A necessary part of running a hospital involves the task of getting everything paid for. In the United States, we use a complex series of codes called ICD-9 to bill insurance companies based upon which disease is treated. In psychiatry, all patients are given a diagnosis based upon the DSM-IV (The Diagnostic and Statistical Manual), the handbook of the American Psychiatric Association. For those of you who are unaware, the DSM-IV reads like a checklist. A typical diagnosis falling under the heading of “major depressive disorder” will list a series of criteria defining the diagnosis based on everything from decreased sleep to loss of interest in hobbies. If a person meets these criteria, then he is considered depressed. The problem arises when the patient doesn’t necessarily fit all the conditions. For example, in major depressive disorder, there are four criteria which must be met. If a patient only meets three of them, he cannot be diagnosed with MDD—no matter how sad he feels.
On my ward, everyone gets a diagnosis and a prescription upon admission. As my attending once told us, “We need a diagnosis. Give me something to put down here.” We then proceeded to force a patient into a category known as “psychosis, not otherwise specified” or anything else that might get us paid. My attending uses a fudge factor to try to force anyone to a diagnosis. To qualify for the label of “psychosis,” a person must have either delusions or hallucinations. When we interview someone in the psychiatry office, the patient is often intrigued by all of the posters on the walls. He may begin looking around the room and reading whatever is posted. Our attending will then use this behavior as evidence of hallucinations by saying, “He’s looking for the voices.”
I’m starting to size up the people around me and trying to fit them into psychiatric categories. My first diagnosis is for my attending, who I’m sure has narcissistic personality disorder. He sits in a high-back leather executive chair during rounds, while the rest of us sit in plastic seats. He begins rounds each day by methodically counting all of the patients’ charts as well as all of the medical students and residents present. We then discuss the new patients of the day, most of whom have schizophrenia.
Schizophrenia is the most devastating disease known to man, with the loss of employment, little hope for education, difficulty in maintaining interpersonal relationships, and the general trend of a downward spiral to the point where the patient is no longer functional. Many schizophrenics are forced to go on disability and receive Social Security income from the government. Many other schizophrenics turn to alcohol and drug abuse as a coping mechanism. When we combine these two, we get patients who are purchasing drugs using tax payers’ money. As one man told us of his cocaine habit, I could hear a sucking sound coming from the Social Security Administration that paid for his expensive addiction.
There are many conditions which resemble schizophrenia: drugs, certain infections, and traumatic brain injury. These diseases can lead to a variety of hard to handle behavior as witnessed this past week when an HIV-positive woman came into the staff area of the psychiatric hospital and then urinated all over the floor. As one physician stated, “Who needs TV when there’s drama here?” True, I do see a lot of crazy stuff.