Which Discipline Does Diagnosis Best?
This is a question I am often asked. Another variant: Is it important I see a psychiatrist for a diagnosis or can I trust my therapist? The answer is complex. No discipline has a monopoly on great diagnosticians or terrible ones. On average, the training and skill in diagnosis would roughly follow the hierarchy: (1) psychiatrists; (2) psychologists; (3) psychiatric nurse-practitioners; (4) social workers; (5) counselors; and (6) psychiatric occupational therapists. But many of the worst diagnosticians I have known have been psychiatrists, and some of the best have been nurses and social workers. So you can’t go just by the diploma. There is more variability within professions than there is across professions. All the more reason to be a smart consumer, studying the issues on your own so that you (and your family) are in effect providing a well-informed second opinion and a monitor on the process.
It is especially hard to place primary care doctors in the hierarchy of diagnosticians. Some are absolutely brilliant at psychiatric diagnosis, but most lack the knowledge or are simply too busy or couldn’t care less. This is important because primary care doctors are such heavy prescribers of psychiatric medicines. If your primary care doctor knows you well and has spent time with you before offering treatment, there is a reasonable chance it may make sense. But always be suspicious about a diagnosis and treatment plan when you are offered a prescription after a seven-minute visit or if the doctor offers to start you out with free samples. Nothing is ever free, and the doctor’s decisions may have been too influenced by drug salesmen and by his desire to get you out of the office as quickly and conveniently as possible. Be aware that primary care doctors prescribe far too many medications in general and are particularly loose with antianxiety drugs (like Xanax) and antipsychotics (like Seroquel and Abilify). I would always get a second opinion before taking them.
I would recommend always seeing a psychiatrist if your psychiatric problems are severe and/or if you also have medical problems.
Is Psychiatric Diagnosis a Family Affair?
Almost always yes, but occasionally no. It is an inherent part of human nature to have biases and blind spots in the way we see everything. And the worst biases and biggest blind spots undoubtedly occur when we look in the mirror. Thus far we have described the uses of self-diagnosis, but we must also recognize its limitations and possible abuses.
Self-unawareness is the nature of the human beast, but it can be a special problem for people who have mental disorders. Severely impaired insight is an inherent feature of some psychiatric problems (e.g., schizophrenia, mania, delusional depression, anorexia, dementia, antisocial and narcissistic personality disorder). But insight can also be impaired in much more subtle ways in many of the less severe disorders. You may be the last to know that your depression (or anxiety or drinking) is causing significant impairment, and the last to want to get the help you need. Remember that two thirds of people with severe mental disorders fail to get the treatment that might make a huge difference in improving their lives.
This is where the family comes in. Loved ones can very usefully fill in gaps in information and insight and instill the sense of urgency that is often necessary before someone will seek help. They often provide a day-by-day awareness that might otherwise be lacking of the evolution of the symptoms and of their impact on functioning and on interpersonal relations. For this reason, I have always tried to include the family in every diagnostic evaluation of a new patient—whenever they are available and willing and if the patient is also willing. If geography makes personal interviewing difficult, phone contact or Skype is far better than nothing at all. Each family member can bring unique information and insights that in aggregate are much more likely to lead to an accurate diagnosis than would the conclusions of any one person. It is also useful if everyone in the family participates in monitoring the nature, course, and severity of symptoms, and if everyone is working from the same knowledge base in implementing the treatment.
There are two exceptions to this rule—situations in which active family involvement in diagnosis may not be a good idea and can cause its own set of problems. Most poignant is when the family is not loving and instead is working at cross-purposes. In the midst of a family feud, psychiatric labels can be used as dangerous weapons. This is particularly true when child rearing or custody issues are part of the dispute. The family needs to resolve the feud before they can be usefully involved in the diagnosis of any one of its members. Sometimes treating the individual successfully helps to reduce the conflict (which may have been triggered at least in part by that person’s psychiatric problem). The family can then be brought together to play a constructive role.
There is a second exception. Young adults who are struggling to become more independent may need to sort things out for themselves without the involvement of their families. But these exceptions are rare. In most situations the family is a crucial ingredient in accurate diagnosis.
When Should a Psychiatric Diagnosis Be Reevaluated?
First impressions in psychiatric diagnosis, as in the rest of life, are not always accurate. Here are three situations when it is especially important to consider the initial psychiatric diagnosis to be no more than a tentative theory, not an established fact.
The first and most common is when the treatment plan that had been aimed specifically at that diagnosis has had unsatisfactory results after a fair trial (i.e., adequate dosing and duration). Treatment failure can, of course, occur even in the presence of a completely obvious and accurate diagnosis and an appropriate treatment. The first question should always be: Did you really take the medicine that was prescribed or do the psychotherapy homework that was assigned? A treatment shouldn’t be judged a failure if it hasn’t had a fair shot. But even good trials have on average about a one-third failure rate. This may call for a next trial of an alternative treatment for the same diagnosis. But another possibility should also always be entertained—that because the initial diagnosis was inaccurate or incomplete there was a less-than-optimal choice of treatment. Suboptimal diagnosis and treatment are always to be considered as possible causes of less-than-acceptable treatment response. A change in diagnosis and a new and more appropriate treatment sometimes work wonders.
Diagnostic failure is also often the result of missing the causative or complicating role of substance abuse (especially in younger patients) or of medical problems or medication side effects (especially in older patients). But missed or inaccurate diagnoses can and do occur for any number of other reasons—an incompetent diagnostician, a withholding patient, insufficient time for evaluation, or situations where diagnostic stability is low. Whenever the first treatment doesn’t work well enough, it is useful to review how closely the diagnostic criteria have been met and whether something was missed during the first go-round. This should be done with your clinician—but it is also a good idea to check things out yourself and/or to get a second (or third) opinion.
Diagnoses made early in the onset of psychiatric symptoms are much less likely to be accurate and stable than those based on a longer track record. This is particularly true of diagnoses made of children (in whom developmental factors can lead to rapid changes) and of teenagers (in whom drugs, peer pressure, family issues, and problems in growing up can also play such a complicating role). Be tentative for all but the clearest presentations in young people. You can’t always assume that a “lifetime diagnosis” (e.g., bipolar disorder or autism) will last a lifetime—especially when it has been based on incomplete information, a short course, and symptoms that occur early in someone’s life.
The diagnostic process is a movie, not a snapshot. Making a diagnosis should never be static and frozen in time by a first impression. An initial diagnosis is just that—initial. It is a hypothesis to be tested and challenged by accumulating experience. Considering the course of the symptoms is a very important part of the diagnostic process, and the course is often revealed fully only with the passage of time. So keep an open
mind and a watchful, introspective inner eye on the progression of symptoms and what it says about the diagnosis.
Some presentations of psychiatric symptoms seem to pop off the page of the DSM criteria set. These are classic textbook examples of the given diagnosis that no experienced clinician will miss and that you can probably make yourself. Some presentations are less obvious and will require considerable clinical skill to tease out. And there are some presentations that are, for the moment at least, so confusing that nobody, no matter how highly skilled as a diagnostician, can make them out. The more prototypical the symptom presentation, the greater (though never absolute) the confidence in the diagnosis and the proper treatment. The more muddled the presentation, the more tentative the diagnosis and individualized the treatment approach. Often only time will tell—the true nature of the disorder declares itself only as its course gradually unfolds.
The bottom line is to strive for diagnostic clarity, but not to impose it beyond what the available evidence allows. Changing a diagnosis midstream is often unsettling, but sticking with an inaccurate diagnosis is far more damaging. You and your clinician should feel comfortable testing the diagnosis with repeated systematic reevaluations. And when things are unclear, accept that they are unclear rather than jumping to a premature and inaccurate closure.
The Risks of Self-Diagnosis
The effort to become a well-informed consumer also has traps and carries risks. The most obvious is that the end result could be your becoming a badly misinformed consumer—leading to possible overdiagnosis, underdiagnosis, or misdiagnosis. It is always wise to stay skeptical about your self-diagnosis, to keep an open mind, and to check it out with family members and a mental health professional.
The most frequent cause of overdiagnosis is assuming that having one (or just a few) psychiatric symptoms means you have a full-blown psychiatric disorder. Many people have some symptoms some or all of the time—this is just part of life, not psychiatric disorder. Remember that you must have the full cluster of symptoms at a sufficient level of severity and duration before talking yourself into having a mental disorder.
The most common cause of underdiagnosis is insufficient information. This is also the most easily corrected. All you have to do is study more and be more thorough in your review of possible diagnoses. More difficult is the underdiagnosis caused by shame, denial, or your being an unusually stoic or hopeless sort of person. You will probably have trouble overcoming these on your own, so try to accept the help of loved ones and clinicians.
The most likely cause of misdiagnosis is to underestimate the role of alcohol and drugs in causing your symptoms. You may not have noticed the connection or you may feel the active urge to deny it because you don’t want to face the thought of having to cut back. The second most common mistake leading to incorrect diagnosis is to miss the fact that your medical illness (or the medicine you are taking for it) may be causing your psychiatric symptoms. This is complicated and difficult to figure out on your own. Working it out will require the collaborative help of all of your medical and mental health clinicians.
The next risk of self-diagnosis is rare but potentially quite harmful. For some, the quest for information can feed a kind of emotional hypochondriasis. Try to remember that the individual symptoms of psychiatric disorder are extremely common and form an inescapable part of everyday life. Everyone has occasional flashes of anxiety, or depression, or attention deficit, or memory loss, or binge eating (and so on down a list of dozens of symptoms). But most people don’t have a mental disorder. If you seem to have every disorder in the book, it is much more likely that you have none at all and are overreading the manual.
Finally, a little knowledge can be a dangerous thing. You may find sport in labeling not just yourself, but also your family, friends, and particularly your boss. This can lead to casting cheap shots, particularly in the heat of battle. Throwing diagnoses like darts can hurt the other person and cause you to experience a vicious cycle of blowback attacks. But for the vast majority of people, the benefits of self-diagnosis far outweigh the risks.
Beware Fad Diagnoses
If everyone suddenly seems to have a diagnosis or to be talking about one (be it ADHD, bipolar disorder, PTSD, or autism), assume it is being overdone and don’t jump on the bandwagon. Also don’t be overly influenced by your friends’ diagnoses or media reports that a celebrity has a particular diagnosis or that a previously ignored diagnosis is now being discovered in lots of unsuspecting people. Cyclical diagnostic fashions come and go and leave much damage in their wake. Always be skeptical of the diagnosis du jour.
Beware the Drug Companies
The pharmaceutical industry will do its best to mislead you. It is in the business of making money by expanding markets and will do whatever it takes to recruit new customers. Drug companies are constantly being fined for unscrupulously passing out false information to consumers and to doctors, but they keep doing it because it is so profitable. Be particularly wary of drug company advertisements that are cleverly devised to move product by casting a wide diagnostic net, often catching people who don’t need the product. Don’t be trapped in it and don’t let your children be trapped in it. Treat drug pitches with the same healthy skepticism you would have toward a glib used-car salesman. And don’t assume that “Ask your doctor” will provide protection against snake oil. Your doctor may also be unduly influenced by the long and strong arm of drug company marketing. Beware doctors who have drug company logos on their pads, pens, and cups and are liberal with free samples. Be skeptical, but not cynical. Used correctly, medication can be very helpful and sometimes curative.
Herbal remedies that make mental health claims are even less regulated than drugs. Because they are not monitored by FDA, promoters of herbal remedies can and do make outrageous claims that are completely unsupported by evidence. There is no way of knowing whether their products are pure, safe, or effective. It is a fair assumption that all are a bogus rip-off.
The Internet is both the best and worst source of information on psychiatric diagnosis. Pick your sites carefully and with skepticism. Some sites are clearly drug company marketing tools; many others may be unduly influenced in less obvious ways by subtle and subliminal drug company marketing. Double- and triple-check things before believing them.
Natural Healing
Time and resilience are almost always on your side. Symptoms that are mild and stress related are probably just part of life and will get better on their own or if you make some simple life or psychological adjustments. I can’t repeat enough times—don’t jump to the conclusion that you are sick just because you are sad or anxious. Give yourself time to sort things out and to see how nature takes its course. And do the obviously helpful things that most people know they should do but don’t. Exercise, exercise, and exercise—it is a great healer of both mental and physical problems. Make sure you are getting enough sleep—sleep deprivation causes psychiatric symptoms. Reduce or eliminate your intake of alcohol or drugs. Reach out to friends and family. Seek spiritual help. Figure out what you would most like to do and put more good minutes into your day. Identify which problems are causing you grief and then figure out solutions. Off-load whatever stress you can safely off-load. All this may seem trite and commonsensical, but trite, commonsensical solutions really do work for everyday problems.
Natural resilience and simple solutions won’t work if your symptoms are severe and/or persistent. Real mental disorders need attention from a mental health clinician. Don’t be shy about getting professional help when you need it, but avoid it when you don’t.
CHAPTER 9
The Worst and the Best of Psychiatry
First do no harm.
HIPPOCRATES
AN ACCURATE DIAGNOSIS can save a life; an inaccurate diagnosis can wreck one. For many people, the day they are first diagnosed is a tipping point that will have a profound impact on how the future will unfold. It will be a terrific day if the diagnosis is done well and leads t
o an effective treatment. But done carelessly and callously, diagnosis can trigger an extended treatment nightmare. There is no better way to bring home the immense impact of diagnosis than through the life stories of people who have experienced it at its worst and at its best. First, we’ll hear the harrowing accounts of eight resilient souls who suffered from incredibly incompetent diagnosis and crazy-making treatment. Their briefly told stories pack more impact than a mountain of dry statistics. Each has found a way out of the psychiatric labyrinth—but not without scars. Aside from all the practical problems, it is nightmarish having to face a distorting diagnostic mirror that reflects back someone strikingly different from who you are and who you want to be.
The clinicians in these sad stories (including me) ignored what should be the first and last dictum in medicine—First Do No Harm. It is painful to discover how many lives have been harmed and harmed badly when psychiatry is done badly. Psychiatric diagnosis at its worst leads to psychiatric treatment at its worst, and together the combination is a recipe for disaster. The casualties are a living and much-needed rebuke to the field and provide the inspiration and passion for the sizable antipsychiatry movement. Psychiatry must learn from its bad outcomes and take very seriously the often well-deserved attacks of its critics.
Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 25
