Table: Educational points
“How could they see anything but the shadows if they were never allowed to move their heads?”
Plato’s Allegory of the Cave is a constant reminder that as clinicians we only see a part of our patients.1 We see the part we project onto them. This selected view of our patients is often further narrowed in our inpatient units. Patients are in distress, displaying only a part of their character. Psychiatric units, with their routines, rules, structures, and boundaries, only allow for the manifestations of certain select aspects of one’s identity and symptomatology. Managed care payers, with their need to minimize cost and duration of inpatient stay, preclude comprehensive evaluations. Finally, our desire for clear diagnoses for our patients can blind us to a multifaceted picture.
We present the case of a patient for whom different attending providers had markedly different interpretations, despite similar presentations within a year. As the case unfolds, we invite you to reflect on your diagnostic understanding of each presentation. We believe that a combination of these factors led to repeated diagnostic oversimplification in our case.
The NeuroBehavioral Medical Unit at the University of California, San Diego, is an 18-bed acute psychiatric unit. Over 800 patients are admitted to the unit each year. In almost half of the patients (48%), there is a diagnosis of some form of psychotic disorder, consistent with the acute nature of the unit. In the vast majority of the rest of the patients, a mood disorder is diagnosed (bipolar 27%, depression 21%). The mean length of stay is short, and averages just 5.9 days (this figure is inflated by unfunded or underfunded patients with long waits for long-term facilities). The unit has a large disenfranchised population, and the majority of patients (53.7%) are either uninsured or have state assistance. The unit is staffed by 2 attending psychiatrists, a chief resident, and 3 or 4 junior residents, as well as 4 medical students.
Overview of the case
Chris is a 22-year-old man who has been treated in many mental health facilities since the age of 19, including long-term private residential programs. He has been hospitalized numerous times for psychiatric problems (usually for depression or failure to maintain housing). During this time, he has spent little time outside of residential facilities or inpatient psychiatric units.
His family history is unremarkable and is only notable for a maternal grandfather with depression. There is no evidence of abuse or significant trauma. He meets developmental milestones and there are no problems with his social development. Chris graduated high school with his peers although he had a learning disability. He attended college for 1 year but was unable to function well in that environment, which led to his placement in various treatment facilities.
He has been treated for schizophrenia, depression, and attention-deficit disorder with haloperidol, risperidone, aripiprazole, quetiapine, olanzapine, and clozapine. At presentation, he is nonadherent to his medications. For the past 2 years, Chris has lived at a private treatment center for mental health in San Diego. His recent departure from the facility was due to resistance to participating in required chores and activities.
Chris presents with paranoia as well as auditory hallucinations, which are derogatory in nature. During the intake interview, he has difficulty in answering questions, which was considered thought blocking. He uses disjointed sentences and some words repetitively, which are assessed to be clang associations and disorganized speech. He also exhibits odd trunk and limb motions, considered to be stereotypy as seen in some forms of catatonia. He is assessed as acutely psychotic. His descriptions of his interpersonal difficulties at the long-term facility are deemed to be a demonstration of the avolition due to psychosis. The main goals of the treatment plan for Chris is to re-start his antipsychotics and provide psychoeducation on the importance of adherence.
Chris demonstrates a prolonged pattern of interpersonal difficulties. His work at Austen Riggs suggests severe personality deficits that culminated in his current state. His parents are no longer talking to him because of his constant dependency on them for financial assistance and lack of action in providing for himself. His departure from the long-term facility in San Diego was another demonstration of his constant ambivalence to commit to independence. His lack of initiative is deemed to be secondary to his need for advice and reassurance.
His movement and speech impairments are assessed to be unconsciously motivated to obtain attention and assistance and to feed his need for others to assume his responsibilities. His father suggests that Chris’s request for antipsychotics is a form of Munchausen, a means to experience adverse effects that will require help from the staff. The diagnosis is a dependent personality disorder with psychotic features. His antipsychotics are stopped because they are hypothesized to be causing severe akithisia; there is no evidence of significant psychosis and Chris is discharged with the recommendation to obtain treatment that focuses on personality traits.
It is revealed that Chris has had an attention-deficit disorder and an unspecified learning disability since childhood. His interpersonal difficulties with the staff and his family are due to developmental deficits in social communication and interactions. Chris demonstrates poor social reciprocity and poor awareness of nonverbal communication. His odd movements are restricted and repetitive, with marked stereotypy. His inability to cope since having left the long-term–care facility is thought to be secondary to the need for sameness and inflexible adherence to routine. The patient is assessed as being on the autism spectrum and a recommendation is made to discontinue antipsychotics and engage in a well-structured behavioral program.
While psychometric scales are invariably elevated in a psychological decompensation requiring hospitalization, Chris’s clinicians want to clarify the differential diagnosis in order to provide targeted, patient-specific treatment. As such, Chris is administered a number of neuropsychiatric tests. The results of the Minnesota Multiphasic Personality Inventory (MMPI) show a thought disorder, some increased psychopathy, and an increased hypomanic scale (of irritability and psychomotor agitation); overall, the MMPI is deemed to be most consistent with schizophrenia.
The results from the Millon Clinical Multiaxial Inventory show increased dependency traits, mania, narcissism, and delusions, but no schizophrenia impression, most consistent with the diagnosis of dependent personality disorder. Results from the Thematic Apperception Test show impoverished capacity to mentalize and relate, as well as a paucity of content consistent with autism.
In 1973, Dr Rosenhan2 challenged the psychiatric paradigm. He postulated that our psychoanalytic reductionism had permitted us to lose sight of objective evidence. Our need to find analytic meaning in our patients allowed our field to label any behavior with a psychic significance. “The facts of the case were unintentionally distorted by the staff to achieve consistency with a popular theory of the dynamics of a schizophrenic reaction.” This task was so time-consuming that the average time spent with a patient per day on an inpatient unit was 6.8 minutes for all practitioners combined.
This case exemplifies many cognitive errors in diagnosis
- psychiatric units have little time to examine complex personality characteristics
- our need to satisfy insurance payers has resulted in the pendulum swinging too far in the other direction
- studies suggest that almost half of our patients have personality disorders
- The introduction of the NIMH RDoC may resolve some of these issues
Today we ponder whether our tendency for biological reductionism and our need to satisfy insurance payers with short hospitalizations has resulted in the pendulum swinging too far in the other direction. Our wish to categorize all psychiatric manifestations under defined diagnostic criteria may have clouded our judgment of our patient. Diagnostic criteria remain guides to follow and not rules to be bound by.
Most likely in the case of Chris, all of the symptom descriptions are partially correct. He has many features consistent with autism, dependency traits, and schizophrenia. As such, a label is less useful than our awareness that any of these possibilities is justifiable. The temptation to project onto the patient an overlearned diagnostic paradigm reduces him to a shadow of whom he truly is, similar to the reality of the prisoners in Plato’s cave allegory.
Modern inpatient psychiatric units have little time to examine complex personality characteristics. Nonetheless studies suggest that almost half of our patients have personality disorders.3 Current diagnostic manuals discourage amalgams of pertinent features from multiple diagnoses, favoring broader and more encompassing diagnoses; however, “explanatory pluralism is preferable to monistic explanatory approaches, especially biological reductionism.”4
In many ways, this case exemplifies many of the cognitive errors in diagnosis as described by Croskerry.5 “Availability” bias may have led the clinicians to see Chris’s phenomenology as consistent with the illnesses they encounter most often, or do research on. “Overconfidence” bias may have led to the inability to examine different differential diagnoses. “Confirmation” and “sunk cost” biases may have led to the interpretation of each symptom to fit the previously assigned diagnosis. “Vertical line failure” bias may have led to the inability of the clinicians to think outside of the confines of diagnostic criteria. These cognitive errors were likely fed by the system of care in which Chris was seen. Having a clear understanding of our own biases and those of the system of care will result in fewer diagnostic errors, less oversimplification of patient presentations, and improved care for our patients.
The introduction of the NIMH’s Research Domain Criteria (RDoC) may resolve some of the aforementioned issues. RDoC offers us an opportunity, as well as a challenge: to expand our understanding of mental illnesses as etiologically complex.6 The risk, however, is to further simplify and codify human experiences on the basis of narrow biological factors, denuded of any applicable significance in cases like the one described in this article. As the RDoC process continues, the onus is on clinicians and clinician educators to recognize and challenge unconscious and systems biases. Otherwise, understanding their patients may be merely a shadow of the reality.
Dr Badre is Resident Physician, Dr Khalafian is Resident Physician, and Dr Steiger is Attending Physician in the department of psychiatry at the University of California, San Diego School of Medicine. They report no conflicts of interest concerning the subject matter of this article.
1. Plato. The Republic. 360 bc.
2. Rosenhan DL. On being sane in insane places. Science. 1973;179:250-258.
3. Zimmerman M, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162:1911-1918.
4. Kendler KS. Toward a philosophical structure for psychiatry. Am J Psychiatry. 2005;162:433-440.
5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:777-780.
6. Insel T. The NIMH Research Domain Criteria (RDoC) project: precision medicine for psychiatry. Am J Psychiatry. 2014;171:395-397.