Misdiagnosis: Where Does the Fault Lie?

John McManamy Health Guide
  • I tend to get my best insights from fellow patients. This occurred last night when I went to a NAMI “In Our Own Voice” presentation. I had twice spoken to this very same local NAMI. But this time, I was here to listen.

    Both presenters - young adults getting their lives back on track - were exceptionally articulate. One, let’s call him Adam, happened to mention that at different times he had been diagnosed with depression, bipolar, and schizophrenia. Someone in the audience happened to ask why the schizophrenia diagnosis.

    Adam explained that when he was depressed he was also experiencing psychotic delusions, which is why his doctor assumed he had schizophrenia. I turned to a friend in disbelief.

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    This is crazy, I whispered to my friend, a schizophrenia diagnosis on the basis of just one psychotic episode? The doctor has to be an idiot.

    My friend was nodding in clear agreement, urging me to continue. I whispered some more, then she joined in, corroborating my point of view. Yes, we both agreed. There are too many idiot doctors out there. Way too many.

    Coincidentally, that very day, I had just completed a new addition to my mcmanweb site dedicated to my commentaries on the draft DSM-5. You can read some of my critiques in earlier shareposts here. This particular set of commentaries first saw the light of day on my Knowledge is Necessity blog, which I presented in two series. The first were Report Cards on why the draft DSM-5’s versions of depression and bipolar leave much to be desired. The second was “The People’s DSM,” which lays out my interpretation of depression and bipolar.

    My main point is that if the DSM is inaccurate or is working off outdated principles then a lot of misdiagnosis is going to occur, and guess who suffers? I know from listening to patients that this is a very common occurrence. So who is to blame? The doctor or the DSM?

    Let’s return to Adam, who was summarily burdened with a schizophrenia diagnosis on the basis of a single psychotic episode. Keep in mind, schizophrenia is viewed as the “abandon all hope” diagnosis. Too often, individuals labeled with schizophrenia are unjustly written off, which accounts the very high suicide rate amongst those recently diagnosed.

    Thus, with this diagnosis more than any other, the clinician needs to be correct. There is absolutely no margin for error.

    Fortunately, the current DSM comes in loud and clear. The obvious call to make when a person is both depressed and psychotic is severe depression “with psychotic features.” The same specifier also applies to bipolar mania. It starts to get confusing with the schizoaffective diagnosis, which is seen as a hybrid between bipolar and schizophrenia, but at least the clinician is presented with another option before considering schizophrenia.

    Keep in mind, psychosis doesn’t equate with schizophrenia. Schizophrenia, tends to come wrapped in other symptoms besides hallucinations and delusions. The DSM also notes schizophrenia symptoms need to persist for six months or more (unless brought to a speedy end by treatment).

  • So would an improved DSM have afforded Adam’s doctor greater guidance? No, sad to say. The current DSM was more than adequate, and therein lies the problem: The best diagnostic manual in the world is only as good as the doctor reading it.

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    As I said to my friend, there are too many idiot doctors out there. Way too many.

Published On: April 09, 2010