Psychiatry

Perlis, Roy H., M.D. RPERLIS at MGH.HARVARD.EDU
Thu Dec 11 16:53:27 UTC 2014


well said.
probably the most in-depth consideration of cognitive biases in psychiatric diagnosis relates to the discordance in diagnosis of schizophrenia between the US and Europe decades ago, which prompted the development of the RDC, the forerunner of the modern DSM. But I'm not aware that the topic has been revisited using more modern frameworks such as Rob describes.

and speaking of cognitive bias: there's a tendency in these discussions to contrast real disease with psychiatric diagnoses, at least implicitly. While I realize this is many patients' experience of receiving such a diagnosis - i.e., your symptoms are not real, they are psychiatric - it's worth recalling that psychiatric illnesses are brain diseases which may mimic or exacerbate other somatic processes.

Roy

--------------------------------
Roy Perlis, MD MSc
Director, Center for Experimental Drugs and Diagnostics
Massachusetts General Hospital / Harvard Medical School / Broad Institute
rperlis at partners.org

________________________________
From: Hamm, Robert M. (HSC) [Robert-Hamm at ouhsc.edu]
Sent: Thursday, December 11, 2014 11:38 AM
To: Society to Improve Diagnosis in Medicine; Perlis, Roy H., M.D.; Harold Lehmann (lehmann at jhmi.edu)
Subject: RE: Psychiatry

I agree with Roy Perlis. To expand:

We can see three realms where psychiatry or clinical psychology has recognized that there are errors in thinking due to heuristic strategies, short cuts, dual processes:

Non-psychiatrists seeing patients with a psychiatric diagnosis, and dismissing their complaints as a sign of their psychiatric illness rather than as a report of an organic illness.

Psychiatrists understanding of how patients think: unconscious, emotional processes, and how it is irrelevant to provide rational explanations for the patient to use.

Understanding of psychiatrists' own dual processes, in relation with the patient: the countertransference, the unconscious emotional reaction to the patient's appearance or actions. Harry Stack Sullivan's rectal twitch sign as a cue to the male patient's sexual orientation, for a joke example.

The theme of raising the issue here is that somehow psychiatry is missing the opportunity to make more accurate diagnoses because the teaching of psychiatry has not (often) taken up a reference to the errors of heuristics, biases, dual processes. We can see there might be a resistance to taking up some ideas which seem to be a de-emotionalized import of psychiatric ideas into mainstream psychology (risk as affect; unconscious automatic use of strategies), and then asking psychiatry to take them back, in simplified form, with an attitude of gratitude.

Yet one might argue that as psychiatric practice itself becomes simplified to pattern recognition and the assignment of the indicated drug, the same cognitive errors made by physicians in general can show up in psychiatry with the same frequency; and perhaps the same remedy is needed.

But psychiatrists could also be justified to say, show us that consciousness raising about heuristics and biases, dual processes in clinician reasoning, makes any difference in any area of medical training, let alone in psychiatric training.

Rob


Robert M. Hamm, PhD
Clinical Decision Making Program
Department of Family and Preventive Medicine
University of Oklahoma Health Sciences Center
900 NE 10th Street
Oklahoma City OK 73104
405 271 5362 ext 32306       Fax 405 271 2784
robert-hamm at ouhsc.edu
________________________________
From: Perlis, Roy H., M.D. [RPERLIS at MGH.HARVARD.EDU]
Sent: Thursday, December 11, 2014 9:23 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Psychiatry

Harold - Psychiatry uses different terminology but of course consideration of biases is a crucial element of training even among more biologically-oriented programs. The only difference is whether it's addressed in terms like countertransference, or with reference to specific cortical/subcortical structures. Remember these folks were thinking about the unconscious long before the rest of medicine.
________________________________
From: Harold Lehmann [lehmann at JHMI.EDU]
Sent: Thursday, December 11, 2014 9:40 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] Psychiatry

A bit off topic, but related to Brent Smith’s question about debiasing med students.

I was speaking with our psychiatry clerkship director. It seems that dual-process theory has not made it into psychiatry, in general, let alone a curriculum on decision making (either physician or patient).

Does anyone have experience in bringing together these two magisteria? (There are 5 articles in PubMed [dual-process theory AND psychiatry], most recently
PMID:
25000504.)

Harold

***************************************************************************
Harold P Lehmann, MD PhD
Professor and Interim Director
Division of Health Sciences Informatics
Johns Hopkins School of Medicine

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