A ‘grand round’ is a term used by doctors to describe a large meeting were doctors who work at the same institution get together and talk about doctory things. Mostly this involves a presentation of an interesting patient, with subsequent discussion. For the habitually parsimonious there is also an added incentive of a free lunch.
I won’t bore you with the fine details of grand round I attended today, but suffice it to say that it concerned a patient with a long psychiatric history who had had several admissions to psychiatric hospital. She had had a very difficult upbringing and, at various times, a pretty broad selection of psychopathology.
Following the presentation, there was a long discussion as to how best to formulate this patient’s problems and with this in mind, how she should be treated. There were five or so experts on hand, and the interesting thing was that they all drew different conclusions from the same information; there was, variously, an animated debate about the possible existence of a personality disorder, a stout defense of the presence of psychosis and suggestion of an affective disorder. One member of the panel, a chaplain but one of only two people in the room who had met the patient, didn’t think that the patient was mentally ill at all; he said this so politely that I didn’t realise at first.
It’s not unusual for a patient with a long term problem with his or her mental health to attract a selection of psychiatric diagnoses over the years. The odd one or two seem quite pleased about this, but I’m sure for most patients and their families this must be quite confusing. A psychiatric diagnosis is made by the elicitation of recognized psychiatric symptoms by (hopefully) a trained professional. There are no tests available and if the constellation of symptoms with which a patient presents changes (the so called ‘clinical picture’) then the diagnosis can also be altered. Diagnoses themselves are standardized in two publications, namely the ICD-10 and DSM-IV. These standards envisage the possibility of patients being given more than one diagnosis at the same time. Which leads to the interesting idea that more than one mental illness can exist in a single brain simultaneously.
That there are no tests, and that psychiatrists themselves find it difficult to agree about individual patients, has often brought into question the validity of psychiatric diagnoses. I will limit myself to two very interesting points here, one a study and one unfortunate woman.
Martha Mitchell, the unfortunate woman and after whom the Martha Mitchell effect was named, was the wife of the attorney general in Nixon’s government. She was considered to have a psychiatric disorder following her allegations of impropriety in Nixon’s government. She was right, and psychiatrists were wrong.
Around the same time as Watergate, in 1973, David Rosenhan conducted a study consisting of two parts. The first involved the use of ‘pseudopatients’ who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different states in the United States. The second involved asking staff at a psychiatric hospital to detect non-existent ‘fake’ patients. In the first case hospital staff failed to detect a single pseudopatient, in the second the staff falsely identified large numbers of genuine patients as impostors.
So what are the use of psychiatric diagnoses at all? Paul and me have been having a polite discussion about this, and despite his making some good points I cannot see the whithering of the ICD-10 yet. Psychiatric diagnoses earn their keep by:
Enabling effective communication between professionals.
Helping avoid unacceptable variations in diagnostic practice.
And allowing more accurate discussion of treatment and prognosis.
But on the other hand they are reductionistic and stigmatizing.
Top tip: if you’ve attended a grand round solely to get the free lunch, then make sure you sit near the door, as the doughnuts go quickly.