Everyone gets a diagnosis and a prescription

February 12, 2008 at 9:08 pm (Clinical rotations)

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.



  1. anonymous said,

    My grandmother was diagnosed with schizophrenia. I was nine and wanted to help her and I decided that she was hearing some type of noise (if I concentrated I could hear things too, but they were things like the heater going off, low sounds that I didn’t hear very often) and that she needed to re-program what she was hearing. My parents were concerened at the conversations I was hearing and they wanted me to see Granma’s doctor. He ah, just wanted to meet me. He had me in his office and we ate cookies and then he started asking me about the voices and I told him, “Oh! I’m helping you!” The effort for him to keep a straight face must have been Herculean as I explained that I thought that Granma was hearing things and was misinterpreting them and instead of arguing with her, “How can you say she isn’t hearing something? If she says she is, then she is and she is 60 years old so you can’t say that she isn’t!” that I was just agreeing but disagreeing with the content.

    He would wind up telling me that I had a future in psychology and psychiatry but that they were not ready for my theories yet, bu until they were, I had to stop my own brand of therapy with my grandmother. I remember him shaking my parent’s hands and telling them that there would be no charge for my visit and he looked down at me and said, “You will remember this visit when you grow up. A lot will happen between now and then but until you are 25, leave the saving of your grandmother to the doctors, OK?” I look at the advances now and I am amazed. I don’t know if my grandmother could be cured. I fear it cropping up in me.

    I’m not a psychologist or a psychiatrist, but I still think we could have changed what the voices were saying to my grandmother.

  2. Nonmaleficence said,

    I can’t help but notice that your thoughts are very similar to the author, Samuel Shem. I hope you are doing well in your residency program.

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