Sunday, December 12, 2010

Diagnostic Errors and The Shrink

Meg sent me a link to Happiness in The World (what an upbeat name for a medical blog!) and The Danger of Early Closure. She wanted to know how it pertains to psychiatry.
The author writes: Sometimes doctors gather all the clues correctly, think all the right things based on those clues, and still get it wrong. But in this case, another significant thought error contributed to the misdiagnosis: my tendency to come to early closure.

Early closure, it turns out, is a danger that lies in wait mostly for seasoned clinicians (far more commonly, at least, than for medical students and residents). Because seasoned clinicians rely more on pattern recognition to make diagnoses and often come to their conclusions rapidly, they’re at far greater risk for leaping toward those conclusions without examining all other should present (luckily for us all, this is the exception and not the rule). At other times, however, these mistakes are made because the physician was simply in a hurry, or tired, or didn’t care enough to think through the evidence in ways he should have, saw a pattern he thought he recognized, and stopped asking the most important question a physician can ever ask: what else could this be? relevant possibilities. Patients often present with a constellation of symptoms that don’t entirely fit the diagnosis they actually have. Often the discrepancies between these presentations and the textbook descriptions are unimportant—but sometimes those discrepancies exist not because the patient’s body hasn’t read the textbook, but because the diagnosis the doctor makes is the wrong one. Such misdiagnoses are occasionally unavoidable: the symptoms with which the patient presents are simply too far afield from the way the medical literature says the disease

It’s the same with us all. We all come to early closure all the time, forming opinions about the behavior of others without sufficient consideration of all relevant facts. We become attached to the explanations that make the most sense from the perspective of our own experience and our own point of view.

Do we do this in psychiatry? Of course. It's not at all uncommon for a psychiatrist to diagnosis a patient with Major Depression when, in fact, the patient has Bipolar Disorder. Why? Sometimes there has been no episode of mania (yet) and a diagnosis can't be made. Other times the symptoms have been explained away as something else: an exuberant personality, anxiety, a reaction to events. And finally, sometimes the doctor simply forgets to ask about such episodes or the patient/family don't report them as they've drawn their own conclusions.

What else? Psychiatrists may attribute mood instability to personality disorders. This is the case less and less, as we've found that when people's mood stabilizes, so does their behavior. Or a psychiatrist may see a patient who is very distraught after an upsetting life event and attribute the mood changes to an adjustment disorder, when in fact the patient has developed depression. Hopefully, we re-think our diagnosis if the symptoms persist or don't follow the usual course.


Anonymous said...

when you succumb to your inevitable fate and start your adventures in vin blog, i think you should create a new language for reviewing wine. don't use the usual vin platitudes. they're a damned snooze. apply terms of psychiatry/psychology to talk about wine. in your reviews, educate people as to the discreet psych meanings and then creatively extrapolate to discuss the taste, nose, finish, et al of the wine. give each a diagnosis. i'm sure i don't know how to do this, but it is yours to do. think, for example, what would make a bipolar wine? a wine with distinctly opposite taste and finish? and maybe there is a bipolar II wine and a bipolar IV wine and maybe you should prescribe the taster a food (vs a psych med) or a mood or occassion for each psychodynamic (i never used that word before, did i get it right?) of the grape. the new yorker would be banging your door down to get the dinah story. it's work, but you're smart. i believe in you.

Battle Weary said...

Since I am procrastinating working on my senior thesis and therefore don't really have time to find citations, I'll call this anecdotal information!

Dissociative disorders, especially DID are often misdiagnosed initially due to attributing symptoms to other issues. For example...what is the first thing that comes to mind when a patient (new or otherwise) reports hearing voices? How about hearing voices and seeing people others do not see? People with DID often hear voices, and a smaller percentage "see" the "people" these voices are coming from. A key here is that these things are both perceived as internal, not external. However, that key question is often not asked and the patient is sent home with anti-psychotics, which will do absolutely nothing to help. Also, switching between alters (or ego states if you prefer) is often missed and attributed to borderline or bipolar.

Doctor Blondie said...

Or, in some cases, a psychologist labels a patient 'borderline' when in fact, the only problem is that she is not willing to confide her innermost secrets to a complete jackass.

Don't worry, my 'team' very soon decided that I was very much not a borderline and treated me for my depression.

I went on to work as a psych intern last year, and I am quite pleased that my own assessment skills surpass that of the person who was supposed to do my intake years ago. How do I know? I asked the patients how they found the intake procedure. I'm not saying that I'm better at diagnostics; I'm just saying that I'm better at getting the relevant information.

I wonder how many people in psych land get a wrong diagnosis because the person giving them the diagnosis can't get past themselves.

Anonymous said...

Dr Blondie, your comment makes me wonder how many other people have had this done to them. What really horrifies me is not only that your medical record can never really be changed and that many doctors judge and treat you according to your "diagnosis".
It's also really sad to think that most 'borderlines' have the most horrific pasts, and the medical professionals that are supposed to help, really just seem to perpetuate the cycle.

Psych seems to me to have a strange dynamic. Often the most painful and private aspects of ones life are relevant to diagnosis/treatment. But when one (ie me) is ill, low in self esteem and paranoid surely this would make them less likely to disclose. How much of the practice of psych is establishing and maintaining trust and rapport?

(do people really share things so openly?? *high levels of anxiety associated with the preceding question!* eek!)

How is such a subjective skill learnt and assessed?
And who lets those jackasses practice!?!

Oh, and Dinah. Thank you so much for your 'how to find a shrink' post.
I saw three people and the Dr I ended up going with was the only one that fulfilled your criteria.

Now all I need is a "fragile - handle with care" shirt for those post-psych days.

Thanks again,

P.S. are you aware (like physios) you work and get paid to cause people pain? Does that explain the jackass sadists?

Alba said...

dr blondie, the same happened to me. common misdiagnosis, apparently.

but i think one should not forget the other side - patients pressing the clinician to provide a diagnosis. i know that side as well. after 30min, they want to know what they have and how you are going to cure it *sigh*.

and people still have the possibility to ask for a second opinion somewhere else when they don't think that their diagnosis fits.

so yeah. diagnostic erros can happen, can be made to happen, but, in most cases, can be corrected. we're humans ;).

S said...

"I wonder how many people in psych land get a wrong diagnosis because the person giving them the diagnosis can't get past themselves." Dr. Blondie: Yes. I am haunted by this same question.

I had this kind of thing happen over and over. I have found myself arguing with an inpatient psychiatrist that no, i have never had any of these symptoms of mania; on another occasion, arguing with two (different) clinicians that no, i have never heard voices (They found my state of "denial" really concerning). I had a doc who suspected schizoaffective disorder, having interpreted my exhaustion and my annoyance with him on the initial interview as "flat affect" and "possible paranoia" (i found this out years later when i pulled my records for a billing dispute). And borderline is of course an old favorite trash can diagnosis for a cutter.

And this: "What really horrifies me is not only that your medical record can never really be changed and that many doctors judge and treat you according to your 'diagnosis'." So true, Anonymous! In fact i suspect that's what happened in some of the above scenarios i described. The doc and social worker who insisted i was hearing voices; well, i was on Zyprexa at that time (prescribed by the doc who thought i had schizoaffective) so not a huge leap. The doc who insisted i was manic; i'd made the mistake of telling him i was on lithium once, years back as a teenager; when i did that, he got a Look... then when i said i'd never had a "manic episode", well, those suspicious words apparently confirmed that i was not to be trusted. He told me i was not being truthful, and when i found it upsetting, that was treated as a symptom!

As unacceptable as i find this behavior, i also feel certain that these doctors (at least most of them) had my best interests at heart. I think they fell victim to very human tendencies and a system that reinforces these tendencies. (And also, i think i present as overly intellectual and somewhat detached, and that can confuse docs initially.) Dinah, i hope you won't think i'm trying to bash shrinks; i am not, i think you have a very hard job and that many of you are not given the support you need to do it well.

(I also really feel for people who truly have borderline PD. Honestly, i could tell the docs who diagnosed or suspected borderline viewed me as a pain -- and i probably was! But what an unfairly prejudicial view against a group of people. Plenty of other medical conditions are difficult to treat, but we don't blame the patient for our lack of treatment options.)

S said...

Alba, you are absolutely right. And yet, i am not concerned for a patient like myself -- at this point, i've learned from experience to not put up with a shrink who latches onto a quick judgment like this, because there are really good ones out there.

My concern is for patients who don't know that they're being misdiagnosed, and are desperate for an answer and will jump at the hope a new diagnosis would give. Or someone who loses hope when they are not listened to (I've been there).

It seems to me that the inpatient setting enables to this kind of snap judgment. The doctor has very little time to get to know the patient and then implement an intervention that will work in this short-term, crisis situation -- you are asked to come to early closure so as to limit the length of the patient's hospital stay. And there's no long-term followup, so if the physician was wrong, he likely won't hear about it unless the patient gets re-admitted.

How can this be improved?

S said...

"...arguing with two (different) clinicians that no, i have never heard voices..."

Sorry last one i swear: I meant two clinicians at the same time, doc and social worker (different from the mania guy). I felt outnumbered in Bizarro-Land.

Anonymous said...

Dr. Blondie, sounds like a psychiatrist I know. Back when I was doing my clinical training there was a philandering psychiatrist who handed out the borderline diagnosis quite liberally. It's easy to see why, if he could believe it was all "them," then he never had to take responsibility for his own behavior. I feel sorry for the women who are unlucky enough to end up in his office.

Anonymous said...

S, there's one more scenario you forgot on topic of dealing with doctors who jump to conclusions-- sometimes there just aren't many available. This became extremely problematic when I moved. I can recognize a bad doctor makes decisions about me without actually knowing anything, but resources in my area are limited. I eventually managed to find somebody I like, but it took a disturbingly long time, and was a generally miserable process. I'm lucky that my parents are paying for me to see someone who isn't covered.. otherwise I'd be up the creek without a paddle.
And while being able to recognize when a doctor is jumping ton inappropriate conclusions makes it somewhat easier, it's still not easy to deal with accusations. Or to answer questions when the person asking isn't listening to the answers. I'm not even sure how it's possible to go about answering a question someone is asking when they've already demonstrated that they're not listening to my answers. And of course, then not knowing how to answer those questions only "proves" that you're being dishonest. [sarcasm] Never mind being totally flustered by questions that don't make sense, being interrupted every 30 seconds, and being told that YOU don't make sense, without being told why. The ONLY reason I could be having trouble answering questions under those circumstances is if I'm being dishonest to begin with. [/sarcasm] The really confusing thing is that as far as I can tell, truly manipulative people rarely seem like they're being manipulative. It seems like a good liar will almost always be easier to believe than an honest person who is nervous. I really don't know how to deal with that.

Carolyn Thomas said...

Very interesting stuff here. I couldn't help but think about Dr. Jerome Groopman's excellent book "How Doctors Think" while reading this post.

Dr. Groopman describes what he calls a doctor's “diagnosis momentum" - like a boulder rolling down a mountain, gaining enough force to crush anything in its way.

For example, he claims that attribution errors can happen when a doctor’s diagnostic cogitations are shaped by a particular stereotype or a dislike of the patient.

But my favourite diagnostic example in his book is the section on what he calls "The 18 Second Rule", which is the average time it takes a doctor to interrupt the patient as the symptoms are being described. By that stage, the doctor already has in mind what the answer is.

Groopman explains: “It’s not that doctors lack sufficient clinical knowledge, but are rather tripped up by their biases.”

More on Dr. Groopman's work at "The 18-Second Rule: Why Your Doctor Missed Your Heart Attack Diagnosis" on HEART SISTERS -