Diagnosis is not just a label, Dr X.

[TheWowEffect]

I hate it when an attending tell me..."Oh! diagnosis is just a label. Doesn't matter what you give." Please don't say that to me again. It does matter and it matters a lot. It matters if it is major depression or depression due to GMC. It matters if it is panic disorder or PTSD. It matters a lot.

Don't bash drug companies just because you want to. Don't tell me that they are pushing it despite there being no studies, when you have made no effort to look for the studies which are out there in large numbers. Don't tell me that we don't know how a certain drug works, when there is ample evidence out there. Don't deny the advances in the field if you don't keep up with them and choose to dismiss them even if someone tells you about those.

It matters and don't tell me again that it does not........

---

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[Anasazi23]

Bad day at the office, hun?
Maybe this will cheer you up...

 

[TheWowEffect]

Bad day at the office, hun?
Maybe this will cheer you up...

Thanks, man! to have SDN around...

 

[Faebinder]

I hate it when an attending tell me..."Oh! diagnosis is just a label. Doesn't matter what you give." Please don't say that to me again. It does matter and it matters a lot. It matters if it is major depression or depression due to GMC. It matters if it is panic disorder or PTSD. It matters a lot.

Don't bash drug companies just because you want to. Don't tell me that they are pushing it despite there being no studies, when you have made no effort to look for the studies which are out there in large numbers. Don't tell me that we don't know how a certain drug works, when there is ample evidence out there. Don't deny the advances in the field if you don't keep up with them and choose to dismiss them even if someone tells you about those.

It matters and don't tell me again that it does not........

You go TWE.... Toss em to the lions.

 

[TheWowEffect]

You go TWE.... Toss em to the lions.

Not the NFL Lions though They suck big time.

 

[prominence]

I hate it when an attending tell me..."Oh! diagnosis is just a label. Doesn't matter what you give." Please don't say that to me again. It does matter and it matters a lot. It matters if it is major depression or depression due to GMC. It matters if it is panic disorder or PTSD. It matters a lot.

Don't bash drug companies just because you want to. Don't tell me that they are pushing it despite there being no studies, when you have made no effort to look for the studies which are out there in large numbers. Don't tell me that we don't know how a certain drug works, when there is ample evidence out there. Don't deny the advances in the field if you don't keep up with them and choose to dismiss them even if someone tells you about those.

It matters and don't tell me again that it does not........

what sh%tty program do u go to? what u described above sounds horrible!

 

[TheWowEffect]

what sh%tty program do u go to? what u described above sounds horrible!

Really Looks like someone has their eyes, ears and mouth shut when that attending talks. "Yes, Dr. X, you are absolutely right. I'll toe the line and never question or second guess you." I don't like to stay in a denial mode. I am sure most programs have attendings like that and anyone suggesting otherwise is not simply looking around.

 

[toby jones]

How much is medication diagnosis specific vs symptom specific? Sometimes it is diagnosis specific, yes. But isn't it more often symptom specific? In which case... One might be led to think that if one is looking to prescribe medication then one should worry more about accurate assessment of symptoms than about accurate assessment of diagnosis.

It can matter a lot to a patient. If they have a psychotic 'episode' or if they have 'schizophrenia' makes a big difference of whether other people and whether they themselves are 'realistically' to expect improvement or not. But that isn't the kind of mattering that you had in mind - was it?

 

[Doc Samson]

My favorite is "Oooh, don't label them as Borderline."

Right... I'll diagnose them with something they don't have (Bipolar, perhaps) so that I can prescribe them meds that won't work for their actual symptoms (though the drug reps keep hinting that they will) while not recommending treatment that does work (DBT) just to make sure that no-one feels I've perjoratively "labeled" them as borderline.

Borderline now is a lot like cancer back in the 50s and 60s. No-one would call it "cancer" instead coming up with a series of euphemisms (neoplasm, tumor, growth, etc.), essentially because it was a death sentence with no treatment. Over the decades, treatments developed, it was no longer a death sentence, and cancer is no longer an epithet. The perception of borderline remains one of an untreatable death sentence despite the strong evidence for DBT.

 

[Chrismander]

My favorite is "Oooh, don't label them as Borderline."

Right... I'll diagnose them with something they don't have (Bipolar, perhaps) so that I can prescribe them meds that won't work for their actual symptoms (though the drug reps keep hinting that they will) while not recommending treatment that does work (DBT) just to make sure that no-one feels I've perjoratively "labeled" them as borderline.

Borderline now is a lot like cancer back in the 50s and 60s. No-one would call it "cancer" instead coming up with a series of euphemisms (neoplasm, tumor, growth, etc.), essentially because it was a death sentence with no treatment. Over the decades, treatments developed, it was no longer a death sentence, and cancer is no longer an epithet. The perception of borderline remains one of an untreatable death sentence despite the strong evidence for DBT.

thanks for the perspective for us newbies, DS. I was under the impression that this phenomenom was due to billing--Axis II being not billable.

 

[Doc Samson]

thanks for the perspective for us newbies, DS. I was under the impression that this phenomenom was due to billing--Axis II being not billable.

Admittedly I have the luxury of being a salaried consult psychiatrist, so individual billing matters less to me, but renumeration strikes me as a poor excuse for diagnosing a patient with a disorder they don't have. My favorite way around this in settings where billing is an issue has been to use "Adjustment Reaction" (a billable ICD-10 Axis I dx) on Axis I, since every pt admitted to the hospital has some level of adjustment although only occasionally manifesting as a full-fledged Adjustment DO. Either way, it's preferable to Bipolar DO which carries the load of potentially harmful (and in these cases not-indicated) pharmacologic interventions.

 

[Faebinder]

Admittedly I have the luxury of being a salaried consult psychiatrist, so individual billing matters less to me, but renumeration strikes me as a poor excuse for diagnosing a patient with a disorder they don't have. My favorite way around this in settings where billing is an issue has been to use "Adjustment Reaction" (a billable ICD-10 Axis I dx) on Axis I, since every pt admitted to the hospital has some level of adjustment although only occasionally manifesting as a full-fledged Adjustment DO. Either way, it's preferable to Bipolar DO which carries the load of potentially harmful (and in these cases not-indicated) pharmacologic interventions.

Thanks for the tip.

 

[nitemagi]

My current pet peeve is ED nurses and staff (sometimes including MD's) who automatically label someone schizophrenia based on inferential or even absent evidence. I've been consulted on people just brought in from the ED to another unit, noted to have schizophrenia, I was consulted for aggressive behavior, ?d/t psychosis. Turns out the guy was just aggressive because he's aggressive. I tracked down the first person to put it in the chart in the ED, who said "well he was so angry I just assumed." WTF????

More commonly is people who've been on antipsychotics for whatever reason (mood stabalization, anti-nausea, etc.), who then somehow magically get into their PMH "schizophrenia." Forget that whole very advanced technique of actually asking the patient if they have it or not. But once it gets into their chart, it's amazing how much work has to be done to unlabel them as such. Have to agree with the OP.

Grr.

 

[toby jones]

> My favorite way around this in settings where billing is an issue has been to use "Adjustment Reaction" (a billable ICD-10 Axis I dx) on Axis I, since every pt admitted to the hospital has some level of adjustment although only occasionally manifesting as a full-fledged Adjustment DO. Either way, it's preferable to Bipolar DO which carries the load of potentially harmful (and in these cases not-indicated) pharmacologic interventions.

I'm finding this interesting... I do get that people shouldn't diagnose someone with something that they don't have. But it does seem to me that there are significant issues of interpretation (inter-rater reliability really isn't good for the majority of diagnoses). In particular with respect to how severe a symptom needs to be in order for it to be judged to be present.

I thought that 'rapid cycling bi-polar' did similar work to 'adjustment reaction'. Everybody has emotional ups and downs though only occasionally manifesting as fully fledged bi-polar. I didn't think that the rapid cycling variant suggested medications... But I don't know terribly much about this.

These pragmatic issues do make a mess of psychiatric classification, though. I mean... if people started studying 'adjustment reaction' in response to an 'epidemic' (if everyone started using that dx where interpretation permitted) then they would find a fairly heterogeneous group of people...

 

[OldPsychDoc]

> .....I thought that 'rapid cycling bi-polar' did similar work to 'adjustment reaction'. Everybody has emotional ups and downs though only occasionally manifesting as fully fledged bi-polar. I didn't think that the rapid cycling variant suggested medications... But I don't know terribly much about this.
...

Oh no no no. Rapid cycling bipolar is VERY specific if you read the DSM, and clearly requires meeting full criteria for manic, depressed, or mixed episodes (4 x year, with periods of normality in between). You might be thinking Bipolar type II? If I had a dollar, though, for every emotionally dysregulated borderline who buys into a "rapid cycling" diagnosis because she "can be happy one minute and bite you head off the next"...well, I think I'd at least be driving a better car.

I have been known to "upgrade" a "depression NOS vs. substance induced depression" to a MDD in order to get a patient to meet criteria for case management. But otherwise, I try to play by the rules.

 

[Chimed]

My current pet peeve is ED nurses and staff (sometimes including MD's) who automatically label someone schizophrenia based on inferential or even absent evidence. I've been consulted on people just brought in from the ED to another unit, noted to have schizophrenia, I was consulted for aggressive behavior, ?d/t psychosis. Turns out the guy was just aggressive because he's aggressive. I tracked down the first person to put it in the chart in the ED, who said "well he was so angry I just assumed." WTF????

More commonly is people who've been on antipsychotics for whatever reason (mood stabalization, anti-nausea, etc.), who then somehow magically get into their PMH "schizophrenia." Forget that whole very advanced technique of actually asking the patient if they have it or not. But once it gets into their chart, it's amazing how much work has to be done to unlabel them as such. Have to agree with the OP.

Grr.

It is scarry that someone else besides myself has faced this! On more then one occasion I've gone to see a pt in the ED with a previous diagnosis of Schzophrenia and they simply didn't come close to that diagnosis. On one occasion, I asked the pt why he thought he had that diagnosis. At first he had no idea what I was talking about, but after probing a little further it turns out that several years ago he had one episode of hallucinating while being severely depressed. He was also heavily drinking!!!! He was admitted during this period for SI and must have mentioned the hallucination during the interview . Amazing....

 

[Heathcliff]

Don't bash drug companies just because you want to. Don't tell me that they are pushing it despite there being no studies, when you have made no effort to look for the studies which are out there in large numbers. Don't tell me that we don't know how a certain drug works, when there is ample evidence out there. Don't deny the advances in the field if you don't keep up with them and choose to dismiss them even if someone tells you about those.

How do you feel about the program on Frontline titled The Medicated Child?
At this time, the entire program can be viewed online here.

 

[TheWowEffect]

How do you feel about the program on Frontline titled The Medicated Child?
At this time, the entire program can be viewed online here.

There is certainly some degree of overmedication in children but from what I have seen during my rotation in Child Psychiatry, the kids definitely needed those meds and most of what was done was evidence based. Newer studies are coming out and a lot of children are helped by these meds. There is, of course, a lot to be said for bad parenting for many problems children today face.

Having said that, this has nothing to do with what I am talking about. Challenges at a residency program are of entirely different kind.

 

[Ypo.]

It's interesting that you bring this up. As a med student, I sometimes wonder if it really does matter for a lot of patients. I've brought this question up and I've been told that what really matters is the billing.

Very often, I see different diagnoses for the same patient. Last week one psychiatrist diagnosed a patient with MDD with psychotic features. Another one diagnosed her with stimulant induced psychosis. Another one diagnosed schizophrenia. All three of them recommended the same class of medication.

 

[TheWowEffect]

It's interesting that you bring this up. As a med student, I sometimes wonder if it really does matter for a lot of patients. I've brought this question up and I've been told that what really matters is the billing.

Very often, I see different diagnoses for the same patient. Last week one psychiatrist diagnosed a patient with MDD with psychotic features. Another one diagnosed her with stimulant induced psychosis. Another one diagnosed schizophrenia. All three of them recommended the same class of medication.

A lot of my patients have asked me what their dignosis is, and were content to know when I explained why it was given. So, it does matter for a big subgroup of patients.

If you are giving the same meds for MDD with psychosis and schizophrenia, something is wrong with what is being done. Either schizophrenic also has a comorbid diagnosis of depression or MDD with psychosis is being given only an anti psychotic which may happen in some cases but is not the only treatment for the condition.

 

[Ypo.]

A lot of my patients have asked me what their dignosis is, and were content to know when I explained why it was given. So, it does matter for a big subgroup of patients.

If you are giving the same meds for MDD with psychosis and schizophrenia, something is wrong with what is being done. Either schizophrenic also has a comorbid diagnosis of depression or MDD with psychosis is being given only an anti psychotic which may happen in some cases but is not the only treatment for the condition.

No, I just mean they all prescribed an antipsychotic. The patient was already on welbutrin when she came in. They all wanted to add risperdal.

To me it looks like most people treat the symptoms.

And as an afterthought, I worked inpatient for awhile and it drove me nuts that they would give a diagnosis on the day of admission. Big thumbsdown for me. Labeling a patient with a mental illness can also have a detrimental effect on them, too.

 

[erg923]

I feel I have to comment here. First, I feel very strongly that diagnosis is important for appropriate treatment. I have no doubt, and have witnessed, many sloppy diagnosis in my time. However, the changing diagnosis of a patient over the course of several years should not be all that surprising, and should not be cause for alarm really. Seeing several different diagnoses in one patient over the course of years is just a reflection of the nature of psychiatric illness. As much as the medical model wants mental illness to be taxometrically distinct entities, the fact is that psychiatric illness is NOT. And we should stop pretending that it is in my opinion. There was a great article by Nancy Andreasen in 2006 about the dearth of interest in modern psychiatry of exploring the once flourishing areas psychiatric nosolology, phenomenology, and taxometrics, and the deleterious effects the lack of research is causing to the field. I know DSM-V is working on these issues, but is that all? Am I biased to think that clinical psychology programs are now valuing these issues, and their students delving into these issues more than those in psychiatry residency programs?

Andreasen, N.A. (2006). DSM and the Death of Phenomenology in America: An Example of Unintended Consequences. Schizophrenia Bulletin, 33(1) 108–112.

 

[toby jones]

Thank you, I think I was suffering from a little conceptual confusion regarding rapid cycling bi-polar vs bi-polar II.

> If I had a dollar, though, for every emotionally dysregulated borderline who buys into a "rapid cycling" diagnosis because she "can be happy one minute and bite you head off the next"...well, I think I'd at least be driving a better car.

Yes, that was where that thought was coming from. How about bi-polar II, though? Do you think the emotional instability in borderline personality could be regarded as bi-polar II similarly to how you were regarding the situationally triggered emotional instability in borderline personality (for example) to be an adjustment reaction? Or maybe I'm still confusing the two with respect to less intense mania and rapid cycling...

I would think that as a doc your first responsibility should be to your patients. I think that making sure that people get the care / treatment that they need should be the first priority. It is unfortunate that health care insurers don't quite see it that way... But given that they do what is a doctor to to????? When there is scope for interpretation, of course...

But by the same token it is a damn shame for psychiatry from the perspective of science. It is hard to construct a good nosology with homogeneous patients when there is so much scope for interpretation and where health insurance companies etc necessitate liberal interpretation for the good of the patient.

I have trouble understanding the desire that some patients have to know what diagnosis they have. I think that part of the desire comes from a misunderstanding of the nature of psychiatric classification. They seem to think that there is a completely objective fact of the matter as to which conditions they have and which conditions they don't have. They want a doctor to 'get things right' and give them the diagnoses for the conditions that they actually have. Maybe it is a little like how labelling emotions is meant to result in their feeling more manageable. Once they have a label that they are sure is objectively correct then their distress feels more manageable and legitimated somehow ('it is just like having diabetes it isn't that I need to pull myself up by my own bootstraps').

> If you are giving the same meds for MDD with psychosis and schizophrenia, something is wrong with what is being done...

There are a few different theories with respect to medication. The 'magic bullet' theory is that there is (or should ideally be) one medication per diagnosis. That is sort of the case for... Crap, I can't quite remember... Social anxiety? There was some anxiety disorder that only made it into the DSM as a distinct disorder in virtue of that medication turning out to help some special subset of people with anxiety. Maybe someone else can better remember. Lithium is another example of a 'magic bullet' medication - for bi-polar. The discovery of lithium went some way towards justifying the distinction between bi-polar and schizophrenia.

But then there is the symptom theory. There the idea is that medication tends to be symptom specific more than syndrome specific. There are problems with how you individuate symptoms, though... (E.g., does drug induced low mood count as a different symptom from situationally induced low mood count as a different symptom from no obvious trigger induced low mood? How about delusions resulting from meds vs delusions resulting from head injury vs delusions resulting from mania or depression vs delusions resulting from a psychotic type illness?)

There ARE people working on conceptual issues for nosology. Some theoretically minded clinicians. Some philosophers who are interested in philosophy of medicine / philosophy of psychiatry. I'm doing some work on different classification systems. E.g., chemistry and the table of elements, biology and the linean classification system vs morphological classification systems. Folk classifications of plants (e.g., weeds, bushes, trees, italian herbs, fruit). Computer science (e.g., 'blank screen on boot-up' and 'program crashes'). Books (fiction, biography, historical novel). Anatomy (hearts and kidneys and language processing areas). Psychiatry...

 

[TheWowEffect]

I feel I have to comment here. First, I feel very strongly that diagnosis is important for appropriate treatment. I have no doubt, and have witnessed, many sloppy diagnosis in my time. However, the changing diagnosis of a patient over the course of several years should not be all that surprising, and should not be cause for alarm really. Seeing several different diagnoses in one patient over the course of years is just a reflection of the nature of psychiatric illness. As much as the medical model wants mental illness to be taxometrically distinct entities, the fact is that psychiatric illness is NOT. And we should stop pretending that it is in my opinion. There was a great article by Nancy Andreasen in 2006 about the dearth of interest in modern psychiatry of exploring the once flourishing areas psychiatric nosolology, phenomenology, and taxometrics, and the deleterious effects the lack of research is causing to the field. I know DSM-V is working on these issues, but is that all? Am I biased to think that clinical psychology programs are now valuing these issues, and their students delving into these issues more than those in psychiatry residency programs?

Andreasen, N.A. (2006). DSM and the Death of Phenomenology in America: An Example of Unintended Consequences. Schizophrenia Bulletin, 33(1) 108–112.

Good points..

 

[sunlioness]

IAs much as the medical model wants mental illness to be taxometrically distinct entities, the fact is that psychiatric illness is NOT. And we should stop pretending that it is in my opinion.

Yes, that was where that thought was coming from. How about bi-polar II, though? Do you think the emotional instability in borderline personality could be regarded as bi-polar II similarly to how you were regarding the situationally triggered emotional instability in borderline personality (for example) to be an adjustment reaction? Or maybe I'm still confusing the two with respect to less intense mania and rapid cycling...

Personally, I think it's better explained by dissociation. The rapid fluctuating mood swings are representative of different ego states.

 

[toby jones]

The DSM says something in the preamble blurb about how even though the current system is categorical a dimensional system would more accurately describe the reality. The problem is basically: What should the dimensions of a dimensional system be? Because there is so much controversy over this I don't think the DSM will be made dimensional anytime soon. The model of dimensionality seems to be personality research (so, the big 5 etc).

There are three distinctly different ways that things could be dimensional, though:

1) The difference between the presence and absence of disorder could be a difference in degree (and there might be funny borderline cases where there is no further fact of the matter).
2) The difference between disorder x and disorder y could be a difference in degree (so a person might be 'more or less' schizophrenic and 'more or less' bipolar).
3) The difference between the presence and absence of symptoms could be a difference in degree (e.g., from firmly held beliefs to overvalued ideas to delusions and there could be funny borderline cases).

If the DSM became dimensional you could still continue to make the same categorical distinctions that are made at present - by introducing arbitrary thresholds. I think that part of the resistence to this is the concern that it really will highlight that the thresholds are, in fact, ARBITRARY. One would anticipate problems with health insurers... The concern is that psychiatry might be dimensional in a way that general medicine is not. But clearly general medicine would be better conceptualized as dimensional too (how many abnormal cells are necessary for cancer? how many hookworms need to be present for disorder?)

I wonder how much the present system could be used for the basic dimensions. Don't know whether this has been done but the thought would be to:

1) List all the symptoms that are currently listed in the DSM. (Some will be variations on a theme e.g., low mood for 2 weeks, 2 months etc).
2) Maybe collect them in broader groupings (in as a-theoretic manner as possible)
3) Rank the presence of symptoms from 0 (absent) to 5 (extreme), for example.

Then... If inter-rater reliability was good (yeah, thats a problem) we could figure out which symptoms really are found clustered together in nature...

Not sure if this would be feasible or not. Ideally... Dx would take as long as it does at present... Not sure how many symptoms there would be and / or whether they could be usefully grouped / chunked such that one could rule out clusters at a time... Might be hard to do it in a way that isn't theoretically driven by the current categorical classification system (where the presence of some symptoms are used to generate expectation that certain other symptoms will be found as well).

 

[Anasazi23]

If I had a dollar, though, for every emotionally dysregulated borderline who buys into a "rapid cycling" diagnosis because she "can be happy one minute and bite you head off the next"...well, I think I'd at least be driving a better car.

I throw up in my mouth a little every time I hear that.

Seriously it makes me get a quiver of nausea when I even read that.

I hate it.

 

[Anasazi23]

Andreasen, N.A. (2006). DSM and the Death of Phenomenology in America: An Example of Unintended Consequences. Schizophrenia Bulletin, 33(1) 108–112.

I ran rounds today and the residents were on the receiving end of my diatribe on this very topic.

20 minutes on jcachoao preparedness bull**** and no time for real, old-world psychiatry.

Bleuler must be turning over in his grave when he sees more concern that no junk is hanging 18 inches from the ceiling than the instruction of medical students and residents on classical descriptive psychopathology.

 

[tr]

I'd agree that the 'diagnosis' per se is less important than the symptoms.

Psychiatry doesn't have diagnosable diseases per se because we don't have any pathophysiology. (Unless you count people waving their hands and naming random neurotransmitters, which is bs if you ask me.)

Instead what we have is a collection of syndromes that bleed into each other. The DSM-IV lets us name these syndromes so we can bill for them, but what we're treating is still mostly symptomatology.

Obviously you want to separate the strictly psychiatric from the due-to-a-drug-or-underlying-medical-condition, but beyond that I'm not certain that the choice of label is as important to treatment selection as is a careful assessment of the specific symptoms exhibited by the individual patient.