Integrated Treatment Approaches

To the Editor: The clinical case of Angela’s illness, presented by Eva M. Szigethy, M.D., Ph.D., and colleagues (1), contrary to what the authors wrote, did not illustrate “the critical importance of how an accurate diagnosis of major depressive disorder…resulted in a reduction of both psychiatric and physical morbidities” (p. 375). Recovery was, as they noted, due to an appropriate multimodal treatment applied over time.

Would the outcome have been different had the accurate diagnosis of major depression not been made? What if the therapeutic team had “erroneously” diagnosed anxiety disorder with a subthreshold depressive syndrome (rather than depression with anxiety, as they did)? What if the DSM-IV authors had allowed for a diagnosis other than depressive disorder in the presence of irritable mood (in adolescents) and accompanying symptoms? What if either conversion or somatization disorder (contemplated by the authors) had been diagnosed in Angela or a combination of any of these and other diagnoses? Would any of these “inaccurate” diagnoses have resulted in a different approach to management and treatment? I hope not; they should not have.

A longitudinal integrated biopsychosocial psychiatric treatment consisting of “a blend of supportive, psychodynamic, cognitive behavior, and family therapy,” an antidepressant/antianxiety medication and a benzodiazepine prescribed temporarily together with “relaxation and distraction techniques,” “continuing head halter traction and frequent but gentle physical therapy” with “passive manipulation of [Angela’s] head” and “neck brace adjustments” (p. 374)—all this, as described by the authors, would have been an optimal approach to Angela’s condition, regardless of the diagnosis of major depression.

Diagnoses are not to be dismissed, but they should not be worshipped either. They are social conventions. It is not a diagnosis that we treat. Not even a disorder. It is a patient. The “accurate” psychiatric diagnosis, a description based on the phenomenology, a description that attempts to approximate our perception of the patient’s particular situation, rarely matches the reality experienced by that patient.

The authors, I am sure, have had many opportunities to use exactly the same management as they described, with equally positive results, regardless of diagnoses. And I hope they would agree with anybody’s claim that the description of Angela’s case would allow for many other diagnoses. Perhaps simply having decided that Angela’s condition was not primarily physical, did not require surgery, and was not likely a psychosis was as accurate a diagnosis as one could have hoped for and quite sufficient.