concerns about over-diagnosing

[rkaz]

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Hi all. Most of you know from my other thread that I'm just about to start MS4, and thinking about a career in psychiatry.

There is something that concerns me. Sometimes I wonder if Axis II disorders are over-diagnosed, or diagnosed too quickly. I am someone who doesn't like to slap labels on people.... unless it is needed for their treatment. I feel like we all come in different variations and personalities, and it's okay to be who you are.... as long as it isn't deeply destructive to yourself or others. There is beauty in our differences, and not everyone has to fit a particular model just to be a normal human being. If someone is antisocial or asexual and doesn't have a problem with it, and neither do the person who lives with him/her... I don't see the need for unnecessary classifications for that person. Let each be the way he or she is, I feel.

I remember on my psych rotation last year (in an inpatient crisis unit), we once had a patient come in who was severely depressed with suicidal ideation. In the interview (which was about 10 minutes or so), he went on in self-pity about how he is such a failure, no one cares for him, he used to be a successful engineer but he spoiled all of his relationships and his wife left him, etc. After he left, the attending was talking to me and another student, and the 2 of them agreed that the patient had narcissistic personality disorder due to his entitled attitude (they stated he felt entitled for the world to give him what he wanted and was moping around when it didn't). I was a bit uncomfortable with their exchange. Although I could see that there may be somewhat of an entitled attitude with him, I still feel that all of us have those 'poor-me' pity-party days sometimes, so I don't want to rush a diagnosis until I've at least seen him a few times to see the trend of his behavior.

Another issue is that I personally don't believe that mental illness is a fixed concept. I don't like for people to think that they are permanently mentally broken, as situations can change. (Possibly not for issues like schizophrenia? but at least for things like depression and anxiety). I used to have depression in the past, but I'm totally fine now and more balanced that most people I know, as I'm super passionate about healthy living. If someone asked me if I am currently mentally ill, I'd most certainly say "no way". Possibly on some existential level we are all mentally ill (in various proportions, compared to the way we were placed on this earth to be), but by comparison to others I'm certainly fine.

Please tell me your thoughts about this. Take into consideration that I've only had one month of psychiatry core rotation so far, so my views may change, once I take more psych rotations in my 4th year. But my experience thus far concerns me, and makes me wonder if I'm not a good fit for psychiatry... based on my stances. I am a thoughtful and reflective person, and think I could be a great asset to the field. But I don't know if my views are congruent with others. Thanks!

 

[rkaz]

Of course I have no way to quantitatively know that I am mentally perfectly healthy. Maybe my brain still produces less neurotransmitters than others. But I have found that by eating healthy, exercising, meditating, that I can still feel pretty darn good. Don't take any meds either. So does that still make a person mentally ill, but managed? I have no clue.

I guess I'm just rambling here, but I'm just wondering if I can still hold these sort of views and still be a good doc.

 

[rkaz]

I remember during our patient interviews, we would have to ask the patient "Do you feel like you are mentally ill?" If the patient agreed, we would mark off on our documents that the patient had good insight. But if the patient didn't think that he/she was mentally ill, we'd say that the person had poor/fair insight. This also made me uncomfortable, as sometimes the patient would respond to the question "Aren't we all a bit mentally ill? Doesn't it just depend on the perspective?"

Internally, I'd totally agree with the patient that there is relativity in mental illness, yet couldn't say that in front of the attending, as she would just look a bit sternly at the patient and move on to the next question. Furthermore, I'd feel sad to have to check off "fair" insight, because that was what we were told to do when a person didn't agree that they necessarily had mental illness. I think many of the patients had a lot more insight then we were giving them credit for.

 

[vistaril]

Of course I have no way to quantitatively know that I am mentally perfectly healthy. Maybe my brain still produces less neurotransmitters than others. But I have found that by eating healthy, exercising, meditating, that I can still feel pretty darn good. Don't take any meds either. So does that still make a person mentally ill, but managed? I have no clue.

I guess I'm just rambling here, but I'm just wondering if I can still hold these sort of views and still be a good doc.

I agree with most all of what you right in these three posts. The fact is our field doesn't do very well with a lot of these things you talk about.

Can you still be a good psychiatrist? Sure. I would argue that some of these views may make you a better psychiatrist.

 

[Jorje286]

I think it's part of DSM criteria that personality disorders are diagnosed only when there's personal/social dysfunction. Also the psychiatrists who taught me almost all agreed that you couldn't diagnose any personality disorder from a first visit, but it's better to wait. Although we would discuss the possibility of them having such disorders.

In general, I agree with your perspective. Part of the issue is that diagnosis in psychiatry is based on subjective criteria, so we are likely to face those issues. It's tough to draw a line between wrong and right, and undoubtedly much will depend on your own perspective, your own personality and your hunches.

I also agree that the center piece of psychiatry and all of medicine really is suffering; not some objective notion of normal/abnormal or natural/unnatural, because there's really no such thing.

 

[SmallBird]

It's certainly wise to be cautious when making a personality diagnosis, but what is often helpful to do from the first visit is to try and understand something about the patients psychology that will help you communicate with them effectively. You may notice that a patient interprets an overly sympathetic attitude as a sign of weakness, and that your therapeutic alliance works better when you come accross as self-assured and directive. Whether or not you decide to label this person as being narcisstic is almost unimportant, but to ignore your sense of the patients underlying psychology, and communicate to all your patients in the same way, will restrict your ability to work well with a broad range of patients.

 

[Bartelby]

To start, I agree that variations in personality are a wonderful thing up until the point (as a rule) that they start causing severe distress for the individual or the people around them. Most of the time people will not come to you unless some real distress is going on.

In the example you give (assuming there was no longitudinal information showing a consistent pattern) I agree that the narcissistic personality disorder diagnosis seems premature. Under stress people can regress and maybe when that patient is out in the world feeling better those traits melt away (assuming he had strong narcissistic traits). Almost all of the time you will see "defer" or "traits" used on axis two for an evaluation based on a single cross sectional interaction.

As SmallBird mentions, though, the patient's long term interpersonal and coping style is of interest to you in helping to guide them to recovery. You should pay careful attention to it, and if a personality disorder is present you will not do the patient any favors by overlooking it.

As for medidation, yoga, exercise, etc, of course you can recommend and enjoy those things and be a good doctor. There is even developing evidence for some. Check out research on meditation and the "relaxation response," for instance, or the SMILE study for exercise (or Spark, an entire book dedicated to reviewing the evidence for exercise).

For insight, "does the patient state he is mentally ill when asked" is not really appropriate as a sole criterion. If they are psychotic and don't even realize anything is wrong then yes, their insight is poor. If they are depressed and holding high level existential conversations with you about the exact nature of their depression and are able to realistically understand their symptoms and reason about them then I don't think "poor insight" is an accurate assessment.

 

[notdeadyet]

There is something that concerns me. Sometimes I wonder if Axis II disorders are over-diagnosed, or diagnosed too quickly. I am someone who doesn't like to slap labels on people.... unless it is needed for their treatment.

Ack! Your statement I bolded is exactly why I think folks are slow to diagnose Axis II disorders. Which can be harmful or potentially fatal.

You should not slap a diagnosis of Narcissistic Personality Disorder on every narcissist. You should also not slap a diagnosis of Borderline Personality Disorder on every person who attempts suicide and generates negative countertransference. I agree that a personality disorder should only be diagnosed if you are able to see their behavior longitudinally, not as a snapshot of their current presentation.

But a diagnosis of PD should be needed for their treatment. All Axis II diagnoses will shape your treatment, dispo, and how you present each. Some Axis II diagnoses (particularly BPD) are in fact treatable in and of themselves and ignoring it because you don't like to "slap labels on people" is substandard care.

Any diagnoses, psychiatric or otherwise, is labelling folks. You don't do it without evidence. You don't do it for fun. You do it because it affects treatment. Underdiagnosing because you feel it does the patient a favor somehow is a mistake.

 

[rkaz]

I appreciate you all sharing your thoughts here. This is giving me some food for thought.

 

[rkaz]

To start, I agree that variations in personality are a wonderful thing up until the point (as a rule) that they start causing severe distress for the individual or the people around them. Most of the time people will not come to you unless some real distress is going on.

Of course. However, in some of the cases I was thinking of, it was the Axis I disorder which caused the life distress to get the person to the crisis unit (either voluntarily or involuntarily). And the Axis II presumed disorder was incidental on presentation. But I'm sure in some cases of personality disorders, their behavior might be severe enough to cause life distress, especially if they cannot interact well with others or if it gets them in trouble with the law.

In the example you give (assuming there was no longitudinal information showing a consistent pattern) I agree that the narcissistic personality disorder diagnosis seems premature. Under stress people can regress and maybe when that patient is out in the world feeling better those traits melt away (assuming he had strong narcissistic traits). Almost all of the time you will see "defer" or "traits" used on axis two for an evaluation based on a single cross sectional interaction.

This really helps. I will use these terms 'defer' or 'traits' in documentation in future interaction with patients. This way my attending knows that I am not oblivious to things, but rather that I want to withhold any judgment until learning more about the patient.

As SmallBird mentions, though, the patient's long term interpersonal and coping style is of interest to you in helping to guide them to recovery. You should pay careful attention to it, and if a personality disorder is present you will not do the patient any favors by overlooking it.

I agree with you, Smallbird, and Notdeadyet on this issue.

As for medidation, yoga, exercise, etc, of course you can recommend and enjoy those things and be a good doctor. There is even developing evidence for some. Check out research on meditation and the "relaxation response," for instance, or the SMILE study for exercise (or Spark, an entire book dedicated to reviewing the evidence for exercise).

Very cool... I'll have to check that out.

For insight, "does the patient state he is mentally ill when asked" is not really appropriate as a sole criterion. If they are psychotic and don't even realize anything is wrong then yes, their insight is poor. If they are depressed and holding high level existential conversations with you about the exact nature of their depression and are able to realistically understand their symptoms and reason about them then I don't think "poor insight" is an accurate assessment.

This really helps to clarify things on insight, which I was confused about... thanks so much. 👍

 

[Psychobabbling]

I appreciate the point you make. The problem some people fail to understand is that we ALL can be a little borderline, a little narcissistic, paranoid, etc at times. It is classified as a 'disorder' (I personally hate this term) when a person is unable to break out of that personality and are "stuck" in that mode

On a first time basis, usually in the Psyc ER setting, I use the term "cluster b traits" for axis II. Whether you put "rule out" in front is up to you, for that term I think it's kind of understood. Because maybe those traits only come out under that setting and normally they are doing great.

The other part to this is, who gives a **** if you can label someone correctly. Lets say you nail a diagnosis of antisocial personality disorder. Good for you. (A) try telling your patient that and (b) lets see how many enter any form of therapy. PS - you don't need a label to converse with someone and help talk through their problems

 

[vistaril]

I appreciate the point you make. The problem some people fail to understand is that we ALL can be a little borderline, a little narcissistic, paranoid, etc at times. It is classified as a 'disorder' (I personally hate this term) when a person is unable to break out of that personality and are "stuck" in that mode

On a first time basis, usually in the Psyc ER setting, I use the term "cluster b traits" for axis II. Whether you put "rule out" in front is up to you, for that term I think it's kind of understood. Because maybe those traits only come out under that setting and normally they are doing great.

The other part to this is, who gives a **** if you can label someone correctly. Lets say you nail a diagnosis of antisocial personality disorder. Good for you. (A) try telling your patient that and (b) lets see how many enter any form of therapy

hopefully none.

 

[strangeglove]

Sometimes it is very clear from someone's history that they have a personality disorder, especially when looking at their relationships and work and how they've been able to engage in treatment over time. If it is clear, I don't hesitate to make the diagnosis and then tell the patient that its not just bipolar disorder or whatever (which could be there, too) if I think that the personality disorder is causing most of the problems in functioning. Surprisingly, if you do it right, most patients find this quite helpful, not to mention that it often leads to more appropriate treatment than deferring on Axis II. The feeling that Axis II diagnoses are more stigmatizing and should not be shared with the patients has a lot to do with countertransference.

 

[kugel]

Sometimes it is very clear from someone's history that they have a personality disorder, especially when looking at their relationships and work and how they've been able to engage in treatment over time. If it is clear, I don't hesitate to make the diagnosis and then tell the patient that its not just bipolar disorder or whatever (which could be there, too) if I think that the personality disorder is causing most of the problems in functioning. Surprisingly, if you do it right, most patients find this quite helpful, not to mention that it often leads to more appropriate treatment than deferring on Axis II. The feeling that Axis II diagnoses are more stigmatizing and should not be shared with the patients has a lot to do with countertransference.

This approach has been pretty successful for me. Most often, for PD's (except ASPD), the response to seeing the description and criteria is "It looks like they're writing about me." And then we can change the focus from more and more meds to manage something meds probably can't manage - to a focus on "strategies to manage the internal conflict," AKA therapy.
A few times it has worked for ASPD, but more often I use reflective listening up to the point that we agree, "You're upset that you got in trouble for doing what you want, even though you knew there would be consequences if you got caught." Then I point out that there's not much psychiatry can do about that; we can't really keep you from getting in trouble when you break the rules. And medicines won't change whether you choose to break the rules. If you want to work on changing the way you make decisions so that you don't keep breaking the rules, you need to plan on a minimum of a year or two in therapy. Certainly, a few days "resting" in the hospital "to get away from the people stressing me" isn't going to change it.

 

[BlueLotus]

I like this thread.

It is an aspect of psychiatry that concerns me greatly, because it can be used to intentionally harm patients. A preceptor once told me that some labels of Axis II are often used as a way to dismiss a patient that a physician does not like.

Further, the personality d.o. concept seems to be looking at the end of a problem rather than its origins. The human experience of anxiety, for example, may be caused by social, cultural, political, economical, and certainly biological origins. Anxiety could then be expressed in many ways that could be labeled as Axis II, yet with a closer view the truth may simply be a diagnosis of anxiety.

The potential flaws that I see with Axis II remind me of how views have changed regarding Autism over the years. Initially, parents – especially mothers – were blamed for their emotionally distant relationships with their children. Yet, at the time, it was not considered if this was a response to rather than a cause of the child's condition. Further, some behaviors that people with autism exhibited were often misunderstood: Temple Grandin, TG, describes the extreme auditory and tactile sensitivities that people with autism can have as a possible cause for some behaviors, for example. In fact, TG's squeeze box and the newer adaptation on this theme, weighted jackets, help provide a sensation of calmness for some autistic individuals. For all the discoveries in the field of Autism, it seems that the concept of personality as a disorder may benefit from further study as well.

Although extreme cases exist of people with personalities that appear to fit without question on Axis II, often this may not be the correct view of the situation. Perhaps this Axis would benefit from being redefined yet again as I am concerned that providers may use this to unjustly pathologize a normal aspect of the human condition which may thereby harm patients.

Thanks for your insight from those of you working in the field.

 

[splik]

I like this thread.

It is an aspect of psychiatry that concerns me greatly, because it can be used to intentionally harm patients. A preceptor once told me that some labels of Axis II are often used as a way to dismiss a patient that a physician does not like.

Axis II is no more. personality disorders and other non-psychiatric medical conditions are now to be listed along with primary aberrant mental states (i.e. axes I, II and III are all defunct).

It is true that personality disorders can be loosely thrown around (typically by non-psychiatric providers) as a slur for heartsick or challenging patients, and may say more about the provider's countertransference and therapeutic helplessness than it says about the patient. At the same time, my experience is that personality disorders are vastly undiagnosed, and these patients often get a diagnosis of depression, bipolar disorder, schizoaffective disorder, or even schizophrenia instead, when none of these has any utility at all. As a result, these patients end up on multiple classes of psychotropic drugs with little benefit.

A good psychiatrist will not stop with a personality disorder diagnosis. They will look at the patient's temperament, ways of relating, affective state, and maladaptive behaviors and attempt to formulate a model to explain the patient's experience. For example instead of labeling a patient as borderline, I may note their tendency to be emotionally reactive, unable to self-regulate negative emotions, both craving and fearing intimacy, fearing abandoment, having no sense of identity, and resorting to suicide attempt, self-harm, drugs, and bingeing and purging as a way of coping with powerful feelings in the context of disorganized attachment style and a failure of mentalization and structure my treatment around encouraging mentalization through the transference affect.

Character disturbances may often explain a patient's propensity to experience depression or anxiety in certain circumstances, help frame the meaning of particular life events, their ability to cope, and again help structure treatment. Also understanding the particular character of the patient will help you understand how to relate to the patient - do you need to set firm limits? would it be wise to challenge basic defensive maneuvers the patient needs to survive? do you need to give the patient a sense of agency or show them that you are in charge? do you risk enacting the role of abuser they have cast you in? and so on...

yes, it is never acceptable to use a personality disorder epithet as a disparaging term in the clinical setting. but to withhold a conceptualization of the patient as having a broken character structure is also often inappropriate, and yet we are often reluctant to share this understanding the with patient. I tend to develop and share a collaborative formulation rather than simply a diagnosis with these patients, but done the right way, it can be very helpful for patients to understand they have a characterological problem and more often than not, my patients have been grateful that someone seems to "understand" them, and get them off the laundry list of drugs they have ended up on.

 

[BlueLotus]

Wow, thanks splik for your response. Really great information + thoughtfully written.

I am intrigued about the new DSM system + I'm glad for your clarification on that.

During my 3rd and 4th years, I did not see anyone practice beyond the assessment and 15 minute med-check follow-up visits. By the end of my training, upon seeing that IM, FM, and PEDs doctors were prescribing and treating pt.s for psych disorders with about the same attention as what I observed in psych offices, I wondered what psychiatry had to offer at this time. A JAMA study found that 74.5% of pt.s receive psych med tx by PCPs. This realization caused me to stop, study the field, and think deeply about the field.

At its best, as you described, I think psychiatry offers what counselors and non-medical psychological providers cannot provide: a much needed blend of medical and neuropsychiatric knowledge. Gosh, yes, and this would include stopping any unnecessary medical therapies that may have been used to appease any patients with complex presentations.

I will need to select my audition rotation soon and I find it difficult to know the best way forward (combined residency, psych, or PCP field). From the outside, as I feel I am at this stage, it is really a challenge to know how I'd best like to serve as a physician when one of my choices, psychiatry, would result in not directly addressing the physical health of the patient. Still, I find that even after reading R. Lustig's book, Fat Chance, I was reminded of how important mental health is for our physical health since many of our chronic medical conditions are a result of what we are doing to ourselves. Yes, even if it is not currently recognized, there will always be a place for good psychiatric care.

Thanks again.

 

[vistaril]

Axis II is no more. personality disorders and other non-psychiatric medical conditions are now to be listed along with primary aberrant mental states (i.e. axes I, II and III are all defunct).

It is true that personality disorders can be loosely thrown around (typically by non-psychiatric providers) .

dont agree....most internists have no interest in slapping diagnosis on patients(either bipolar or bpd) and starting them on seroquel and depakote. 90% of the cluster**** that is the crappy treatment most of these patients recieve is given by board certified psychiatrists, and we need to recognize that these patients do recieve poor treatment in our system and that we are the ones mainly providing it.

 

[vistaril]

dont agree....most internists have no interest in slapping diagnosis on patients(either bipolar or bpd) and starting them on seroquel and depakote. 90% of the cluster**** that is the crappy treatment most of these patients recieve is given by board certified psychiatrists, and we need to recognize that these patients do recieve poor treatment in our system and that we are the ones mainly providing it.

let me clarify I bit what I mean here...I think many psychs do have skills in dealing with these patients and have the ability to treat them appropriately. The problem is not enough pts like this have the kind of resources to get access to appropriate treatment. A good number bounce in and out of inpatient units, are on medicaid, and are treated at community mental health centers.....

 

[BlueLotus]

Kudos on your honest responses, Vistaril. Much appreciated, indeed!

Yes, I tired of seeing the us vs. them mentality of providers when it came to labeling a person with a personality disorder. That concerns me.

With little exposure to the field, aside from the extremely obvious cases, I still question how a personality disorder is distinguished from a person's normal human character traits (per McHugh pt. of view).

When we look at the life of an aspiring Olympic athlete, for example, and the rigid life regimen such a person must have for years to possibly perform a well rehearsed routine for a few minutes, would this person be labeled with a pers. d.o.? In fact, would the rigorous focus that one must have to get through medical training also make one an easy target for the pers. d.o. dx as well?

Good thread for those of use on the outside looking in + dipping our toes in the water : )

Cheers!

 

[OldPsychDoc]

With little exposure to the field, aside from the extremely obvious cases, I still question how a personality disorder is distinguished from a person's normal human character traits (per McHugh pt. of view).
..

"clinically significant distress or impairment", per our previous DSM.

 

[Psychobabbling]

Lotus - lets say you "slap" a label of Borderline Personality Disorder on someone. This person, since as far back as they can remember (and their parents and siblings would agree), has always had trouble really knowing who they are. They often display emotions in extremes, and tell you it's difficult for them to understand what they are really feeling at times. They get into relationships, and immediately notice a connection. They share their deepest secrets with this person and know they've found "the one" almost immediately. A week or two goes by, and this person didnt respond to a text right away. After ruminating about this for hours, they 'knew' they were being cheated on and proceeded to leave several angry messages on their voicemail. This has been a pattern in all romantic relationships, and is similar to other relationships in their life. They tend to resort to cutting and have tried to kill themselves by overdose after any relationship over a few weeks ends. Usually during the day they try and get high because it makes the feelings of being numb inside almost bearable.

I'd really consider helping this person, maybe some meds, hopefully some DBT. The "I don't want to label you" won't fly

Granted, psychiatry diagnoses based on clusters of symptoms, it's the best we have, for the time being. Maybe the person above is dealing with life long issues of anxiety, or depression, or cannabis use....and THAT'S what's causing these symptoms. Maybe these issues are co-occurring, but as the sole diagnosis would be....not very reality based 🙂

 

[SeniorWrangler]

Read GE Vaillant, "The Beginning of Wisdom is Never Calling a Patient Borderline", 1982.