Wednesday, June 17, 2009

Do Not Remove This Tag

It's incredibly difficult to remove a psychiatric diagnosis. I've read quite a bit on the blog from readers about the trouble caused by an incorrect or premature diagnosis; I know what they say is true and I've seen it myself. What you may not know is that psychiatrists share the frustration about inaccurate or incorrect information in a medical record.

Many years ago a patient of mine had to get admitted to a medical unit for a diagnostic procedure. She called me weeks later after getting a copy of her discharge summary because the medical resident wrote that she was a "psychiatric patient with a history of multiple admissions". In fact, she had only been admitted once, for depression. My patient wanted to know how to fix this incorrect and potentially very damaging information. That was the first time I ever had to deal with this problem so it took a little investigation, but after calling around I found out the only thing she could really do was write a letter to be included in her chart with the correct information. It also makes me crazy to get a discharge summary from a hospital that lists a discharge diagnosis---particularly one that involves a psychotic spectrum illness---with no data to support the diagnosis.

The problem happens in correctional facilities too. It goes something like this:

Intake nurse to newly arrived prisoner: "Do you have any mental problems?"

Inmate: "I hear voices."

Nurse writes "schizophrenia" on the problem list and fills out a referral to the psychiatrist. I see the guy.

Clink: "Have you ever been in a psychiatric hospital on the outside?"

Inmate: "Nope."

Clink: "Have you ever seen a psychiatrist or taken psychiatric medication?"

Inmate: "Nope."

Clink: "The referral says you've been treated for schizophrenia. Can you tell me about that?"

Inmate: "I hear voices. I have schizophrenia."

After a multitude of questions I figure out this is another inmate self-diagnosis. I clearly document that he does NOT have a psychiatric condition. Then he gets released, re-arrested and convicted, re-sentenced and comes back to my building six months later. His medical problem list still documents "schizophrenia". No one has bothered reading my note. At times I've resorted to writing directly on the problem list: "This patient does NOT have schizophrenia." That seems to help.

I'm careful about how I document my diagnostic thinking. If I'm not sure about a condition, I don't diagnose it. If I'm about 75% sure but not positive, I write that I'm considering a diagnosis but not making it and then I document why I'm not making the diagnosis yet. If I disagree with someone else's diagnosis I explicitly write out the differences in the data that I'm relying on and how I'm interpreting that data. Doctors don't have to agree with one another and our diagnostic criteria are certainly not absolute, but it helps to know how people are thinking.


alfavita y2k said...

You know, maybe the problem is not what you think, the problem is bigger and it starts at the beginning of the wrongly concieved and forgotten Prison Correctional system.

Let's say that it seems like no one ever have ever thought about a asimple fact that is the Prison.

There is a short axiome in psychiatry that says:

"If the country has all the system requirements to offer life quality to the citizens, then everybody who is considered a criminal is to be automatically considered to be a mentally insane person also".

This means, that if a country has abnormal social system status, which includes social deviations or degenerations, such as Dictatorship of any political or religious group, nobody knows for sure if someone put in jail is just a simple insane criminal, or a fighter for freedom against the unfair governement.

In case we are talking about any normal country, where the social system has all the requirements to be considered normla, such as Democratic Republic that allows any kind of required freedom to any citizen, it is obvious that anybody who is jailed is becouse of mental problems concerning mental deficiency or schizophreny, that makes peoples minds unable to comprehend that they just cananot harm or kill other citizens.

You might call th ecurrent situation a paradox, irony of faith, or whatewer you want, but the only fact tht ais so obvious, is thta someone just forgot to advise the democratic governements that all the inmates are clearly allready crazy, and proison psychiatrists should just be responsable to undarstand what exactly is wrong with inmates.

tracy said...

i have been hospitalized several times for ODing and "stiches/staples" cutting and so it's obvious with just that much information that i am a Borderline, but i have seen a copy of my charts and the notes in them and i have been "diagnosed" with so many "Axis", i can't list them Dr. even cam up with "Body Dysmorphic Dysorder"...that was a first. Was it because i said i thought i was ugly? Because i said i wanted to lose weight?

Heh. What a diagnonsenical mess.

tracy said...

PS i'm "tagged" for life...oh, well...i'm pretty old, so the chances of anything "holding me back" from a "future" are p r e t t y slim.

Anonymous said...

In these days of protected medical files, I don't see how a diagnosis can affect employment. Am I missing something? otherwise I am "tagged for life" also, but I managed to get a teaching job so I do not feel "tagged". My current psychiatrist does not agree with the initial diagnosis, so I am not still being treated by someone who will not look at me objectively.

Retriever said...

Great post.

Anonymous, where I live and work, it doesn't matter if your medical files are "protected". One has to pass a pre-employment physical and fill out an exhaustive health questionnaire before a job offer being finalized. If one lies (to conceal a potentially stigmatizing diagnosis), or if one writes down what one has been told is one's diagnosis (without knowing of other, more perjorative or just wrong diagnoses in the past) one risks being fired at some future date when previous diagnoses come to light.

In addition, in this dreadful economy, where nobody can be assured unbroken employment, most of us will have to purchase private insurance at some point. There again, one can either lie to get the insurance (and risk future claims being denied when they search the record to discover what you left off) or tell the truth and be denied.

So it really matters what diagnosis sticks to one.

On the other hand, with many disabled kids, it can be to their advantage (if parents can overcome their own denial and understandable grief at their beloved child being ill) to have as many serious diagnostic labels as possible in the file, as insurance will not pay for treatment without them, and school systems will not provide needed services ditto. Furthermore, depending on the issues, mentally ill children may get into trouble with the law because of behaviors caused by their disorders, and they need the legal protection of a diagnosis. Not so that they can misbehave with impunity, but to protect the vulnerable from predatory kids in reform schools, etc.

It would be interesting to track changing diagnostic labels and whether they follow diagnoses reimbursed more generously by insurers (I believe they do). When relatives were hospitalized, the clinicians would be quite up front about how they would attach as many labels as possible to be sure the person got the care they needed paid for.

I think this is a factor in the explosion of kiddie bipolar diagnoses: they may or may not actually be bipolar, but calling them that assures them at least a modicum of care and treatment for symptoms of dreadful severity.

wetnurse said...


If I were the nurse doing the intake on that inmate who told me he "heard voices", schizophrenia would be the last thing I would write on the chart.

First I would say, "The only voice you'll be hearing is mine saying over and over "you are soooo NOT getting any seroquel'".

My intial diagnosis would be 'quel-seeker.

Anonymous said...

There is indeed a problem with these tags - especially erroneous ones.
There is an opposing problem with how to correct them due to legal records and such.

I don't think the problem belongs to the patient or clinical service.

I tear out and shred pages and amend errors at the stroke of a pen - I write all over doctor's (or other clinicians') obvious errors.

The pt is happier.
The clinical service is better.
Let the legal dept now sort out their problem.

Sara said...

It's not just psych. I see it all the time. Say a patient comes in with a discharge letter after a cardiac cath, and the file says, "Hypertension, Hyperlipidemia, Diabetes." Not uncommon to find that a patient never had any sugar problems. But you can NEVER get that off there. Next time they go to the hospital, the admitting doc doesn't believe them when they say they don't have diabetes...they must just not know.

alfavita y2k said...

I believe before attempting to understand any kind of physical dysfunction in patient's mind and body, any not mentally retarded psychiatrists sboud carefully investigate if the patient's mind was hacked by external couses, which are of course "Mesmerisation" or better suited as deep hypnosys.

It is strange, but it seems no one seems to care ab out the simèple fact that any patient that looks physically normal cananot have psychiatric or physical problems by natural causes.

It would be very helpful if in any psychiatri chospital, and even prison dorctors could have a warning to be careful about patients minds in first place becouse of possible cause of victims of deep hypnosis.

Jim F. said...

I also worked as a therapist and clinical supervisor in a prison psych hospital, and I saw some of this problem too - we couldn't remove pages from a chart, but we could add updated diagnostic summaries. If I was changing an earlier dx I would spell out my reasons at length, basically addressing each of the DSM-IV-TR criteria for both the old and new dx and giving concrete examples of whatever I saw. I had a guy who had been diagnosed as bipolar when in fact his symptoms indicated he had severe PTSD along with a moderate level of antisocial personality dx - I wrote that I didn't think he was bipolar because, among other reasons, I had worked with him for over a year during which he was not medicated and never saw anything that could have been interpreted as mania.

With a lot of doctors in other settings, I believe the problem is the fear that if they change a diagnosis they made earlier they'll be accused of having blundered with the first dx and sued. I always just specify that the diagnosis is provisional based on information available as of that date, and if I need to change it later I specify the new info that's based on. Haven't had a problem as a result so far in 22 years.

TheCrazyMusicLady said...

Working with Children and Adolescents, it's scary sometimes how many tags these kids already come with.

It's even more frightening that the DX on discharge papers from previous admissions still says r/o or vs.

Not being a psychiatrist myself, I asked the question of one patient whose discharge diagnosis was cyclothymia. I asked the MD why cyclothymia and not just Mood Disorder NOS or any of the other mood dxs that aren't bipolar.

Apparently that's one of the dx's that slip under the radar. Just wish that other MD's were this thoughtful about what impact their current treatment will have on a patient's future.

Good stuff.

Also. Alkavita, I'm curious about this statement "simèple fact that any patient that looks physically normal cannot have psychiatric or physical problems by natural causes."

The nature of psychiatric illness is that it might not always manifest physically. The only possibly application I could think of this would be ADL completion, but certainly a patient who is narccissitic or grandiose might be inclined to bathe themselves, since they do, after all, have to look beautiful for their admirers.

But perhaps I'm just misunderstanding your statement.

alfavitay2k said...

Certainly my dear CrazyMusicLady, you misunderstood a lot. I will be glad to help you in th emost professional way. Here it comes:

Almost 2000 years ago there was a psychiatric and psychological consortium between th emost two developed countries in scientifical terms, the Roman and Greek empires.

Thye had jeniuses among scientists, that were able to write the code of human beings.

This is the main part of the code:


ALFA + OMEGA = Death

VITA + OMEGA = Death



If you are unable to understand what is the meanaing of this code,it means only two things, you are a lower class uneducated - ignorant person, or you might be in need of a psychiatric help becouse in unconscius state of mind. In both cases you are in great danger.

TheCrazyMusicLady said...

Wow, if that was your professional manner, I think you might need to work on it, because that was just rude.

However, history aside, the point I was referring to was the statement that a person cannot look physically normal and have a psychiatric or physical problem due to natural causes. How then, do you explain the perfectly handsome and normal looking son in a wealthy family that just happens to be strung with bi-polar disorder?

I ask in the nature of general interest, not looking for a lecture. While I am no MD, I am far from uneducated, and I find your manner of speaking to someone asking a legitimate question in the spirit of debate very inappropriate.

alfavita y2k said...

I am sorry, but do you have some kind of agressive - passive disorder that has to deal with schizophreny?

Becouse from what and how you communicate it is obvious that you tend to be a passive agressor, probably hiding yourself in denial, by the fact that you are female and everybody should be passive - naive with you.

Anyway my way to communicate is not natural, as I tend to communicate in a professional manner when i see a potentially disturbed person like you.

First I need to explain to you, that what I wrote was not any kind of disrespecteful towards you in any way.

Uneducated or ignorant are not insults, but unfortunately a huge social problem in psychological education missing in schools even today and even in developed countries.

If you know that even a lot of psychiatrists are mentally insane themseves, you might see how dangerous the situation is in reality, hidden very deep by the mass media showing polurar shows like American Idol instead, or news channels thta are constantly showing only news about god forgotten third world countries basic problems about civil wars or famine.

And now answering your question:

If you follow these simple three rules of Conspirology:

1 If it looks like a freak, it acts like a freak, and it sounds like a freak, it must be a freak. - Trust your instincts.

2 If you eliminate all the impossible, whatever remains, however implausible, must be the truth. Trust your logic.

3 Every action as a cause has always the same or the opposite action as the effect in time or space. Trust all hints.

So back to your question, it is siimple to remeber a sit is a naturally universal physical law:

If you see someone who is not quite normal, it is always the parents foult, as peolle get crazy only becosue they were mesmerized since childhood by night by theor respective crazy parents.

Dr. Alexander Odinson

Aqua said...
This comment has been removed by the author.
Aqua said...

Hi Clinkshrink,
Thank goodness there are psychiatrists like you. What makes me sad is that our psychiatric diagnosises, whatever they are, become "...potentially very damaging information" Not something you would worry about with a physical illness. This has to change. It is a ridiculous division of how we perceive illnesses. This stigma is what is the most damaging.

TheCrazyMusicLady said...

I just want to apologize to Roy, dinah, and ClinkShrink for feeding into the attention seeking. Going through previous posts, I've realized that this is someone seeking a rise and I'm sorry I provided that.

Carry on with your excellent blogging.

Anonymous said...

Yes this is particular problem. Mental health professionals should never forget that labels they use day to day can have a serious impact on a citizen. Labels are hard to remove.

A diagnosis should not be given lightly and they are hard to remove once applied.