Getting The Right Diagnosis


In the middle of downtown Paris, I was having a snack when I was a mere medical student, honored guest of a famous and chic woman professor/scientist. She was telling me about how her son, who had numerous psychological problems, had two distinguished medical school professors fighting over his proper diagnosis. Of course, while they were doing this, he did not appear to be getting any better.

She confided in me more than I would have expected.

“A male doctor with a diagnosis is like a woman with a baby. He won’t let it go. He will defend it, whether it is right or wrong. He will treat it like it is his glory.”

I had little to say back then, but her message could have been burned on my brain.  Although I am not a mother of children, the baby analogy seemed to be at least one of the things that is wrong with medicine.

Just yesterday I saw a patient who had been diagnosed with schizophrenia. He had been “treated” for it for 20 years. He was clearly not schizophrenic. Nor did he seem to have achieved basic goals in life like having a way to make a living or having a romantic partner, at the age when such things would be expected.

Me, I see many people who have been misdiagnosed, I often change their diagnoses, sometimes even as I get to know them. Sometimes diagnostic categories change too. For me, diagnoses are more interesting for billing purposes than they are for real life.  I have seen the diagnosis of “schizophrenia” overused. In looking for “disabilities” it has been estimated in the past that 1% of the population meets criteria of both “positive” and “negative” symptoms. The positive symptoms are hallucinations and/or false beliefs. The negative symptoms are the isolation, an excessive sort of “shyness” with deep social consequences.

Modern psychiatry is on its fifth (5th) Diagnostic and Statistical Manual. I am far from happy with it, even though I memorized the then-current edition for my boards. Not everyone does this. Older review articles have suggested subjective bias on who gets this diagnosis and why.

Pretty much all of the patient selection for research studies will be primarily based on diagnostic criteria.

As the psychiatrist-author says in the link above, you have to have a “right” diagnosis before you can design an effective treatment.

I have never thought of the quality of my diagnoses as my “glory.”

Maybe, if I am doing things right, the quality of my treatments could become my glory.

But even the idea of “treatment” comes from the “Medical Model,” the assumption that all that happens with a patient is a “defect” that needs fixing.

Much of the life-blood of psychiatry now comes from groups of patients, who would (rightly, I believe) assert that mental health means much, much, more.

My true work is getting a misdiagnosed schizophrenic out of the limits that his diagnosis may have put on the development of his life.

And bringing that paient out to enjoy the freedom of life in the California sunshine.

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