Why A Checklist is Not A Psychiatric Diagnosis

I was inspired by a post by Massimo Pugliucci on his excellent philosophy blog Rationally Speaking, to start using concept mapping software to describe some of the things that psychiatrists do and rarely get credit for.  There is the associated problem (as I have posted here many times) of checklists being seen as the equivalent of a psychiatric diagnosis.  That has been carried to the extreme that some have said rating scales are actual "measurements" or validating markers of psychiatric diagnosis.  Any cursory inspection of the combination of parallel and sequential processes that actually occur during an interview will demonstrate that is not remotely accurate.

Click on this link for the actual concept map.  A click on the diagram will zoom it for viewing.  Another click will zoom out.  Navigate by mouse wheel or scroll bars.  It should print out onto one standard sheet of paper in a landscape view.

I am interested in feedback from psychiatrists on what aspects they would modify.  If you have suggestions about what should be modified post them in the comments section or send me an e-mail.

Concept Map

The concept map may also be useful for explaining some findings that are commonly held up as "problems" with the diagnosis such as low reliability.  A common ( and purely hypothetical) example would be the 35 year old patient with a clear diagnosis of depression as a teenager, no history of remission of symptoms and multiple antidepressant trials who develops a polysubstance dependence (alcohol, cocaine, heroin) problem who is being seen in various states of withdrawal for the treatment of depression, insomnia and suicidal ideation. At this point does the patient have major depression, dysthymia, substance induced depression, or depression due to withdrawal symptoms?  What would tell you more about this patient's problems - a psychiatric diagnosis or a PHQ-9 score?  What would be more helpful in developing a treatment plan?

This answer to that question is the difference between medical quality and a term that is frequently substituted by governments and managed care companies.  That term is "value".  Governments and managed care companies apparently believe that giving someone an antidepressant medication for a PHQ-9 score is a better value than a psychiatric evaluation.

George Dawson, MD, DFAPA

How to Improve the Accuracy of Psychiatric Diagnoses - My Take

Allen Frances, MD has just blogged his ideas about how to improve the accuracy of psychiatric diagnoses.  His ideas basically come down to "be extremely alert to severe mental disorders and extremely cautious and patient before diagnosing mild ones."  He suggests a posture of "watchful waiting" of mild conditions to avoid attributing a treatment effect to a medication when in fact it is a placebo response.  He suggests erring on the side of underdiagnosis rather than over diagnosis.  I suppose that is all well and good but I have a few ideas on my own:

1.  Be a physician first - anyone coming for an evaluation needs to be assessed from a triage perspective.  Most American Psychiatric Association (APA) guidelines emphasize the need to assess the psychiatric parameters of acuity such as suicidal ideation and aggressive ideation and the risk of those behaviors, but there is very little medical guidance.   Psychiatrists need to be able to rapidly recognize both acute medical illness and medical illness that is causing the psychiatric presentation. They need to be able to rapidly assess medical problems that may interfere with the treatment of the psychiatric disorder.  The best way to have those  skills is to have adequate exposure to the full range of medical problems that can be encountered, especially from a pattern matching and pattern completion perspective.  That occurs only from treating many people with variations on the problem.  That starts in Medical School where every prospective psychiatrist should be focused on those experiences.

2.  Interpret your own studies - that means actually taking a look at actual brain scans, ECGs, lab tests, and other reports relevant to the care of your patients.  Psychiatrists need to be actively involved in the medical aspects of the care their patients, especially when they know more about the problems than the other physicians on the scene.  A few examples would be in the area of drug interactions, movement disorders, toxic syndromes like neuroleptic malignant syndrome and serotonin syndrome, the evaluation of delirium, electrocardiogram effects of psychiatric medications, and drug intoxication and withdrawal syndromes.

3.  Communicate well with the patient and their family.  Psychiatrists are trained and observed extensively in interviewing techniques.  They should understand the limits of specific interview situations and they should have well developed therapeutic neutrality that other physicians do not necessarily have.  In that environment they should be able to have the most productive dialogue with the patient and their family.  Psychiatrists should be experts in a diagnostic process that includes information from multiple sources.  Psychiatrists are also schooled in the concept of a therapeutic alliance and the implications of that orientation in treatment.

4.  Recognize the importance of psychotherapy.  Many diagnostic sessions require that psychotherapeutic interventions to be woven into that interview to support the patient, alleviate acute anxiety and to allow for a more thorough diagnosis.  Careful approaches to the diagnosis and treatment of patients requires recognition of the fact that some people will not tolerate any medications and psychotherapy may be the only available modality.  I do not hesitate to tell patients after an assessment that psychotherapy may be the best approach to the problem as well as discuss non medical approaches that have documented efficacy.

5.  Perform an actual psychiatric diagnosis.  This task is critical in the training of psychiatrists there is a lack of understanding about what making a diagnosis actually means.  Contrary practically everything that you read in the media, checking off criteria in the DSM 5 is not a psychiatric diagnosis.  Rating scales are also not psychiatric diagnoses and they are not quantitative measures.  It is very common these days for a psychiatrist to see a patient who carries 4 or 5 misdiagnoses like Bipolar Disorder/Major Depression + Attention Deficit-Hyperactivity Disorder + Intermittent Explosive Disorder + Asperger's Syndrome.  These folks are frequently on medications that are supposed to address the various disorders and they may not have ANY of the disorders.  In some cases they may not require medical treatment.  There are many people out there making complicated psychiatric diagnoses and initiating treatment in a 20 minute visit who are not qualified to make these diagnoses.  The other line of demarcation is the impact that a disorder has on the patient.  People who are functioning well in all spheres of their lives, by DSM definition - do not have a psychiatric disorder.  Many people are relieved to hear that they do not have a diagnosis or if they have had a diagnosis in the past that they no longer require treatment.

That diagnosis should be more comprehensive than a list of diagnoses.  There should be a formulation that describes the phenomenology and potential etiologies of the current disorder(s).  A narrative that makes sense to the psychiatrist and the patient.  At the end of my diagnostic session with the patient, I will frequently state it out loud in order to let the person know what I am thinking and get their feedback on my formulation.  I think that there is inherent flexibility in these formulations because the psychological etiologies can still vary based on the model that seems most applicable or the model that the psychiatrist prefers to use.  As an example it could be psychodynamic, behavioral, interpersonal, or existential.  It may employ a more recent model like one based on third generation behavior therapy or be a more supportive model focused on bolstering the patient's defenses.  The formulation is part history but also a discussion of etiologies (biological, social, psychological), dynamics, and defensive patterns.  The formulation can provide convergent validation for the diagnoses.  It provides both a pathway to understand the patient and guide psychological interventions.  The bulk of the material for this assessment occurs in parallel with the discussion of symptoms.

6.  Know the literature on borderland syndromes.  There is a significant overlap between medical conditions that are fairly non-specific in terms of diagnosis and treatment response like chronic fatigue syndrome, fibromyalgia, and chronic pain.  There are a significant number of people who present to medical and surgical clinics with symptoms and they never receive a diagnosis or an explanation for those  symptoms.  Familiarity with these syndromes will greatly assist in the diagnosis and treatment of these individuals if they are referred for psychiatric evaluation.  Specific knowledge of these conditions will allow the psychiatrist to consider an effective approach and effective patient education.

7.  Don't compromise your process because of extraneous variables.  The largest extraneous variable these days is the intrusion of business into the practice of medicine.  Psychiatrists may find that they are subject to limitations that do not apply to other physicians.  As an example, I have been told (by a managed care company reviewer) that psychiatrists don't diagnose or treat delirium when I was the only physician capable of making the diagnosis.   If you assess the patient and believe they need further diagnostic procedures or a medication trial that may be diagnostic do not give in to a case manager or pharmacy benefit manager who refuses to authorize what you need.  Make sure you communicate what you think the best possible care is to the patient rather than what the business people think.  Don't confuse medical quality with what a managed care company is calling "value".  They are probably unrelated.

8.    In the case of children, the best diagnostic approach looks at the family process both initially and in an ongoing manner.  The family should see the psychiatrist as someone who is not only an interested observer, but someone who can offer good advice right from the start of the process and recognize that symptoms in the identified patient can be a product of family dynamics.

9.    Take enough time.  The only valid way to make a diagnosis is to see the patient and interact with them in such a way that they feel understood.  Anything that takes away from that process can negatively impact on the flow of information and the task of providing that person with the best possible diagnosis and treatment plan.  The patient in this situation should not have the same experience they would have in primary care clinic discussing their depression or anxiety symptoms and the most obvious difference should be the total time spent talking with the patient.

10.   Review your findings thoroughly with the patient and family members if they are involved.  The process of psychiatric diagnosis differs from typical medical or surgical evaluations because of the sheer amount of data involved.   As an example, it might typically involve a sleep history similar to what might be obtained in a sleep lab with an additional 200 data points to look at the major diagnostic categories.  Even at that point there may be constraints on the data in terms of accuracy or detail that require corroboration of active debate.

11.  Know your diagnostic thought process - there a number of biases in the diagnostic process that have been written about in the literature on diagnostic decision making and in some journal features like the excellent series in the New England Journal of Medicine.  If you know the heuristics involved you can prevent diagnostic errors.

12.  Consult with your colleagues - consultation with colleagues serves a couple of useful purposes.  No matter how industrious you are it is impossible to see every possible presentation of every possible illness.  When you discuss patient presentations with colleagues who are also treating patients you are in effect extending your own pattern matching capability to include what your colleagues have seen and treated.   In many cases your colleagues have diagnostic and treatment experience with very low volume illnesses that are ordinarily seen a few times in the course of a career.

These are a few ideas I wanted to post today and there are a lot more.  Many of them seem like common sense, but the diagnostic approach to mental illness as practiced in most medical settings these days is anything but common sense.  You cannot get a comprehensive evaluation and diagnosis in ten minutes and you cannot really be walking out of a clinic with multiple prescriptions for medications that are supposed to work for that diagnosis in ten minutes.    

George Dawson, MD, DFAPA

On the dangers of psychiatric diagnosis no longer being a process

I am inspired by a post on another blog having to do with the dangers of “premature psychiatric diagnosis”.  The author uses an anecdote to make a point about how a diagnosis of a psychotic disorder and then mismanagement of the treatment leads to a situation where there is no hope for the person affected.

From my perspective there are very few people with even severe psychiatric disorders who are hopeless.  In fact, people with some of the most severe cases of catatonia that I have treated became fully functional and were restored to their roles in their families and society.  That frequently occurred after months of inpatient treatment by a psychiatrist and staff who were interested and skilled in treating severe psychiatric disorders.  Much of what I did in 22 years of inpatient work was restoring hope and maintaining a hopeful atmosphere on my treatment team.

Diagnostic uncertainty is frequently cited as an area where mistakes are made.  Many studies document the medical comorbidity in patients with psychiatric disorders.  Despite anecdotal cases true medical causes of psychiatric disorders are rare.  I should qualify that by saying a brain disease, neurological or endocrine condition that is a direct cause for the psychiatric disorder is rare and I base that on screening patients and reviewing thousands of negative studies.  That said any acute care psychiatrist should know more about medicine and neurology than psychiatrists in outpatient settings because unlike their outpatient colleagues – they are responsible for making that determination.  On the psychiatric side, the potential list of causes of various syndromes is long and the actual diagnosis may not be evident until something happens on a long term basis.   A good example would be a drug induced psychosis.  In the ideal case, the patient is able to remain sober and any medical treatment for the associated syndrome can be tapered and discontinued.  In the real world, the chances of sobriety or even referral to a functional addiction treatment are low.

   

There are numerous limitations on psychiatrists.  The obvious one that practically all commentators leave out is managed care.  Is it reasonable to think that the diagnosis and treatment of any severe psychiatric problem like a psychotic disorder can be accomplished in 3 – 5 days?  That is the time frame that most managed care case managers are using to get people out of the hospital.  They often refer to purely proprietary guidelines on hospital lengths of stay that were clearly written by business people rather than clinicians.  I have been in the position of having a patient discharged by an administrator against my wishes so I know that it happens.  Managed care coercion is more subtle.  A managed care reviewer sitting at a desk in another state – reads chart notes and presumes to make a remote diagnosis and suggest that the person should leave the hospital.  They have no responsibility to the patient or their family.  Their only job is to get the patient out of the hospital to save the insurance company money.  Another constraint is at the level of public assistance.  Almost incredibly, many states link the availability of case management services to psychiatric diagnoses and they will clearly say in the statute that the person must have schizophrenia, major depression, bipolar disorder, schizoaffective disorder, or borderline personality disorder in order to qualify.  Having one of those diagnoses at discharge can be crucial to get housing and funded medical rather than be homeless.  That is a strong incentive to get the correct diagnosis sooner rather than later.

The work flow on inpatient units and in clinics is generally not considered.  If you have a psychiatrist seeing 12-15 inpatients and some outpatients and they are seeing 3 – 5 new patients a day that is not a lot of breathing room.  They will be (depending on other members of the team) able to collect collateral information from the family and outside sources, make direct behavioral observations, and relay treatment decisions and recommendations to the family.  In my experience occupational therapists, nurses, and social workers are all indispensable team members and often function in dual roles as a liaison with family members.  They can act as consultants to the family on legal and social issues as well as keeping them apprised of any changes in medical treatment on a day to day basis.

One of the key areas where care becomes fragmented both from a diagnostic and treatment standpoint is anytime there is a transition.  In terms of hospitals that occurs with any admission or discharge.  It also occurs between different outpatient clinics and between psychiatrists and primary care physicians.  I have been in situations where it took me two hours and calls to different physicians, pharmacies and relatives to reconcile a list of 10 medications.  At the end of that two hours I was still not absolutely certain of the patient’s correct medication list. 

The bottom line here is that good psychiatric diagnosis is a process. It is not like taking your car in to a mechanic and the mechanic plugging it in to an analyzer.  The best results occur when the patient and the family can communicate openly with the psychiatrist and any identified treatment team.  The diagnosis needs to take into account all of the available information and by definition it will only be as good as that information.   The critics of psychiatry always seem to think that this is a situation that is unique to psychiatric treatment.  As I have previously discussed it happens in all of medicine.  The basic difference being that many nonpsychiatric conditions lend themselves to analysis by a single observer.  There is something readily visible, audible or palpable that suggests an abnormality.  In psychiatry we are focused on communication, self report, and the observations of others.  We are also generally dealing with more information to make a diagnosis, especially if the patient’s capacity for self report is limited.  Psychiatrists more than anyone else need to be comfortable with diagnostic uncertainty and explaining these nuances to the patient and their family.

When the diagnosis is made it should be fully explainable to the patient and family.  Any stigma or negative reaction to the diagnosis should be discussed.  It should be evident that nobody is reducible to a psychiatric diagnosis given the fact that no two people are alike and each person is a unique individual with unique attributes.  This is true for any medical diagnosis and psychiatric diagnoses do not differ in that regard.   Nobody should leave the encounter with the idea that they are “hopeless”,  particularly in the case of a pure psychiatric diagnosis in the absence of a neurodegenerative disease.

I realize that most of us in one way or another are held hostage by a certain health plan, but if your psychiatrist or more probably your health plan does not follow that basic process – find a new one.  Getting stuck on whether or not a misdiagnosis has occurred without a plausible explanation for what has happened or continues to happen is generally not productive.  If you can’t get out of your health plan talk to the medical director and explain the deficiencies.  If that doesn’t work and you are concerned about the diagnostic and treatment process being rationed, contact your state insurance commissioner and file a complaint against the health plan.

Quality psychiatric care is possible, but it has been demonstrated that in many cases you have to fight for it.

George Dawson, MD. DFAPA