Grand rounds and psychiatric diagnoses

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.

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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.

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Links

Spurious precision: procedural validity of diagnostic assessment in psychotic disorders

9 Responses to “Grand rounds and psychiatric diagnoses”

  1. Rachel says:

    There’s a BBC show on next week – ‘How mad are you’ – where psychiatric professionals have to guess which 5 of a group of 10 people have mental illnesses, by observing them doing a series of tasks… details from the Guardian.

  2. Northern Ireland Exile says:

    I’m not sure how relevant it is that people are able to fake symptoms that psychiatrists then believe to be true. Presumably doctors of all types are faced with patients faking symptoms for numerous reasons, be it in order to avoid work or to gain access to drugs. Based on the fact that doctors often have only the patients’ word on which to base their opinions, why is it wrong that doctors cannot detect liars – they do not carry lie detectors.

    Perhaps the most important question is whether the psychiatrists in question treated the sysptoms that were presented to them appropriately. Surely that would be the measure of how effective the diagnosis was?

  3. NIE – this is an important criticism of the Rosenhan experiment. The vulnerability of psychiatric diagnoses to being based on false reports is no different to what would happen if someone lied about medical symptoms.

    However, in the experiment pseudopatients were instructed to act normally once they were in hospital and despite this the average inpatient stay was 19 days. Also despite only having reported one symptom consistent with a psychiatric diagnosis, and this only at admission, some if not all were discharged with a diagnosis of schizophrenia in remission. One symptom does not make a diagnosis etc.

    You need to find your wordpress profile and delete your picture. Until this time put in a different email address, as this is what identifies you I believe.

  4. Paul says:

    Hi FP

    “Enabling effective communication between professionals.”

    I agree with you that we need to be able to communicate. But how much complexity needs to be sacrificed in the process?

    As you say, diagnoses can be stigmatising and reductionistic. Many service users (and perhaps the chaplain) would also argue that people become their labels through the diagnostic process. For instance, once someone is described as having ‘borderline personality disorder’ this can lead to all kinds of dodgy attributions (manipulative behaviour and so forth). With respect to psychosis, Rosenhan discussed how ward staff described the inpatient’s attempts to keep a diary of their experience as ‘writing behaviour’.

    “Helping avoid unacceptable variations in diagnostic practice.”

    I’m not sure how diagnoses help avoid variation in diagnostic practice? And I’m also not sure why variation is unacceptable. This seems to imply the evaluative judgements underpinning the classification of certain experiences as symptoms of illness ought to be invariant across culture. I may be jumping the gun here but it also seems to suggest that consistency of diagnosis is of higher value than flexibility in response to shifting cultural values over time.

    I expect consistency is certainly achievable and valuable with respect to dementia and brain injury for example – but psychosis, ‘personality disorder’, gender identity disorder, ADHD, asperger’s and so on?

    Accurate discussion of treatment and prognosis is essential of course, however is anyone really convinced that the current systems actually allow that, with respect to schizophrenia-spectrum disorders and personality disorders anyway? I may be wrong but I’ve a suspicion you’re also not convinced by the scientific or philosophical merits of ICD-10 or DSM-IV when it comes to these specific categories?

    Best wishes
    Paul

    P.s I heard on the ‘vine that the chair of the DSM-V task force might be one of MH professionals appearing on the programme Rachel mentions, as well as Richard Bentall. Could be interesting!

  5. Oliver Smith says:

    FP,

    A very interesting article and some very interesting points have been made in the comments. I particularly like NIE’s point about all doctors being faced with fake symptoms and them only having the patient’s word to go on. However, other doctors sometimes have tests which they can perform which can rule out certain conditions. For example, an MI can be ruled out in a patient presenting with chest pain following an ECG. It is of course not unheard of for doctors to be lead down the garden path for years by patients presenting with symptoms that are not really there. I seem to remember reading about a case a number of years ago where doctors even performed investigatory surgery on a patient to get to the bottom of their non-existent symptoms.

    Psychiatry does come in for a lot of (unfair) criticism by the public and by fellow doctors. I’ve heard doctors describing psychiatry as wishy-washy and not really medicine at all (often on the grounds that there isn’t any definitive tests that can be run to make sense of the symptoms).

    Another issue that psychiatrists face is cultural norms. A lot of psychiatric medicine is based on what is ‘abnormal’. For example, hallucinations and delusions of control are two of the clearest manifestations of mental illness in Western culture, but among some African cultures, hallucinations confer status. More generally ‘possession states’ are regarded as normal and indeed valued in many cultures.

    It is a very interesting topic and I could spend hours typing away various arguments on both sides, but will leave it here for now.

    Oliver

  6. not mad at all says:

    Just watched the 2nd part of How Mad are You, and I think the programme was laughable. The psychiatrists got 2 of the 5 diagnoses right. All it told me was: stay clear of mental health professionals! Interesting defence of the show here by a producer: http://blogs.bmj.com/

  7. feathers says:

    Think anyone we fakes symptoms has a problems going off. Also would like to state that having seen a psychiatrist this week was not impressed as he made the greeting…..no one gets to see him sooner through suicidal thoughts….many of his patients had suicidal thoughts and he was stubborn.

    My thought perhaps many of his patients are suicidal for that reason, he does not see them :) ………just a passing thought :) from a mere patient.

    When a person goes from acting on suicidal thoughts to actually expressing them and asking for help….then it is a sad reflection that the people there to help seem to view their patients in this manner, Have adopted an overall opinion, however slight that implication was for me personally then have no trust or faith in that person to oversee my treatment, have more respect for myself.

    This is life, not a game, when life is unbearable and severe depression you need help not people working in an environment where they see their patients in this light…..it seemed not a direction at myself but the manner he oversaw all things.

    Which is their problem not mine, but will not be part of a system that is meant to help people and has this attitude prevailing.

    As far as diagnosis are concerned it is true they like tick boxes and unfortunately am not a box but a person. Was also relayed to myself that psychiatrists are learned to discount emotions, text book material, will state people from abused situation their emotions are how their depression hurt pain is built in them, to discount this area is a detriment to the treatment of that person, they need to start looking at the whole person in order to be more effective.

    Text book is good but experience and learning from situations holds more keys to the treatment of people, would think that most that have rose to the top of their profession have learned and unlearned many things along the way.

    My opinion is if they viewing patients in this manner they need to take a step back and rethink why they joined the profession, was it to enable people to lead better quality of life’s?

    Surely not all the majority of patients who end up in mental health sector are faking symptoms? after all you have to have some serious mental health illness to actually get a referral, the mere fact that you are even there, means that your illness is such that you need extra treatment and support…. to then view patients in that manner is perhaps an excuse for not actually seeing them? Something is wrong and it is not the patients who are greeted by the hard environment that they seem to wish to work within working with vulnerable people

  8. chris says:

    for over 5 yrs iv been back n forth my gp been given ssri’s asked to see a mental health person 2 months ago heard nothing since i told the last doc y i needed 2talk i was sxually abused about 5-13 i am male i am embarrassed but i cant go on ive hearrd nothin yet about seeing a psychiatrist i feel i cant go on i tried to kill myself last sunday a+e for a few hrs still cant talk to any1 so here i am cant gethelp been iven samaritans number oh yes that will do if i knew andha thecourage how to kill myself fite this moment without harming any1 else i would

  9. Dana Williams says:

    The Martha Mitchell effect being of one unfortunate woman? I believe there could be a lot more than just one out there!

    Classic example of clinicians not assessing background data and other variables before checking that box for a diagnosis. All too common now where people are not believed, voices are not heard, and related information that could be rationales are excluded. You get the diagnosis and RX just like you would get a boxed up happy meal through McDonalds. It is as fast and swift as getting lunch through a drive through!

    There are pharmacological seekers that fake their signs and symptoms, but I believe there are far more misdiagnoses people that are not seekers, but sadly believe their misdiagnoses due to a multitude of lazy, uncaring providers our our mental health field. Like the write Feather stated regarding in the boxed patient from a background of abuse, the immediate negative stigma attached and false belief system is mental illness that apparently, is now integrated in their psyche, concious and subconscious, and into their behavior (sooner or later). They are even pre diagnoses before full fledge symptoms are even observed (which is more than a mood swing or two). The Martha Mitchell effect may come in to their care that minimizes any story and/or injustices that may occurred (or can occur), thus eliminating the victim’s right to their voice and what could have been positive implications with spreading awareness and implementing changes in society to others in similar situations.

    However, old-school-diagnosis-happy-lazy psychologists/psychiatrists, a discriminatory MD that doesn’t want to deal with historical data and a possible previous injustice, and a unsupported family that believes such atrocities… is all it takes to box up the human being in a false diagnostic happy meal that is spun off to other incompetent healthcare providers through the drive throughs of clinician appointments.

    Now, welcome to what is the beginning of ground rounds in the psychiatric, mental health field.

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