Essay Grade

The Case of Sam
Sam is a 62-year-old, widowed, African American male. He is unemployed, receives
Social Security benefits, and lives on his own in an apartment. Sam has minimal peer
relationships, choosing not to socialize with anyone except his daughter, with whom he
is very close. Sam raised his daughter as a single father after his wife passed away.
Melissa is 28 years old and works as an emergency medical technician (EMT). When
Sam was 7 years old, he was placed in foster care and has had very limited contact with
his extended family.
Prior to September 11, 2001, Sam had a steady employment history in food services
and retail. He had no psychiatric history before that time. Sam reported his religious
background is Catholic, but he is not affiliated with a congregation or church.
Sam became depressed and psychotic sometime after 9/11 and had to be taken to an
emergency room. He was hospitalized at that time for several weeks. His mental status
exam (MSE) and diagnostic interview showed no history of alcohol or substance abuse
issues, and he had no criminal background or current legal issues. Sam was released to
outpatient care but was deemed unable to return to work. At that time, he had a
diagnosis of major depression with psychotic features; he also has a history of high
blood pressure and migraines. After several additional multiple psychiatric
hospitalizations, he was gradually stabilized.
Sam has been seeing a psychiatrist once a month for over a decade for medication
management and is currently prescribed Depakote®, Abilify, and Wellbutrin®. Sam has
a positive history of medication and treatment compliance. He was treated by a social
worker at an outpatient program for about 2 years after his hospitalizations for his
psychosis and depression. He gradually stopped attending sessions with the social
worker after his symptoms stabilized, and his termination from the outpatient program
was deemed appropriate; he continued to see the psychiatrist monthly for medication
management.
After about 10 years of seeing only the psychiatrist, Sam scheduled a meeting with this
social worker for increased feelings of depression. These feelings were brought on after
his daughter moved out of the apartment they had shared for many years to live with
her boyfriend. He reported difficulty adjusting to living alone and said he often feels
lonely and anxious. He reported during sessions with his social worker that he speaks to
his daughter frequently, and although she only lives 10 blocks away, he misses her
terribly.
Our sessions for the last 3 months have focused on his mixed feelings around his
daughter’s new life with her boyfriend. He said he is happy that she is happy but misses
her very much. I emphasized his strengths and helped him reframe his situation by
focusing on the positive changes in her life as well as his own life. Our goals were to
help him reduce his symptoms of anxiety and begin searching for new opportunities for
socialization outside of his daughter.
During our last two sessions, I became concerned because Sam, who was normally
articulate, had been appearing confused and slightly disorganized. I asked him if he had
a recent medication change and if he had been compliant with his current medications,
but he denied noncompliance or any recent medication adjustment.
I asked Sam if he was experiencing any physical health problems. He denied any
ongoing problems but mentioned that he had collapsed on the street recently. He
reported that he had been hospitalized and had undergone a number of tests, which he
thinks were all negative. He said he still feels “foggy” at times, and sometimes time
seems to be “missing.”
I reviewed his medications with him. As he went down the list, he reported taking
Cogentin® and Ativan®, which according to his chart history had been discontinued
months ago. When I asked Sam where he obtained these medications, he stated, “I got
them out of the bag.” Sam reported he has a bag at home in which he puts all leftover
and discontinued medications. He could not explain why he was taking discontinued
medication or for how long. Sam stated, “I thought I was supposed to take it.”
I called his daughter, and she verified he had recently been hospitalized and that the
MRI, CT scan, and EEG tests were negative. I requested that Melissa go to her father’s
apartment to look for the bag of medications he mentioned, because it seemed likely
that her father was taking discontinued medications. I then scheduled a meeting with
Sam and his daughter for later that week. During that session, Melissa reported that she
found multiple vials of old medication on the kitchen counter mixed in with her father’s
current medications. Melissa reported that she collected and disposed of all the old
medications. I recommended obtaining a daily medication planner. Although the hospital
tests were negative, I recommended scheduling an appointment with a neurologist, and
both agreed.
Sam saw a neurologist who reported that his test results were negative but did not rule
out the possibility of a seizure disorder. The neurologist recommended a follow-up
appointment in 3 months. He also contacted Sam’s psychiatrist and recommended that
the Wellbutrin be discontinued because it is known to have the potential to cause
seizures and that Sam should start on another antidepressant. Sam began to focus and
become more cognitively alert after the discontinued medications were disposed of and
the Wellbutrin was discontinued.
I scheduled another family session for Sam to discuss his feelings regarding Melissa
moving out. Sam was tearful when he told Melissa he missed her and her dog Sonny.
He also told her he was concerned he would not be financially able to remain in the
apartment. Melissa reported working long and odd hours but did call her father often
and invited him over to her apartment. She further reported that he often declined her
invitations. Sam reported he declined because he did not want to intrude on her life or
her boyfriend. Melissa assured her father that both she and her boyfriend wanted him to
visit and be part of their lives. I asked Sam if Melissa’s dog had been company for him,
and he replied, “Yes, and I miss him.” I asked Melissa if it would be possible for Sonny
to spend some time with her father. Melissa reported her long work hours were making
it difficult to take care of Sonny and asked her father if he would like Sonny to live with
him. Sam replied, “I would like that.”
I discussed with Sam how he spends his time, which normally consists of reading a
newspaper, watching television, or listening to talk radio. I suggested Sam increase his
socialization and recommended a social club for older adults that is near his home. Sam
said he would consider this idea. I asked Sam to discuss his financial concern that he
may not be able to remain in his apartment. Sam stated that Melissa had been
contributing to the household expenses but stopped when she moved out. He stated he
had been too embarrassed and ashamed to discuss this with Melissa and had been
keeping this to himself. Although Sam is on a fixed income, he is currently able to meet
his expenses. However, he is concerned about his rent, which is his largest expense.
I explored state and federal rent assistance programs for seniors and the disabled. I
found a program through which tenants who qualify can have their rent frozen at their
current level and be exempt from future rent increases. Sam met the program
requirement of being at least 62 years of age, currently living in a rent-controlled
apartment, and having a household income that was within the specified guidelines. I
obtained the required forms and personal documentation from Sam and completed the
application, sending it to the appropriate agency.
Adapted from: Plummer, S.-B., Makris, S., & Brocksen, S. (2013). Social work case
studies: Concentration year. Baltimore, MD: Laureate Publishing.
Diagnosis Made Easier
Diagnosis
Made Easier
Principles and Techniques
for Mental Health Clinicians
James Morrison
The Guilford Press
New York
London
© 2007 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com
All rights reserved
No part of this book may be reproduced, translated, stored in a
retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording, or
otherwise, without written permission from the Publisher.
Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9
8
7
6
5
4
3
2
1
Library of Congress Cataloging-in-Publication Data
Morrison, James R.
Diagnosis made easier : principles and techniques for mental
health clinicians / James Morrison.
p. ;
cm.
Includes bibliographical references and index.
ISBN-13: 978-1-59385-331-0
ISBN-10: 1-59385-331-9
1. Mental illness—Diagnosis. 2. Mental health services.
I. Title.
[DNLM: 1. Mental Disorders—diagnosis. 2. Interview,
Psychological. 3. Physical Examination—methods.
WM 141
M879di 2006]
RA469.M67 2006
616.89′075—dc22
2006011629
For Chris, who makes everything easier
About the Author
James Morrison, MD, earned his BA at Reed College in Portland, Oregon, and obtained his medical degree and psychiatric training at Washington University in St. Louis. With an extensive work history in both the private and public sectors, he is currently Professor of Clinical Psychiatry at
Oregon Health and Science University in Portland. Dr. Morrison’s other
books for professionals include The First Interview, DSM-IV Made Easy,
When Psychological Problems Mask Medical Disorders, and Interviewing
Children and Adolescents. In 2002 he published a manual for patients and
their relatives, Straight Talk about Your Mental Health.
vi
Contents
Introduction
PART I
ix
The Basics of Diagnosis
1 The Road to Diagnosis
3
2 Getting Started with the Roadmap
7
3 The Diagnostic Method
14
4 Putting It Together
23
5 Coping with Uncertainty
42
6 Multiple Diagnoses
56
7 Checking Up
68
PART II The Building Blocks of Diagnosis
8 Understanding the Whole Patient
87
9 Physical Illness and Mental Diagnosis
98
10 Diagnosis and the Mental Status Examination
116
PART III Applying the Diagnostic Techniques
11 Diagnosing Depression and Mania
127
12 Diagnosing Anxiety and Fear
164
13 Diagnosing Psychosis
182
14 Diagnosing Problems of Memory and Thinking
213
15 Diagnosing Substance Misuse
235
and Other Addictions
vii
viii
Contents
16 Diagnosing Personality and Relationship Problems
248
17 Beyond Diagnosis: Compliance, Suicide, Violence
267
18 Patients, Patients
277
Appendix: Diagnostic Principles
301
References and Suggested Reading
303
Index
309
Introduction
When I set out to write about the diagnostic process, I envisioned a text
that could both complement classroom teaching and provide a guide for independent study. That was before I undertook a completely unscientific
survey of practicing health care professionals, to learn how they had
learned about mental health diagnosis. What I found surprised me.
For most of the practitioners I surveyed, training in the refined art of
diagnosis was—well, no training at all. Most of the professional schools at
which my interviewees trained presented no formal course material on diagnosis, and still do not do so. Even in medical schools, students and residents are expected to know the current diagnostic criteria, but they receive little if any exposure to a method for making diagnoses. Almost to a
person, my sample endorsed the sentiment “I learned diagnosis through
on-the-job training.” Similarly, chapters and books that strive to teach clinicians how to perform a competent clinical evaluation focus on the product,
while largely ignoring information about the process.
That process is neither simple nor intuitive, and I’d certainly never
describe it as easy. But after decades of experience and months of consideration, I believe it can be explained it in a way that is straightforward and
comprehensible—in short, to make diagnosis easier.
In this book, I present a way of thinking about diagnostic problems.
The material doesn’t depend much on the vagaries of the latest diagnostic
standards or code numbers. Instead, I focus on the essential characteristics
of mental disorder, which have been recognized for decades. What’s imperative to learn is the scientific method—yes, and the art—of evaluating patients and arriving at logical diagnoses consistent with the facts.
Part I focuses on the process of diagnosis. Learning how to diagnose
well involves systematically applying logical, easily understood principles
to information of several different types, assembled from a variety of
sources. Although real life requires us to confront many diagnostic issues
ix
x
Introduction
at once, for convenience I’ve divided the tasks into chapters. By the end of
Part I, you’ll see how seasoned clinicians unite their experience with new
information to create a working diagnosis.
The three chapters of Part II explore the social and other background
data you need to understand each patient’s mental health diagnosis. Of
course, this is the stuff you need to have first, so you can make the diagnosis. But when learning new material, you have to start somewhere, and I
have judged that many (probably most) of my readers already have some
familiarity with interviewing and information gathering. That’s why I’ve
gone ahead and presented the diagnostic method first.
Finally, in the chapters of Part III, we’ll sift through a great deal of clinical material to see how the Part I methods and the Part II data apply to
various clinical disorders. We won’t consider every disorder, or even all the
varieties of the main disorders; other manuals (including my own DSM-IV
Made Easy) handle that chore. Rather, we’ll concentrate on the issues and
illnesses that mental health clinicians confront every day.
To illustrate the diagnostic methods, I’ve included over 100 patient
histories. Before you read my analysis of each clinical example, I recommend that you try working through the decision trees and writing up your
own list of relevant diagnostic principles. It has been amply proven that we
all learn far more efficiently by actively thinking about the solution to a
problem, rather than just passively reading something printed on a page. I
think you’ll benefit from the practice of thinking about the histories and determining how their clues direct you to the diagnosis.
You may wonder why each decision tree endpoint reads “Consider . . .” Why not just name the disorder and move on? After much thought
about these diagrams, I have decided that the more tentative wording is
safer. Without being too prescriptive, I want to encourage you to avoid a
trap that any clinician can fall into: rushing headlong into diagnostic closure
before you have all the necessary facts.
Figure 1.1 of this book (which is also printed on the front endpaper)
provides a roadmap that shows the diagnostic process graphically. The Appendix (which is also printed on the back endpaper) lists the diagnostic
principles I consider important to apply in making a mental health diagnosis. In the interest of space and economy, I’ve put quite a lot of information
relevant to currently recognized major diagnoses into tables in Chapters 3
and 6. Table 3.2 provides a differential diagnosis for each major diagnosis;
Table 6.1 lists the illnesses that are commonly comorbid.
If I haven’t covered every question you have about diagnosis and the
diagnostic method, I urge you to consult my website (http://mysite.
Introduction
xi
verizon.net/res7oqx1). There I’ve archived some of the queries I’ve received over the years. And to try to repay, in some small way, the debt I
feel I owe to my profession, I’ll continue to answer questions from readers
and others on the site.
Finally, every writer owes an unpayable debt to many unseen hands
who provide inspiration, guidance, and courage. For my most recent effort,
I owe special thanks to my wife, Mary. Though she has midwifed each of
my books, for this one she provided prenatal checkups in the form of careful reviews of the manuscript. I salute my collaborators at The Guilford
Press, especially my long-time friend and editor, Kitty Moore, who worked
closely with me to develop the concept of this book. Through her superb
copyediting, Marie Sprayberry added immeasurably to the readability of
the text, whereas our production editor, Anna Brackett, had the patience to
hold my hand through the final stages to make this book possible. These
people are the best in the business. I am indebted to the fine writing and
teaching of George Staley. And innumerable clinicians and countless patients have, however unwittingly, furthered my own education and helped
show me the way.
PART I
The Basics
of Diagnosis
1 The Road to Diagnosis
Carson
Years ago I evaluated Carson, a 29-year-old graduate student in psychology. He had always lived in the town where he was born, among numerous relatives and friends. Through a long history of repeated depressive
episodes, he had taken antidepressant medications on and off for a decade.
At one time or another he had complained of trouble concentrating on his
studies, of worries that he wouldn’t be able to find a job, and of fears that
he would become chronically depressed like his maternal grandmother.
When Carson was at his worst (usually in the late fall), he had trouble sleeping and eating, so he was pretty thin by the time Christmas rolled
around. Each spring his mood picked up, and he invariably felt well the entire summer and early fall, though he admitted that he was prone to be
“sensitive to the minor vicissitudes of life.” What he meant, his wife told
me, was that he sometimes felt down when things weren’t going well.
A typical teenager, Carson had experimented with both alcohol and
drugs. Once, when withdrawing from a 3-day run of amphetamine use, he
had briefly become depressed, but his mood had lifted spontaneously
within a few days. His girlfriend had agreed to marry him only on the condition that he “clean up his act”; now he swore he had been completely
clean and sober for the 4 years they had been together. He had never had
symptoms of mania, and he thought his physical health was excellent.
Medication had helped Carson get through college, after which he
had spent the summer searching for a graduate fellowship. Finally, though
the economy was depressed and few positions were available in the social
sciences, he was offered a graduate fellowship with a generous stipend in
a good department. Despite the triumph, his celebration was muted: His
new university was nearly 2,500 miles away, in a part of the country
where he’d never lived before.
On a Friday afternoon in late June, at his regular clinician’s request,
Carson appeared for an emergency evaluation. He sat slumped uneasily in
3
4
THE BASICS OF DIAGNOSIS
his chair, with one knee jumping up and down, and his gaze drooping. He
complained of terrible anxiety: His wife was pregnant with their first
child; the following day they would start driving across the country to the
site of his new job, in a city he’d never even visited. The previous afternoon he had become “almost panicky” when he was asked to sign a routine extension of his student loan.
As Carson described his fears for the future, his eyes reddened and
he brushed away tears. Though he didn’t think he felt depressed, he confessed that he “couldn’t go through with it”—that he felt abandoned and
alone. “I’m falling apart,” he said, and broke down in sobs.
A Roadmap for Diagnosis
As you can imagine, a lot rides on an evaluation like Carson’s. If you were
his clinician, you would need to answer a lot of questions. What’s wrong? Is
it the same as his previous problems with depression? Does he need treatment at all? If so, what’s most likely to help? Should he have more medicine, or a different antidepressant, or psychotherapy? What should you tell
Carson and his wife—should they postpone their move? What should Carson tell his new boss? The answer to each of these important questions
would depend on your assessment of his condition. To be helpful, it must
be based on information that will assist you in finding a road to the future.
Reaching an initial destination on that road—we can call it a diagnosis—is
what this book is all about.
The ancient Greek term diagnosis means “distinguishing” or “discerning.” Beyond the word itself, the concept of distinguishing one disease
from another is crucially important to patients and medical scientists alike.
As British psychiatrist R. E. Kendell wrote a generation ago, without diagnosis our journals would print only case reports and opinions.
When a person goes to a medical doctor with a physical complaint, in
most cases the diagnosis conveys three sorts of information: the nature of
the problem (symptoms, signs, and history), its cause, and the physical
changes that consistently occur as a result. Any disorder that clearly meets
these criteria can be called a disease. Take pneumonia, for example. This
term tells us that the patient feels weak and tired, and that the person suffers from the symptoms of shortness of breath, fever, and a cough that produces sputum. But only after we learn the results of sputum cultures and
other tests do we learn that the cause of the pneumonia is bacteria growing
in the patient’s lungs, causing the air sacs to fill with fluid and cells, producing shortness of breath. Then we can say that the patient has the disease of pneumococcal pneumonia.
The Road to Diagnosis
5
The clinical symptoms and other information establish coordinates on
the roadmap a doctor follows in prescribing treatment and predicting outcome. I’m somewhat geographically challenged, so whether I visit the automobile club or log onto Mapquest.com, I like to have both driving directions and a graphic depiction of the route for my trip. Having both verbal
and pictorial guidance is a belt-and-suspenders approach that helps reassure me I’ll arrive on time at the right place. In the list below, we’ll take a
brief overview of the “driving directions” for mental health diagnosis. I’ve
indicated the page numbers where you can find discussions of these parts
of the evaluation. (In Figure 1.1, I’ve drawn them as a map so you can see
just where we’re going. For convenience, you’ll find the same graphic inside the front cover.) Don’t worry if some of the terms seem unfamiliar—
we’ll define them as we go.
• Level I. Gather a complete database, including history of the current
illness, previous mental health history, personal and social background, family history, medical history, and mental status examination (MSE). Obviously, you must first have material that describes
your patient as fully as possible. Most of it will come from interviews with the patient and, very often, with other informants. You’ll
read a lot about these building blocks in the Part II database quarry.
Pages 87–123.
• Level II. Identify syndromes. Syndromes are collections of symptoms that go together to produce an identifiable illness. Major depression is a syndrome; so is alcoholism. Page 9.
• Level III. Construct a differential diagnosis. Differential diagnosis is
just a term for all of the disorders you think that a patient could
have. You don’t want to overlook any possibilities, however unlikely, so at first you must cast a very wide net. Page 14.
• Level IV. Using a decision tree, select the most likely provisional diagnosis for further evaluation and treatment. Page 19.
• Level V. Identify other diagnoses that might be comorbid with your
principal diagnosis. Arrange multiple diagnoses according to the urgency of their need for treatment. Page 56.
• Level VI. Write a formulation as a check on your evaluation. This
brief statement of your patient summarizes your findings and conclusions. Page 79.
• Level VII. Reevaluate your diagnoses as new data become available.
Page 81.
6
THE BASICS OF DIAGNOSIS
FIGURE 1.1. The roadmap for diagnosis.
2 Getting
Started
with the Roadmap
Most often, the information the patient provides at the initial interview
starts you on the road to diagnosis. As with Carson (see Chapter 1), relatives can provide additional details. I cannot emphasize enough the importance of collateral information to the overall clinical picture. Patients don’t
usually mislead us on purpose, but often they lack the advantage of perspective on their own situations. I have frequently found that friends, relatives, and other clinicians provide information crucial to my appraisal. At
the very least, such information adds color and depth to the emerging portrait of a new patient. When available, old records can sometimes save
hours of digging for background information; at times they’ve saved me
from a calamitous misdiagnosis.
The clinical history usually begins with the problem that was immediately responsible for bringing the person to clinical attention—the history
of the present illness. Perhaps this was an acute episode of depression, the
recent onset of hearing voices, a heavy bout of drug use, or conflict within
a personal relationship. Woven through will be information that helps you
understand how the lives of patients, relatives, and close associates have
been affected. You’ll also begin to pick up previous mental health history,
which includes information about other mental or emotional problems, or
earlier episodes of the current problem, which can also be important in determining what’s currently wrong.
In the movies, in novels, and on the stage, far more is involved in storytelling than a simple narrative. Any but the simplest Dick-and-Jane story
implies information about the main character’s surroundings, culture, family, and social milieu. Sometimes this material is called the back story, and it
provides texture and layers of meaning that illuminate the motives, actions, and emotions of the characters. So it is with patients—all of whom
7
8
THE BASICS OF DIAGNOSIS
have their back stories, too, which clinically we call personal and social history. For the same reasons that a play is more compelling when we understand what motivates its characters, this information is not just interesting
but often highly relevant, even vital, to diagnosis. I consider this information to be so important that Chapter 8 is devoted to discussing childhood
background, current living situation, and family history, especially of mental
disorder. Medical background (Chapter 9) is another important part of your
evaluation. Finally, you’ll make use of the MSE (Chapter 10)—though perhaps not quite as much use as you’d initially think. Throughout Part I of
this book, we’ll be examining these various parts of the mental health evaluation and how we can use them to create a diagnosis.
In the real world, patients, like Shakespeare’s sorrows, tend to come
not as single spies, but in battalions. As a result, you may not have enough
time to gather all the material you need for a complete initial evaluation.
That’s OK. The task here is to learn how the job is done when conditions
are ideal; with practice, you will later become able to accomplish the same
thing in the course of a busy office day or frantic emergency room evening.
Symptoms and Signs
In Chapter 3 we’ll discuss the basic plan for making a sound diagnosis. But
before we get there, we need to define some terms that relate to the raw
materials for any health care diagnosis. Technically, symptoms are what patients complain of, whereas signs are what clinicians notice. The patient
with pneumonia described in Chapter 1 has complained of several symptoms, including a cough, shortness of breath, and feeling tired. Symptoms
are the indicators of disease that are perceived by patients or their friends
and relatives; they are the issues that patients mention when they talk to
their care providers. In the mental health field, symptoms can include a
tremendous variety of emotions, behaviors, and physical sensations. At
one time or another, Carson’s symptoms included feeling depressed, trouble concentrating on his studies, panicky feelings, trouble sleeping, and
poor appetite. Hallucinations and delusions are symptoms. So are “nervousness,” fear of spiders, and ideas of suicide.
Of course, circumstance and degree play important roles in determining what is and is not a symptom: Many people don’t care for spiders, and
doctors normally wash their hands frequently, so as not to spread germs
from one patient to another. So we can see that symptoms are always more
or less subjective; they depend on a person’s perspective. Signs, on the
Getting Started with the Roadmap
9
other hand, are far more objective clues to illness. Usually patients and informants don’t complain of signs; rather, the clinician identifies them from
a patient’s appearance or behavior. The patient with pneumonia would
probably show the signs of fever,
increased heart rate, and perSymptom: A subjective sensation,
haps altered blood pressure, and
discomfort, or change in functioning
a physician with a stethoscope
that a patient or informant complains
about. Examples include headache,
would hear crackling sounds of
abdominal pain, itching, depression,
fluid in the lungs. Carson’s signs
and a tickling sensation in the nose.
of mental illness included tearSign: An indication of disease that
fulness and slumped posture.
can be noticed by others. Examples
The sets of signs and sympinclude a lump on the head,
toms sometimes intersect. At
abdominal tenderness to touch,
times in this book, I may talk
skin rash, weeping, and sneezing.
about a sign that could be a symptom (see the sidebar “Symptoms
and Signs”). You’ll have to put up with that ambiguity; it’s part of the clinical mystique. So why, you may want to know, do we need to note that there
is a difference? The reason is that because signs are more objective, we
can rely on them more than symptoms. In fact, one of the diagnostic principles that we’ll use later on is that “signs trump symptoms”—not always,
but often enough that it justifies paying attention to the differences between signs and symptoms. For example, despite his doubt that he felt depressed, Carson’s tearfulness and slumped shoulders told another story.
Symptoms (and signs) are useful in two ways. First, like Carson’s
panic attack, they signal that something is wrong. In the same way, suicidal
thoughts, poor appetite, or hearing voices can indicate the need for a mental health evaluation. The second use of signs and symptoms is to set us on
the path to an appropriate diagnosis: Repeated public intoxication suggests
alcohol dependence; an arrest for shoplifting should prompt an evaluation
for kleptomania; and an anxiety attack when watching a war movie might
motivate a combat veteran to seek attention for posttraumatic stress disorder (PTSD).
Why We Need Syndromes
Signs and symptoms by themselves aren’t enough to make a usable diagnosis. Our physical medicine patient with cough, shortness of breath, and
weakness could have pneumonia, but the same symptoms could indicate
10
THE BASICS OF DIAGNOSIS
Symptoms and Signs
Mental health doesn’t have a lot of signs, but here are a few of them: weeping, sighing,
pacing, weight loss, tattered clothing, and poor hygiene. Some indicators can be either
a sign or a symptom, depending on who notices. Carson wouldn’t have complained
about his own slumped posture, but his wife or a next-door neighbor might notice it
and mention it to a clinician. Depending on circumstances, nearly any behavior that can
be observed by others and that is usually treated as a sign could be a symptom instead.
Until about 1850, clinicians didn’t discriminate between signs and symptoms;
now whole books are devoted to the concept. Recently, however, there have been a few
indications that we may once again be blurring the boundary, at least in the United
States. In the late 1990s, concern that medical people too often ignored patients’ pain
led to calling pain a “fifth vital sign.” The intent of this was that pain would be documented at every clinical visit, along with the four classical (and undeniable) vital
signs—temperature, blood pressure, pulse, and respiration rate. Technically, however,
pain is a complaint that can only be a symptom, because of its innate subjectivity.
Sometimes we clinicians get careless in our speech and forget the very real difference between signs and symptoms. After decades of experience, I’ve decided that
there’s no winning this battle. But we should never forget that there is a difference, and
that we can use it to help us evaluate our patients.
lung canc