Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen. All patient vignettes are confabulated; the psychiatrists, however, are mostly real. --Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)
We've talked before about psychiatric diagnoses and whether the label can be part of the problem. See Diagnostic Labels that Change Lives, for starters.
Today, Dr. Allen Frances joins us to talk about whether a diagnosis with a poor prognosis can become a self-fulfilling prophecy. I'll leave you to decide.
The Dangers Of Premature Diagnosis
Psychiatric diagnosis is a serious business. Done well, it can significantly help a life, sometimes save it. Done carelessly, it can lead to disaster, even to premature death.
I have been witness to many thousands of patients who benefited greatly from psychiatric diagnosis and treatment. But I have also seen many hundreds who have been harmed by it.
When you lose a son partly as the result of a premature and wrong diagnosis, it ignites in you a painful and prolonged search for answers. Suzanne Beachy shares her deep and heartfelt perspective here.
Ms. Beachy writes:
I, along with a growing number of fed-up mental health consumers and family members, believe that disability and loss of hope can often be made worse by premature diagnosis that highlights weakness, ignores strengths, and predicts a dire prognosis based on meager evidence.
Jumping to a diagnosis of schizophrenia and starting long-term pharmaceutical treatments can turn a potentially temporary problem into a chronic one. In the not-too-distant past, a person reacting strangely to extreme distress was said to have a “nervous breakdown.” People who “broke down” were expected to become well again. Today, the diagnostic names are scarier and the prognosis is expected to be much grimmer- in a way that can become a self-fulfilling prophecy.
At age 21, my son Jake landed in the psych ward of a teaching hospital because he was having a 'psychotic episode.' Although he had no prior history of mental problems, the psychiatrists immediately emphasized that he had a life-long and serious 'mental disorder' with no hope of recovery. Among the staff, there seemed to be absolutely no interest in the possibility that his problem could be brief and temporary.
On only his second day on the psych ward, he was told that he probably had 'schizophrenia.' The next day, his doctors were leaning toward a diagnosis of 'bipolar disorder.' Why not the much less discouraging and more accurate 'brief reactive psychosis?' It was never even suggested as a possibility.
Jake was told that the stresses in his life (the potential loss of his home and his best friend, capped off by 9/11) would not bother a “normal” person. None of the clinicians expressed any willingness to help Jake reclaim his life. They were all laser focused on which chronic DSM diagnosis might best 'fit' him so they could assign him to a long-term drug protocol."
In hospital, a low dose of olanzapine helped him to finally sleep at night (for the first time in weeks), and he was steadily improving. But that was not good enough for the white coats. They insisted on titrating the dosage immediately to the 'therapeutic level' and adding lithium. Jake was told he needed these drugs like a diabetic needs insulin.
Alarmed by the staff’s refusal to engage in any sort of dialogue about the situation, Jake and I fought for his discharge (A.M.A), and he left the hospital with a diagnosis of 'Psychosis, NOS.' His outpatient psychiatrist, aptly named Igor, told us that Jake’s brain was 'just like a broken bone' and the drugs were 'like a cast.'
Unlike a broken bone, though, Jake’s 'broken brain' would need to be immobilized by the 'cast' of medication for AT LEAST a year in order for his brain to heal. And even though the drugs almost completely incapacitated Jake, and he requested a reduced dosage, Igor refused.
A doctor friend of mine says that when a psychiatrist tells a young adult he/she has a life-long mental illness, hope crumbles. Being told that mental illness is like diabetes is misleading and discouraging. This is not a fair comparison.
Diabetes is due to a well understood defect in a body part, the pancreas. Mental illness, on the other hand, literally means that your mind is sick. Your mind, unlike your pancreas, is not just a body part. Your mind enables you to relate, set goals, dream, and have hope. If you and the people around you believe that your mind will be defective and sick for the rest of your life, you are left without hope of ever having the agency to build a life.
The dire prediction of chronic disorder became a self-fulfilling prophecy for my son Jake. Being told he needed to 'set more realistic goals for himself' presumably because of his 'chronic mental illness,' Jake gave up on his goals and decided he might as well be homeless. And that’s the way he died in April of 2008, two weeks after his final birthday. (Happy Birthday, Jake).
What I have learned in the wake of Jake’s tragedy is that psychosis, mental breakdown, going bonkers – whatever you want to call it – need not be a self fulfilling prophecy of permanent illness.
We need not burden distressed young people with hope-sucking labels of chronic mental defect. There is a better way.
Thanks so much, Suzanne, for sharing with us your tragedy and your grief. Surely, your experience will be helpful to others faced with a similar situatIon.
Young people are particularly difficult to diagnose accurately. Their track record is so short; the future course is impossible to predict; developmental factors unpredictably affect the clinical picture; and substance use is so common.
We should preserve uncertainty when it is the most accurate prediction of the future. The most common mistake in psychiatry is to prematurely jump to conclusions and to mislabel someone with a inaccurate diagnosis that has a terrible prognosis.
It is much safer to under-diagnose than to over-diagnose and much better to encourage realistic hope than to shoot from the hip with unrealistically gloomy predictions that can become self-fulfilling prophecies.
Diagnosis most often helps, but sometimes hurts. The loss suffered by Suzanne Beachy reminds us just how high are the stakes. We must get it right and first do no harm.
Dr. Allen Frances was the Chair of the DSM-IV Task Force. He hasn't been so happy with the DSM-V. He is author of Saving Normal: an Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.
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I thought people might be interested to know that the Associated Press just updated its style manual to give guidance to journalists writing about people with mental illness. Besides the obvious advice like "don't use words like 'crazy' or 'nuts'" (and it's sad they'd really have to tell someone not to do that), they also advise journalists not to automatically attribute the behaviors they're covering to mental illness: "Avoid interpreting behavior common to many people as symptoms of mental illness. Sadness, anger, exuberance and the occasional desire to be alone are normal emotions experienced by people who have mental illness as well as those who don’t." Writers were advised that violence alone is not solely a sign of mental illness and to avoid relying on bystanders' statements that the subject of a story is mentally ill.
This is good. Now the American Psychiatric Association needs to put together a style manual for talking head mental health types. If you go in front of a camera or behind a microphone (or keyboard) to comment on someone in the news and their alleged mental problems, you should know your professional and ethical limits. I've written about the problem of mental health professionals in high profile cases before over on Clinical Psychiatry News.
This is not to say that mental health professionals shouldn't be involved in the media. They can provide a broader context for a story, correct inaccuracies and give an 'insiders' view of a story that may help the people get a better handle on what's going on. But, this should be done responsibly.
On CBS news yesterday I saw this report about mentally ill people who end up in jail. The sheriff of the Cook County jail complained that psychiatric patients who don't take their medication become criminals and added, "We're not a mental health facility. These people should not be here.''
Simultaneously this week in the Baltimore Sun we have this story, where hospital workers complained because malingering criminals were being held at their facilities.
This week's news is a terrific example of what I call the Reese's Peanut Butter Cup problem of forensic patients. (I put up the old commercial for reference.) Each side is basically complaining that they have to provide care for someone. Nevermind that people can't be cleanly divided between the "mad" and the "bad," or that people who "only" have personality disorders can still die from those disorders. We waste a lot of time and energy arguing about who should be where and who should be doing what.
The bottom line is that we have to figure out how to deliver the right care to the patient regardless of the setting. Forensic patients require treatment as well as security. That sheriff needs to realize that his facility will always require a psychiatric infirmary and mental health services and that he's not going to be able to "clean house" off all the psych patients. Similarly, hospital workers can't write off every assaultive patient as being "just a sociopath."
We need to beef up hospital security so everyone, patients and staff alike, can feel safe. And jails need to be given enough mental health staff so the administrators won't feel like they're being overrun with chaos.
Getting rid of the patient is never the right answer to a health care system problem.
Over on the Clinical Psychiatry News website, I have posted the testimony I gave at the legislation hearings in Annapolis on Friday. It's a open letter to any legislator, in any state, who is thinking of following suit after New York's SAFE Act which requires mental health professionals to report patients who may be dangerous.
“If any Shrink Rapper ever has the time and inclination it would be interesting to read about what you would do to fix the mental health system, particularly the issue of involuntary hospitalization, if you had unlimited funds and political resources. You've been in the trenches, it would be great to hear your thoughts.”