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Diagnosis – schizophrenia and complete remission

27 September, 2013 Reply

Psychiatric diagnosis is a funny process – even with the operational criteria in DSM and ICD. There are so many things that affect the way one thinks about it. I was confronted with one of those things recently, with a patient for whom I've made the diagnosis of schizophrenia. On the basis of phenomenology and history, it was (and is) clear to me that schizophrenia is the most appropriate diagnosis. While there have been some symptoms of mood disturbance of one sort and another, they've not been to the level, or of such a nature, that they have turned me away from schizophrenia towards mood disorder.

As a quick aside, while I don't entirely dismiss "schizoaffective disorder", I … well I kind of do. ;-) It is a diagnosis that is most often mis-applied, in a sloppy fashion, because a patient has a mix of symptoms that are somewhat difficult to tease apart. In this specific case, I have not thought that schizoaffective disorder was a justifiable diagnosis (unsurprisingly, if you don't meet the requirements for a mood disorder, you don't make it to schizoaffective disorder).

And we're back…

So with what have I been confronted? With the fact that this person no longer has any symptoms. That's what. And we are so conditioned to see schizophrenia as unremittingly awful that our immediate response to someone doing that well is to question that we could be dealing with a schizophrenia. "Maybe it's really a mood disorder…"

Even though we know that in fact mood disorders, just as schizophrenias, can indeed have functional decline and chronic or residual symptoms. And even though we know that schizophrenia has a variable outcome, with a group doing very poorly, a group doing ok, and lo and behold a group doing well.

Anyway, I'm sticking with schizophrenia, because symptomatic remission now doesn't invalidate the earlier phenomenology – or most particularly, the history. I just think it's interesting that someone doing well makes us* question the diagnosis. Yes we should be open to questioning and revisiting diagnoses, but this isn't really enough of a reason. It's a manifestation of the nihilistic and hopeless view we often maintain about schizophrenia. Sadly it is an illness that sometimes has an awful outcome – but that's not always the case, and we seem to have trouble recognising that.

And that has to have an effect on how able we are to provide hope to someone newly diagnosed with schizophrenia….

(* not just me; I've often heard it said, when discussing someone with schizophrenia who's functioning well: "it can't be schizophrenia, they must have schizoaffective disorder" or similar.)

A Little Bit Pregnant

28 April, 2013 1 comment

Perhaps unsurprisingly, something has annoyed me today. :P Today’s something has to do with diagnostic rigour, and the impact that has on the appropriateness of the treatments offered to patients.

We often see people referred following some stress or conflict or other. Sometimes there is psychiatric illness behind it; often there is not. Sometimes when there is not, a suggestion is still made (not by me, nor generally by any member of my team) that involves medication (usually antidepressants, sometimes – perhaps often – quetiapine), and even referral for ongoing follow-up by a psychiatric team.

My question: why? Why would you give a psychiatric medication to someone not psychiatrically ill? Why would you have a psychiatric team have ongoing contact with someone not psychiatrically ill?

The usual response? They have “some depressive features”.

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Honestly, that is like being a little bit pregnant, or having some features of a heart attack. It’s stupid.

In other areas of medicine, including pregnancy and myocardial infarctions, we have investigations which can tell us if the condition really is present: we can do a serum βHCG, and ultrasound scans; we can check your troponin-I, and do ECGs.

In psychiatry we don’t. That’s why we have lists of symptoms -crucially, with thresholds: for both numbers and duration of symptoms. Without that, everyone in the world could be diagnosed with some psychiatric illness or other. The thresholds (eg at least 5 of the listed symptoms, for at least 2 weeks, for major depressive disorder) are there in an attempt to differentiate illness, or at least legitimate cause for clinical attention, from not.

Now, I’m one of the first to point out the problems with DSM (and probably would do so with ICD if I was as familiar with it). However, that doesn’t give me licence to ignore it. For people to prescribe antidepressants to someone who does not have a depressive disorder, only “some depressive features” goes against all the work that has gone into delineating major depressive disorder as a real entity. It is also not supported by evidence: not only are the trials that show antidepressants to be effective done in groups of people with actual major depressive disorder (not “some depressive features”), recent meta-analyses suggest (despite their shortcomings) that antidepressants might not even be much better than placebo for mild or moderate depression … So how likely is it that they would help “some depressive features”?

It’s too common though. A recent study (sorry, I can’t find the reference right now) looked at antidepressant prescribing – in the USA, but I don’t see that we have cause to assume we’d be different – and found that around a third of the prescriptions were written in the absence of major depression.

Any question as to why so many people find that their antidepressants don’t work?

Grrrrrumble.

EVestG, in the Material World

28 February, 2013 Reply

Something interesting came up today. One of our nurses mentioned a patient who had said that they were looking to soon get some new treatment with a device that could cure schizophrenia and other mental illnesses. I mentioned electrovestibulography – which is a device, being developed/promoted in Melbourne, which purports to be useful (though as far as I’m aware still just for diagnosis) for a number of psychiatric illnesses. The nurse instantly replied “that’s it!”.

So. There we go. I found out about this – and blogged it – 6 months ago … and here it is popping up in the real world.

I doubt that there would have been any substantial developments or further evidence in that 6 months; I certainly haven’t heard or read anything further. So as far as I’m aware this is still basically quackery: 2 people, promoting a device that purports to do what no-one else can, for a large number of widely-ranging diseases, with a company already formed to commercialise it, despite there being very few publications – none of which are in peer-reviewed journals.

It rather pains me to say quackery, as Professor Kulkarni is a respected researcher, who does excellent work. But this …

Again: it would be lovely to have some objective tests. I understand the desire to develop such tests. Maybe we’d feel validated and less inadequate as a profession if we found something that gave us a positive squiggle from a machine that goes bing. But at least so far, this ain’t it. It saddens me that real people are getting probably false hope from the way this thing is being marketed.

Armchair Diagnosis, Stigma, and Discrimination

16 February, 2013 Reply

It’s tempting to do: to see some well-known person behaving oddly, or badly, and trying to fit them into some psychiatric diagnosis. There are even published papers – I recall one in the British Journal of Psychiatry years ago discussing jazz musicians.

We seem now to look at rugby players.

Who all seem to have bipolar disorder.

I understand it. It’s a nice intellectual exercise – kind of detective work: not like a real-life police detective actually finding out facts, but sitting Holmes-like and declaiming on what one has seen. There’s also the appeal of possibly helping to de-stigmatise psychiatric illness – or even to “normalise” it (though surely “normalising” a serious illness is a bit of a funny idea…). It’d be nice to be able to point to some well-known and successful people with the illness you’ve just diagnosed a young person with, and perhaps give them some hope (justified or not is a different question).

The thing that occurs to me (in addition to the question of whether or not being a publicly-known figure makes it ok for all and sundry to speculate about your health, psychiatric or otherwise) is that it can be hard enough to be definitive about the diagnosis of the person sitting right in front of you, when you’ve asked the questions you want, and observed the person directly. To read second and third hand accounts of behaviour, and see footage of them in non-interview settings and so on, and try to extract a diagnosis from that, is a seriously fraught endeavour.

…

I’ve just deleted a paragraph that included a couple of names, because even saying overtly that it’s speculation and using them as examples of why we shouldn’t so speculate, it seems wrong to me. It would imbue the notion that these people have or had psychiatric illnesses with a semblance of authority, when in fact it is nothing more than somewhat idle speculation.

I’m not sure that it is all that good for psychiatry – or psychiatric patients – either. Well-known people are well-known. ;) Or at least we all think they are. We think we know about them. We have our own ideas about them – so when a shrink comes along and is seen to excuse some bad behaviour by saying it’s psychiatric illness, if it doesn’t gel with our conception of them, we see it as just that: an excuse. The reality and impact of psychiatric illness is potentially then downgraded. Perhaps thereby psychiatric illness is somewhat “normalised” … but I don’t think we want to “normalise it”.

It is not normal to be so depressed you stand in a corner not moving, eating or drinking – not eating because you believe your insides have rotted away. It is not normal to sleep only an hour at night (if you really can’t keep your eyes open) because you’re too busy being the new prophet of god and satan working to bring peace to the Middle-East by sending thought messages to Oprah Winfrey. It is not normal to be unable to leave the house for fear of crippling panic attacks that leave you drenched in sweat, with your heart pounding out of your chest, sure you’re about to have a heart attack, drop dead and go crazy. It is not normal to be unable to function because you spend 18 hours a day showering, and washing your hands, or to take 2 hours to get down the road because you have to keep doubling back to check you locked the door – even though you know absolutely that you are clean, or did lock the door, and that your thought and behaviour are irrational. It is not normal to believe that you have an implant in your brain by which the FBI are tracking you, because you said something negative about George Bush in a FaceBook status update.

I don’t see that this sort of thing addresses the stigma – or more properly the discrimination suffered by people with psychiatric illnesses. The stigma is real: some illnesses (thinking particularly psychotic illness) do mark a person as different. The treatments can do that pretty well too: blunted affect, worsened negative symptoms, movement disorders – these are all stigmata of psychiatric illness. Anecdotes about people living well with psychiatric illness don’t change the stigma. The discrimination is related but different. We discriminate against those who are different from us – hence the importance of the stigmata.

But really, I don’t see that saying this or that famous person has this or that psychiatric illness has much of a show of reducing discrimination against people with psychiatric illness in general. What? Are we all going to think when we see someone obviously psychotic “oh, that famous rugby player was diagnosed with bipolar disorder; I won’t discriminate against this person”? Like so much elsegood and important in life, I think it comes down to empathy. We don’t want to normalise psychiatric illness, we want to encourage an empathic response. Some education about what happens in psychiatric illness is needed, and trying to help people to think “how would I be feeling if that were happening to me? How would I hope people would react to me?”

… Instead of “omg lock up the crazy person!” – which I see far too often.

postscript, as though it needs saying: the above descriptions are not of any actual people’s symptoms. They’re more  like archetypes off the top of my head, if you like ;)

Diagnose to Prescribe

19 January, 2013 Reply

Anecdotal discussion alert … aOOOOga! aOOOOga!

I’ve decided this morning that diagnostic restrictions on prescribing of medications are not helpful. What am I talking about? The more expensive a medication is, the less the funding agencies want you to prescribe it; they would rather we use dirt-cheap haloperidol than expensive quetiapine for example. These expensive medications are therefore regulated, generally by way of subsidising them only for particular conditions (not necessarily all for which the medication is indicated – quetiapine as an example again: it was indicated in bipolar disorder in Australia for much longer than it has been subsidised for that indication).

You might think that’s a reasonable approach, but I’m not sure it has the intended effect. It seems to me, working in an acute community team which receives referrals from all and sundry, that more and more people appear to have these diagnoses – particularly bipolar disorder, once quetiapine became subsidised for the treatment of that condition….

Bipolar disorder’s the flavour of the month anyway (and has been for quite some months), and I’m not shy of making the diagnosis myself, but I have a sense it’s being used in order to “justify” prescription of quetiapine (or sometimes olanzapine) to people with other problems – not even necessarily based in psychiatric illness. Someone talks about “mood swings” (which seems very often to mean “I get angry easily”) and you can almost bet nowadays that someone is going to think about “the bipolar”. It’s then not a terribly big step to give quetiapine (flavour of the month again) which will in fact help in a case like that: it’s calming, sedating, it’ll help them sleep.

But taking an antipsychotic drug in order to keep calmer, and to sleep a bit better? Arguably even if these medications were completely innocuous (which they’re not) and inexpensive (which they’re not) there would still be something wrong with that: it’s (again) pathologising normality/real life, externalising control, abdicating responsibility and so on. And of course these medications are neither innocuous nor inexpensive.

So why do I think the diagnostic regulations are bad? Don’t I want them restricted to only the people who should have them? Yes, but … I wonder if it’s really working, or whether it’s actually just resulting in pressure to give diagnostic labels to people without real justification, in order to give them basically a non-addictive tranquilliser.

Like everyone used to use thioridazine (Melleril).

… Until we found out it does nasty things to the conduction in your heart and might kill you dead without warning …

Again, it comes back to our profession’s inability to differentiate sufficiently between illness and reaction to life. If we could do so, this would be much less of an issue.

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