Diagnostic disagreements

[ADDICTED2STATS]

Let’s say you meet with a pt that had been previously diagnosed by a psychiatrist you currently work with. The pt is being treated (by said psychiatrist) for this diagnosis with a medication that has a fairly complex SE profile.

You do a pretty comprehensive (~3 hour) diagnostic work-up (MMPI, MINI, Clinical Interview, and some others that don’t really matter here) and the person doesn’t even come close to meeting the diagnosis they’re being medically treated for by the MD. This isn’t a case where the meds might do some good for multiple issues; they’re highly specific to this D/O.

Further, this is a D/O that research indicates is frequently misdiagnosed when done so in the absence of a good diagnostic assessment. You meet with the psychiatrist, and despite all evidence they disagree with your assessment.

What do you do?

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[WisNeuro]

This happens all the time. You have no idea how many patients I see diagnosed with "Bipolar Disorder" who don't have anything close to a manic or hypomanic episode in their history. Granted, I'm usually doing an evaluation in a cognitive eval context, but since we do also take into account psychiatric factors, I assess for it. I am clear that they do not appear to meet diagnosis for that disorder in my report. In some contexts not much you can do for lazy diagnostic workups. I make known my disagreement, if the patient wants to discuss it, I do. They should be advocates for themselves and have all of the information available.

 

[smalltownpsych]

I second what WisNeuro says. All you can do is write it up and present the info to the parties involved. On the other hand, I have found that hitting the MD with the hard facts in a brutally honest and extremely concise manner can be effective too. Sometimes we are too nice and use too many words. MDs are trained differently recognizing this can help. Since I work in a medical setting now, I am getting much better at speaking their language. Brief clipped sentences with good technical jargon. Works like a charm.

 

[erg923]

What psychotropic these days is specifically designed for ONE psychiatric disorder? Clozaril? Lithium? I'm out...

My guess is that you guys are disagreeing about the presence of manic episodes? Does he know something you dont? Do you have a relationship with his/her supervisor? Might wanna post this to the psychiatry forum as well.

 

[ADDICTED2STATS]

I guess it's fairly obvious what the Dx is. As for whether the MD knows something I don't, that's a good question. It seems there is evidence from a third party supporting the Dx, though this isn't documented anywhere, and didn't come to light until the MD and I met. Generally, I take pride in my diagnostic skills, but I felt like I really screwed this up after meeting with the MD. I don't want to get into the specifics of what transpired in my discussion with the pt, but suffice it to say the pt apparently left feeling like they were misdiagnosed (though I never stated this, and specifically told them more testing was needed).

 

[erg923]

It happens. A NP on my team just sent a patient off to mental health after I evaluated him 3 weeks ago and found him to be largely asymptomatic. I was expecting him to ship him back to pcp to refill some traz and a low dose SSRI. But apparently she pulled some stuff from him that I didn't get. Still seemed a little overkill though. PHQ was like 6 and PCL was like 33.

 

[CheetahGirl]

Same happened here. And I could monologue about the frustration I personally experienced as a clinician-in-training. After evaluation of this patient, I found a completely different d/o than what psychiatry had been treating for several years. In fact, all I had to do was LISTEN to the patient who verbalized that the MDs were 'missing the mark' and the feelings that something more could be done with a different approach. Thankfully, this was an outpatient clinic and my supervisor & his new attending paid attention to my eval and decided to switch things up which produced better results. But, this type of experience doesn't seem the norm (as this thread implies). And if you really think about it, 'fresh eyes & ears' were really what was needed b/c the initial eval from ~3-years prior addressed the patient's issues THEN, and the patient had since 'evolved' in a different manner.

 

[Therapist4Chnge]

The biggest disagreements I see are with (pt. reported, pre-existing but never formally assessed) ADHD v. executive dysfunction due to a medical condition/TBI ("…but they had a positive response to the stimulant medication"), bipolar v. BPD, and too great a focus on neurologic sequelae at the expense of consideration for psychiatric etiologies. Treatment for the first pairing is not much different, but the treatments for the latter two pairings are hugely different. Throwing cocktails of meds at BPD just causes more problems, with cognitive dysfunction usually being far down the list.

I should note that I'm usually on the same page with my most frequently referring providers, though the random community referral or out of state case can be very hit and miss.

 

[WisNeuro]

The biggest disagreements I see are with (pre-existing but never diagnosed) ADHD v. executive dysfunction due to a medical condition/TBI ("…but they had a positive response to the stimulant medication"), bipolar v. BPD, and too great a focus on neurologic sequelae at the expense of consideration for psychiatric etiologies. Treatment for the first pairing is not much different, but the treatments for the latter two pairings are hugely different. Throwing cocktails of meds at BPD just causes more problems.

Yeah, I see the "they improved with stimulants" argument used as a basis for ADHD diagnosis. It's ridiculously stupid, we're not talking about Parkinson's and Levodopa here. Everyone improves with stimulants

 

[Therapist4Chnge]

Yeah, I see the "they improved with stimulants" argument used as a basis for ADHD diagnosis. It's ridiculously stupid, we're not talking about Parkinson's and Levodopa here. Everyone improves with stimulants

I am actually a big supporter of stimulant use for off-label purposes (e.g. more significant head injury, treatment resistant depression in the elderly, help with initiation, etc) and I'm okay with it for an adult who finds benefit from it for work, though diagnostically I want to be accurate because other treatment considerations are still needed.

 

[AcronymAllergy]

I am actually a big supporter of stimulant use for off-label purposes (e.g. more significant head injury, treatment resistant depression in the elderly, help with initiation, etc) and I'm okay with it for an adult who finds benefit from it for work, though diagnostically I want to be accurate because other treatment considerations are still needed.

That's generally my take as well. Stimulants can be great exactly because they do work for just about everyone, but having the accurate diagnosis is important not just for implications with other potential treatments and/or impact in influencing the mindset of other providers, but for the patient's education and peace of mind as well. And using response to stimulants as a diagnostic marker of any kind for ADHD is basically laughable, yep.