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Well differential diagnosis is always a struggle to deal with because symptoms may be compatible with a handful of underlying conditions. Common symptoms are also more often than not precursors to more narrowly defined symptoms that can be isolated to a diagnosis. Medicine is a hugely multifactorial discipline and it’s understandable why seemingly simple things involve a complex decision making process. Seems like it’s still messy enough that a lot of it is educated guesswork. How much would you say the average person takes for granted that particular matters are “settled” as far as concepts like “health,” and “disease,” go and that these debates don’t exist behind closed doors between doctors? In other words do these disagreements and debates only belong to relative edge cases or is it pretty widespread across ailments?
Do physicians generally “know” or feel with a high degree of confidence when they’ve correctly zeroed in on what the problem is? I’m just imagining the mental flowchart-like references to chasing a problem down isn’t actually that much different from a mechanic who chases down the chain of failure in a car, or a technician who’s chasing down a motherboard failure on a laptop. By what clinical standard do absurd ideas like Drapetomania, or genetic feeblemindedness, or pathological altruism fail to pass scrutiny? Is it simply because our culture doesn’t legitimize such assumptions?
One book I loved reading years ago was Atul Gawande’s Checklist Manifesto, and it was striking how it effective it’s been proven in medical settings. It’s a great thing to have in a discipline that involves some of the most complex pattern matching capabilities needed that are known to man.
Also, why was it a miracle prions were discovered?
It depends on the thing, but it is important to keep in mind that for many problems diagnosis is not important (especially in psychiatry). Fixing a problem is important, but a clear diagnosis? Nah. In psychiatry most problems are fixed by an SSRI or an antipsychotic - who cares if they have schizophrenia, schizoaffective, or bipolar disorder if the solution is the same. Who cares what the cause of the hypertension is? Rule out some important things to rule out, and then move on.
Also because the level of specificity - sick, infection, bacterial infection, anaerobic bacterial infection, a specific organism, the specific genetic profile of the specific strain of that organism, all of these are accurate diagnosis, but you can stop early and often should.
So it's hard to answer some of these questions without being reductive or ponderous.
Our tools aren't magic - for a long time the start of the art for identifying bacteria was dumping dye on it. Identifying something as weird as your own bits during slightly weird shit is hard as hell.
You're giving me exam PTSD, and I haven't even given the exam. SSRIs are not just what you'd rely on for BPAD, there's a ton of context for when they're actively harmful, or when you need antipsychotics and mood stabilizers. Good to know that the exam prep prepares me for discussions on this underwater basket weaving forum.
All granny with a UTI needs is Prozac and Zyprexa!
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But diagnosis is about defining what the problem is, right? Scope, range, severity, etc. In psychiatry I’d imagine it’s even more difficult than a standard internal medicine practice or surgery for instance. Last I’d read, some reports have indicated that most SSRI’s probably don’t work, which I assume demonstrates how robust the placebo effect can be. A bandaid doesn’t cure a cut. A bandaid creates a space for the wound to heal on its own. And for some injuries that’s all that’s necessary from a medical perspective. Suppose the medical efficacy for SSRI’s were 100% though. The treatment takes the form of a bandaid more than it does a fix if you ask me. The latter isn’t exactly what I’m asking a psychiatrist to do, that’s a near impossible task; I’m only saying that’s more what I’d liken it to.
Should the average person be surprised about the fragility and active debate over active cases? I don’t think there should be concern or worry over it TBF, what other alternative is there to trust when you’re in agonizing pain?
I mean lifestyle interventions are always the first recommendation for everything - lose weight and your BP improves. Socialize and exercise more and your depression improves. People don't do these things so we hit the second line interventions of actual medicine that are a band-aid not a solution.
In the case of SSRIs, if one doesn't work....you just switch to the next thing. Psych has more viable first and second line agents than most disciplines. Even if hit rates are lower it isn't a big deal.
Additionally, depression is more of a syndrome than a disease - shit life syndrome, major depression due to a cardiac problems, classic melancholic depression, all of these things manifest slightly differently but more or less the same and zero percent chance we have a full understanding of the underlying pathophysiology. Shit life syndrome likely responds poorly to medication, but how are you going to define that and separate it for the purposes of research?
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