SPECIAL REPORT: NEUROPSYCHIATRY
A complete, accurate, and timely diagnosis is the cornerstone around which effective treatment is constructed. Yet, the complex skills involved in the art and science of diagnosing have only been the focus of investigation for less than a decade.
While the process of diagnosing is common to all fields of medicine, this article specifically addresses missed “medical” diagnoses in patients who present to or are being followed by psychiatrists and other mental health clinicians. It is hoped that by learning about vulnerabilities within the diagnostic process, readers will have the opportunities to reduce diagnostic error rates in their own practices and institutions.
Diagnostic errors and delays are so widespread that most individuals will experience a diagnostic error during their lifetime.1 And surely, every physician has had the experience of missing a diagnosis or coming to the correct diagnosis only after too long a delay. Memories of missed opportunities for earlier intervention weigh heavily upon us.
Recent studies have found that any individual with a “psychiatric history” or with “presenting symptoms in the sphere of mental functioning and behavior” is especially prone to experiencing a diagnostic error.2 This should alert all psychiatrists, since these are the very patients we are called upon to see. Rare diseases might be misdiagnosed, but, more often, common diseases are missed, especially if they present atypically.
In 2015, an Institute of Medicine report—Improving Diagnosis in Healthcare—concluded that, “. . . improving the diagnostic process is not only possible, but presents a moral, professional, and public health imperative.”1
The diagnostic process
How do doctors make a diagnosis? As you read the following vignette of a referral, try to be aware of your diagnostic hypotheses.
CASE VIGNETTE: Psychosomatic Concerns
According to his primary care physician (PCP) who referred him, Mr O has a long history of psychosomatic complaints. Mr O is a 63-year-old accountant who recently retired. He’s been sleeping restlessly and waking up depressed each morning. He jogs a few miles a day, most days, but says that lately he’s been feeling stiff and somewhat unsteady on his feet. Also, he says he’s “plagued by” constipation. The patient told the PCP that he can’t tell whether these physical problems are “all in my head” or whether there’s really something to worry about.
Dr Schildkrout is Assistant Professor of Psychiatry, part time, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA. She is the author of two books: Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders and Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems.
1. Ball J, Balogh E, Miller BT, Eds. Improving Diagnosis in Health Care. Washington, DC: National Academies Press; 2015.
2. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:75-780.
3. Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Ed. 2009;14:27-35.
4. Yates BL, Koran LM. Epidemiology and recognition of neuropsychiatric disorders in mental health settings. Ovsiew F, Ed. Neuropsychiatry and Mental Health Services. Washington, DC: American Psychiatric Press; 1999: 23-67.
5. Koranyi EK. Morbidity and rate of undiagnosed physical illness in a psychiatric clinic population. Arch Gen Psychiatry. 1979;36:414.
6. Schildkrout B. Complexities of the diagnostic process. J Nervous Mental Dis. 2018;206:488-490.
7. Schildkrout B. Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems. New York: John Wiley & Sons; 2014.