Take the Shrink ChallengeCan a psychiatrist really tell what's wrong with you?
Updated Thursday, June 22, 2006, at 7:29 AM ETIf a dozen shrinks each interview the same patient, will they arrive at the same diagnosis?
PRINT
DISCUSS
E-MAIL
RSS
RECOMMEND...
Facebook
MySpace
Mixx
Digg
Reddit
del.icio.us
Furl
Ma.gnolia
Sphere
StumbleUponThe question has dogged mental-health clinicians for more than 30 years, ever since a famous experiment—a ruse, really—appeared to show that healthy people will be labeled sick if they merely go to a psychiatric emergency room and act sick. Recently, a new study tried to repeat the experiment and failed, supposedly proving that shrinks aren't as clueless today as they were a generation ago.
But the study's methods were questionable, and the results aren't as definitive as the authors make them out to be. Psychiatry still has a problem reliably diagnosing patients and will continue to until researchers better understand mental illness at the level of brain cells and molecules.
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.
The sweeping conclusions that Rosenhan drew from his elegant hoax are debatable. But in her 2004 book, Opening Skinner's Box: Great Psychological Experiments of the 20th Century, journalist Lauren Slater claimed to have replicated Rosenhan's results to some degree. She said she visited nine psychiatric ERs incognito and reported having the same auditory hallucinations mentioned in Rosenhan's study. Although she was never admitted as an inpatient, she says she received multiple prescriptions and was diagnosed with "depression with psychotic features" every time.
This was not supposed to happen. In 1980, the field had overhauled the manual used to classify mental disorders, the Diagnostic and Statistical Manual. Speculative Freudian theories of disease etiology were discarded in favor of straightforward descriptions of pathological behavior and checklists of behavioral symptoms for each diagnosis. The goal was to increase the reliability of psychiatric diagnosis.
In response to Slater, psychiatrists struck back with their own study. A team led by Columbia University's Robert Spitzer, who spearheaded the revision of the DSM in 1980, sent a survey to 431 ER psychiatrists. The survey presented a Rosenhan-model vignette—a person without a history of mental illness says she is bothered by a voice saying "thud." Of the 74 psychiatrists who responded, 80 percent said they would not give a firm diagnosis without more information, 82 percent said they would send the patient to an outpatient clinic rather than recommend hospitalization, and 66 percent said they would not prescribe medication. The study was published last November in the Journal of Nervous and Mental Disease. The editors gave Slater space to respond, and she belittled Spitzer's reliance on surveys rather than real testers.
Spitzer relied on a survey for practical reasons—these days, sending pseudo-patients to ERs would be expensive and ethically dubious. But the survey method conveniently sidesteps many of the variables that continue to plague psychiatric diagnosis. I was a social-work clinician in a community mental health center in Seattle for nearly two years. Most patients coming through my office had received more-or-less consistent diagnoses, from many different clinics, over the course of their illness. But a significant minority had not.
Perhaps the most important reason for a wrong diagnosis is the lack of time most clinicians have to do the job. The initial interview with a patient usually lasts less than an hour. Many are defensive or show ambiguous symptoms. Yet the rules of insurance reimbursement are relentless—you have to come up with an immediate diagnosis and treatment plan, which usually means a medication trial. Often follow-up "med checks" last only 15 to 20 minutes and occur just every few weeks or months. Even if patients are admitted to a hospital, they rarely stay longer than a few days. In these circumstances, a hasty initial diagnosis may never get revisited.
In addition, clinicians tend to overdiagnose diseases that they see a lot of. A doctor surrounded by schizophrenia at a clinic that serves the poor (the illness is so disabling that victims tend to lack private insurance) may begin to see the disease even more often than it actually appears. Then there's the mundane problem of missing medical records. Clinical history helps put current symptoms into context. But because of the nature of mental illness, many patients cannot, or will not, reveal information about their past psychiatric treatment. And if a patient agrees to have her chart sent for, it often arrives too late to make much difference.
Of course, doctors in other specialties face time constraints and other threats to accurate diagnosis. But unlike psychiatrists, they usually have a molecular definition of disease to go on and biological tests to administer. The current lack of molecular knowledge in psychiatry is no fault of psychiatrists; the human brain is complex and difficult to experiment on. But it cannot be denied that the DSM is not a collection of diseases so much as syndromes—groupings of symptoms that may have many different molecular causes. Because the molecular causes are largely unknown, biological tests don't exist, and a psychiatrist making a diagnosis is left without the lab results that in other areas of medicine help correct doctors' subjective impressions.
This may change. Last November, several researchers reported the creation of a computer algorithm that can differentiate, with 81 percent accuracy, the MRI images of schizophrenic brains compared with healthy ones. And some clinical trials have already begun to track how the presence of certain genes influences a patient's response to medication. The cost of sequencing a patient's genome has dropped by a thousandfold in the last five years, so genetically based psychiatric studies should soon become commonplace.
None of this means that psychiatrists will develop a magic diagnostic test, though. After all, genes only tell you so much. There are, for example, many genes implicated in schizophrenia, and a genetic predisposition does not guarantee illness. (If one identical twin gets schizophrenia, there is a 50 percent chance the other one will.) Even a brain scan isn't clear-cut. For example, many healthy family members of schizophrenics have been found to have subtle schizophrenic symptoms. If an entire family were to show different degrees of the illness on an MRI, establishing who gets an official diagnosis and who does not would still be a matter of judgment.
The Rosenhan study, which is still mentioned in undergraduate textbooks, continues to be an albatross for psychiatry. Working with the tools available to his generation of psychiatrists, Spitzer has done his best to put the profession on a scientific footing. But the psychiatrists who will integrate psychiatry into medicine—by finally linking the study of the mind to the study of the brain—have just begun to get to work.
Happy Birthday, Smokey Bear
Are Gas Grills More Eco-Friendly Than Charcoal Ones?
He-Man: Briefs of Rage and Other Toy-Inspired Movies We're Dying To See
Kaus: Seven Possible Theories Explaining Palin's Resignation
The U.S. Embassy in Djibouti Cordially Invites You to a Fourth of July Cookout
The Week's Best Editorial Cartoons
Remarks from the Fray:
A critical factor overlooked in analysis of the Rosenhan study is that the vague history of hallucinations was NOT the only information available to the clinicians who made presumptive diagnoses of schizophrenia. The fact that a person evidently felt distressed enough about the symptom to have presented to an emergency department, and subsequently to remain in hospital without objection, is abnormal enough to prompt a conscientious clinician, in the absence of other evidence, to err on the side of making a presumptive diagnosis and offering treatment.
Diagnosis is not an academic exercise, it is done in a context. If the subjects in Rosenhan's study had sat down for a structured diagnostic interview with a researcher, no diagnosis would have been made based on the limited symptoms described. But behavior is often the most salient information available to the clinician, more so than the reported symptoms. In the context of a patient seeking help, the ethical physician assumes the need is immediate and offers help, even if the information is incomplete.
--dnfmcknnn
(To reply, click here.)
The medical model of mental illness suggests that mental illness is analogous to physical illness, that there is some "chemical imbalance" in the brain that we will eventually be able to detect with a blood test/MRI. This may be true for some/all disorders. But, maybe not. Although it is undoubtedly true that mental disorders (unwanted thoughts and emotions) are materially manifested in the brain, it does not necessarily follow that the result is a neurochemical or neuroanatomical change that can be easily detected.
--liberalnancy
(To reply, click here.)
Should mental health workers doubt the sincerity of their clients right off the bat? That's a difficult question. I think my position is that they should start out biased toward assuming they are sincere, without lapsing into complete credulity. Furthermore, certain assertions by patients that violate ordinary experience (like alien abductions) or that could harm someone else (such as accusation of criminal behavior) should be handled differently from things like hearing a voice saying "thud".
But in the end, it is probably good rather than bad that the "thud" study produced the results it did, and I don't think the mental health community should be ashamed of it.
--gshenaut
(To reply, click here.)
I feel that two important distinctions are being left out of the discussion. The psychiatric field contains many different subspecialties, and there is a huge difference between seeing a patient in the emergency room vs seeing a patient in an office.
Believe it or not, it is not critical to accurately diagnose a patient in the emergency room. What a psychiatrist is attempting to assess in the ER is whether that patient is a danger to self, to others, or is gravely disabled with regards to being able to provide food, clothing, or shelter. That's it. Legally, a psychiatrist need only document probable cause (more likely than not likely) with regard to those criteria before involuntarily commiting that patient to the hospital for up to 72 hours. That is their role. Better safe than sorry is their motto. [...]
It falls on the outpatient therapists who spend months/years with a patient to make the definitive diagnosis. These are what is most often meant by the term "shrink." They spend countless hours fretting and agonizing over every little detail and nuance in an attempt to fully explore a patient's thoughts, feelings, etc.
Brus' charge that emergency room psychiatrists operate with relatively poor diagnostic accuracy is correct. However, lumping emergency room psychiatrists with inpatient psychiatrists with outpatient psychiatrists, all of whom have very different roles, only confuses the issue. Can a psychiatrist tell what's wrong? Only if it's his/her job.
--kneesandknose
(To reply, click here.)
While there are certainly some DSM diagnoses that are clearly physiological in origin (with more to be discovered), it seems equally evident that many other behavioral "syndromes" are simply in the words of existentialist psychiatrist Thomas Szasz, "problems with living," having more to do with personal or even societal issues that some genetic predisposition.
Sadly, psychiatry has for decades sought credibility as a "hard science" and thus has posited the reductionist holy grail of physiological cause - and, of course, the corresponding pharmacoloigcal remedies.
What's more, in our increasingly wealthy yet neurotic society, perhaps the idea that my depression is a sickness that I can treat (or mask) medically is more palatable to me than seeing depression as a consequence of an empty and unfulfilling life that I am largely accountable for and that has no easy "cure" or treatment.
--Okakura
(To reply, click here.)
(6/27)