There is much more scope for interpretation and dissent in psychiatry than in most other medical fields due to the more rudimentary knowledge base, and the greater distance from clinical realities.78 It is axiomatic that psychiatrists often disagree on a diagnosis, and if not the diagnosis, on the treatment needed for the management of the symptoms.79 An example of this type of polar disagreement between mental health professionals became apparent when five men who were experiencing mental illness died in Tasmania’s 260 bed prison within a five month period in 1999/2000. The deaths prompted a public outcry that resulted in two separate inquiries: a Death
75
Rick Mayes and Allan V Horwitz, ‘DSM-III and the Revolution in the Classification of Mental Illness’ (2005) 41 Journal of the History of the Behavioral Sciences 249, 266.
76
Gary Greenberg, ‘Not Diseases, but Categories of Suffering’, The New York Times (online), 29 January 2012 <http://www.nytimes.com/2012/01/30/opinion/the-dsms-troubled-revision.html?_r=2&ref=opinion>.
77
Australian Bureau of Statistics (ABS), National Health Survey: Summary of Results, (Report, No 4364.0, Canberra, 2001).
78
Michele T Pathé and Paul E Mullen, ‘The Dangerousness of the DSM-III-R’ (1993) 1 Journal of Law and Medicine 47.
79
The New York Times published an article by Benedict Carey on 11 November, 2006 titled What’s Wrong With a Child? Psychiatrists Often Disagree in which he referred to a 13 year old boy who had had 13 different the diagnoses. His first diagnosis was depression. He was aged 7. ‘Each diagnosis was accompanied by a different regimen of drug treatments.’
in Custody inquest conducted by the state coroner and another inquiry initiated by the Tasmanian Ombudsman.80
The issue of medical diagnosis and misdiagnosis was a prominent factor in the subsequent findings of the mens’ deaths and led to the coroner’s recommendation that a system of peer review of psychiatric decisions be implemented.81
...the diagnosis by Dr. Pargiter on the 18/8/99 of a major depressive disorder which Dr. Jager disagreed with 3 days later without allowing for any period of observation by him82... Dr Jager agreed he read Fabian’s forensic file which included the reports of the psychiatrists and psychiatric registrar all of whom had previously diagnosed Fabian as suffering from schizophrenia. His view however was that Fabian was a severely personality disordered individual with an anti-social and narcissistic profile. His condition was likely to be a
psychopathic personality disorder and unlikely to be schizophrenia.83...While Dr. Sale disagreed with Dr. Jager’s diagnosis...he said that the treatment Dr.Jager was giving Fabian....the anti-psychotic drugs, would have been what he would have done anyway.84
Psychiatrists use the diagnostic classification lists to aggregate symptoms,
manifestations and behaviours deemed abnormal or dysfunctional then subjectively afford different value weights and rankings to, too often, arrive at inconsistent, uncertain, unprovable, unreliable and inaccurate diagnoses.85 The strategy of constructing standardised definitions of designated behavioural indicators to aid psychiatrists to make appropriate and consistent diagnoses has not been as successful as hoped.86 Suggested causes for this include the view that severe
80
Ombudsman Tasmania, ‘Report on an Inquiry Into Risdon Prison: Risdon Prison Hospital & Forensic Mental Health Services’, volume 1, June 2001.
81
Recommendation 26, Magistrates Court Tasmania, ‘Findings Deaths in Custody Inquest’ (Inquest Report, Magistrates Court Tasmania, 26 March 2001)
<http://www.justice.tas.gov.au/__data/assets/pdf_file/0014/18050/Findings__Deaths_in_Custody_inquest.pdf>. 82 Ibid, 140. 83 Ibid. 84 Ibid, 141. 85
Marlene Busko, Adults Admitted to a Mood-Disorder Clinic Are Often Misdiagnosed. <http://www.medscape.com/viewarticle/582125>.
86 Aleen Frances, ‘The Forensic Risks of DSM-V and How to Avoid Them’ (2010) 38 Journal of the American
Academy of Psychiatry and the Law 11. See also Allen Frances, ‘PTSD, DSM-5, and Forensic Misuse’,
Psychiatric Times (online), 30 September 2011
<http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1959645>. ‘In preparing DSM-IV, we worked hard to avoid causing confusion in forensic settings. Realizing that lawyers read documents in their own special way, we had a panel of forensic psychiatrists go over every word to reduce the risks that DSM IV could be misused in the courts. They did an excellent job, but all of us missed one seemingly small mistake— the substitution of an “or” for an “and” in the paraphilia section that lead to serious misunderstandings and the questionably constitutional preventive psychiatric detention of sexual offenders.’
mental disorders may exist on a continuum rather than as discrete binary
possibilities and clinical entities,87 and the differences in the ways that clinicians account for the social context of behavioural symptoms.88
Psychiatrists can also differ on what symptoms are necessary to trigger a particular diagnosis. For example, some psychiatrists will diagnose every person
experiencing a mood disorder as ‘Bipolar’. A requisite symptom of Bipolar is a manic episode which involves a distinct period of abnormal, irritable moods, characterised by inflated self-esteem, sleeplessness and other traits. When ‘mania’ is not present, some psychiatrists will assume that it has occurred, but the person was unaware, or that it will occur at some point in the future, so make the Bipolar diagnosis. On the other hand, many patients who do have Bipolar but who have not experienced a manic episode are initially diagnosed and treated for major
depression.
Many patients carry each of the diagnoses of Schizophrenia, Major
Depression, Bipolar illness, and Schizoaffective Disorder at some points in their lives ... A recent review of the case of a woman who had committed suicide found that her psychiatrist had diagnosed her with all of these disorders within the past year. It's a rare patient who carries the same psychiatric
diagnosis throughout their lifetime...Our field's inability to agree on what disorder an individual actually suffers from is held up by some as confirmation of their belief that psychiatry is just a bunch of pseudoscience at best or, at worst, a profit-driven business.89
The results of a 2000 Bi Polar study by the American Psychiatric Association that followed up an earlier 1992 study reported that:
Over one third of respondents sought professional help within 1 year of the onset of symptoms. Unfortunately, 69% were misdiagnosed, with the most frequent misdiagnosis being unipolar depression. Those who were
misdiagnosed consulted a mean of 4 physicians prior to receiving the correct
87
John Cloud, ‘The DSM: How Psychiatrists Redefine 'Disordered'’, Time (online), 13 February 2010 <http://www.time.com/time/health/article/0,8599,1964196,00>.
88
Stuart A Kirk and Derek K Hsieh, ‘Diagnostic Consistency in Assessing Conduct Disorder: An Experiment on the Effect of Social Context’ (2004) 74 American Journal of Orthopsychiatry 43, 53.
89
Kevin Turnquist, Problems with Psychiatric Diagnosis, Readings in Humanistic Psychiatry <http://kevinturnquist.org/problemsindiagnosis.php>.
diagnosis. Over one third waited 10 years or more before receiving an accurate diagnosis.90
The researchers expressed their concern that in 2000, psychiatrists were still misdiagnosing at the same high rates that had been occurring in 1992 while the numbers of family physicians misdiagnosing had significantly increased during the intervening period.
The high levels of misdiagnosis in psychiatry may be a function of symptom overlap. For example, Bipolar disorder was often misdiagnosed as schizophrenia because psychosis was more commonly associated with schizophrenia. A study of 100 patients with a primary diagnosis of major depression or Bipolar disorder found that 26% actually had an anxiety disorder, a thought disorder (schizoaffective disorder), or a personality disorder.91 Another study that examined psychiatric misdiagnoses in patients with chronic fatigue syndrome found that doctors often mentioned symptoms consistent with a depressive or anxiety disorder but failed to make a formal diagnosis. This failure may have been due to a general reluctance to ‘label’ a patient with a stigmatised diagnosis.92