The other day, a patient sent me an e-mail explaining that, after consulting with her spouse and parents, she had changed her mind about taking the medication we discussed during her appointment.
The other day, a patient sent me an e-mail explaining that, after consulting with her spouse and parents, she had changed her mind about taking the medication we discussed during her appointment. She had reviewed the DSM criteria and was confident that she had bipolar disorder, despite my conclusion that her symptoms were not consistent with that diagnosis. This situation—a patient using the DSM to trump her psychiatrist and diagnose her own disorder—happens often in psychiatry. I would guess it happens more often in psychiatry that in other specialties. I can't imagine a patient moving his sore knee around while reading about the examination for a torn ACL, or a person who is told that he has coronary disease, discusses the diagnosis with family members, and concludes that he instead is experiencing esophageal spasm. I suppose there are those patients who are angered when told they have viral infections and who demand antibiotics. But there is little harm done in such cases when the doctor gives in and writes the prescription, unless one has a strong moral compass about preventing resistant bacteria in the community.
It is ironic that self-diagnosis is so specific to the field of psychiatry, given that psychiatry is an area of medicine that is probably among the most complex and least understood. Given that psychiatric experts have trouble making consistent diagnoses, what are the chances that people with no psychiatric training are going to get the diagnosis right?
I understand a counter-argument: that knowing a person for a lifetime provides a more “complete picture” than the short-time view of an outsider. The history of a patient over time can be valuable information, but only if seen through a perfect lens—as opposed to the distorted view of family members. In reality, lifetime observations of a relative or a close friend’s personality are too distorted to be of much historic value. The medical records over time would be far better sources of information for a diagnosis that requires remote history—especially if the records contain observations by impartial experts. The distortion caused by “closeness” is not only because of the distorted perspective of the close observer, but also because the person being observed will act—and FEEL—different depending on who is watching. Psychiatric symptoms themselves are strongly influenced by the nature of the relationship between the observed and the observer.
It is considered unprofessional for a psychiatrist to diagnose and treat a close family member, and no court would consider testimony valid that comes from a psychiatrist who had a personal relationship with his or her patient. Yet, laypersons cling to the idea that the closer one is to a person, the better one knows that person. This leads to the sometimes incorrect notion that a spouse, mother, or child of a patient is in a better position to make a diagnosis than a psychiatric expert who has only known the patient for a short time.
It is difficult to address this situation with patients without arousing anger. A patient who is told to trust his doctor over his family is likely to see the doctor as arrogant, or even insulting to his family. Likewise, family members in such a situation are going to do all they can to get their beloved patient away from "that crazy psychiatrist" who is making a diagnosis without knowing their sister the way that only
Part of the problem may come from easy access to the DSM criteria on the Internet. There is an impression among psychiatry hobbyists that diagnosing psychiatric conditions is simply a matter of checking off symptoms from section A and a few more from section B. But as any experienced psychiatrist knows, making a correct diagnosis requires much more consideration and wisdom than can be found in the DSM alone. The DSM criteria, when read by a layperson, take on the nature of horoscopes or fortune cookies. Any person can pick up the DSM and self-identify with a number of disorders. And of course I have done the same thing myself, as have most medical students at some point. We all looked through the criteria for personality disorders for example, wondering if we were cluster A, cluster C, or (oh no!) cluster B. I now know that the mind provides a veil of repression thick enough so that any self-diagnosis is guaranteed to be profoundly incorrect.
I remember an incident from my teen years when my dad went to a retreat—one of those California-style retreats that were popular back in the 1970s when people tried to better understand themselves by going through humiliating, overly personal experiences with strangers. I remember my dad talking about an exercise in which people first ranked themselves on qualities like empathy, happiness, cooperation, optimism, and friendliness. Then they were ranked on those same qualities by people who spent the course of a week getting to know them. I remember my dad's anger that everyone at the retreat had him all wrong. I don't mean to pick on my dad, as I give him credit for going through a number of similar self-exploratory activities throughout his life. But his angry reaction to the impartial observations by outsiders was a universal reaction. We see ourselves as we want to see ourselves, or even more, as we have been told to see ourselves over many years by those close to us. This misperception is why diagnosis by family committee is pure folly. Families have their white knights and their black sheep. Families see a family member as they want to see him—and as they need to see him. On the other hand, an impartial, practiced observer can see the patient/family member as he truly is, making such an observer a threat to the tightly held opinions of those who care about their brother or husband.
I often write about the deficiencies of modern psychiatry that result from the insufficient length of time for encounters between psychiatrists with their patients—a length of time that is shortened by the scheduling practices of health systems and the reimbursement schedules of insurers. The effectiveness of psychiatric care would be greater if patients understood the phenomenon that I just painstakingly described, but discussing this phenomenon with a patient takes at least an hour. It is more efficient—not to mention easier—to go with the flow of the family diagnosis. Bottom line: if a family is convinced that one of their own has bipolar disorder, it will take a great deal of time to convince them and the patient otherwise.
But on the other hand, we all went into medicine to do the right thing. We take an oath to first do no harm, and the medications used to treat bipolar disorder affect multiple organ systems, so it is important that we get the diagnosis right. And so, I am left with a question: When a patient comes into my office and I need to spend 60 minutes explaining this phenomenon in order to have any hope for compliance with treatment, what should I use as the billing code?