Monday, December 1, 2008 One Page or Less

I said, "Hold it, Doc, a World War passed through my brain."
He said, "Nurse, get your pad, this boy's insane."
He grabbed my arm, I said "Ouch."
As I landed on the psychiatric couch
He said, "Tell me about it."

Bob Dylan, "Talkin' World War III Blues"

(Continued from last post). As I see it, whenever I see a patient for the first time, any of the following general considerations counts for more than nailing the best of 297 possible DSM-IV diagnoses.

1. Does the patient need to be in a hospital?
2. Regardless of the answer to #1, is the patient suicidal (or, very rarely, homicidal) at all?
3. Very likely the patient presents with some aspect of high neuroticism (anxiety, depression, and/or eating disorder) as this constitutes the bulk of general practice. If not, why is he here? If so, is there anything in addition?
4. Is the patient bipolar, or at least bipolar enough to affect prescribing decisions?
5. Is the patient psychotic?
6. Is there a substance abuse issue?
7. Is the patient cognitively impaired, by mental retardation, dementia, or delirium?
8. Could a medical condition or medication of the patient's be generating the symptoms?
9. Is there a personality disorder, or at least sufficient character pathology to affect prognosis and the clinical relationship?
10. Could the patient have ADHD?
11. Is the patient impaired enough to warrant medication treatment at all?
12. Does the patient have the curiosity and determination to pursue psychotherapy, or is he seeking a pill?
13. Does the patient have financial and logistical access to treatment, both psychotherapy and medication?

Obviously, the answers to these often are not straightforwardly yes or no. The question is always whether there is enough bipolarity or psychosis or whatever to affect clinical decision-making. Whether to call it bipolar I or bipolar II on the one hand, or schizophrenia or schizoaffective disorder or delusional disorder on the other, is hair-splitting, indeed, it's academic. This sort of hair-splitting was fascinating in medical school, somewhat less so in residency, and not at all any more (as Cleopatra put it, those were "My salad days, when I was green in judgment...").

I mentioned last post that diagnosis can matter for prognosis more than for treatment. That is true, but each of the following factors might influence prognosis even more:

1. Has the patient ever maintained a long term (maybe greater than one year) significant relationship?
2. Has the patient been able to hold down a job?
3. How much formal education has the patient had?
4. Is the patient able to live independently?
5. Is the patient on disability?

In general I do not, unsurprisingly, make a big deal of diagnosis. The exception is when doing so might influence motivation for treatment. If a person is seriously depressed or psychotic, but has poor insight or motivation, then it can be useful to pull the somewhat paternalistic medical card of emphasizing Diagnosis (perhaps while brandishing a caduceus and declaring, "By the power vested in me, I name you Sick."). If someone really needs psychotherapy but is reluctant, even the Borderline Personality Disorder card can be played, with sensitivity. But in general, the DSM is for researchers and insurance companies.

I don't expect any of this to change, of course, with DSM-V in 2012. There is a long way to go.


Anonymous said...

It's reassuring to know that you don't just throw labels around -- it humanises the profession. Labeling stigmatises the patient to themselves; and it may cause the patient to intensely identify with their disorder/illness as a fundamental aspect of their being.

I can also understand how not labeling can be considered as a failure of diagnosis and subsequent therapy -- from the perspective of the therapist and the patient

Gerard said...

Ooops, power of suggestion here made me do it.

Gerard said...

Fixed now. I'd say more about this page, Doc, but I'm afraid our time is up.

Pete said...

LOL at Gerard above. Very good post and I loved the Dylan. Now there would be an interesting client for the couch. And agree with you on the diagnosis bit. Sometimes helpful, sometimes not but your questions are more so.