Diagnosing mental illness can be a doubled-edged sword. The benefits of having an accurate diagnosis are many, including assignment of targeted treatment, relief in having an explanation for nebulous symptoms and contributing to academic and scientific understanding of the condition, among others. There are also drawbacks, including contributing to self-fulfilling prophecies and victim mentalities in some patients, and justifications for detrimental or dangerous behaviors in others. Although the assignment of accurate diagnoses can be destructive in its own right, the misdiagnosis of mental illness is far more destructive – and often in ways that are not plainly obvious.
As I have previously written about, the history of mental healthcare in America has many examples of mistreatment, dangerous so-called scientific interventions, abuses and poor outcomes (see Mentally Paralyzing the Generations and Mental Illness in the Legal System for more on this). In addition to these unfortunate stains on the profession’s history, the American mental healthcare system also has a long and disturbing problem with assigning wrong diagnoses. Even more troubling are the all-too-often cavalier attitudes, careless lack of time invested in quality assessment, and the frequent and stubborn defense of these diagnoses and the faulty systems that allow for them.
To be fair, the far-reaching problem of misdiagnosis should not be simply or solely attributed to lazy or incompetent providers failing to engage in a simple and straightforward task. Psychiatric diagnosis is complicated, subjective, nebulous, convoluted and dynamic – and this is when we have all the information we need, which is rare. Even when a clinician is well trained, ethical, competent and thorough, arriving at an accurate diagnosis can be extremely challenging.
Sadly, a substantial number of misdiagnoses are at the hands of unqualified providers. Many patients bring their mental health concerns to the primary care providers, OB/GYNs or other non-mental health providers. While physicians are highly trained and skilled in many ways, they do not receive extensive training in understanding, diagnosing and treating mental illness. Nor do most have the time necessary to conduct the thorough assessments necessary to arrive at a quality diagnosis and recommend the proper treatment. The more likely scenario is that a quick screening is done during an already short appointment, a diagnosis is assigned and a prescription is written. Studies have suggested that over 75% of antidepressant prescriptions come from primary care doctors, not trained mental health prescribers (see Barkil-Oteo, 2013 for example). Most agree this is an undesirable and ineffective way to diagnose and manage any mental illness.
Unfortunately, the practice of many psychiatrists (who are highly trained in mental illness and proper diagnosis) is often not much different. Various pressures, not the least of which is insurance companies, have altered how psychiatrists are required to practice, often leaving them inadequate time for robust assessments, full record reviews, consultations with previous providers and the other necessary components to assure a comprehensive knowledge of the patient. Thus, in many cases, a 15 or 30 minute interview to review symptoms and prescribe or adjust dosages is the reality.
While these problems and limitations are quite real and often understandable, they are substantially responsible for the broader issue and inevitable consequences of patients who are poorly, wrongly diagnosed. Since it is our job to care for the patient, their outcomes should be paramount to how we think about, and ultimately assign diagnoses.
For patients who are genuinely motivated to understand and address their mental health problems, misdiagnosis can lead to a great deal of wasted time and needless suffering. In my practice, I have seen many patients who carried wrong diagnoses for years and did not experience improvement with prescribed treatments. As I gathered their histories, listened to their stories and applied the diagnostic criteria, I often found gross oversights by practitioners who usually spent far too little time with the patient, missed or ignored critical information or arrived at indefensible conclusions.
A misdiagnosis invariably leads to inappropriate and/or unnecessary treatment recommendations. Such treatment is, at best, a waste of precious time. At worst, it can be harmful. I recently saw a patient who was diagnosed with Schizophrenia in his mid 30s (this is a highly atypical first manifestation) because he allegedly heard voices. His medical records contained scant information and virtually no substantiation for how this debilitating serious mental illness was warranted (i.e. records only mentioned vague voices as proof of the diagnosis). For several years, he had been taking, among others, antipsychotic medications, from which he experienced unpleasant side effects but no change in his distress or reduction in his ‘hallucinations.’ Nonetheless, his providers continued with the same diagnosis, added medications and increased doses.
This case helps to illustrate another problem with misdiagnosis, although this one is more indirect. Because of his schizophrenia diagnosis and the side effects of medications (as well as, unbeknownst to him, an undiagnosed and untreated mental illness that he actually did have) he was seeking disability benefits. Subjectively, he knew was suffering and it was inhibiting his ability to function, including holding a job. However, his trusted care providers told him this was due to his psychotic disorder. Although he was receiving the recommended treatment, his symptoms remained and he was led to believe his condition was chronic, deteriorating, treatment resistant and he could not provide for his family.
After a thorough assessment, it was quite obvious that he was suffering from Posttraumatic Stress Disorder (PTSD). Trauma can have major effects on those it afflicts, including hallucinations. However, with appropriate diagnosis and proper interventions, trauma sufferers can recover, achieve a high level of functioning and even return to work. Sadly, a sloppy misdiagnosis wasted my patient’s time, money, and resources. It damaged his relationships, self worth and needlessly subjected his body to medications he did not need. This man’s life was significantly, negatively impacted by the misdiagnosis of a mental illness; something that could have been completely avoided with quality care.
There are also cases in which patients are diagnosed with mental illness when they do not have one at all. If they are being honest about their symptoms (some patients fabricate mental illness for various reasons), the symptoms are often due to an underlying medical condition, substance abuse disorder, neurological condition or some other obscure reason.
Perhaps an atypical, but no less serious example of problems with misdiagnosis is the impact it can have on a legal case. As I wrote about in Mental Illness in the Legal System, mental illness interacts with the law often and in many ways. Perhaps more than in other areas, thorough assessment and accurate diagnostic formulations are even more important since the court is relying on high quality information. This information is frequently used by attorneys and judges to make significant legal decisions; sloppy, incomplete and inaccurate work can carry dire consequences. Consider this example:
A patient in his early 20s was charged with murder after killing an elderly relative. He had a history of antisocial behavior, including various violent acts against family members, but no discernible history of mental illness. He had manifested no symptoms, received no treatment and carried no diagnoses throughout his childhood and early adult life. However, when he went to trial for the murder, he and his attorney alleged mental illness and opted to pursue the insanity defense (i.e. he should not be held criminally responsible for the murder on the grounds his mental illness inhibited his ability to appreciate the wrongfulness and criminality of his actions). In the end, he was adjudicated Not Guilty by Reason of Insanity (NGRI) with a diagnosis of Schizoaffective Disorder. He was sent to a forensic psychiatric facility to be treated and have his risk of violence mitigated.
Schizoaffective Disorder is a very rare condition (lifetime prevalence of about 0.3%) and requires a person to meet the diagnostic criteria for Schizophrenia while simultaneously meeting criteria for a major mood disorder (e.g. Depression, Bipolar Disorder). For example, the person may have auditory hallucinations or delusions, disorganized thoughts, blunted emotional expressions, poverty of speech and behavior and others. In addition, they would have had extremely depressed and/or elated moods, risky behaviors, poor self care and/or other symptoms associated with mood disorders. For these reasons, this condition is exceptionally rare.
In the example above, the patient’s history contained no indication of any symptoms of mental illness, much less this very rare and serious condition. He never heard voices, experienced delusions, nor was he ever cognitively or behaviorally disorganized. He never experienced depression, mania or any of the significant symptoms associated with major mood conditions. What’s more, the patient spent many years in the hospital where he never manifested symptoms of any mental health condition. He never took psychiatric medications, nor did he meaningfully engage in any aspect of the treatment program. Instead, he was exceptionally intelligent and painfully narcissistic, leading him to press boundaries, challenge the rules, file grievances and generally harass, intimidate and exasperate the staff on (no exaggeration) a daily basis. There was simply no doubt he did not have Schizoaffective Disorder.
Although this case represents a rare and unusual circumstance, it illustrates a powerful point. The NGRI defense requires a defendant to have a mental illness. The central tenet of the defense is that the person should not be held responsible for a criminal act because of the effects that illness had on their behavior. If there is no mental illness, there can be no NGRI finding. In the above example, the patient (and victim) did not receive proper justice as prescribed by the law because he was wrongfully diagnosed with a condition he did not have. The court was provided with and ultimately ruled on poor and inaccurate information that allowed a calculated murderer to avoid prison.
It is not likely that we will ever be able to easily and reliably diagnose mental illness; as noted above, it is highly complex. However, there is a great deal of room for improvement in our current practices and outcomes for patients. Although we cannot conduct a lab test or brain scan to confirm a diagnosis, we do have adequate tools at our disposal to conduct quality work and do better than we have been for much of the last century. A large percentage of the many misdiagnoses could be curbed by employing well known best practices: good quality assessment, thorough review of known history, working knowledge of diagnostic definitions and use of those criteria and using solid clinical reasoning to arrive at reasonable conclusions.
While mental health practitioners face numerous pressures that serve as a temptation to cut corners and compromise ethics, we cannot afford to succumb. As briefly outlined in this article, there are too many destructive possibilities to allow a reckless misdiagnosis to take root.
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