Clinical Pearls

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How to Avoid the ‘Diagnostic Trap’

… and Discover the Value of Schmoozing

New “clinical pearls” have been posted to the ACLP website—video vignettes from Academy members who were asked to put themselves in front of a camera during CLP 2019 in San Diego

Jeffrey Staab, MD, MS, FACLP, professor of psychiatry at Mayo Clinic, talks about how we need to get in the right mindset for consults on patients who are said to have medically unexplained symptoms.

C-L psychiatrists are commonly called to patients said to have nothing medically wrong that causes their symptoms.

At that point, we shouldn’t fall into a “20th century diagnostic trap.” We can never be certain all medical conditions have been worked through—nor should we believe that patients without an identifiable structural illness automatically have a psychiatric problem.

Usually, when a psychiatrist carefully considers structural, functional, and psychiatric contributors to the patient’s symptoms, a complete diagnosis can be given.

But, if we don’t know what’s wrong, we should say so, says Dr. Staab, rather than “pigeonhole a patient into a category of psychiatric or functional pathology that doesn’t fit.”

We should tell patients of our uncertainty (“patients know we don’t know everything”) and have a full conversation with them and their families about our uncertainty, enabling us to plan with them a follow-up that helps identify shifts in ongoing behavioral patterns in the patient that may lead to a better diagnostic impression. “Time is a great diagnostic test,” says Dr. Staab.

He adds: “Patients will feel abandoned if everybody points their finger in another direction and says: ‘It’s not our problem, it’s their problem.’”

The “clinical pearl” is here.

Idris Leppla, MD, psychiatrist at John Hopkins University, discusses Medical Personality Change Due to Primary and Secondary Brain Tumors here.

Dr. Leppla summarises the epidemiology of primary and secondary brain tumors and describes how personality change depends on the tumor’s location.

She provides a case study of a middle-aged actress, who was very independent and flamboyant, who stopped doing auditions, put on weight, became irritable and apathetic, and slept for 18 hours a day. Within one to two months of treatment for a meningioma brain tumor her personality began to return.

Yet, says Dr. Leppla, some symptoms of such a condition can be misdiagnosed.

Some patients with a temporal lobe lesion causing hallucinations or other psychotic experiences are at first diagnosed with schizophrenia.

So, Dr. Leppla gives indicators on how and when to look out for a possible brain tumor.

Philip Muskin, MD, MA, FACLP, senior consultant in C-L Psychiatry, Columbia University, discusses what he says is an “ancient psycho-analytic concept,” Regression in the Service of the Ego.

As he says—you may wonder why. After all, “people don’t usually talk about it.”

When there is everyday stress and strain, our ego (our ‘self ’) usually copes with it and its impact on us psychologically. “Most of time we do just fine.” But when you’re critically ill and hospitalized, stresses cause you to operate in a way you once did earlier in your psychological development—“we call that regression.”

In hospital, your condition and those caring for you impose upon you the need to behave as once you did earlier in your developmental sequence—those previously active may become frustrated and aggressive.

Dr. Muskin describes how C-L psychiatrists called to attend can respond to this regression in a “plastic” way so patients are not harmed by post-traumatic stress disorder but enabled to “go with the flow,” allowing themselves to be passive and to be cared for as they deal with their crisis.

“The C-L psychiatrists that I know like to talk with people,” says Dr. Muskin. “It’s this schmoozing with our patients that enables regression in the service of the ego to be a very positive experience for our patients.”

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