Wednesday, 27 March 2013

Diagnostic Utility 1: Suicide.

For many practitioners today, mental health diagnoses are largely invalid categories so we are better off without them. This is a position I completely agreed with for a while, after all it was Richard Bentall's magnificent "Madness Explained", a comprehensive deconstruction of post-Kraeplinian psychiatry, that persuaded me I wanted to be a clinical psychologist. However, I noticed that even once I started working alongside people who disavowed the use of psychiatric diagnosis, they still seemed to need to benefit from the use of a language for describing the different sorts of problems experienced by those they were working with (distinguishing psychosis from depression for example). This is a contradiction that I think largely goes ignored, but this paper by Kendall and Jablensky provides one solution. They distinguish between the Validity (largely non-existent) and the Utility (more debatable) of psychiatric diagnosis and conclude that the latter does not require the former. They seem to be advocating a fast and loose approach whereby mental health professionals accept the limitations of diagnosis but nonetheless use them as heuristics for as long as they can be helpful.

Of course this raises a further question, can they be helpful? Do the pros of thinking "diagnostically" outweigh the cons?* In this post I want to flag up one answer given by Paul Meehl in his long and ill tempered paper "Why I Do Not Attend Case Conferences",which I think every aspiring and trainee clinical psychologist should read. Below is a dialogue Meehl includes in his paper to emphasise the value of giving at least some minimal consideration to diagnosis. It serves as an amusing demonstration of how Meehl himself could be rather pompous and self-satisfied but it also, I think, shows vividly how diagnosis can be helpful in the rough and ready context of mental health. Anyone who sees only the bad in "labels" should consider the point Meehl is making here:

MEEHL: “You look kind of low today.”
STUDENT: “Well, I should be—one of my therapy cases blew his brains out over the weekend.”
MEEHL: “Oh, I’m sorry to hear that—that is a bad experience for any helper. Do you want to talk about it?”
STUDENT: “Yes. I have been thinking over whether I did wrong, and trying to figure out what happened. I have been his therapist and I thought we were making quite a bit of progress; we had a good
relationship. But then he went home on a weekend pass and shot himself.”
MEEHL: “Had the patient talked to you about suicide before?”
STUDENT: “Oh, yes, quite a number of times. He had even tried to do it once before, although that was before I began to see him.”
MEEHL: “What was the diagnosis?”
STUDENT: “I don’t know.”
MEEHL: “You mean you didn’t read the chart to see what the formal diagnosis was on this man?”
STUDENT: “Well, maybe I read it, but it doesn’t come to my mind right now. Do you think diagnosis is all that important?”
MEEHL: “Well, I would be curious to know what it says in the chart.”
STUDENT: “I am not sure there is an actual diagnosis in the chart.”
MEEHL: “There has to be a formal diagnosis in the chart, by the regulations of any hospital or medical clinic, in conformity with the statistical standards of the World Health Organization, for insurance purposes, and so on. Even somebody who doesn’t believe in diagnosis and wouldn’t bother to put it in a staff note must record a formal diagnosis on the face sheet somewhere. He has to put something that is codeable in terms of the WHO Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death.”
STUDENT: “Oh, really? I never knew that.”
MEEHL: “Did you see this man when he first came into the hospital?”
STUDENT: “Yes, I saw him within the first week after he was admitted.”
MEEHL: “How depressed did he look then?”
STUDENT: “Oh, he was pretty depressed all right. He was very depressed at that time.”
MEEHL: “Well, was he psychotically depressed?”
STUDENT: “I don’t know how depressed ‘psychotically depressed’ is. How do you tell a psychotic depression?”
MEEHL: “Hasn’t anybody ever given you a list of differential diagnostic signs for psychotic depression?”
MEEHL: “Tell me some of the ways you thought he was ‘very depressed’ at the time he came into the hospital.”
STUDENT: “Well, he was mute, for one thing.”
MEEHL: “Mute?”
STUDENT: “Yes, he was mute.”
MEEHL: “You mean he was not very talkative, or do you mean that he wouldn’t talk at all?”
STUDENT: “I mean he wouldn’t talk at all—he was mute, literally mute.”
MEEHL: “And you don’t know whether that tells you the diagnosis—is that right?”
STUDENT: “No, but I suppose that means he was pretty depressed.”
MEEHL: “If he was literally mute, meaning that he wouldn’t answer simple questions like what his name is, or where he lives, or what he does for a living, then you have the diagnosis right away. If the man is not a catatonic schizophrenia, and if you know from all the available evidence that he is some kind of depression, you now know that he is a psychotic depression. There is no such thing as a neurotic depression with muteness.”
STUDENT: “I guess I didn’t know that.”
MEEHL: “Why was he sent out on pass?”
STUDENT: “Well, we felt that he had formed a good group relationship and that his depression was lifting considerably.”
MEEHL: “Did you say his depression was lifting?”
STUDENT: “Yes, I mean he was less depressed than when he came in-although he was still pretty depressed.”
MEEHL: “When does a patient with a psychotic depression have the greatest risk of suicide?”
STUDENT: “I don’t know.”
MEEHL: “Well, what do the textbooks of psychiatry and abnormal psychology say about the time of  greatest suicide risk for a patient with psychotic depression?”
STUDENT: “I don’t know.”
MEEHL: “You mean you have never read, or heard in a lecture, or been told by your supervisors, that the time when a psychotically depressed patient is most likely to kill himself is when his depression is ‘lifting’?”
STUDENT: “No,I never heard of that.”
MEEHL: “Well you have heard of it now. You better read a couple of old books, and maybe next time you will be able to save somebody’s life.”

As a sort of footnote to this, I want to point out that Meehl trained in a psychological tradition that has long since disappeared. As a psychodynamically inclined clinical psychologist  in the 1950s and 60s he would have been trained with DSM versions I and II. These are distinct from their "atheoretical" predecessors by dint of their grounding in psychodynamic thinking. Whatever the problems with this orientation, it is distinct from the "medical model" in that it incorporates the notion that psychology is a process rather than just a momentary state or illness. There is an excellent blog post here which outlines how this fact has created a theoretical minefield for DSM-III and IV's Bereavement Exclusion for Major Depressive Disorder, which is being dropped in DSM 5.

It would be interesting to know if the current opposition to psychiatric diagnosis is partly a product of the shift to DSM-III, which ditched the language of "processes" in favour of "illnesses" or "disorders". Distress is always (by definition) the result of distressing life events. For this reason many (most?) people find it insulting to suggest that what they are experiencing is simply an illness within them rather than the product of many complicated processes and interactions. Perhaps this is less of a problem when a diagnosis itself is viewed not as a discrete "illness" label but rather as a distilled description of the sort of process that has commonalities across multiple cases.

* I am working on a post about the cons of diagnosis at the moment

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