Thursday, December 07, 2006

Question For Fellow Shrinks

Do you ever feel that there is just no hope of truly knowing whether a given person has a mental illness—let alone what the illness is? I mean, with all the possible confounding factors inherent in the history of any adult who has had even a moderately tough life— and with the fragility of the human brain (have you ever looked at this organ, out of a skull? It’s as sturdy as slightly overcooked oatmeal)-- how can you ever winnow out a diagnosis?

Example (purely fictitious, but hardly unusual in my practice): A 32 year old man presents with a wide variety of mental symptoms. Doesn’t even matter what they are—just assume they are many and varied—a mixture of mood, thought, cognitive, behavioral, and personality features.

You are lucky enough to get the following (unusually detailed) history: His mother was a smoker and drank heavily. He says “I almost died when I was being born.” He remembers his father beating his mother, but doesn’t know if his father ever beat him— he can’t recall anything before about age 6. The family lived in a run-down neighborhood and he had little supervision. When he was 9 he had an accident of some sort. He thinks he was unconscious for a time. He doesn’t remember the accident. His parents told him he fell off a deck. He also fell off a moped at some point and hit his head, without a helmet. In high school he drank heavily and used marijuana daily. He had few friends, but he hung out with a group who huffed inhalants (he says he “never tried it.”) He enjoyed asphyxiating himself for erotic arousal. His grades were always poor and he was frequently disciplined for bullying smaller children. He dropped out before graduation. He worked in a string of blue collar jobs including a smelting plant, an industrial cleaning service, and a cannery. He was arrested for possession of crack (which he says he was “holding” for a friend), as well as assault vs. the arresting officer. He was imprisoned for 9 months. He reports being raped in prison. He had a girlfriend but she took out a restraining order after accusing him of killing her ferret with a shotgun (which he denies). He says he has never been able to concentrate on anything, but felt this improved when he snorted cocaine (which he states he did only once.) He feels “jumpy” all the time.

The diagnos(es) is/are:

(a) Fetal alcohol syndrome
(b) PTSD from physical abuse from his parents
(c) PTSD from an accident
(d) PTSD from rape
(e) ADHD, lifelong, untreated
(f) Antisocial personality disorder
(g) Mild mental retardation, congenital.
(h) Mental disorder due to traumatic brain injury (“fall”)
(i) Mental disorder due to traumatic brain injury (moped accident)
(j) Mental disorder due to acute cerebral anoxia (at birth)
(k) Mental disorder due to repeated cerebral anoxia (autoasphyxiation)
(l) Mental disorder due to substances (childhood lead poisoning)
(m) Mental disorder due to substances (chronic alcoholism)
(n) Mental disorder due to substances (marijuana, crack, coke, PCP, heroin, LSD, mushrooms, god knows what.)
(o) Mental disorder due to substances (hydrocarbon inhalants)
(p) Mental disorder due to substances (heavy metals or other industrial toxins)
(q) Bipolar Disorder of any flavor
(r) Psychotic Disorder of any flavor
(s) Anxiety Disorder, of any flavor

Without some kind of time-machine, or magic CSI brain pathology decoder lab, it seems simply impossible to sort this out. So frustrating.


Anonymous Doug said...

I'm not a shrink, but I wanted to say that a more inclusive problem might be the lack of appropriate environments in which to place such a person. Even if you had some fine-grained diagnosis of interacting factors, what could you do? The life of a sailor on a British naval vessel in the days of sail comes to mind as a place where this man's history, behavior and symptoms would not seem unusual, and he might have lived an active, possibly healthy and useful life. A hundred years ago a logging camp might have provided a fair environment. Today it's hard to think of a comparable spot, and no one has the power to place him there, anyway. Prison, hospital, or drugged in front of a TV are pretty much the range of end-points here, aren't they?

12/7/06, 12:20 PM  
Anonymous Turbomom said...

Based just on this history, I would choose e.(ADHD) which, untreated, could lead to a lot of the problems of he has had, beginning in childhood. This could be especially true in a person not too bright who can't figure our ways to compensate.

Then I would R/O mental dusorder due to multiple traumas and R/O mental disorder due to substances (all of them).

12/7/06, 2:20 PM  
Blogger DrivingMissMolly said...

I am curious about the potential, if any, of using the functional mri to see potential damage that may have led to or caused mental illness. Are there any uses or studies yet using this tool? What about the value of tests such as the MMPI, wouldn't those help to some extent?


Sorry, I'm not a fellow shrink...I just noticed this was a 'question for fellow shrinks.'

12/7/06, 5:22 PM  
Blogger ClinkShrink said...

What, no lead poisoning or HIV? You're no fun :)

The two challenges to diagnostic accuracy that I see here are: 1. you've collected a great database with no coherent structure, and 2. there's no mental status exam presented anywhere. Granted you're doing a blog post and not an admission note but that's kind of a killer issue. (For folks who aren't mental health professionals, you'd usually organize a history in terms of domains: educational history, marital history, occupational history, etc. Then you'd describe the person's current symptoms in what's called a mental status exam.)

Skipping over that, this guy has more going for him than several of my prison clinic patients.

The first thing to do with someone like this in my institution would be to sort out the effects of illicit chemicals. Fortunately, he has been in prison. While you can certainly get drugs in prison the risk of using is higher and guys are less likely to do it. I'd focus on his longest stretch of abstinence and question him about symptoms and functioning while clean. You can also ask about his history of violence, if any, while incarcerated to tease out substance or mood-related violence from personality-driven violence designed to meet a specific goal. From the standpoint of his cognitive functioning, I'd want to know his MMSE score and the results of any psychological testing, if any. His educational history is quite sketchy as presented, but you'd flesh that out when you organized your data. The one thing the prison history will be useless for is for making a diagnosis of ADD/ADHD. You'd need an external informant who can give you a childhood history for that if he's never been diagnosed before.

Regardless, once all that is done it will be apparent that you'd have to expand your multiple choice diagnostic options to include some K-Type choices (bipolar variant + ASPD + substance abuse). Treatment options flow from that.

And for followup for Doug's comment, I can say that I have seen a correctional environment be an appropriate place for someone like this. I know it's popular to be nihilistic about corrections, but the fact of the matter is that some guys actually do use their time well. They get GED's, learn work habits from institutional cadre jobs, and the maintained abstinence reduces the strength of drug cravings. It is not a wasted effort, you just never hear about the people who do well. It's not a popular thing to talk about.

Thanks for the fun post Turbo. And Harold the Vampire Cat sends his regards to 9.

12/7/06, 8:13 PM  
Blogger Dinah said...

Yeah, what ClinkShrink said. OhMy.
Sometimes you aren't completely sure of the diagnosis and you do your best.

12/11/06, 8:30 PM  
Blogger Roy said...

I'm sure House can figure it out.

12/17/06, 10:18 AM  

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