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.