Wednesday 5 September 2007


Psychiatrists diagnose mental health problems.

We have been trained to sift through symptoms and signs in order to ellucidate relevant psychopathology and ascribe significance to this, then weigh the constellation of relevant symptoms and signs and intensity and duration to generate a robust diagnosis.

One comment from my ST1 doctor (Specialist Trainee year 1 doctor, what used to be an SHO) stirred my thoughts. He's just finished his Foundation training which included a stint in GP land.

He was surprised at the diagnostic rigour in psychiatry.

A lot of diagnosis in Primary Care is based on clinical impression formed from history, examination and occasionally relevant investigations to confirm or refute a diagnosis. Many diagnoses are formulations made with the best evidence available before the GP, which can be a bit thin. Diagnosis of, say, Irritable Bowel Syndrome or a Chronic Fatigue Syndrome can be difficult to make in a robust fashion. Even before diagnosis, symptoms can be hard to quantify (such as dysmenorrhoea that means different things to different people).

My junior doctor was surprised that in Primary Care most GPs diagnosed problems intuitively through each consultation, seemingly at whim. Psychiatric diagnoses are determined within the World Health Organisation's International Classification of Diseases, 10th Edition, ICD-10.

In psychiatry we need to tick many boxes before we can say, "This patient has a diagnosis of F33.11 Recurrent depressive disorder, current episode moderate, with somatic syndrome."

It was interesting to see a young doctor realise that determining diagnosis of mental health problems is oft times more considered and robust than diagnosis of physical health problems.

We're not just musing and making stuff up!


Dr Andrew Brown said...

We certainly use a lot of fuzzy thinking, intuition and hunches based on previous experience that has been assimilated into our subconscious.

And we suffer a lot from being told "GPs ought to do this" by experts in their ivory hospitals who are appalled by our sloppy ways.

They fail to understand that we are not an amalgamation of consultants in all disciplines. We are untidy GPs, irredeemably tainted by prolonged contact with our patients.

Perhaps we are like democracy - the worst form of doctoring apart from all the others that have been tried from time to time. :-)

The Shrink said...

"fuzzy thinking, intuition and hunches based on previous experience"

I would see this as good clinical acumen and I'd value it over protocols and guidelines any day.

My point wasn't that diagnosis in GP land was sloppy, it was that diagnosis of mental health problems is at least as rigorous (and often more so) than diagnosis of physical health problems.

Given that in common parlance folk say, "Oh, she's just depressed," it's often seen as an easy label to generate. A formal diagnosis from our mental health service is quite the opposite, it's very considered.

Which isn't necessarily how folk think of psychiatry!

Dr Andrew Brown said...

Yeah, sorry for riding off on one of my (our) hobby-horses.

And of course you make your diagnoses by talking and observation, which is much less impressive than shiny nuclear imaging technology.