Comprehensive Psychiatry Official
VOL.
Journal
of the American
Psychopathological
18, NO. 2
Association
MARCH /APRIL
1977
On Diagnosing David E. Raskin
D
IAGNOSING IS A WAY OF LABELING behaviors that are associated statistically, have a predictable course, and perhaps definable etiologies. At the present time, only in the area of organic brain syndromes can contributing etiologies be demonstrated. Diagnosing is therefore conducted mainly on the basis of the observed behavioral picture and a course. In addition, family history is examined, and an attempt is made to isolate those modifying genetic and learned behaviors (intelligence and social skills) which may mask the behavioral picture and course. Diagnostic ability seems to vary considerably amongst clinicians. Several studies have suggested that the major problem in diagnosing consists in the lack of validity and reliability in the system we use.’ Other studies show that in a given region with a well-taught internally consistent approach considerable diagnostic reliability can be achieved.* This paper will discuss those errors in diagnosis related to 1) poorly developed observational skills, or 2) problems within the physician, sometimes broadly referred to as counter-transference. These problems lead to characteristic errors in diagnosing which I shall attempt to categorize and illustrate. When these errors occur, patients are inappropriately treated, are labeled in ways which have devastating effects on their own self-esteem, can lead to problems with employment and insurance coverage, and can place a patient on medications whose potential side effects are by no means benign. The author therefore discusses those diagnostic errors that are not problems in our methodology, but problems in ourselves. INCOMPLETE
Errors in evaluation Thoroughness
can be subgrouped
EVALUATIONS
into three varieties:
of Workup
Psychiatric workup must include a detailed personal and social history, family history, and a careful delineation of the course of the disorder. In addition to From the Department oJ Psvchiatry and Behavioral Sciencrr. Lfni\,er.rity oJ Washington School of’ Medicine, Seattle, Wash. David E. Raskin. M.D.: Associate Professor of Psychiatry. Department of Ps>lchiatry and Brhavioral Sciences, University of Washington, Seattle, Wash. Reprint requests should be addressed to David E. Raskin. M.D.. Department oJP.y.vchiatry and Behavioral Sciences, University of Washington School of Medicine. Seattle, Wash. 98195. L 1977 h,, Grune & Stratton, Inc.
Comprehenave
Psychiaby,
Vol.
18. No. 2
(March/April).
1977
103
104
DAVID
E. RASKIN
physical and neurological examinations, a standard laboratory battery including urine screen is necessary in order to identify clinical syndromes of a temporary nature which can easily present with a symptom-sign picture compatible with schizophrenia. A misleading record from past hospitalizations along with a behavioral picture resembling schizophrenia, is often responsible for a perfunctory history and physical exam. Example. A 35 year old male was admitted to the hospital with a history of hallucinations of unknown duration with no other symptoms present. The patient was frightened by these hallucinations but was oriented to time, place, and person. Past history revealed three to four hospitalizations with a diagnosis of schizophrenic chronic undifferentiated type. The initial diagnosis in the Emergency Room agreed with this. Further history obtained on the unit indicated a family history of alcoholism and the patient’s long-term use of alcohol. In addition, the patient had had a good work history, was married, and had a few close friends. Physical exam revealed the signs of chronic alcoholism; this was verified by laboratory workup. The diagnosis was therefore changed to probable Alcoholic Hallucinosis. The patient was treated with minor tranquilizers for a period of six days. The hallucinosis state decreased over this period of time. The patient appeared comfortable, oriented, and without any psychotic symptomatology. He was referred, after the six-day hospitalization, to an alcohol agency for the treatment of this disorder. Comment. The above case has been repeated many times in both the area of alcoholic hallucinosis3 and amphetamine psychosis.4 A patient presents with a behavioral-symptom sign package which appears very typical for schizophrenia. The admitting physician does not determine the course, social or family history, and his physical and laboratory examinations are performed in an unsatisfactory manner. Such patients are than treated with antipsychotic medication which, unless it lowers the seizure threshold producing actual convulsions, will appear to be treating successfully the hallucinois state. Diagnosis of schizophrenia is felt to be confirmed and the patient is placed on a disability status plus given moderate doses of antipsychotic medication for a period of years. Alcoholism and drug abuse often go unrecognized and the consequences of the “schizophrenia” labeling procedure on a treatment program’s perceptions of treatability and prognosis are set in motion. It is therefore critical that every picture consistent with schizophrenia be confirmed by a determination of course, the absence of substance abuse, evaluation of social and occupational skills, and careful physical and laboratory workup. The Time Factor
Diagnosis, in psychiatry, does not occur at one point in time. Many of the problems with our objective rating scales have to do with the problem of one point evaluations. It is critical that full evolution of a disorder is permitted to occur. An attempt to diagnose on the basis on a one-point evaluation, will prevent an understanding of the evolution of the disorder. Evolution must be evaluated retrospectively as well as prospectively. Many so-called paranoid schizophrenics are in fact Manic Depressives in stage 3,5 and a careful retrospective investigation of course will reveal the presence of hypomania prior to the onset of the paranoid phase.
DIAGNOSING
105
There are many disorders which can be diagnosed on the basis of fluctuation over time. By evaluating the patient’s social interactions and behavioral symptoms in the morning and evening we are in a better position to isolate depressive disorders with early morning behavioral dysfunction from organic brain syndromes with night-time disorientation and from schizophrenia with autistic behavior which may vary depending upon the kinds of interpersonal tensions occurring on a unit.
Contexl Evaluations differ greatly depending upon the nature of the evaluator, the set of the patient, and the setting of the interview. If a family has visited, if some outburst has occurred on the unit, if there have been recent admissions and discharges, if an important staff member is away on vacation, the patient’s performance in a given interview can be drastically effected. In addition to the patient variables, there are many therapist variables which include the sex of the interviewer, his age, his professional identity (physician, nurse, or mental health specialist), plus his capacity to successfully deal with the patient’s behavior in the interview. The problems of projective identification6 and transference psychosis’ have been well described. Analogues of these relationships which occur in intensive treatment may be observed in the initial interviews with the patient and will clearly determine the symptom-sign package which the patient emits. Example. A 20 yr old female was admitted to the hospital after having lacerated both her wrists in what appeared to be a serious suicide attempt. On admission, she was agitated, complained of frightening visual hallucinations, and stated she felt that people were trying to hurt her and read her mind. She appeared anxious and became more agitated during the course of the interview. The initial impression was acute schizophrenic episode. Immediately following the interview, the patient was permitted to socialize with other patients on the unit. She was comfortable, relaxed, friendly, and gave no evidence of psychotic symptomatology. The patient had a positive history for drug abuse. She complained of multiple neurotic symptoms, and described relationships with significant others leading to rejection and consequent suicidal behavior. She had been working successfully up to the time of her hospitalization. On the basis of her history of impulse disorder pan-anxiety, a “stably unstable” course plus the observations of marked symptom fluctuation in her behavior with staff and patients, the diagnosis was revised to that of borderline personality disorder. Comments. Diagnosing is a function of context. Patients’ behavior will vary greatly depending upon their internal state and upon the interviewer who is evaluating them. The observation of marked fluctuations in behavior, in the absence of an organic brain syndrome, in a patient who has many defense mechanisms in often a tip-off to the presence of a borderline condition. It is critical that such a patient be correctly diagnosed. If a borderline patient is responded to and treated as if they are schizophrenics, what should be a transient psychotic episode is prolonged into lengthy hospitalizations with high doses of medications which are not helpful, and an assessment of the patient, which underevaluates his coping skills and capacity to function realistically. Once the borderline condition is recognized, appropriate behavioral approaches which include limit-setting, focus
DAVID
106
E. RASKIN
on adult problem solving behaviors along with low dosage medication, and careful planning for outpatient psychotherapy becomes the major treatment plan. I have delineated three major problems relating to incomplete evaluations. These consist of a lack of thoroughness, a lack of respect for the time dimensions involved in evaluations, and a disregard for context. A complete evaluation entails a complete history, a careful physical and laboratory workup and a capacity to delay diagnosis until both the time dimension and context are adequately investigated. This requires multiple evaluations of a patient by different observers under different conditions. Such an approach to evaluation will markedly decrease the numerous errors that are made, not because of any problems in our diagnostic system, but because of deficiencies in our approach to the psychiatric workup. THE FORM-CONTENT
DILEMMA
Diagnosing is essentially related to form rather that content. American Psychiatry with its heritage of psychodynamics has often confused content issues with formal issues. Content issues provide an understanding of the patient’s life experiences. Diagnosis, however, addresses itself to form. Form
Form addresses itself to whether or not the human clock is slowed down, speeded up, broken down, or perhaps operating on the basis of a different mechanism. Formal mental status considers the following kinds of issues: 1) The presence of gross versus fine motor movements. 2) Formal speech disturbance as indicated by rate and volume variation. 3) Diversity of affect, affect modulation (fine tuning), and lability of affect. 4) The presence of delusions and/or hallucinations. 5) The patient’s perceptual experience of himself and the outside world. 6) The presence of global confusional states or the amnestic syndrome. Congruence
Form concerns itself with congruence. Congruence involves the total fit between a patient’s behaviors, his movements, speech, thinking, and affect. Does he appear to be a person, or does he appear to be a “dehumanized robot.” Understandability
Are the patient’s experiences and behaviors understandable? can his psychosis be understood in terms of a predominant affect, or is the content of his psychotic experience understandable on the basis of psychological conflicts? Understandability, a term introduced by Jasper9 relates to content rather than to form, and this is one content variable which is of significance in diagnosing. A depressed man who feels he is guilty and that he has syphilis presents an understandable delusion. A schizophrenic who states that he has special rays from Mars piercing his brain demonstrates a nonunderstandable delusion. The Concept of Balance
Psychotic experience presents with a driven preemptory quality which leads to great difficulty in living in the world. As we move from more grossly psychotic disturbance to borderline conditions towards neurotic and characterological dis-
DIAGNOSING
107
orders, we can still detect psychotic experience in which the formal presence of delusions, hallucinatory or pseudo-hallucinatory experience, and serious object relationship disturbances are present. In the serious psychoses, there are few alternatives to such experiences. In the presence of minimal interpersonal or physiological stress, psychotic disturbance appears. In the borderline and in particular neurotic disturbance only in the presence of overwhelming stress, daydreams, nightmares, etc. do we observe the presence of psychotic-like behaviors and/or experiences. However, such experiences are surrounded by a buffer zone of adaptive socially appropriate behaviors, and/or a number of psychological defense mechanisms. In serious psychosis the buffer has been destroyed or never developed and all that remains is psychosis or behavioral withdrawal. The concept of balance is useful in distinguishing the serious psychoses from the transient psychotic disturbance of the borderline condition from the occasional psychotic experience of the neurotic or normal individual. The principle of balance helps us recognize the value of modifying behaviors and the quality and quantity of defenses in determining diagnosis. THE
DILEMMA
OF
FOREST
OR
TREES
The forest-trees dilemma can be a function of inexperience leading to an inappropriate focus on a single behavior such as aggression or hypomania without taking into account other observable behaviors. Many of these mistakes are not related to inexperience or poor observational skills. They are rather a function of distortions in the mind of the therapist leading to selective inattention or overevaluation of one amongst a variety of presenting symptoms. A clear example is a diagnosis of manipulative behavior in schizophrenics as indicating the presence of a characterological disturbance. Other examples are all seductive women being labeled as hysterical personalities” or any aggressive male patient being labeled antisocial personality. ‘I) This problem which I term the forest-trees dilemma is responsible for some serious errors in diagnosis. As indicated there are two main causes for such mistakes. One is correctible through education and experience. The mistake which is attributable to selective inattention or overvaluation secondary to the therapist’s personality problems requires improved self-awareness on his part, or treatment. One way of avoiding the forest-trees dilemma is to use rating systems such as the WashingtonSt. Louis” form or the Flexible System” for diagnosing disorders. These forms are useful in demonstrating the distortions which enter into clinical diagnosing and in providing a method of diagnosing which eliminates subjective distortions. EXPERIENCE
AND
BEHAVIOR
Experience and behavior are words referring to a complicated dichotomy. Issues such as the mind-body problem, the psychoneural identity thesis,‘” and other awkward and confusing philosophical problems relating to dualistic versus monistic views of persons lurk in the wings. We shall therefore distinguish between verbal behavior and nonverbal behavior and avoid questions relating to the Cartesian question of dualism. It is clear that nonverbal behavior is a poor criteria for diagnosis. It provides at best a peripheral subtantiation of what we observe on the basis of verbal behavior (experience). Even catatonic behavior which
DAVID
108
E. RASKIN
is often symptomatic of schizophrenia can be found in organic brain syndromes, drug-induced immobility, mutism, and depressive stupor.14 Recent studies I have performed indicate that the extremely detailed delineation of catatonia as described by Karl Leonhard15 does not seem to distinguish that group of catatonics who are schizophrenic from that group who are not. Therefore nonspecific, nonverbal behavior can only be used to corroborate diagnosis. This even applies to depressive behaviors as described,in the following case. Example. A 20 yr old man presented in the Emergency Room with complaints of suicide ideation. He disclaimed any eating disturbance, insomnia, somatic complaints, etc., and his appearance gave no indication of motor behavior often associated with depression (psychomotor retardation). Past history revealed four serious suicide attempts plus a positive family history in which three relatives had died by suicide. In investigating the patient’s experience (verbal behavior) he indicated a sense of emptiness, and a sensation of decreased thoughts both as to numbers of thoughts and to flow of thoughts. His experiences particularly in the quality of his thinking and feelings substantiated a diagnosis of endogenous depression. Comment. This patient did not present the usual behaviors associated with this condition. Although this is not a typical situation, it does occur and it is important to recognize that verbal behaviors are sufficient to establish a diagnosis. In the absence of verbal behavior, the psychiatrist must be extremely careful. A distinction between organic brain syndrome with lethargy-stupor (WernickeKorsakolQ retarded depression, or chronic schizophrenia with autism is a difficult differential diagnosis in the absence of verbal behavior. For this very reason performing amytal interviews on all catatonic patients is important in order to determine the presence of verbal experiences consistent with schizophrenia, depression, and organic brain syndrome. SYMPTOMS
AND COURSE
Once an experience-behavioral package, a symptom-sign constellation has been identified and labeled, the patients’ course must be added. Monrad Krohn16 in his textbook develops the concept of curves of development (Decursus Morbi). He describes vascular catastrophe, tumors, arteriosclerosis, disseminated sclerosis, and poliomyelitis, as all having differing and characteristic curves of development. Similar curves can be developed in psychiatry, although we must recognize that modifying behaviors may influence the course of a disturbance. It is entirely possible to have a symptom picture of hypomania or mania with a course of chronic disability. Such a picture is typical of the course of some schizo-affective disorders.17 A first episode patient with a schizophrenic picture does not permit the identification of a course. It is important that such patients not be diagnosed as schizophrenics until the course has been outlined. Genetic data now indicates that acute schizophrenia may progress to produce the picture schizophrenia with a chronic deteriorating course or may be more akin to manic depressive psychosis in which we have periodic psychotic disturbances with return to base-line function between episodes. In psychiatry we can outline the course most typical of schizophrenia which is either a chronic deteriorating one, or a course characterized by repeated dysfunction without return to baseline levels.
DIAGNOSING
109
We can also determine the most typical course of bipolar disease which consists of periodic disturbance with return to baseline functioning. We can delineate the course of delirium which is characterized by a periodic disturbance with return to a baseline function. We can outline the course of dementia in which we have either a chronic deteriorating course or a step-wise deterioration characteristic of arteriosclerotic disease. Similar courses can be determined for neurotic dysfunction and characterologic disorders (Briquet’s syndrome).” The presence of modifying factors makes the course of a disturbance not the absolute indicator of the kind of dysfunction but atypical courses can be tipoffs to mistakes in diagnosis. For example, periodic courses with a symptom picture of schizophrenia can be in fact stage 3 mania5 misidentified as paranoid schizophrenia. Although initial drug treatment is often on the basis of the symptom or behavioral picture, aftercare planning including living situations, vocational rehabilitation, social network, and outpatient treatment are often a function of the course of the disturbance. Three other diagnoses are often identified by course. Alcoholic hallucinosis,” and amphetamine psychosis4 are in actuality periodic psychotic states in which the patient returns to his interepisodic functioning. In the presence of hallucinosis or a paranoid state in which the patient has returned to baseline, we must consider either of these diagnoses. The borderlinelx patient is often mistaken for a reactive or an endogenous depressive patient. Once we have identified the stablyyunstable course of the borderline patient, appropriate treatment can be planned which will differ greatly from the kind of treatment we would provide for the more periodic depressive syndromes. LINGUISTIC
MUDDLING
In a previous paper,lg I indicated that schizophrenia can be defined in a global way as a disturbance which will encompass a large number of patients and include a number of patients who are not schizophrenic (so-called false positives). On the other hand, schizophrenia may be defined in such a way that very few nonschizophrenic patients will be included in our sample. But many patients omitted from the narrow definition would fit in the broad diagnosis of schizophrenia. The Washington-St. Louis” criteria of schizophrenia delineates such a subsample of the disturbance. Both ways of diagnosing are useful. The broad method helps us identify large groups for drug treatment and structured milieu approach. The narrow diagnosis identifies homogenous populations for research purposes. The major problem of the diagnostician is unconscious oscillating between the broad and narrow definition. This leads to some diagnostic errors. If we diagnose schizophrenia using the broad diagnosis, we must be prepared to make few prognostic statements, because in the broad diagnostic classification are included some borderline patients, some reactive psychoses, and some bipolar disorders. On the other hand, by diagnosing within the narrow framework, we must recognize that there will be large numbers of patients whom we will have to call “undiagnosed.” CONCLUSION
Some characteristic errors leading to diagnostic imprecision have been identified. These are created by deficiencies in knowledge and skills and/or
110
DAVID
E. RASKIN
countertransference difficulties of the therapist. The errors include incomplete evaluation, form-content dilemma, forest-trees problem, the diagnosis of experience versus the diagnosis of behavior, symptoms versus course, and lastly, linguistic muddling. Every clinician should be aware of these contributions to poor diagnosing. In addition rating scales should be utilized as supplements to clinical diagnosis. In these ways it becomes possible to minimize diagnostic errors related to ignorance and/or countertransference. REFERENCES I. Beck AT, Ward
Reliability
of psychiatric
CH, Mend&on M, et al: diagnosis. Amer .I Psy-
chiat 119:351-357, 1962 2. Sandifeiz MG Jr.: Psychiatric dignosis: cross national research fundings. Proc R Sot Med 65:497-500, 1972 3. Victor M, Hope JM: The phenomenon of auditory hallucinatons in chronic alcoholism. J Nerv Ment Dis 126:451-481, 1958 4. Ellinwood EH Jr: Amphetamine psychosis: Individuals, settings, and sequences in current concepts of amphetamine abuse. Department Health, Education, and Welfare publication, 1972, pp 143-159 5. Carlson GA, Goodwin FK: The stages of mania. Arch Gen Psychiat 28:221-228, 1973 6. Jaffe DS: The mechanisms of projection: its dual role in object relations. Inter J Psychoanal 49:662-677, 1968 7. Rosenfeld HA: Psychotic States. NYC, International 8. Jaspers
University, 1965, ch. 5, p 104 K: General Psychopathology.
University of Chicago, 1963 9. Lewis WC: Hysteria: the consultant’s lemma. Arch Gen Psychiat 30: 145-15 1, 1974
di-
IO. Vaillant GE: Sociopathy as a human process. Arch Gen Psychiat 32:178-183, 1975
I I. Feighner JP, Robins E, Guze SB et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiat 26:57-63, 1972 12. Carpenter WT Jr, Strauss JS, Bartko JJ: Flexible system for the diagnosis of schizophrenia. Science 182:1275-1278, 1973 13. Globus GG: Consciousness and brain. Arch Gen Psychiat 29:153- 176, 1973 14. Raskin tonic stupor.
DE: Herpes Arch Gen
encephelitis with cataPsychiat, 31:544-546,
1974 15. Fish F: Leonhard’s schizophrenia. J Ment Science
classification 104:943, 1958
of
16. Monrad-Krohn GH: The Clinical Examination of the Nervous System. Hoeber Medical Division, New York, Harper and Row, 1964 17. Weiner A, Croughan JL: The group of schizoaffective and related psychoses-critique, record, follow-up, and family studies. Arch Gen Psychiat, 31:628%637, 1974 18. Gunderson derline patients: 132:1-10, 1975 19. Raskin schizophrenia. Psychiatr)
JG, Singer An interview.
M: Defining borAmer J Psychiat
DE: The problem of diagnosis in (submitted for publication, Br J
VOL.
Journal
of the American
Psychopathological
18, NO. 2
Association
MARCH /APRIL
1977
On Diagnosing David E. Raskin
D
IAGNOSING IS A WAY OF LABELING behaviors that are associated statistically, have a predictable course, and perhaps definable etiologies. At the present time, only in the area of organic brain syndromes can contributing etiologies be demonstrated. Diagnosing is therefore conducted mainly on the basis of the observed behavioral picture and a course. In addition, family history is examined, and an attempt is made to isolate those modifying genetic and learned behaviors (intelligence and social skills) which may mask the behavioral picture and course. Diagnostic ability seems to vary considerably amongst clinicians. Several studies have suggested that the major problem in diagnosing consists in the lack of validity and reliability in the system we use.’ Other studies show that in a given region with a well-taught internally consistent approach considerable diagnostic reliability can be achieved.* This paper will discuss those errors in diagnosis related to 1) poorly developed observational skills, or 2) problems within the physician, sometimes broadly referred to as counter-transference. These problems lead to characteristic errors in diagnosing which I shall attempt to categorize and illustrate. When these errors occur, patients are inappropriately treated, are labeled in ways which have devastating effects on their own self-esteem, can lead to problems with employment and insurance coverage, and can place a patient on medications whose potential side effects are by no means benign. The author therefore discusses those diagnostic errors that are not problems in our methodology, but problems in ourselves. INCOMPLETE
Errors in evaluation Thoroughness
can be subgrouped
EVALUATIONS
into three varieties:
of Workup
Psychiatric workup must include a detailed personal and social history, family history, and a careful delineation of the course of the disorder. In addition to From the Department oJ Psvchiatry and Behavioral Sciencrr. Lfni\,er.rity oJ Washington School of’ Medicine, Seattle, Wash. David E. Raskin. M.D.: Associate Professor of Psychiatry. Department of Ps>lchiatry and Brhavioral Sciences, University of Washington, Seattle, Wash. Reprint requests should be addressed to David E. Raskin. M.D.. Department oJP.y.vchiatry and Behavioral Sciences, University of Washington School of Medicine. Seattle, Wash. 98195. L 1977 h,, Grune & Stratton, Inc.
Comprehenave
Psychiaby,
Vol.
18. No. 2
(March/April).
1977
103
104
DAVID
E. RASKIN
physical and neurological examinations, a standard laboratory battery including urine screen is necessary in order to identify clinical syndromes of a temporary nature which can easily present with a symptom-sign picture compatible with schizophrenia. A misleading record from past hospitalizations along with a behavioral picture resembling schizophrenia, is often responsible for a perfunctory history and physical exam. Example. A 35 year old male was admitted to the hospital with a history of hallucinations of unknown duration with no other symptoms present. The patient was frightened by these hallucinations but was oriented to time, place, and person. Past history revealed three to four hospitalizations with a diagnosis of schizophrenic chronic undifferentiated type. The initial diagnosis in the Emergency Room agreed with this. Further history obtained on the unit indicated a family history of alcoholism and the patient’s long-term use of alcohol. In addition, the patient had had a good work history, was married, and had a few close friends. Physical exam revealed the signs of chronic alcoholism; this was verified by laboratory workup. The diagnosis was therefore changed to probable Alcoholic Hallucinosis. The patient was treated with minor tranquilizers for a period of six days. The hallucinosis state decreased over this period of time. The patient appeared comfortable, oriented, and without any psychotic symptomatology. He was referred, after the six-day hospitalization, to an alcohol agency for the treatment of this disorder. Comment. The above case has been repeated many times in both the area of alcoholic hallucinosis3 and amphetamine psychosis.4 A patient presents with a behavioral-symptom sign package which appears very typical for schizophrenia. The admitting physician does not determine the course, social or family history, and his physical and laboratory examinations are performed in an unsatisfactory manner. Such patients are than treated with antipsychotic medication which, unless it lowers the seizure threshold producing actual convulsions, will appear to be treating successfully the hallucinois state. Diagnosis of schizophrenia is felt to be confirmed and the patient is placed on a disability status plus given moderate doses of antipsychotic medication for a period of years. Alcoholism and drug abuse often go unrecognized and the consequences of the “schizophrenia” labeling procedure on a treatment program’s perceptions of treatability and prognosis are set in motion. It is therefore critical that every picture consistent with schizophrenia be confirmed by a determination of course, the absence of substance abuse, evaluation of social and occupational skills, and careful physical and laboratory workup. The Time Factor
Diagnosis, in psychiatry, does not occur at one point in time. Many of the problems with our objective rating scales have to do with the problem of one point evaluations. It is critical that full evolution of a disorder is permitted to occur. An attempt to diagnose on the basis on a one-point evaluation, will prevent an understanding of the evolution of the disorder. Evolution must be evaluated retrospectively as well as prospectively. Many so-called paranoid schizophrenics are in fact Manic Depressives in stage 3,5 and a careful retrospective investigation of course will reveal the presence of hypomania prior to the onset of the paranoid phase.
DIAGNOSING
105
There are many disorders which can be diagnosed on the basis of fluctuation over time. By evaluating the patient’s social interactions and behavioral symptoms in the morning and evening we are in a better position to isolate depressive disorders with early morning behavioral dysfunction from organic brain syndromes with night-time disorientation and from schizophrenia with autistic behavior which may vary depending upon the kinds of interpersonal tensions occurring on a unit.
Contexl Evaluations differ greatly depending upon the nature of the evaluator, the set of the patient, and the setting of the interview. If a family has visited, if some outburst has occurred on the unit, if there have been recent admissions and discharges, if an important staff member is away on vacation, the patient’s performance in a given interview can be drastically effected. In addition to the patient variables, there are many therapist variables which include the sex of the interviewer, his age, his professional identity (physician, nurse, or mental health specialist), plus his capacity to successfully deal with the patient’s behavior in the interview. The problems of projective identification6 and transference psychosis’ have been well described. Analogues of these relationships which occur in intensive treatment may be observed in the initial interviews with the patient and will clearly determine the symptom-sign package which the patient emits. Example. A 20 yr old female was admitted to the hospital after having lacerated both her wrists in what appeared to be a serious suicide attempt. On admission, she was agitated, complained of frightening visual hallucinations, and stated she felt that people were trying to hurt her and read her mind. She appeared anxious and became more agitated during the course of the interview. The initial impression was acute schizophrenic episode. Immediately following the interview, the patient was permitted to socialize with other patients on the unit. She was comfortable, relaxed, friendly, and gave no evidence of psychotic symptomatology. The patient had a positive history for drug abuse. She complained of multiple neurotic symptoms, and described relationships with significant others leading to rejection and consequent suicidal behavior. She had been working successfully up to the time of her hospitalization. On the basis of her history of impulse disorder pan-anxiety, a “stably unstable” course plus the observations of marked symptom fluctuation in her behavior with staff and patients, the diagnosis was revised to that of borderline personality disorder. Comments. Diagnosing is a function of context. Patients’ behavior will vary greatly depending upon their internal state and upon the interviewer who is evaluating them. The observation of marked fluctuations in behavior, in the absence of an organic brain syndrome, in a patient who has many defense mechanisms in often a tip-off to the presence of a borderline condition. It is critical that such a patient be correctly diagnosed. If a borderline patient is responded to and treated as if they are schizophrenics, what should be a transient psychotic episode is prolonged into lengthy hospitalizations with high doses of medications which are not helpful, and an assessment of the patient, which underevaluates his coping skills and capacity to function realistically. Once the borderline condition is recognized, appropriate behavioral approaches which include limit-setting, focus
DAVID
106
E. RASKIN
on adult problem solving behaviors along with low dosage medication, and careful planning for outpatient psychotherapy becomes the major treatment plan. I have delineated three major problems relating to incomplete evaluations. These consist of a lack of thoroughness, a lack of respect for the time dimensions involved in evaluations, and a disregard for context. A complete evaluation entails a complete history, a careful physical and laboratory workup and a capacity to delay diagnosis until both the time dimension and context are adequately investigated. This requires multiple evaluations of a patient by different observers under different conditions. Such an approach to evaluation will markedly decrease the numerous errors that are made, not because of any problems in our diagnostic system, but because of deficiencies in our approach to the psychiatric workup. THE FORM-CONTENT
DILEMMA
Diagnosing is essentially related to form rather that content. American Psychiatry with its heritage of psychodynamics has often confused content issues with formal issues. Content issues provide an understanding of the patient’s life experiences. Diagnosis, however, addresses itself to form. Form
Form addresses itself to whether or not the human clock is slowed down, speeded up, broken down, or perhaps operating on the basis of a different mechanism. Formal mental status considers the following kinds of issues: 1) The presence of gross versus fine motor movements. 2) Formal speech disturbance as indicated by rate and volume variation. 3) Diversity of affect, affect modulation (fine tuning), and lability of affect. 4) The presence of delusions and/or hallucinations. 5) The patient’s perceptual experience of himself and the outside world. 6) The presence of global confusional states or the amnestic syndrome. Congruence
Form concerns itself with congruence. Congruence involves the total fit between a patient’s behaviors, his movements, speech, thinking, and affect. Does he appear to be a person, or does he appear to be a “dehumanized robot.” Understandability
Are the patient’s experiences and behaviors understandable? can his psychosis be understood in terms of a predominant affect, or is the content of his psychotic experience understandable on the basis of psychological conflicts? Understandability, a term introduced by Jasper9 relates to content rather than to form, and this is one content variable which is of significance in diagnosing. A depressed man who feels he is guilty and that he has syphilis presents an understandable delusion. A schizophrenic who states that he has special rays from Mars piercing his brain demonstrates a nonunderstandable delusion. The Concept of Balance
Psychotic experience presents with a driven preemptory quality which leads to great difficulty in living in the world. As we move from more grossly psychotic disturbance to borderline conditions towards neurotic and characterological dis-
DIAGNOSING
107
orders, we can still detect psychotic experience in which the formal presence of delusions, hallucinatory or pseudo-hallucinatory experience, and serious object relationship disturbances are present. In the serious psychoses, there are few alternatives to such experiences. In the presence of minimal interpersonal or physiological stress, psychotic disturbance appears. In the borderline and in particular neurotic disturbance only in the presence of overwhelming stress, daydreams, nightmares, etc. do we observe the presence of psychotic-like behaviors and/or experiences. However, such experiences are surrounded by a buffer zone of adaptive socially appropriate behaviors, and/or a number of psychological defense mechanisms. In serious psychosis the buffer has been destroyed or never developed and all that remains is psychosis or behavioral withdrawal. The concept of balance is useful in distinguishing the serious psychoses from the transient psychotic disturbance of the borderline condition from the occasional psychotic experience of the neurotic or normal individual. The principle of balance helps us recognize the value of modifying behaviors and the quality and quantity of defenses in determining diagnosis. THE
DILEMMA
OF
FOREST
OR
TREES
The forest-trees dilemma can be a function of inexperience leading to an inappropriate focus on a single behavior such as aggression or hypomania without taking into account other observable behaviors. Many of these mistakes are not related to inexperience or poor observational skills. They are rather a function of distortions in the mind of the therapist leading to selective inattention or overevaluation of one amongst a variety of presenting symptoms. A clear example is a diagnosis of manipulative behavior in schizophrenics as indicating the presence of a characterological disturbance. Other examples are all seductive women being labeled as hysterical personalities” or any aggressive male patient being labeled antisocial personality. ‘I) This problem which I term the forest-trees dilemma is responsible for some serious errors in diagnosis. As indicated there are two main causes for such mistakes. One is correctible through education and experience. The mistake which is attributable to selective inattention or overvaluation secondary to the therapist’s personality problems requires improved self-awareness on his part, or treatment. One way of avoiding the forest-trees dilemma is to use rating systems such as the WashingtonSt. Louis” form or the Flexible System” for diagnosing disorders. These forms are useful in demonstrating the distortions which enter into clinical diagnosing and in providing a method of diagnosing which eliminates subjective distortions. EXPERIENCE
AND
BEHAVIOR
Experience and behavior are words referring to a complicated dichotomy. Issues such as the mind-body problem, the psychoneural identity thesis,‘” and other awkward and confusing philosophical problems relating to dualistic versus monistic views of persons lurk in the wings. We shall therefore distinguish between verbal behavior and nonverbal behavior and avoid questions relating to the Cartesian question of dualism. It is clear that nonverbal behavior is a poor criteria for diagnosis. It provides at best a peripheral subtantiation of what we observe on the basis of verbal behavior (experience). Even catatonic behavior which
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is often symptomatic of schizophrenia can be found in organic brain syndromes, drug-induced immobility, mutism, and depressive stupor.14 Recent studies I have performed indicate that the extremely detailed delineation of catatonia as described by Karl Leonhard15 does not seem to distinguish that group of catatonics who are schizophrenic from that group who are not. Therefore nonspecific, nonverbal behavior can only be used to corroborate diagnosis. This even applies to depressive behaviors as described,in the following case. Example. A 20 yr old man presented in the Emergency Room with complaints of suicide ideation. He disclaimed any eating disturbance, insomnia, somatic complaints, etc., and his appearance gave no indication of motor behavior often associated with depression (psychomotor retardation). Past history revealed four serious suicide attempts plus a positive family history in which three relatives had died by suicide. In investigating the patient’s experience (verbal behavior) he indicated a sense of emptiness, and a sensation of decreased thoughts both as to numbers of thoughts and to flow of thoughts. His experiences particularly in the quality of his thinking and feelings substantiated a diagnosis of endogenous depression. Comment. This patient did not present the usual behaviors associated with this condition. Although this is not a typical situation, it does occur and it is important to recognize that verbal behaviors are sufficient to establish a diagnosis. In the absence of verbal behavior, the psychiatrist must be extremely careful. A distinction between organic brain syndrome with lethargy-stupor (WernickeKorsakolQ retarded depression, or chronic schizophrenia with autism is a difficult differential diagnosis in the absence of verbal behavior. For this very reason performing amytal interviews on all catatonic patients is important in order to determine the presence of verbal experiences consistent with schizophrenia, depression, and organic brain syndrome. SYMPTOMS
AND COURSE
Once an experience-behavioral package, a symptom-sign constellation has been identified and labeled, the patients’ course must be added. Monrad Krohn16 in his textbook develops the concept of curves of development (Decursus Morbi). He describes vascular catastrophe, tumors, arteriosclerosis, disseminated sclerosis, and poliomyelitis, as all having differing and characteristic curves of development. Similar curves can be developed in psychiatry, although we must recognize that modifying behaviors may influence the course of a disturbance. It is entirely possible to have a symptom picture of hypomania or mania with a course of chronic disability. Such a picture is typical of the course of some schizo-affective disorders.17 A first episode patient with a schizophrenic picture does not permit the identification of a course. It is important that such patients not be diagnosed as schizophrenics until the course has been outlined. Genetic data now indicates that acute schizophrenia may progress to produce the picture schizophrenia with a chronic deteriorating course or may be more akin to manic depressive psychosis in which we have periodic psychotic disturbances with return to base-line function between episodes. In psychiatry we can outline the course most typical of schizophrenia which is either a chronic deteriorating one, or a course characterized by repeated dysfunction without return to baseline levels.
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We can also determine the most typical course of bipolar disease which consists of periodic disturbance with return to baseline functioning. We can delineate the course of delirium which is characterized by a periodic disturbance with return to a baseline function. We can outline the course of dementia in which we have either a chronic deteriorating course or a step-wise deterioration characteristic of arteriosclerotic disease. Similar courses can be determined for neurotic dysfunction and characterologic disorders (Briquet’s syndrome).” The presence of modifying factors makes the course of a disturbance not the absolute indicator of the kind of dysfunction but atypical courses can be tipoffs to mistakes in diagnosis. For example, periodic courses with a symptom picture of schizophrenia can be in fact stage 3 mania5 misidentified as paranoid schizophrenia. Although initial drug treatment is often on the basis of the symptom or behavioral picture, aftercare planning including living situations, vocational rehabilitation, social network, and outpatient treatment are often a function of the course of the disturbance. Three other diagnoses are often identified by course. Alcoholic hallucinosis,” and amphetamine psychosis4 are in actuality periodic psychotic states in which the patient returns to his interepisodic functioning. In the presence of hallucinosis or a paranoid state in which the patient has returned to baseline, we must consider either of these diagnoses. The borderlinelx patient is often mistaken for a reactive or an endogenous depressive patient. Once we have identified the stablyyunstable course of the borderline patient, appropriate treatment can be planned which will differ greatly from the kind of treatment we would provide for the more periodic depressive syndromes. LINGUISTIC
MUDDLING
In a previous paper,lg I indicated that schizophrenia can be defined in a global way as a disturbance which will encompass a large number of patients and include a number of patients who are not schizophrenic (so-called false positives). On the other hand, schizophrenia may be defined in such a way that very few nonschizophrenic patients will be included in our sample. But many patients omitted from the narrow definition would fit in the broad diagnosis of schizophrenia. The Washington-St. Louis” criteria of schizophrenia delineates such a subsample of the disturbance. Both ways of diagnosing are useful. The broad method helps us identify large groups for drug treatment and structured milieu approach. The narrow diagnosis identifies homogenous populations for research purposes. The major problem of the diagnostician is unconscious oscillating between the broad and narrow definition. This leads to some diagnostic errors. If we diagnose schizophrenia using the broad diagnosis, we must be prepared to make few prognostic statements, because in the broad diagnostic classification are included some borderline patients, some reactive psychoses, and some bipolar disorders. On the other hand, by diagnosing within the narrow framework, we must recognize that there will be large numbers of patients whom we will have to call “undiagnosed.” CONCLUSION
Some characteristic errors leading to diagnostic imprecision have been identified. These are created by deficiencies in knowledge and skills and/or
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countertransference difficulties of the therapist. The errors include incomplete evaluation, form-content dilemma, forest-trees problem, the diagnosis of experience versus the diagnosis of behavior, symptoms versus course, and lastly, linguistic muddling. Every clinician should be aware of these contributions to poor diagnosing. In addition rating scales should be utilized as supplements to clinical diagnosis. In these ways it becomes possible to minimize diagnostic errors related to ignorance and/or countertransference. REFERENCES I. Beck AT, Ward
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