February 10, 2009

Pondering on: Psych diagnosis

I tweeted the following:
Psych disorders: diagnosis with cause or arbitrary definitions w/o reason?

Here's my follow-up on this question.

What is the reason for coming up with a diagnosis?

Initially, the attraction for coming up with a diagnosis is to determine the CAUSE of the disease. It's nice to have an explanation and for a long time, Freud's psychoanalysis gave us causes. Internal conflict of competing and often unconscious desires manifested themselves as various disorders. It was an attractive hypothesis.

However, psychiatry has come a long way since then. Namely, the discovery of a number of psychoactive drugs that are successful at treating conditions.

Suddenly, the underlying predisposing causes and precipitating factors that were the emphasis of a psychiatric visits took a back seat as a set standardized definitions emerged in the form of the Diagnostic and Statistical Manual of Mental Disorders: the DSM for short.

Initially, it started off as a way for psychiatrists to communicate clearly with each other and for researchers to make sure that treatment modalities were consistent. After all, if one psychiatrist called something "schizophrenia" while another thought it was a clear-cut case of "manic-depression," they would have different approaches. And indeed, British psychiatrists were wondering why the rates of U.S. schizophrenia and bipolar disorder were so different from their own.

However, it has now become an engrained part of oh-so-important BILLING. There are codes attached to all of these diagnoses and in order to ensure that they are properly billed, they must be documented to meet criteria. Before, psychiatrists had an intuitive sense from taking a history with the patient and observing them about what the diagnosis is. Now, it has almost become a requisite to slog through a long list of things to establish criteria.

Here's an example of the criteria for ADHD:
A. Either (1) or (2):
(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Code based on type:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, "In Partial Remission" should be specified.
That's a long list to try and wade through!

Indeed, the "checkbox" medicine was the sort of approach that I had taken when I was doing in-patient psychiatry. Unfortunately, a list of criteria is much harder to memorize than some elegant "pathoneurology"/psychoanalysis, unless it's in the form of some handy-dandy mnemonics. For example, I'd routinely hit a few things from SIGECAPS and DIGFAST to rule out depression and bipolar disorders during the interview with some very scripted questions.

My psych preceptor has challenged me to think more about the genesis of the DSM criteria and indeed, many of these so called "criteria" are based on professional opinion with very little evidence or scientific basis. So I've become much more accustomed to a more natural interviewing process and I think that this will help my approach to psych diagnoses much more.

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