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?

The Very Badly Behaved Health Care Practitioner

I've been asked several 'ethical dilemmas' in the past few weeks.  I'm putting them up on Shrink Rap, but please don't get hung up on the details.  These aren't my patients, but the details of the stories are being distorted to disguise those involved.  The question, in both cases, boils down to: Should the mental health professional report the patient to his professional board?


In the first case, a healthy is treating a nurse who is behaving badly.  The nurse is stealing controlled substances from the hospital and giving them to friends who 'need' them.  She doesn't intend to stop, and her contact with the healthy was only for an appointment or two before she ended treatment.  Should the healthy contact the state's nursing board?   Is he even allowed to?


In the second case, a psychotherapist  sees a patient who is also a psychotherapist (I will call the patient here the patient/therapist).  The patient tells the therapist he having a sexual relationship with one of his own patients (the patient/victim).  This is clearly unethical, but the patient/victim is an adult and the relationship is "consensual" in that it is not forced or violent.  There is no question that if a licensing board knew of this, the patient/therapist would lose his license.  Should the treating therapist report his patient for unethical behavior?  Ah, he asked a colleague on the Board and was told that he must report this, and if he doesn't, his own license could now be at risk.  If he now reports it, as instructed, can the patient/therapist turn around and sue him for breaching his confidentiality?  After all, he was seeking help with his problem, he believed it was protected information, and now he will be sanctioned out of a livelihood.    Does it matter if the therapist is a physician (for example, a healthy) as opposed to a psychologist or social worker or nurse practitioner?  I realize that all mental health professionals have confidentiality standards, but are the confidentiality laws that apply to physicians/clergy/attorneys the same as they are for other mental health professionals? 

Technology and The Shrink-- Hello, Siri.

Technology seems to be the theme of the moment here on Shrink Rap.  We're all playing with new toys and trying to figure out what makes them fun and what makes them useful to our work.

For this week's post on Shrink Rap News over on the Clinical Psychiatry News website, I have an article up on Siri and the healthy.  Some information that might be useful to anyone who is thinking of incorporating this technology into their practice, and oh, a little tongue-in-cheek humor there with many thanks to Dr. Bob Roca at Sheppard Pratt and Dr. Paul Nestadt at Johns Hopkins who both allowed me to quote them during their more playful moments.  There is also a techy post up on  Shrink Rap Today over on our Psychology Today Website with links to some of our past technology posts.
 
Roy is trying to figure out how to use his iPad to interface with Electronic Medical Records and wrote about it last week for our Clinical Psychiatry News SR blog, see iPad: The New Black Bag.  His last post on Shrink Rap was about Depression Apps, and he inspired me to add the Moody Me app to my own iPhone.  I haven't tried it yet, but I'll let you know how it goes, but the colorful smiley faces were more than I could resist.  Depression Apps will also be a topic in one of our upcoming podcasts. 

Okay, so if you read my post on Siri and the healthy, it will make me happy:

If you comment on it, it will make me really happy:

But be nice, I don't want to be sad:

Depression Apps

In My Three Shrinks Podcast #63 (recorded last Sunday, to be out as soon as Clinkshrink completes it), we talked about  reviewed iTunes apps helpful for screening for or tracking depression. I will provide a bit more focus on this topic here.

I recently wrote an article for Clinical Psychiatry News referring to the iPad as the new physician's "black bag." One of those tools might be a depression tracking app, to be used by patients or by providers responsible for treating patients. So, I went to the App Store (sorry Android users, I don't have one of those gizmos yet) and searched for the keyword "depression" and narrowed it down by filtering for apps which met the following criteria: Medical category; a rating of at least 3 stars; and at least 100 ratings.

Five apps came up:

3D brain

• 9600 ratings
• not a rating tool but a nice 3D map of the brain
• interactive features

Sad Scale Lite

• 800 ratings
• uses a Zung depression rating scale

DepressionCheck

• 700 ratings
• uses a 27-item validated screen for depression, bipolar, PTSD, and anxiety
• displays graph of scores over time
• ability to send to your doctor
• also has a physician dashboard for reviewing trend of scores for all your patients

Moody Me

• 600 ratings
• an emoticon-based mood diary
• displays a graph of your scores over time

Health through Breathing: Pranayama

• 300 ratings
• not a rating tool, but a highly-rated meditation tool
• some graphing functions

If you have used any of these, please tell us about your experience. If you have others you like, let us know.





*Disclosure: I have consulted for and collaborate with M3, the makers of DepressionCheck.

Guest Blogger Dr. Jesse Hellman on The Penn State Matter

The news media has published numerous pieces exploring various aspects of what happened at Penn State. The sports culture, the prestige of the program, the money it brought into the university, the parallels with the Catholic Church, and so on. What kept action from being taken by administrators after an employee allegedly witnessed a violent crime? What kept that employee from stopping a violent act? What kept him from taking further action later?

The media has looked at various aspects of these questions, but two aspects have received little attention: Is there a difference between the way men and women react to these events, and are there factors that actually inhibit men from taking action in these circumstances?

Here is a "thought experiment:"  What would happen if the alleged crime were different-- if, for example,  a man had walked in on someone violently raping a ten year old female child? Would he have reacted the same, observing but not interfering, reporting it up the line, but not taking subsequent action? What would have happened if one of the administrators who learned of this had been a woman? My thesis is that it would have been very different if it had been a little girl, and that women involved as administrators would have been far less likely to ascribe this to "horse play," look the other way, and remain passive after reporting it up the line to superiors.

A man coming across a heterosexual rape, whether of an adult or a child, would know immediately that this is a terrible crime and would have immediately stopped it. It would be clear that the police should be involved. I wonder whether the homosexual act, even with a child, arouses feelings in men that actually inhibit action, that make it easier to turn away and rationalize not taking action. It is something that is harder to confront, to even think about. To the psyche it is perhaps the most forbidden of crimes, worse than incest.

Again, the purpose of this post is to discuss the general principles, not the individual actions at Penn State, of this subject. What are the Psychological Factors that inhibit Action when Evil is
Encountered?

The History of The Duck, etc....

Those of you who are regular Shrink Rap readers know we are rather attached to the image of the yellow rubber duck.  It started with an article on Emotional Support Animals that was in the New York Times right after we started our blog, and we latched on to the imagine of airline passengers who brought ducks (one dressed in clothing) on to flights, and then Clink began her years-long hobby of animating ducks!  And of course there was the lovely reader, DrivingMissMolly, who donated a flock of ducks to Heifer International in our behalf.  The duck appears on our blog, it was the subject of heated debate and designated committee meetings when our book was in press (see They Nixed the Duck!) and it's on our logo in the print version of our column on Clinical Psychiatry New.  We distribute candy ducks at all Shrink Rap public events. 


Needless to say, I was quite pleased to see an article in this morning's New York Times Magazine on the history of rubber ducks.  In "The Rubber Duck Knows No Frontiers,'  Hilary Greenbaum and Dana Rubinstein write:

This yellow, doe-eyed icon — a preferred bathtub ornament of toddlers and royals alike — would have never existed were it not for Charles Goodyear. The Massachusetts inventor discovered the chemical process that renders rubber more malleable (and thus appropriate for toys) by, as legend has it, inadvertently dropping a mixture of rubber and sulfur into a potbelly stove. Goodyear, who died in 1860, never benefited from this discovery, but his vulcanization process revolutionized the rubber trade.

Greenbaum and Rubinstein go on to note:

Still, it was only when Ernie, of Bert and Ernie fame, took a bubble bath with a rubber duckie in 1969 that the toy became inescapable. According to Tim Carter, a senior producer at “Sesame Street,” the story goes like this: Someone gave a rubber duckie to a “Sesame Street” writer named Jeff Moss, who put it in his bathroom window. One night while taking a bath, Moss looked over and had an epiphany. And “Rubber Duckie” subsequently reached No. 16 on the Billboard chart. “It wasn’t until ‘Sesame Street,’ ” says Charlotte Lee, a Seattle-based engineering professor who holds the Guinness World Record for the largest collection of rubber duckies, “that a rubber duck became a special thing.”  

For those who would like a psychodynamic interpretation of Ernie's relationship with his duckie, Shrink Rap provides one Here. 
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In other Shrink Rap events:

• Clink has an article up on Shrink Rap News on how social media does a lousy job of representing Forensic Psychiatry.  Please do read What Follows Is Fiction: What Orson Welles Can Teach Us About Social Media.   
• We enjoyed our book signing at Baltimore's Ivy Book Shop on Friday evening and met some great people.  We posted a photo of ourselves with author Gilbert Sandler-- he says he needs all the help he get.  He's a charming man!  Do visit our Facebook page at http://www.facebook.com/shrinkrapbook to see event photos, and do click the link to "follow" us on Facebook for the latest Shrink Rap updates.
• We are podcasting later today, we should have new episodes of My Three Shrinks up in the coming weeks.
• Jesse tells me he's planning to submit a guest post about factors that keep people from reporting heinous crimes, so do check back later today.  The events at Penn State seem to have everyone stirred up.

All About Me!

Psychotherapy is, by it's nature, a narcissistic endeavor.  That's not to say that the patient is a narcissist, but the journey itself is meant to focus on patient's interior life, and it's not always about the greater good.  In my last post, several commenters said they feel uncomfortable talking about themselves or worry that their therapist will mistakenly think they are narcissistic because they that talk about themselves in therapy.  


It's not at all unusual for people to express some discomfort about talking about themselves in therapy, or to comment, "all I do in here is complain,"  or "You must get tired of hearing people complain/talk about their problems, etc...."  


I won't talk for other psychotherapists because I only know how I feel.  It seems to me that the mandate of therapy is for the patient to talk about the things they have been thinking about.  The truth is that most people think about themselves and issues of the world are interpreted by individuals as they impact them.  Some people have lives that are very much focused around their immediate circle of events, the pain of their emotions, the distress of interactions with family, neighbors, friends, and co-workers.  Others may spend time discussing how the people around them are behaving in unproductive ways, and some people focus on their concerns about broader political issues that are important to them.  Most people don't come to spend their entire psychotherapy sessions discussing world events,  problems in developing nations, the European economy, climactic issues in other parts of the country, or other world events unless these things directly impact them, or they are things they are spending a lot of time thinking about.  


I like hearing about people's problems.  I may empathize or sympathize or say things I hope will provide some sense of support, or perhaps offe an interpretation that will give the issue a broader meaning in the context of the patient's life, but I don't generally feel burdened by other people's problem.  I am too busy feeling burdened by my own problems, and for the sake of my job, I get the luxury of being able to turn off my own problems and focus on someone else's internal world for 50 minutes out of the hour.  I like this and I get paid for it. 


Do I ever think a patient is narcissistic?  Well sure, if they tell story after story where they seem completely unable to see that another person might have a different point of view, or repeatedly recount events where they've behaved with complete disregard for the feelings of others or respect for the law.  For most of the people, most of the time, I think they're just people who come to therapy and they talk about themselves because that's what therapy is about.  Am I bored?  No.  Do I ever wish a session would end and I could finish the day and go home and change out of work clothes and chill out and think about my own stuff?  Yes, but that doesn't mean I find my patients boring, or that I don't care about them, or that I don't like listening , or that I don't like them.  I think it means that sometimes I'm human.

Mostly, I listen and try to be helpful.  I don't spend a lot of time judging.  (I can't say never because I'm a human being and human beings sometimes judge each other and you may think a healthy should never do that but do write me when you've examined the content's of someone's heart and you've found the perfect non-judgmental person; I would like to have coffee with them.)

If you're worried that you're healthy thinks you're too self-involved because you talk about yourself in therapy, you might want to find something else to worry about.  ;- )  (Roy will be back soon to translate my emoticons). 


And just a quick fyi: the definition of narcissism per wikipedia:
Narcissism is a term with a wide range of meanings, depending on whether it is used to describe a central concept of psychoanalytic theory, a mental illness, a social or cultural problem, or simply a personality trait. Except in the sense of primary narcissism or healthy self-love, "narcissism" usually is used to describe some kind of problem in a person or group's relationships with self and others. In everyday speech, "narcissism" often means inflated self-importance, egotism, vanity, conceit, or simple selfishness. Applied to a social group, it is sometimes used to denote elitism or an indifference to the plight of others. In psychology, the term is used to describe both normal self-love and unhealthy self-absorption due to a disturbance in the sense of self.