Ways to improve diagnostic skills?

[hebel]

---

Members don't see this ad.

I'm in my 3rd year as an outpatient attending. I'm hoping it's just a case of me moving into the trough of the Dunning-Kruger curve, but lately I'm finding diagnosing to be quite a bit more challenging than the treatment aspect of clinical practice.

Do you have any resource recommendations for getting better at it?

Some more diagnostic focused texts I've gone through include The Psychiatric Interview (MacKinnon's), Systemic Psychiatric Interview (Chisholm), Fish's Clinical Psychopathology, Psychoanalytic Diagnosis (McWilliams), The Psychiatric Interview (carlat), Formulation in Psychology and Psychotherapy (Johnstone), the DSM5 handbook of differential diagnosis, and am currently going through a compilation of old Kraeplin lectures.

There's definitely plenty of people with more straightforward diagnoses, but I still often (almost daily) feel much less certain about people's dsm-5 "clinical" diagnoses then I feel I should following their initial evaluations.

 

[littlefred]

I'm in my 3rd year as an outpatient attending. I'm hoping it's just a case of me moving into the trough of the Dunning-Kruger curve, but lately I'm finding diagnosing to be quite a bit more challenging than the treatment aspect of clinical practice.

Do you have any resource recommendations for getting better at it?

Some more diagnostic focused texts I've gone through include The Psychiatric Interview (MacKinnon's), Systemic Psychiatric Interview (Chisholm), Fish's Clinical Psychopathology, Psychoanalytic Diagnosis (McWilliams), The Psychiatric Interview (carlat), Formulation in Psychology and Psychotherapy (Johnstone), the DSM5 handbook of differential diagnosis, and am currently going through a compilation of old Kraeplin lectures.

There's definitely plenty of people with more straightforward diagnoses, but I still often (almost daily) feel much less certain about people's dsm-5 "clinical" diagnoses then I feel I should following their initial evaluations.

Bob's DSM-5?

 

[Celexa]

I'm in my 3rd year as an outpatient attending. I'm hoping it's just a case of me moving into the trough of the Dunning-Kruger curve, but lately I'm finding diagnosing to be quite a bit more challenging than the treatment aspect of clinical practice.

Do you have any resource recommendations for getting better at it?

Some more diagnostic focused texts I've gone through include The Psychiatric Interview (MacKinnon's), Systemic Psychiatric Interview (Chisholm), Fish's Clinical Psychopathology, Psychoanalytic Diagnosis (McWilliams), The Psychiatric Interview (carlat), Formulation in Psychology and Psychotherapy (Johnstone), the DSM5 handbook of differential diagnosis, and am currently going through a compilation of old Kraeplin lectures.

There's definitely plenty of people with more straightforward diagnoses, but I still often (almost daily) feel much less certain about people's dsm-5 "clinical" diagnoses then I feel I should following their initial evaluations.

It's good to feel uncertain after some initial evals. I'd be more worried if you were certain every time. Some people it takes time and multiple sessions to refine the diagnosis. Some patients will baffle you forever. Such is life.

If I had a nickel for every patient who got ****ty care bc their provider anchored completely on a diagnosis after one visit I could retire tmr.

 

[Old&InTheWay]

I kind of feel like the DSM doesn't fully capture all of the nuance of human experience and it would be odd if we felt certain about DSM diagnoses all of the time.

 

[DOswag]

I felt this way somewhat for a time after residency. I don't know if my diagnostic skills have improved so much per se (I mean i feel a little more confident now after some experience under my belt) but I think I was able to take a step back and realize that just because I make a certain diagnosis now, doesn't mean I have to stick with it if further eval yields more diagnostic clarification. Or after seeing them for several encounters, they'll tell you something that you were certain you asked about before but they forgot which can change diagnosis/treatment. To some aspect, patients are just going to be baffling because they don't fit neatly into the checklist of DSM diagnoses. But I bet you'll benefit from the extra reading you've been doing and you will improve with time and experience.

 

[Stagg737]

There's definitely plenty of people with more straightforward diagnoses, but I still often (almost daily) feel much less certain about people's dsm-5 "clinical" diagnoses then I feel I should following their initial evaluations.

Why do you feel it's necessary to have a specific DSM diagnosis? For complex cases a good formulation is usually better than trying to narrow things down to the DSM. I've found myself using "other XYZ disorder" more often since residency as the DSM just doesn't seem to capture their situation well. I've also had some people that seem to fit certain conditions not currently in the DSM almost perfectly (cycloid psychosis most recently), so continuing to read and collaborate with educated colleagues has been very beneficial for me.

 

[vanfanal]

Agree with all that’s been said. Sometimes time if the best intervention.

I was very hung up on the diagnosis when I started as an attending, especially because I worry wort when it comes to malpractice. But I’ve grown more comfortable with gray areas, discuss the impression with the patient and let them decide, and let’s see where time takes us. Though I think regular follow up, like monthly, is essential.

 

[Fan_of_Meehl]

I'm in my 3rd year as an outpatient attending. I'm hoping it's just a case of me moving into the trough of the Dunning-Kruger curve, but lately I'm finding diagnosing to be quite a bit more challenging than the treatment aspect of clinical practice.

Do you have any resource recommendations for getting better at it?

Some more diagnostic focused texts I've gone through include The Psychiatric Interview (MacKinnon's), Systemic Psychiatric Interview (Chisholm), Fish's Clinical Psychopathology, Psychoanalytic Diagnosis (McWilliams), The Psychiatric Interview (carlat), Formulation in Psychology and Psychotherapy (Johnstone), the DSM5 handbook of differential diagnosis, and am currently going through a compilation of old Kraeplin lectures.

There's definitely plenty of people with more straightforward diagnoses, but I still often (almost daily) feel much less certain about people's dsm-5 "clinical" diagnoses then I feel I should following their initial evaluations.

James Morrison's books (The First Interview, DSM-5 Made Easy) are pretty good and Christopher Shea's psychiatric interviewing text (Psychiatric Interviewing: The Art of Understanding) has a lot of depth and clinical wisdom infused throughout the text.

 

[splik]

Well I think it is great you are being thoughtful about it. I would suggest seeking clinical consultation from a master clinician if you want to improve your skills. But I can also tell you it is a relatively recent phenomenon that psychiatrist made diagnoses after the initial encounter. Historically, this was often done after a series of visits, sometimes over months or even a year. Of course most patients it does not take that long and many people can be accurately diagnosed after 1 visit, but there are a lot of times when this is not the case. And it definitely takes more than one visit to have the most accurate or useful formulation for patients who are more complex. Clinical presentations evolve over time and may not initially declare themselves. Being open to new information and constantly revising your formulation is more important.

 

[hebel]

Thank you all for the replies so far. A big take away so far is that I probably need to reset my expectations, which has been very helpful to hear.

My first few years were mostly in a position that had little interaction with other psychiatrists, so there were few opportunities for case discussions or even a general discussion of topics like this.

 

[hebel]

Why do you feel it's necessary to have a specific DSM diagnosis? For complex cases a good formulation is usually better than trying to narrow things down to the DSM. I've found myself using "other XYZ disorder" more often since residency as the DSM just doesn't seem to capture their situation well. I've also had some people that seem to fit certain conditions not currently in the DSM almost perfectly (cycloid psychosis most recently), so continuing to read and collaborate with educated colleagues has been very beneficial for me.

I don't think it's necessary, but for better or worse the published efficacy statistics for the medications we use come from studies utilizing specific DSM diagnoses.

I do agree with your philosophy though.

 

[surfguy84]

I would say I've gotten very comfortable saying "diagnostically unclear, but it appears....." in the formulation. I'll lay out my thoughts why I'm thinking something but essentially say, there's no way in hell 90 minutes with this person is enough time to make a diagnosis based upon the totally contradictory and generally unhelpful history they've provided. It is what it is. At the end of the day, if I have more than a 51% hunch it's something, I'll treat that.

 

[Fan_of_Meehl]

Thank you all for the replies so far. A big take away so far is that I probably need to reset my expectations, which has been very helpful to hear.

My first few years were mostly in a position that had little interaction with other psychiatrists, so there were few opportunities for case discussions or even a general discussion of topics like this.

NEVER forget (and this is helpful with your patients, too...especially if they try to corner you on 'Why are you not diagnosing me with PTSD??? I have 'the PTSD' (or 'the ADHD' or whatever diagnosis they 'want'): you can never 'prove' a negative (I can't PROVE you don't 'have' PTSD, but I can do a full differential diagnostic process using multiple sources of information like interview, objective testing, symptom self-report, observation over time, etc.) and I can consider multiple diagnostic/etiologic possibilities and exercise reasonable clinical judgment to choose one over the other and fully articulate the reason and evidence behind that decision. In the end, with few exceptions (maybe specific forms of dementia, delirium (with known etiology) and obstructive sleep apnea, for example) there are simply NO definitive physiological/medical 'tests' to determine a psychiatric diagnosis. In the end, nearly ALL of our psychiatric diagnostic categories represent 'working hypotheses' that may enjoy or fail to enjoy empirical/logical support based on all the data we have available to us and our clinical reasoning.

 

[J ROD]

I got drugs that treat symptoms....I will figure what to call it later.

 

[forchinet121]

I got drugs that treat symptoms....I will figure what to call it later.

People are not gonna like this 😂

 

[Fan_of_Meehl]

People are not gonna like this 😂

I like it...I think it shows style.

Reminds me of my dream to, on the very last day of my VA employment before retirement, diagnose the following in the chart for about half my patients:

Service-Connection Deficit Disorder, Recurrent, Severe, Most Recent Episode Manic, Without Interepisode Recovery

 

[calvnandhobbs68]

I like it...I think it shows style.

Reminds me of my dream to, on the very last day of my VA employment before retirement, diagnose the following in the chart for about half my patients:

Service-Connection Deficit Disorder, Recurrent, Severe, Most Recent Episode Manic, Without Interepisode Recovery

Exactly why I take any study that comes out the VA with a grain of salt. When you're dealing with a population where a significant proportion of them have a vested interested in being as "disabled" as possible, prettyyy easy to see how that could skew your data on basically any somewhat subjective (medical or psychiatric) diagnosis.

 

[Fan_of_Meehl]

Exactly why I take any study that comes out the VA with a grain of salt. When you're dealing with a population where a significant proportion of them have a vested interested in being as "disabled" as possible, prettyyy easy to see how that could skew your data on basically any somewhat subjective (medical or psychiatric) diagnosis.

You are wise to be skeptical. The entire research database is probably forever skewed/borked due to this. I think Rosen (2007?) wrote an excellent (but nearly completely ignored) article about this and the VA admin as well as the MH professionals higher up in the organization are in complete and utter denial (at least 'publicly'). The clinicians on the front lines are more than aware of this reality because they live it every day. It's kind of surreal the degree of disconnect between the MH higher ups and what the reality is on the front lines.

I was on a video TMS training today by an 'expert' discussing how to deal with problems in terms of treatment response to the 'evidence-based protocols.' Half the people in the chat room were bringing up the issue of what they called 'secondary gain' / malingering for service connection. The expert cited a really crappy 'study' from years back that I remember scrutinizing the details of when I was doing C&P's years ago that claimed that there was evidence that malingering or symptom exaggeration was 'extremely rare.' In case anyone is wondering, that 'study' (if I remember correctly) basically examined the percentage of cases of service connection claims that had been essentially proven 'fraudulent.' I mean...we're talking about a damned disorder that is 100% based on subjective self-report. To anyone with above room temperature IQ, it's pretty clear that a very small percentage of these cases will be investigated and found to be 'fraudulent.'

On the other hand, I read a study the other day indicating that even conservative cut-offs for overreporting using the MMPI-2-RF (when they looked at ALL the administrations of that instrument nationwide (through Mental Health Assistant)...the N was something wild like 14,252 or something, lol) they found high rates of failure on symptom validity scales (F, Fp and the like) on the order of high 20%'s all the way up to nearly 40% across many types of VA clinics. Highest rates I think were in PTSD specialty clinics (something like 38%).

But...you know...symptom over-reporting doesn't even exist at the VA. Even though just a single full version of the DSM ago (DSM-IV) essentially required us to rule out malingering prior to diagnosing PTSD. And when they changed the law (2010? I believe) that removed the requirement that the traumatic stressor in wartime needed at least some form of corroborating paperwork (i.e., that they actually were involved in a specific combat action), it opened the floodgates for people claiming PTSD and the need for MH services like quadrupled.

 

[tr]

I got drugs that treat symptoms....I will figure what to call it later.

I totally agree with this. The DSM is just a checklist for billing purposes anyway. We don't have a diagnostic framework based in pathophysiology so it's just a matter of finding a convenient label really.