Monday, November 21, 2011

The Stability of Psychiatric Diagnoses

We've talked a lot about diagnoses here on Shrink Rap.  We've talked about how diagnoses are made, how valid they might be, how as labels they can be stigmatizing or damning in a person's life.  We've talked about how they are used to guide treatment and how they are demanded to obtain reimbursement for care.  What we haven't talked about is how they hang out over time.

When I see a patient for the first time, we meet for 2 hours, I take a full history, family members may come in, and subsequent to the appointment, I may talk with a past psychiatrist, a current primary care doc, and I may request old records that I will review.  I take the information I have and I form a diagnosis.  Is it the right diagnosis?   Oh, who knows.  I don't sit there with the DSM and read off a check list and some of it is art.  The DSM diagnoses aren't science, they were voted on by a committee.  I come close.    Like what is the exact divide between Major Depression, recurrent, mild versus Major Depression, recurrent, moderate ?  To the extent that it guides treatment, I care about getting it right, but sometimes the honest answer is I Don't Know.  Or the patient comes to me after they have gotten well--- they are not currently having symptoms, but they are on medications which they say help, and they report that before they were on medications, they had symptoms consistent with Diagnosis X.  If they are medications that are usually used to treat Diagnosis X, if they had symptoms consistent with Diagnosis X, I believe them and diagnosis X.

So here's how treatment goes.  Usually the patient has symptoms and the majority of the time the symptoms are consistent with a specific diagnosis and everyone agrees.  Let's say the diagnosis is recurrent major depression, moderate in intensity, coded 296.32.  I start the patient on medications for this condition and they come for therapy.  A few weeks go by, and the patients symptoms get better, but they still have issues going on in their life.  Stressful things that they are dealing with, or troubling relationships, or life just not going the way they'd like, so they still come for therapy.  And each visit, a bill is generated and the bill needs a diagnosis, so the diagnosis remains,  because this is what is being treated and this is what the patient is getting medications for, and so it's 296.32, even if the patient's symptoms are at bay, or even if the patient comes in saying that they are anxious today, or even if the patient spends the entire session talking about the fight they had with their sister and never mentions a word about their mood or symptom complex.   The diagnosis is usually a stable thing for the paperwork issues that call for it.  I mentioned statements for insurers, but in clinics, it needs to be on treatment plans, and in EMRs, and any form that goes to an agency which has regulations, including Day Programs, Psychosocial Rehab programs, Care provider organizations, etc.  No diagnosis, no services.  And some services are only accessible to the patient with specific diagnoses that indicate a severe and persistent psychiatric illness.  I would say that for a patient who has had numerous psychiatric hospitalizations, is unable to work, gets benefits from the government because they are disabled by mental illness,  and requires medication to remain well, it seems reasonable to agree that a major psychiatric disorder exists, even if on a given day, the patient says he is not having any symptoms of the illness and is feeling well.  It has to be this way, or no therapy would ever be done: every session would be a diagnostic evaluation with check lists of symptoms.  Now I'm not saying that diagnoses never change...they do...people get manic and we realize that their unipolar depression is really bipolar depression, or with time we realize that there is more than one diagnosis, or that a preliminary diagnosis was simply wrong, or that alcohol or drugs were a bigger contributor to the symptom complex than we realized at first.

But when our theoretical patient, the one with major depression, moderate, who had a long hard course with it, notes that a long time has gone by with no symptoms of the illness (on medications and with therapy) and he asks, "So do I still have depression?"  it does make for an interesting session.

What do you think?


Sherri said...

I resemble that remark, so I do find it an interesting question. My take is yes, I do still have depression, even though right now, today, I am symptom free, just like I have migraines even though I don't actively have a migraine this very second. Both conditions require me to take medication to manage. Both conditions require me to be disciplined about lifestyle choices. Both conditions require regular doctor visits.

My condition is under control, it's not gone.

Liz's Blog said...

i understand how this is so confusing. after all, if i'm maintaining a stable sense of self, keep my excellent interpersonal relationships (excellent marriage/excellent friendships/close with extended family), and have no impulse/self destructive issues, do i still have bpd?

in the end, however, i agree with sherri: the answer is YES.

i suffered from awful depression and bpd until i was around nineteen or so. i was relatively symptom free until the age of 24. because i thought i was "cured," i wasn't in treatment or taking any medicine during that time, and i got more severely mentally ill more quickly than i could have ever expected. i lost my vigilance... had i continued with, let's say, monthly meetings with a counselor, or an ongoing relationship with a psychiatrist, i don't know that i ever would have fallen that far...

i appreciate the need for labels. but when i tell a new practitioner that i have been diagnosed with bpd, i can sometimes see the shift in how they respond to me. i remember, though, that my "label" doesn't define me, and any practitioner of mental health services who thinks it does isn't worth the price of their degree.

Anonymous said...

interesting food for thought. I would have to say that if someone has had these issues over 20-30 years and they have a predictable time table that they follow, that regardless of medication they take and being stable, they still have the diagnosis. Take those meds away and give that person a major stressor ( loss of job, divorce, death of a loved one) and you would have the same issues/diagnosis pop up all over again - in my opinion.

When I am stable, I just like to say that I am in remission, but I still have issues.

rob lindeman said...

Rephrase the question: "So do I still have a chemical imbalance?" or "So do I still have an organic brain disease?"

Do you reply "no, you never had a chemical imbalance to begin with", or "no you never had an organic brain disease"?

Now that's a session I'd love to observe as a fly on the wall.

FWIW, my answer to the query is "no, you don't have depression any more."

wv = dessess. Tings da girls weah wen dey goes out.

Dinah said...

What if it had been 3 years since you'd had a migraine (or depression), then what? Do you hope you're cured and stop the medicine?

Liz's Blog: Given your first paragraph, and a 5 year period without symptoms, I would contend that it's likely that you don't have borderline personality disorder....personality disorders need to be enduring.

But, Rob, I never phrased it that way to begin with....

Anonymous said...

As a patient who has been shortchanged by diagnostic labels, I can say that you shrinks are sooo concerned with looking only at the mental stuff, that you don't see what's staring you in the face. I have mental symptoms that don't appear until a slew of transient physical complaints precede them. It's starting to look like I have an autoimmune disorder with inflammation of the brain/Central Nervous System. But all the shrinks in the world keep saying that I have Bipolar Disorder (Type I) with Psychosis, even despite my advanced age at onset and my complete lack of any depressive episodes. During a hospitalization a few years back, the burning sensation in my arms was called a tactile hallucination. Except it wasn't!

If the mood symptoms only appear during a time of whole-body inflammation due to connective tissue disease (likely; no MD can see past the mental to work me up), then how is this a mental illness? Some day, my shrink will see the light and change my label and code from 296.40 to "Mood Disorder Due to a General Medical Condition." But until you shrinks stop focusing on always making the mental primary, my physical stuff will get shortchanged. I'll still take the mood stabilizers, but I want to be looked at a person inside an whole body, not just someone with misfiring neurotransmitters.

Kartik said...

I believe that this article brings to the forth the predicament of psychiatrists and psychologists in making certain diagnoses. The usefulness of diagnosing a disorder correctly and accurately lies in the fact that, it facilitates a better patient-doctor relationship or patient-therapist relationship, which only helps in understanding, conceptualizing and managing the disorder better. For a long time a question always kept me skeptical, "What is the clinical difference between Mild Mania and Hypomania? How is the diagnosis of Bipolar I or Bipolar II disorder facilitated by understanding the difference between the two(Mild Mania and Hypomania) should the patient have an episode of major depression too?"

The diagnosis is particularly important as a misdiagnosis can lead to a treatment which can traumatize the patient for a long time, leading to non-compliance also. As regards to the last question, "So, do I still have depression?", I feel it's a difficult question to answer. You never know how the diagnosis would change, how the prognosis would shape out to be, how a relapse could curtail the perfect remission of a disorder under medication.

This article surely throws a light on the difficulties in diagnosing a disorder.

Please keep this blog and the discussions active.

Anonymous said...

I think of my depression as episodic, so it's fair to say that I'm not in a depressive episode these days (and an episode to me means something lasting at least 2-3 weeks ... to years). But I have a susceptibility to these episodes, and if I don't take meds, monitor moods, exercise, live right etc. etc., the mood dips return and are way harder to turn around once they've begun. (It also can be harder to recognize as "symptoms" in the first place.)

Thinking of myself as cured, on or off of medication, hasn't been a successful strategy for me, though there have certainly been times (2-3 weeks to years) when I'm not depressed.

By the way, I did attend a program for people with chronic mental illnesss and found it very helpful, though once my symptoms eased it was clear that I was way higher functioning than most of the others -- none of whom were exhibiting active manifestations of their illnesses (no one manic or hallucinating (much)). Still interesting to me to think of how much of my sense of self needs to be tied up with this illness -- clearly some, but not as much as some people who spend most of their time in therapeutic programs of one type or another.

Thanks for letting me blab!

rob lindeman said...

Regarding anon who appears not to have a mental illness at all: what do you shrinks do when you encounter a person who has organic disease that mimics mental illness?

I hope you triage her directly back to their internist. Do you? Or is the temptation to continue treating her putative bipolar disorder too great?

wv = decring; turning down the volume on her cell phone ringer.

rob lindeman said...

Great piece from NYT

How come more shrinks aren't doing medical work-ups before putting folks on meds? Why aren't more internists doing work-ups before sending folks to psychiatrists?

wv = piefula; what you end up with when you hit a walk-off RBI in the major leagues these days

Anonymous said...

This is Anon with the physical problem. Rob, you make me feel vindicated. I don't expect to get the same sort of support when I hand my psychiatrist a copy of
<a href =">this</a> journal article.

Sherri said...

I might stop the medication if I'd been symptom free for three years, but I wouldn't/couldn't/shouldn't stop the other stuff I do to manage my condition, or I know from experience what will happen. The migraines have varied in frequency and intensity over the years, and I haven't always been on daily medication to prevent them, and probably won't be forever.

As for the recurrent major depression, I don't know. My psychiatrist and I have talked about maybe coming off the meds after two years symptom free. The last time I stopped the meds after being symptom free for a year, but had a recurrence about a year later, tried to manage with just therapy and lifestyle, then went back on meds a year after that. I'd like to be off the meds, but I like being symptom free more, even with the side effects of the meds.

So, you can get a sense of why I think my condition is under control, not cured.

Liz's Blog said...

@ dinah:

you may be right... the bipolar II access one diagnosis consistantly fits me well, so it's possible, in my opinion, that i have bipolar II with some borderlinish tendencies when i'm depressed... regardless i'm so thankful to dbt for the stability it has reintroduced into my life.


Anonymous said...

I totally agree with the article concerning the thyroid. Another item that needs to be checked is the Vitamin D levels. I have seen test results where the person is chronically low. That is another item that can have an impact on a person's mood as well.

Anonymous said...

Psychiatric diagnoses can feel somewhat arbitrary. I am diagnosed with a bipolar spectrum disorder, most likely BP II. She cannot officially make a slam dunk diagnosis because I was always on SSRIs and one cannot be diagnosed with BP II if hypomanic while on SSRIs. After some medication trials, I am currently (mostly) well on Lithium.

Should my doctor take me off Lithium and wait for hypomania to develop in order to "correctly" label me as BP II?

rob lindeman said...

Disagree about Vitamin D. No data.

wv = luckcmli; Hey, I need all the luckcmli I can get

CatLover said...

I am still angry about having a borderline diagnosis for years, when in fact, Ativan was making me have such outrageous behaviors. I was angry all the time, and could not control my behavior. So even though this problem showed up in my 30's, psychiatrists tacked borderline onto the bipolar diagnosis. There were plenty of other meds that caused this problem too, although Ativan was definitely the worst. It isn't just substance abuse that mimics mental problems - side effects from properly taken meds can do it too. My new bf, (now my husband) is the one who figured out what was happening. After the fact, many docs have said that kind of thing happens a lot with benzos (is that true?) but how come I went thru years of hell, and all they did was say I suddenly developed borderline in my 30's? I am disgusted with psychiatric diagnosis.

I have never ever ever been seen for 2 hours by a psychiatrist. It was always 1 hour for intake, then 15 min med checks, no matter who I saw. Thankfully, my brand new doc, he sees me for an hour and it is going much better, even though I am still not taking pills for things, since they were such a disaster for me.

Kartik said...

@ Catlover:
I understand how difficult it must be for you to see a psychiatrist. But, what I have learned is that Borderline Personality Disorder is on a continuum with Bipolar disorder, so it's that patients with BPD may have increased chances that they be diagnosed with Bipolar disorder as well. And as you made a mention of Ativan with is a Benzodiazepine, there are many side effects, not only that, to make matters worse, they can also precipitate withdrawal symptoms, which can include insomnia to hypersomnia, nightmares and horrible stuff of symptoms.

I reckon that when a person is supposed to have a medical condition or an organic brain disease that is precipitating the mood symptoms, in that case, the patient should be referred to the concerned neurologist for treating that condition first.

Anonymous said...

Some years ago, my primary care physician diagnosed me with high blood pressure and prescribed a daily med for it. I decided I didn't want to take a daily med, and so I increased my exercise, improved my diet and lost weight. My blood pressure dropped so significantly that I was able to stop taking the med. Still, my primary doctor continued to see me, first quarterly, then twice yearly to monitor the condition, and she had me monitor it on my own. Today, she pronounced me free of hypertension and said she doesn't need to see me any more other than annually for my regular physical.

It seems like psychiatric diagnosis should work on this model. After a certain period of time with no symptoms and no meds, the diagnosis should go away. But this is not the current paradigm. The diagnostic label sticks. Patients are told there is no lasting recovery, only temporary remission, and that meds are forever. I think this can promote a feeling of hopelessness that is detrimental to the patient and can become a self-fulfilling prophecy.

For Jesse's sake, I'll adopt a handle.


Dinah said...

I think it does kind of work that way (depends on the diagnosis and the course the individual has with it). The usual treatment for a single episode of major depression is 6-12 months with an antidepressant. If it doesn't recur, or not for years, the diagnosis isn't particularly relevant-- so a medical history may include History of Hypertension, resolved, or treated with diet & exercise, just as it may include, History of single episode of major depression 25 years ago. Or the patient forgets about it and doesn't even mention it and it vanishes from the chart over time, just like any other diagnosis.

People drop out of treatment all the time, they stop their meds all the time. Sometimes they are fine and "lost to followup". Often I know they were fine because I get a call years later with "I saw you five years ago and now I'm having this problem" and they tell me they've been fine (without me or my medicines or my therapy) for years. For many people, the conditions themselves are chronic, or they just do better with a treatment. Seems like that should be just fine.

checking thyroid hormones in patients with depression is a knee-jerk response. It was when I was in medical school. The standard is that in the absence of all other symptoms but depression, TFTs are checked in women over 40 and men over 30-- if there are any other symptoms, they should be checked regardless of age. What I find interesting is how hard it is to get my patients with known hypothyroidism to go to the lab!

jesse said...

@Blue: thank you first of all for adopting a Shrink Rap Handle (SRH). I'm with Dinah. You noted, "Patients are told there is no lasting recovery, only temporary remission, and that meds are forever." As Rob has pointed out, the art of psychiatry is extremely imprecise. Diagnoses are attempts to classify groups of symptoms and history for the purpose of being better able to treat patients. Often the prognostic nature of these diagnoses is very wrong.

If you have a friend who wrenched her back and was in bed as a result for a week, you and she would be very aware of the danger of sudden movements for a period of time; if the back injury were even three years ago it would likely be long out of mind.

There are certainly some illnesses in which taking meds long term is wise (assuming correct diagnosis!) but others in which sequential events layer over the injury until there are no sequelae other than a memory of it.

Arielle said...

It always feels like "a long time" to me until it's over. Then it feels like it never stopped, even if I know for a fact it's been a year and a half of pure health.

That's part of what depression is a chronic condition. I personally don't believe that a biological depression can be permanently cured without medication - and if you are on medication, it is not a cure; it is a control. I suspect that if a depression is "cured," then it may have been significantly higher on the situational then the biological side of the scale in the first place, diagnosis be damned.

(And I am envious of that person, too.)

Anonymous said...

My best description of my main issues are major depression, recurrent, treatment resistant, currently in remission on SNRIs AND PTSD, chronic, in remission. The management strategies - a generous dose of Effexor XR, PRN benzo for anxiety and PRN ambien for sleep - weekly therapy with a skilled LICSW who helped me through incest recovery twice (memories when I turned 30, and more when I turned 46), and as much healthy lifestyle and good self care as I can manage. Sometimes I can do well with diet, exercise, and self talk to manage stress/conflict - other times, not so well. I have been lucky enough to have good insurance all these years so I have generally had access to what I need, and I am intelligent enough to be a good treatment candidate. I can also pay a psychiatrist directly who gives me all three meds and trusts me to report accurately and use them wisely - so I do. For me, it is what works. I do believe there are both organic roots and processes and psychological ones in my disordered head. The level of intrapsychic distress i experience and the interpersonal stressors both can exacerbate my organic imbalances and trigger or intensify sx (mood, thought, behavior changes). I believe that there were permanent changes in my neuroendocrine systems due to chronic emotional abuse and episodic physical and sexual abuse that cannot be erased or totally rewritten, from a physiological perspective. So, yes, I do believe that for me the psychiatric diagnoses are stable over time and across situations. Nothing in medicine is black or white, all or nothing, except perhaps the presence/absence of spontaneous respiration.

C.J. Brenner said...

I disagree that one should offer a diagnosis after a single visit.
One should take the time to review all facts and experience more then a few visits with a patient before arriving at a suggested diagnosis as by doing so without a full experience, one is apt to stigmatize a patient in an unhealthy manner and one will also be prone to a possibility that their working diagnosis at that state is abrupt and possibly misleading. True you may have a medication history and maybe you have enough accurate information to truly understand the diagnosis.
Instincts will allow you to arrive at a true diagnosis, and perhaps it is clear to you in the outset; that shared, one must arrive at a working diagnosis after being in a setting of insightful differential diagnoses that will guide you in your immediate treatment and continued work up of the patients illness.
Confidence in a provider is assured more faithfully when the provider is ethically more involved in the care of a patient than pressing a diagnosis simply to either enter it into the medical records or to delegate a patient into a category of psychiatric acceptablity as a patient who is categorized and not allowed to continue as a presumptive diagnosis.