or anyone else) have "figured it out"?

rob lindeman said...

By the time you ask for the fourth time, you figure it out

Anonymous said...


You already knew that life is fatal. Since we all know that, both nothing and everything should matter to you and to me and everyone else.

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