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.
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
