Medical students often ask how to know if a patient actually has a psychiatric diagnosis for which he or she “meets criteria.”
Even in 2016, long after the “decade of the brain,” psychiatric diagnosis remains a discipline based on phenomenology without confirming pathology. We cannot take a sample of the emotional state or behavior, stain it, and read it off a slide in the lab. There is no “biopsy proven” major depression. Our data is limited to what the patient says about his internal experience and associated observable behaviors.
It is a conceptual error to confuse the notion of meeting criteria with being the entity. We systematically commit the fallacy of “misplaced concreteness,” treating the abstract or hypothetical as if it is real and tangible when it is not. So if the criteria do not constitute the entity, then what?
“Meeting the criteria” is not the end of making a psychiatric diagnosis, it’s just the beginning. I have taught this point over decades by coining the following mock German admonition/aphorism (since, one can imagine Freud growling it, gesturing for emphasis with his ever-present cigar):
“To Make the Diagnosis you have to know the patient’s SIGECAPS und (his/her) Sitz im Leben!”
SIGECAPS identifies “meeting the criteria” as a necessary but insufficient condition for diagnosis. However, the criteria must themselves be interpreted in the context of the patient’s unique “sitz im leben” or “situation (sitting) in life.”
Note: Sitz im leben, from German biblical criticism, denotes the presumed context in which a text was created and upon which its interpretation depends.
A patient’s symptoms must be interpreted with an eye towards the details of their immediate and prior medical status and comorbidities, including the effects, side effects, and interactions of the drugs they are prescribed. The details of their lived experiences and personal narratives must also be considered, including a fine grained understanding of typical coping strategies, psychosocial circumstances, recent and remote stressors, and historical and contemporaneous supports.
Although I coined this aphorism recently, I learned its lesson at the very beginning of my psychiatry training. I had just completed a straight medicine internship and was a newly minted PGY II during one of my first overnight calls in the emergency room.
Mr. Z was a 47 year-old whose friend brought him to the ER because “he was worried I would kill myself since I’ve been feeling like I’ve failed my daughter and deserve to die.”
He explained that six weeks ago his daughter ran off with “a really bad guy,” dropped out of school, and got hooked on drugs. They “had words” and she disappeared. He had no idea where she was.
Over the next six weeks, he became “very depressed,” saying, “I can’t sleep, lost 25 pounds, have no energy, and feel like it’s all my fault.” In the last few days he had thought, “Maybe I should just end it all.”
His friend remained in the ER to be sure that Mr. Z “got the help needed,” and confirmed his story.
I was quietly thrilled. I thought that I had been presented with a textbook case of profound “endogenous depression” with overwhelming guilt and suicidal ideation with intent. I was going to manage my first “true psychiatry emergency.” I ordered 1:1 nursing observation and anticipated warming up the ECT paddles the next day.
The next morning on rounds, Mr. Z leaped from bed to greet me saying, “Thanks Doc. You saved my life. I’m all better and ready to go home!”
Picking my jaw up off the floor, I asked, “What happened? Last night you said you were so depressed you were ready to kill yourself!”
With a sheepish, wry smile he said, “You’re right, Doc, I have been down, and last night I did feel like killing myself. The stuff with my daughter is all true, but she will have to learn her own lessons. There was something else going on that I was too embarrassed to tell you about. See, I like the cards. I gamble. I had gotten $3,000 in the hole and bad guys were starting to make noises, you know, the kneecap stuff…..I didn’t know what to do. But after I came into the hospital, I decided I couldn’t die without telling my mother… so I called her and she agreed to pay them off, one last time. I promise Doc, this is it. I’m out. I’m never going to blow it like this again!”
Following another yet to be coined dictum, “If it’s important it’s worth verifying,” I called his Mom who confirmed his report and her intentions.
His narrative was truthful and his symptoms genuine – I believed this then and I believe it now. He met criteria for melancholic depression. But a presentation instantiates a syndrome, not a unique disorder or entity, so other possibilities, the differential diagnosis, must be considered. In this case, he suffered not from major depression but rather an identically appearing but entirely distinct episode of demoralization due to his life situation, or sitz im leben. For its relief, it required not an emergency course of ECT, but the salutary psychological effects of his mother’s chicken soup (in this case, her checkbook) and the still warm spot in her heart “for my errant but only son.”
I have learned the same lesson many times over in my 40-year practice of consultation-liaison psychiatry, where consultations for depression and suicidality were the result of patients’ attempts to express distress over demoralization related to something far more concrete and banal than the typical existential questions posed by suicidality.
In each of the following two examples, the patient’s suicidality was cured by defecation alone.
First, there was a 73 year-old man I was asked to evaluate for “depression and suicidality.” He was three weeks post-op after a colon resection with anastomosis complicated by a wound dehiscence. The surgeon said he was improving but getting more depressed. Though on his sixth day of a soft diet with healthy bowel sounds, he was “only picking at food, refusing physical therapy or to get out of bed at all,” and this morning he had announced, “I’d be better off dead!”
I asked the patient why he felt this way. He explained that he generally defecated “every morning like clockwork,” which he took as a “sign of health” and was thereby discouraged at his failure to defecate after a week of eating. He explained his logic, “When I’m regular I’m good! When I’m clogged up… no matter what the surgeon tells me, I know it’s bad!”
Following a hunch, I asked the surgeon to give him an enema to determine whether he was depressed or just suffering from “terminal constipation.”
I returned later that afternoon to find him beaming. “Doc, I just had the best bowel movement of my life,” he said, explaining that his depression and suicidal thoughts were now gone. He was discharged home several days later in good spirits. When asked if he would like psychiatric follow-up, he asked, “Why would I need that?” I agreed.
The second example is a 53 year-old man who was admitted with cellulitis, complicated by a clostridium difficile superinfection. He had intractable watery diarrhea with dozens of daily bowel movements for weeks. That morning, he asked to be discharged, “so I can go home and kill myself!” The stat consult was for suicidality and commitment to inpatient psychiatry.
I rushed to his bedside to find him packing his belongings, his brother by his side. Strangely, both men appeared at ease, chatting amicably.
Explaining my sudden appearance, the patient said,“Oh yeah, I’ve was feeling that way last week and this morning, but about an hour ago I had my first solid stool, so now I can see that there is ‘light at the end of the tunnel,’ and I’ll be alright so I’m ready to go home!”
In both cases, what each patient needed for the relief of his “depression” was a bowel movement, or evidence of a “turn for the better,” not psychiatric medications or care.
For me, “meeting the criteria for a psychiatric disorder” means nothing more than meeting the criteria, and signals not the conclusion of the diagnostic inquiry, but merely its beginning.
It is more epistemically correct and more helpful to interpret meeting the DSM criteria as marking the presence of a syndrome just as we recognize a cluster of physical symptoms like shortness of breath, distended neck veins, and lower extremity edema to define congestive heart failure. Meeting the criteria generates a differential diagnosis, not a unique diagnosis.
As many more things look like depression than are Major Depressive Disorder (MDD), we need more data to rule in or rule out specific entities that constitute its differential diagnosis. We must rule out symptomatic medical entities like hypothyroidism and post-stroke depression as well as situationally based disturbances, like demoralization. These things can simulate perfectly an episode of “endogenous MDD,” but are not the “bona fide” disorders that reflect the agreed upon categories of DSM-V.
Obliging this analysis certainly makes “making the diagnosis” more complicated than matching symptoms to criteria and requires much more data, but pays off in an enriched understanding of the patient that will permit you to “see through” the presenting syndrome to discern the “true” entities beneath. Ultimately, “making the diagnosis” is an act of interpretation, not codification.
All psychiatric presentations must be interpreted with and through the prism of a full understanding of the patient’s “lived experience,” if we are to make good sense of it for ourselves and for them.