Symptom Contextualization: 2 Reasons Why

Farah is a 49-year-old female, who complains of difficulty sleeping (insomnia), feeling sad (depressed mood), and has held the belief that her daughter, Mia, was stealing her money and was trying to poison her food (paranoia). Ron, the psychiatrist seeing Farah for the first time, examined her and noticed a lump (nodule) in her neck, some hand tremors, and weight loss. Ron quickly assessed for acute risk and referred Farah to an endocrinologist, who confirmed a diagnosis of hyperthyroidism, treated Farah, and the psychiatric symptoms, including paranoia, subsided.

This paragraph introduced the second article in the series on Symptom Contextualization, entitled, Psychosis – Symptom Contextualization: 5 Steps to Follow, in which I outline five steps to use as a framework or follow when evaluating psychosis. I explained the need to consider the following:

1. Rule out general medical conditions;
2. Rule out substance or toxin induced psychosis;
3. Rule out neurological conditions;
4. Rule out other contexts; and
5. Rule out neuropsychiatric conditions.

“I used to just equate hearing voices with schizophrenia,” said Clara, a clinician employed at the Hope Center. “Now, I know how naive of me that was. I walked in the room expecting it to be psychosis related to schizophrenia, not realizing that it could have been a physical or a different mental health issue. I feel embarrassed and wonder how often I have misdiagnosed clients who have been under my care,” Clara added.

If you have been thinking like Clara, I will tell you there is no need to feel embarrassed, guilty, or to beat yourself up. Mastering the basics of mental health, psychiatry, and medicine, in general, takes time, and it only takes place through daily work, where there is an opportunity to process, reflect, read, discuss, learn, and train, all with the proper supervision.  Reading this article is also a best first step. Here are the first 2 of 5 reasons why we all need to put symptoms into context.

1. Accurate and reliable diagnosis:

“I wonder how often I have misdiagnosed clients who have been under my care,” Clara added. A question all of us should reflect on. Not to beat ourselves up, but to start taking the required steps to

1. better develop sound clinical judgment in diagnostic formulation, and
2. render accurate and reliable diagnoses.

Diagnosing in itself can be controversial. Some believe it like it is the bible, while others take an atheist stance and sustain that it is meaningless. Some think it is just about labeling and pathologizing, while others believe that it has been engineered just for economic reasons. Regardless of where you stand, I would like to invite you to take one step back, reflect, and attempt to examine your position, as it relates to the diagnosis. Is it an obstacle for you to go through the required process of diagnostic formulation? Symptom contextualization will then be your guide for this.

2. Effective and efficient treatment:

Related to accurate and reliable diagnosis, whether you believe it or not, you will less likely be able to provide effective and efficient treatment to your patients and clients unless you have been able to contextualize their symptoms. “I used to just equate hearing voices with Schizophrenia,” says Clara, a clinician, who added, “Now, I know how naive of me that was.” It is indeed easier to diagnose whoever hears voices with Schizophrenia and put him or her on Risperidone. For example, in a 70 year-old-woman, the real issue not addressed could be dementia. A population rather vulnerable to the side effects of medications, including antipsychotics.  Antipsychotics in this specific population, the geriatric population dealing with dementia, have been found to cause sudden death.

We live in a society where everything needs to go fast; time is money, and patients are no longer patients, but “numbers” instead. It is no longer psychiatric care, but “fifteen-minute med check,” which of course translates, “When I meet a patient who hears voices, it is time to start Haldol.” What if we treated these patients and clients as we would our mother or father, our sibling, or other family member, our spouse or child, or our best friend? What about the oath we took to do no harm, and to always do good for our patients and clients? What about our calling to serve, and serve well?

Farah is a 49-year-old female, who complains of difficulty sleeping (insomnia), feeling sad (depressed mood), and has held the belief that her daughter, Mia, was stealing her money and was trying to poison her food (paranoia). Ron, the psychiatrist seeing Farah for the first time, examined her and noticed a lump (nodule) in her neck, some hand tremors, and weight loss. Ron quickly assessed for acute risk and referred Farah to an endocrinologist, who confirmed a diagnosis of hyperthyroidism, treated Farah, and the psychiatric symptoms, including paranoia, subsided.

In summary, there are at least 2 main reasons why we all need to contextualize the symptoms of our patients and clients, and, to, master the how in doing so:

1. To render accurate and reliable diagnosis, which requires a sound, clinical and diagnostic formulation, one that only symptom contextualization can provide;
2. To provide effective and efficient treatment, which is unlikely to take place unless we are clear on the real issues, the steps needed to solve or manage them, and the subsequent steps to follow, should the first one fail to work.

I hope you found this article enjoyable, informative, and translational to your practice.  If you use it as an empowering tool to continue doing your best for the patients and clients you serve, then, this article has served its purpose.  But, will you keep this as a secret or will you share it with your colleagues?  If you do share, you will be contributing to the change we all strive to see, understanding how care can be better provided to our patients and clients.

References:

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3. Chadwick, J. & Mann, W.N.(trans.) (1978). Hippocratic writings. Harmondsworth, UK: Penguin. pp. 170–171.
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