The Challenge of Psychiatric Diagnosis

From Slate:

In 1973, academic psychologist D.L. Rosenhan sent himself and seven friends and colleagues to the psychiatric emergency rooms of 12 different hospitals. Each told ER workers that for several weeks he or she had been distressed by voices saying "empty," "hollow," and "thud." The testers gave false names and occupations but otherwise accurately reported their histories, which did not include mental illness. In all 12 instances they were admitted to a psychiatric ward. At that point, they stopped pretending to have symptoms. Nonetheless, they were held for an average of 19 days (their stays ranged from seven to 52 days) and were all released with a diagnosis of "schizophrenia, in remission," or something like it. Rosenhan titled his study "On Being Sane in Insane Places" and argued that psychiatric diagnosis has more to do with the presumptions of clinicians, and their tendency to treat ordinary behavior as pathological when it occurs on a psych ward, than with a rational assessment of symptoms.

I hadn't heard of this study before, but it is fascinating. Unlike many other medical specialties, psychiatric diagnosis can be subjective and elusive. When a surgeon removes an appendix, and sends it to a pathologist, it is either read as appendicitis or not. Cardiologists rely on EKG's and troponins to diagnose myocardial infarctions with a high degree of accuracy. There is very little gray area in these two clinical situations.

However, psychiatrists have no "gold standard" test to rule in or rule out schizphrenia. No CT scan, angiogram, or bloodwork is going to definitively rule in or out a diagnosis like schizophrenia, manic depression, or an anxiety disorder. For better or worse, the mental health clinician must diagnose based on the observed signs and symptoms, carefully ruling out other disorders along the way (like hypothyroidism mimicking depression for example).

Based on the "clinical gestalt," the psychiatrist then attempts to fit the patient into one of the known disorders of the DSM. Of course, there are some vague categoreis for things that don't quite fit, like "psychosis nos" (nos=not otherwise specified).

The other pitfall is that once a patient gets labeled with something, even when the symptoms have long resolved, they end up being branded for life. Before a patient gets labeled a schizophrenic, for example, the clinician needs to be quite sure that the patient truly has that disorder.



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