Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments

The Relative Unimportance Of Diagnosis In Psychiatry

Look, he came back! Guest blogger Mitchell Newmark, M.D., put on his armor and came to blog with us again.

The Relative Unimportance of Diagnosis In Psychiatry

As we will soon be witness to the emergence of DSM-V, the new rule book for psychiatric diagnosis, I am reminded of all the pitfalls of diagnosis in psychiatry. In other fields of medicine, diagnosis is based primarily on etiology, with objective findings, rather than on symptoms alone, as it is in psychiatry. When you go to your internist with stomach pain, there’s an endoscopy to look for ulcers, a sonogram to look for gall stones, a blood test to look for hepatitis. But in psychiatry, there is no CT scan to check for bipolar disorder, no blood test to assess if the patient has schizophrenia, no spinal tap to check for major depression.

For the psychiatric community at large, diagnosis is important for many reasons. It helps doctors sort out patients so that clinical trials can be conducted on similar groups of patients. It enhances communication among psychiatrists when behavioral, affective and cognitive symptoms can be categorized. But for the individual patient, it is less useful. Some patients fit nicely into DSM categories, and others don’t. There are many patients who have unique combinations of symptoms across several diagnostic criteria. This leads to assigning multiple diagnoses, and confusing the treatment picture.

Since diagnosis is based on symptomatology, treatment should also be based, more often than not, on symptoms, regardless of the “official diagnosis.” Latching on to a diagnosis may often limit the treatment options because medicines or psychotherapies designed to treat one disorder are considered inappropriate for treating another disorder. Flexibility is essential for coming up with the best treatment plan for an individual, especially those patients who do not fall neatly into a diagnostic box.

I am always happy to discuss diagnosis with patients, but even this can cause difficulties. For example, when I see a patient in their late teens or early twenties with protracted psychotic symptoms, not due to drug abuse or medical issues, and without the mood changes seen in depression or mania, I am asked: “Is this schizophrenia?”

According to the DSM, the answer is yes, but many patients recover from these episodes completely. The psychiatric answer is: “This seemed like schizophrenia, but it must have been something else.” Meanwhile, the patient has had to cope with being labeled with a devastating diagnosis. I would prefer to answer: “These are the symptoms you have, so let’s treat them with the appropriate medicines. We may discover over time that you have schizophrenia, or an illness like schizophrenia, an illness that does not have a clear-cut diagnosis, or this episode may resolve completely and indefinitely.” And that’s the truth.

Someday I may be able to send a patient for a PET scan and get a report back stating: “Impression: Bipolar disorder, type [x]!!” By then the DSM will be a thing of the past.

*This blog post was originally published at Shrink Rap*

You may also like these posts

    None Found

Read comments »

Comments are closed.

Return to article »

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »