Guest Blogger Dr. Meg Chisolm on Systematic Psychiatric Evaluation

Over on our Clinical Psychiatric News blog, I've written a review of a new book, just published by Johns Hopkins University Press, Systematic Psychiatric Evaluation,  A Step-by-Step Guide in Applying The Perspectives of Psychiatry, by Margaret S. Chisolm, M.D. and Constantine G. Lyketsos, M.D., M.H.S.  Do check out my review over on CPN (it should be up later today), along with ClinkShrink's article on "Debunking The Mad Artistic Genius Myth" and Roy's piece on World Mental Health Day which lists some great resources. 

Dr. Chisolm was kind enough to write a Shrink guest post for us on her inspiration for writing the book, with just a little about French cooking.  Sorry no recipes here.  Meg writes:

I did my psychiatry residency training at Johns Hopkins University in the late 1980s, under department chair Paul McHugh and residency director Phillip Slavney.  These leaders also are the authors of the textbook The Perspectives of Psychiatry, whose principles informed the way I and a generation of Hopkins healthys since have been trained.  The basic idea of The Perspectives is that by conducting an evaluation that considers a patient’s psychiatric presentation from each of four perspectives, the clinician can better understand the nature(s) and origin(s) of the patient’s problems, and develop a more comprehensive and personalized formulation and treatment.  (The four perspectives are: disease, dimensional, behavior, and life-story.) 

The most frequent question raised about the Perspectives model by trainees and clinicians unfamiliar with the approach is “How are the Perspectives any different from Engel’s biopsychosocial model?”  In response, McHugh and Slavney are fond of saying that the biopsychosocial model provides the ingredients (atoms to biosphere) for understanding patients with psychiatric illness, but the Perspectives provides the recipe.  I like this analogy (or is it a metaphor?) because, in addition to enjoying my work as a healthy, I like to cook.  But, more about that later. 

As a Hopkins-trained healthy, I had probably read The Perspectives of Psychiatry about five times, beginning with my stint as a medical student during my sub-internship at Hopkins.  Let me tell you, The Perspectives is a good, but hard read.  As a student, I don’t think I understood much of it.  Reading it again as a psychiatry intern, having seen many more patients with psychiatric conditions, it started to make some sense.  As a junior resident, I began to understand it a little better, which was a good thing since – by then – I was expected to be teaching the book to medical students.  By the time I was a chief resident teaching junior psychiatry residents how to apply the Perspectives approach to patients, I thought I had it down.  Well, I was wrong.  It wasn’t until I began writing a casebook companion to The Perspectives of Psychiatry that I finally figured it out.  So, if the biopsychosocial method provides the ingredients and The Perspectives of Psychiatry the recipe, that’s one highfalutin’ cookbook!  And that’s where our new book Systematic Psychiatric Evaluation: A Step-by-Guide to Applying ‘The Perspectives of Psychiatry’ (Chisolm & Lyketsos) comes in.

So, back to French cooking.  If any of you are into cooking, reading cookbooks, or just watching the Food Network, you may have heard of Auguste Escoffier’s 1903 Guide Culinaire.  Escoffier wrote his book for professionally trained and experienced European chefs (working in restaurants, hotels, ocean liners, private estates, etc).  Escoffier’s book outlined recipes and discussed methods of professional food preparation and kitchen management.  Escoffier did not offer his reader detailed recipes with instruction on basic cooking techniques, as he assumed the reader would already have this set of knowledge and skills.  His book’s target reader was not the average home cook looking for advice on how to keep a soufflé from falling.  Enter Julia Child and friends.  In Mastering the Art of French Cooking Julia Child et al translated a selection of Guide Culinaire recipes into simple steps and added detailed instruction on the basic techniques (How do you keep a soufflé from falling?  Ask Julia).  Julia Child’s goal was to start someone off in French cooking with the hope that someday they would be ready to go deeper and perhaps read the master himself. 

And so it is with Systematic Psychiatric Evaluation.  If you’re a clinician who already conducts a systematic psychiatric evaluation and are adept with applying the Perspectives approach to patients, there’s no need to read our book.  But, if you are new to the Perspectives and/or want to familiarize yourself with the model, we’ve got you covered.  Systematic Psychiatric Evaluation walks the reader through the basic concepts of The Perspective of Psychiatry and shows, step-by-step, how to apply these concepts to evaluate, formulate and develop individualized treatment plans for patients with psychiatric conditions.

Bon appétit!

Blame the DSM?

In the Washington Post, April 27, 2012, "Psychiatry's Bible, the DSM, is doing more Harm than Good," Paula J. Caplan writes:


About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.

After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.

Caplan goes on to express her concerns with psychiatric diagnoses, the DSM, the problems with these labels that lead to the use of dangerous medications.  Oh, we've been here on Shrink Rap before, see "Diagnostic Labels That Change Lives". 

Caplan continues

In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.


According to the healthys’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis.
When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.

Caplan goes on to say that because of the existence of a psychiatric label-- one she contends is wrong-- the patient lost her friends, her marriage, her home, her self-confidence, her wealth, was forced to move across the country to somewhere she was isolated, and the six weeks she spent on medication (presumably Seroquel) left her with a condition that may someday leave her blind. 

Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering — and help them find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.


Caplan, a Harvard psychologist, goes on to discuss a complaint she is helping to file against the DSM editors on behalf of 10 patients who were misdiagnosed. "Psychiatric diagnoses," she concludes, "are not scientific and they put people at risk."
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Where do I even begin?  Please, please, I don't know the patient, I only know the presentation given, and I'm going to be very sarcastic, because the way it was presented struck me a ridiculous and it distracted from some valid points that might have been made if there wasn't the Evil, Idiot healthy Theme with a sensationalist tone.  Shame on the Washington Post for printing this.

Okay, so   I couldn't quite follow the case she presented, at first it sounds like the patient went to the ER with symptoms of a cardiac problem, or exhaustion, or a maybe a panic attack.  Perhaps, but some imbecile ER doc did a check list of symptoms, told her she had Bipolar disorder, and without even listening to her,  weighing other options, or taking into consideration the context of her life,  sent her off with Seroquel and a recommendation for  therapy.  This misdiagnosis then destroyed  her life, because  why would her husband and friends stick with her if she's got bipolar disorder?  What better time to leave your wife then when her grandmother is dying, she's stressed out and sick?  So she went to the ER because she was tired and her heart was racing.  I think they see this all the time...I think they do an EKG and perhaps make sure the patient isn't having a heart attack or arrhythmia, and if they think it's anxiety, the patient gets a dose of a benzodiazepine, and gets sent home.  Okay, but it's an ER and the docs are rushed and focused on what the patient needs now.  They make wrong diagnoses all the time, and it's not just psychiatry, and it's not just  because the doctor is sitting there with the DSM or has memorized the hundreds of possible diagnostic criteria.


Okay, but it turns out that she was on a psychiatric ward.  You can't get admitted to a psychiatric ward because you're tired, with racing thoughts, a fast heartbeat, talking fast and being distracted.  Pretty much, you need to be a danger--, suicidal, or having severe hallucinations or delusions, or be in extreme distress in some way.  This was a wealthy patient who could afford outpatient care.  All I'm sure of, is there is something more to the story. 


Finally, the patient was admitted to a psychiatry unit, so presumably there was a second doctor who met with the patient and a treatment team that observed her behavior for a few days.  Okay, I've stories of really lousy inpatient care, and I do believe the diagnosis could still be wrong and the treatment that was recommended might be wrong, or helpful at the moment but not necessary for the long-term, but I don't buy that a misdiagnosis let to the complete demise of this patient's life and a need to move across the country.  These are the types of problems one sees as a result of the behaviors a person might have because they have a mental illness, perhaps one such as bipolar disorder.


So I don't know the patient, or the diagnosis.  But I do know that the entire premise for this article is based on the idea that the patient was simply tired and stressed and perfectly normal and did not have a psychiatric disorder (the author tells us this) and this label alone destroyed her life.  The reader is not allowed to even entertain the idea that the patient had a psychiatric disorder-- that maybe the healthy did get some history and make reasonable observations, and the patient really did have bipolar disorder? (Obviously, I don't know this).  There's no mention of a review of the records, discussion with family, interview of the doctor, Caplan is telling us her impression based on the patient's report only.   Maybe the patient had panic disorder, or a personality disorder, or even an adjustment disorder (perfectly possible given the stresses involved).  Oh, but then she took a bum recommendation to go on disability, and she got it!  I've seen really sick people not get disability.  It takes a lot of documentation and the government looks for ways to avoid paying this-- you don't get disability for having a psychiatric diagnosis, you have to be disabled by it.  So, somehow, this patient who  was simply exhausted and stressed, with No Psychiatric Disorder, per Dr. Caplan, managed to get admitted to a hospital and get disability benefits.


There were some valid points Caplan could have made.  The DSM is not a 'scientific manual.'  Personally, I don't find it terribly helpful in clinical practice.  I don't keep a copy in my office (I bought one to use while writing Shrink Rap), and I'm not planning to buy the DSM-V.  The overall concept is good, and it's very helpful to researchers to be certain that the groups they study have some diagnostic reliability, otherwise there is no way if knowing if a certain treatment addresses a specific group of people who can reliably be classified as having a specific illness.  This isn't all bad, but I don't need 370-400 diagnosis for my work (predicted in the new DSM-V).  And Caplan makes the statement that the editor, Allen Frances, says the work is based in science but has spread it's net too far.  If you read Dr. Frances' blog, you'll note that he is quite skeptical and opposed to many of the proposed changes for DSM-V.   It's not like the healthys aren't thinking hard about these diagnostic categories and the ramifications they have.  Still, I'm skeptical about how we think about these disorders, especially Bipolar Disorder. 


I agree with Caplan that healthys should listen more.  Fifteen-minute med checks have made a mockery of our profession.  I also tell all of my patients to exercise, eat healthy, and look for ways to solve their problems.  But to imply that these things are the answers for the majority of people who are suffering (and often too distressed, depressed, and unmotivated, to just pull up their bootstraps,  get up and exercise and cook a healthy meal )-- is an insult.  You know, sometimes those things really do work, but if people are able to do those things, they've often tried them before seeking psychiatric opinions.  To read Caplan's piece, you'd think everyone is an idiot.  And finally, ECT: it still in use because some people find it helps.


Okay, I am ranted out.  

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 http://iamnothouse.com/2012/02/25/square-peg-no-hole/ 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 healthy 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 healthy 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 healthy 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.

The Stability of Psychiatric Diagnoses

We've talked a lot about diagnoses here on Shrink Rap.  We've talked about how diagnoses are made, how valid they might be, how as labels they can be stigmatizing or damning in a person's life.  We've talked about how they are used to guide treatment and how they are demanded to obtain reimbursement for care.  What we haven't talked about is how they hang out over time.




When I see a patient for the first time, we meet for 2 hours, I take a full history, family members may come in, and subsequent to the appointment, I may talk with a past healthy, a current primary care doc, and I may request old records that I will review.  I take the information I have and I form a diagnosis.  Is it the right diagnosis?   Oh, who knows.  I don't sit there with the DSM and read off a check list and some of it is art.  The DSM diagnoses aren't science, they were voted on by a committee.  I come close.    Like what is the exact divide between Major Depression, recurrent, mild versus Major Depression, recurrent, moderate ?  To the extent that it guides treatment, I care about getting it right, but sometimes the honest answer is I Don't Know.  Or the patient comes to me after they have gotten well--- they are not currently having symptoms, but they are on medications which they say help, and they report that before they were on medications, they had symptoms consistent with Diagnosis X.  If they are medications that are usually used to treat Diagnosis X, if they had symptoms consistent with Diagnosis X, I believe them and diagnosis X.


So here's how treatment goes.  Usually the patient has symptoms and the majority of the time the symptoms are consistent with a specific diagnosis and everyone agrees.  Let's say the diagnosis is recurrent major depression, moderate in intensity, coded 296.32.  I start the patient on medications for this condition and they come for therapy.  A few weeks go by, and the patients symptoms get better, but they still have issues going on in their life.  Stressful things that they are dealing with, or troubling relationships, or life just not going the way they'd like, so they still come for therapy.  And each visit, a bill is generated and the bill needs a diagnosis, so the diagnosis remains,  because this is what is being treated and this is what the patient is getting medications for, and so it's 296.32, even if the patient's symptoms are at bay, or even if the patient comes in saying that they are anxious today, or even if the patient spends the entire session talking about the fight they had with their sister and never mentions a word about their mood or symptom complex.   The diagnosis is usually a stable thing for the paperwork issues that call for it.  I mentioned statements for insurers, but in clinics, it needs to be on treatment plans, and in EMRs, and any form that goes to an agency which has regulations, including Day Programs, Psychosocial Rehab programs, Care provider organizations, etc.  No diagnosis, no services.  And some services are only accessible to the patient with specific diagnoses that indicate a severe and persistent psychiatric illness.  I would say that for a patient who has had numerous psychiatric hospitalizations, is unable to work, gets benefits from the government because they are disabled by mental illness,  and requires medication to remain well, it seems reasonable to agree that a major psychiatric disorder exists, even if on a given day, the patient says he is not having any symptoms of the illness and is feeling well.  It has to be this way, or no therapy would ever be done: every session would be a diagnostic evaluation with check lists of symptoms.  Now I'm not saying that diagnoses never change...they do...people get manic and we realize that their unipolar depression is really bipolar depression, or with time we realize that there is more than one diagnosis, or that a preliminary diagnosis was simply wrong, or that alcohol or drugs were a bigger contributor to the symptom complex than we realized at first.


But when our theoretical patient, the one with major depression, moderate, who had a long hard course with it, notes that a long time has gone by with no symptoms of the illness (on medications and with therapy) and he asks, "So do I still have depression?"  it does make for an interesting session.


What do you think?

What is Bipolar Disorder?

 

I'd like to ask your help for a moment.  I'm going to write a blog post for this week's Clinical Psychiatry News on Bipolar Disorder.  I'd like to know how you see the term used, or the symptoms that are hallmarks of the illness for you.  If you respond as my favorite commenter, "Anonymous," could I ask that you define yourself...healthy, psychologist, pediatrician, patient with bipolar disorder, friend of someone diagnosed with bipolar disorder....


Also, please just off the top of your head, I can read DSM or Google myself, and I'm more interested in your ideas about what exactly the disorder is.


I may not use your responses (I sort of know what I want to say) but no matter what, I'm curious.  
Thank you so much...

Retriever Blog: Fad Diagnoses in Kiddie Psychiatry?

In response to Joy Bliss' post (Fad diagnosis in Psychiatry: Bipolar Disorder in children) on Maggie's Farm,  Retriever wrote about her experience with a child with an early and severe mental illness, and short-sighted attempts to reduce access to needed intensive mental health treatment for children.

I do think that diagnosing behavior problems in kids has been overextended, due more to loose interpretation of current diagnostic criteria rather than to overbroad criteria. But let's not throw the baby out with the bath water.

(Speaking of water, taking a break here from vacation to post an image from Southwest Harbor, Maine.)

Weiner Diagnosis?

 

In Shrink Rapper world, we get a lot of email from publicists about books, TV spots, upcoming events.  This was in my spam box today:

Rep Anthony Weiner is expected to resign today after weeks of scandal surrounding his lewd text messages, tweets and photos.  Even in his tearful media conference, Weiner could not explain why he participated in such behavior.  According to NYU Medical Professor and Internist, Dr. Marc Siegel, the congressman’s behavior is systemic of a larger psychological problem, which must be addressed before fixing the addiction to online sexual activities.  

 

Dr. Siegel says, “This seems to be an example of extreme narcissism, inflated self image, depersonalization, loss of contact with reality, addiction, and the power of the Internet as a medium (like the Wizard of Oz you feel you are hiding behind the curtain)”.

 

To discuss the dangers of addiction and steps to overcome the serious illness, Dr. Siegel is available to offer is medical knowledge.  As a medical practitioner and FOX’s House Doctor, Dr. Siegel has spent years diagnosing and treating people in the national media spotlight.

 

If you are interested in speaking with Dr. Siegel, please contact me at .

 

Best,

Rena  

 

Rena Resnick

5W Public Relations

Oh my, I thought.  I read it twice. An internist is going to comment on Anthony Weiner's narcissism, motivations, sense of self, and contact with reality?   Sounds like a shrinky thing to me, but the Goldwater Rule prohibits healthys from commenting on the mental state and diagnosis of someone they haven't personally examined.  Does that mean it's okay for other specialists to talk about the mental state of someone they don't know?  Hmmm...   I guess we'll see what he has to say, but I'm not so sure about this.

The Unwilling Patient: New Yorker Article

In balancing rights against needs, though, psychiatry is stuck in a kind of moral impasse. It is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than as an authentic wish.
-- Rachel Aviv, God Knows Where I Am, The New Yorker, May 30, 2011

In the May 30th issue of the New Yorker, Rachel Aviv writes about the plight of a woman who does not believe she has bipolar disorder, or any psychiatric illness for that matter. It's a poignant and tragic article about a woman who is incarcerated for a crime, spends a year and a half in jail before she is found incompetent to stand trial, then goes to a psychiatric hospital where she remains until she is discharged with no plans for housing, money, follow-up, or notification of family--- it's not that the hospital wouldn't offer any help, it's that the patient wanted her freedom and would not allow interventions. Aviv gives examples of the woman's psychosis as a motive for her behaviors. Free, she finds a vacant farmhouse and breaks in. She is fearful of being re-captured, and remains hidden in the farmhouse, subsisting on 300 apples. She journals, she appreciates nature, and she reads books she finds in the attic. In mid-January, three months after her release from the hospital, and 39 days after she ate the last apple, she dies of starvation. Her body was not found until May.

Aviv's article focused on two aspects of the psychiatric system: the emphasis on the patient's insight as a focus, even requirement, of treatment, and the issues of involuntary treatment in patients who aren't posing an imminent threat of violence. I couldn't quite tell where Aviv stood on these issues--she seemed to waiver from condemning a system of forced care, to condemning a system that would let an ill patient leave untreated with no money and no notification to family members. She definitely does not like that the system would have provided for housing for this patient, but the patient wouldn't sign the requisite forms because they noted that she had a mental illness, a fact she did not agree with. Aviv mentions the concept of "thank you theory" --the idea that once patients get well they will agree that the treatment was in their best interest. She notes that only about half of patients who are involuntarily hospitalized later believe it was necessary. It's a difficult statistic to work with--because it means the other half did believe that treatment was necessary, so how, as a society, do we know what we should do? She talks about advance psychiatric directives.

I'd like to share parts of the article, but I had to buy the issue online to read it and it doesn't seem to let me copy and paste. You can listen to a podcast with the author on The New Yorker's website at:
http://www.newyorker.com/online/2011/05/30/110530on_audio_aviv

---

Read more here: http://www.newyorker.com/reporting/2011/05/30/110530fa_fact_aviv#ixzz1NbdWI6sM
So really, this is a ClinkShrink article. Maybe she can read it and post again?

Transfering Care and Do You Have to Meet All Criteria for a Disorder to get Meds?

A college student wrote in and asked the following questions:
1. Do you ever transfer care and how do you decide when to transfer care? If a patient is stable do you transfer care and prescribing over to a general/family/primary care doc? I know that most depression, anxiety, adhd, etc is diagnosed and treated in primary care these days anyways, under what situation is diagnosis and treatment management by a healthy recommended over a general practitioner or conversely when is treatment management by a general practitioner recommended over a healthy? Do you ever feel like your patient's level of need/functioning/distress doesn’t warrant your care, such as when they are improving with treatment, if so do ever you suggest that they should reduce their visits or seek care elsewhere?

2. Does a patient have to be diagnosed with a disorder in order to be prescribed medications? For example, do they have to fit the clinical criteria in the DSM for depression before you will feel comfortable prescribing antidepressants to them, or is just complaining of feeling sad and hopeless enough? Is complaining of being inattentive and failing classes enough to warrant adhd medications? I know it gets dicey with controlled substances and insurance coverage/reimbursement, but in general I am curious regarding the indications for medication prescriptions? If a patient doesn’t fit the exact DSM criteria for a disorder but they feel they will benefit from medications, do you give it to them?
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Wow, that is a lot! The student began by telling us she sees a healthy for 7 minutes every three months to get stimulants.

Do I transfer care? Not usually. Maybe the better answer is really rarely. I get patients from primary care docs who feel the patient needed more. I figure people come to me because they want a healthy, they like having someone to talk to (I do Not do 7 minute sessions, but I certainly do see people a few times a year), and they like knowing they have a healthy if something should go wrong. If someone who is stable for a while on a set dose of medicines were to ask, "Can I just get this from my primary care doctor?" I would say "Sure." I really have only been the one to suggest it when the patient makes it clear that scheduling with me is a burden, and I don't think I'm adding to the mix in any meaningful way. When this has happened, I've said, why not just have your primary care doc prescribe it and if you have any problems, I'm happy to see you again. This hasn't happened much. What happens more often is that people drift out of treatment, and I imagine they either stop their medicines, or get them from their internist. Sometimes they come back when they have a problem, and that's fine with me.

Regarding questions about whether meeting DSM criteria is a necessity for medications, that really depends on the doctor. I don't keep a DSM in my office and I never sit there with a check list of symptoms to say "Yup, you got it," "Nope, you don't." Why is that? Because the book was written by consensus-- a bunch of guys in a room agreed these are the symptoms you need to have Panic Disorder, not by a blood test or some thing that clearly correlates with prognosis. Precise diagnoses are really good for insuring that everyone in a research protocol has the same condition, and I don't do research. So maybe the patient doesn't quiet have enough symptoms for a diagnosis of depression, or perhaps they haven't gone on quite long enough, but perhaps the symptoms that are there are intense, incapacitating, or dangerous, and the patient is requesting medications. I'm not likely to send them out saying "You need one more symptom and 2 more days before your suicidal misery meets criteria, so come back when you have another symptom."

ADD may be it's own issue because of the controlled substance/addictive substance question, and the fact that some clinicians feel the diagnosis is over-made. People can be inattentive for many reasons: depression, pretty girl outside the room, boring instructor, cell phone texts keep coming in, worried about not being invited to big party tonight, upset about cat's cancer diagnosis...and the list marches on. Failing tests may be due to lower than needed IQ, partying too much, misunderstanding about what would be on the test, instructor with lower than needed IQ, girl in next seat vomiting, poor preparation, bad night's sleep, substitution of decaf for caffeinated coffee (Clink's version of Hell). Lots of people with ADD do just fine without meds. Being smart helps in the way of compensation. Lots of people with ADD seem to have disabilities beyond what one might expect with some distraction. I don't treat a lot of ADD, and my guess is that it depends on who you go to for this: the people who have large practices and do a lot of this work seem to have somewhat lower thresholds for aggressive prescribing, and a greater comfort level with the problem and the cure.

I hope I answered the questions okay.

Diagnostic Labels That Change Lives

From time to time, our readers comment that they are distressed with a diagnosis a healthy has given. They've met with a doctor, talked for a while (half an hour, an hour, maybe two hours) and based on whatever information the healthy has, a diagnosis is made. Maybe it's right, maybe it's not, and maybe the diagnosis will change over time. Some readers have commented that they object to the idea that healthys must assign a diagnosis to be paid, when in fact there is no diagnosis, and they think that's wrong. The healthy should work for free? Since I don't accept insurance, I'm not obligated to make a diagnosis, but if I don't put one on the statement, the patients won't get reimbursed. Some tell me that they aren't submitting psychiatric claims to an insurance company, others don't have insurance, and many do submit claims. I'm left to wonder why someone with no psychiatric diagnosis would consult a healthy to begin with, especially since some diagnoses (Adjustment Disorder, for example, or Anxiety Not Otherwise Specified) are not particularly stigmatizing.

I understand that people are miserable with mental illnesses-- the symptoms are debilitating and miserable. I also understand that people are angry about being told they have an illness that they don't agree they have-- it's a bit like being judged, or like feeling unheard, or even dismissed. Some docs may not spend the time necessary to make the right diagnosis, sometimes the diagnosis evades us, and sometimes patients don't agree with us as to what we deem 'pathology' or symptoms, versus normal reactions or behaviors.

What has perplexed me, however, is the claim that the label itself is what causes the problem. I've been practicing for a long time, and I'm not aware that anyone has ever had a problem because of a diagnostic label I've stuck on an insurance form. I think that most people who worry that their diagnosis will cause others to judge them negatively, simply don't tell people that a doctor says they have disease X. And many will say that's unfair, that people should be able to openly announce their psychiatric illnesses without worrying about the reaction or judgments of others, the way they do their medical illnesses, but personally, I'm not much for announcing health issues in open ways unless it's necessary. Enlarged prostates, diarrhea, vaginal discharges, coughing up phlegm, the details of where one is injecting one's insulin, are simply not everyone's cup of tea at the dinner table.

Sometimes people behave in distressed or dysfunctional ways and the fact that they have a psychiatric disorder is obvious. This is not because of the title of the label, it's because of the symptoms of the illness and the person's behavior. The healthy's diagnosis gave it a name, but the problem belongs to the patient.

Here's my question for you: if a diagnostic label alone has caused your life to change, tell us your story. I don't mean if it's upset you and caused you personal subjective distress, or if you've worried about having your psychiatric history discovered, but if the label itself has caused you outside difficulties or limited your life, tell us how.

The DSM-5 Controversy

I've followed in bits & pieces. Sometimes for Shrink Rap, sometimes because the issues fill my email in-box, sometimes because there's no escape. Oh, and lots of the players have familiar names.

In the December 27th issue of Wired, Gary Greenberg writes a comprehensive article on the debates around the revision of the American Psychiatric Association's upcoming revision of the Diagnostic and Statistical Manual. So, "Inside the Battle to Define Mental Illness." Do read it. Here's a quote:

I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.

“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.

“No.”

“So what would you say was the value of the diagnosis?”

“I got paid.”

As scientific understanding of the brain advances, the APA has found itself caught between paradigms, forced to revise a manual that everyone agrees needs to be fixed but with no obvious way forward. Regier says he’s hopeful that “full understanding of the underlying pathophysiology of mental disorders” will someday establish an “absolute threshold between normality and psychopathology.” Realistically, though, a new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all. To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched. As Frances points out, a complete elucidation of the complexities of the brain has so far proven to be an “ever-receding target.”

What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench. Regier and Scully are more than willing to acknowledge this. As Scully puts it, “The DSM will always be provisional; that’s the best we can do.” Regier, for his part, says, “The DSM is not biblical. It’s not on stone tablets.” The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are healthys ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.

Scratch, Sniff, Prescribe

I was surfing around the net one day and I found this article about scientists who are creating a machine that will detect acetone in someone's breath. Acetone can be a sign that someone suffers from diabetes, so in theory this machine could use scent to diagnose this disease.

That story brought to mind other stories I've heard about people using dogs to sniff out cancer in people. According to this article:

"The results of the study showed that dogs can detect breast and lung cancer with sensitivity and specificity between 88% and 97%. The high accuracy persisted even after results were adjusted to take into account whether the lung cancer patients were currently smokers. Moreover, the study also confirmed that the trained dogs could even detect the early stages of lung cancer, as well as early breast cancer."

People have even tried "smelling" schizophrenia.

But what if there were a pheromone for violence? About a year ago, someone approached my hospital and wanted to bring in dogs to do a study on violence. They wanted to see if canine scent detection could be used to predict which patient would be aggressive. The idea seemed pretty bizarre to me at the time, and in fact there is nothing in PubMed to suggest that it would work.

While googling around on the topic of scent detection I also found this novel, The Nadjik Pheromone. The plot is based on the idea that somebody discovers a pheromone that gets emitted when someone lies. It's an interesting idea. The author came up with the idea when he heard about people using fMRI for lie detection.

I don't really have a conclusion for this post, I just thought I'd throw out some ideas. Maybe someday people will be giving "truth perfume" for Christmas.

Diagnostic Errors and The Shrink

Meg sent me a link to Happiness in The World (what an upbeat name for a medical blog!) and The Danger of Early Closure. She wanted to know how it pertains to psychiatry.
The author writes: Sometimes doctors gather all the clues correctly, think all the right things based on those clues, and still get it wrong. But in this case, another significant thought error contributed to the misdiagnosis: my tendency to come to early closure.

Early closure, it turns out, is a danger that lies in wait mostly for seasoned clinicians (far more commonly, at least, than for medical students and residents). Because seasoned clinicians rely more on pattern recognition to make diagnoses and often come to their conclusions rapidly, they’re at far greater risk for leaping toward those conclusions without examining all other should present (luckily for us all, this is the exception and not the rule). At other times, however, these mistakes are made because the physician was simply in a hurry, or tired, or didn’t care enough to think through the evidence in ways he should have, saw a pattern he thought he recognized, and stopped asking the most important question a physician can ever ask: what else could this be? relevant possibilities. Patients often present with a constellation of symptoms that don’t entirely fit the diagnosis they actually have. Often the discrepancies between these presentations and the textbook descriptions are unimportant—but sometimes those discrepancies exist not because the patient’s body hasn’t read the textbook, but because the diagnosis the doctor makes is the wrong one. Such misdiagnoses are occasionally unavoidable: the symptoms with which the patient presents are simply too far afield from the way the medical literature says the disease

It’s the same with us all. We all come to early closure all the time, forming opinions about the behavior of others without sufficient consideration of all relevant facts. We become attached to the explanations that make the most sense from the perspective of our own experience and our own point of view.

Do we do this in psychiatry? Of course. It's not at all uncommon for a healthy to diagnosis a patient with Major Depression when, in fact, the patient has Bipolar Disorder. Why? Sometimes there has been no episode of mania (yet) and a diagnosis can't be made. Other times the symptoms have been explained away as something else: an exuberant personality, anxiety, a reaction to events. And finally, sometimes the doctor simply forgets to ask about such episodes or the patient/family don't report them as they've drawn their own conclusions.

What else? healthys may attribute mood instability to personality disorders. This is the case less and less, as we've found that when people's mood stabilizes, so does their behavior. Or a healthy may see a patient who is very distraught after an upsetting life event and attribute the mood changes to an adjustment disorder, when in fact the patient has developed depression. Hopefully, we re-think our diagnosis if the symptoms persist or don't follow the usual course.

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 healthys 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.