Learning from Cases
I will introduce a case that actually happened at a certain university hospital in the Kinki region of Japan. All the cases I'm going to introduce now are of patients who are undergoing psychiatric treatment. All of the symptoms were misdiagnosed as "psychogenic" because the cause was unknown.
Case report 1)
Initial diagnosis: psychogenic vomiting due to depression
A 79-year-old, previously healthy woman presented with symptoms of vomiting and anorexia. Nine months earlier, she had been involved in a car accident and sustained a hemothorax, right clavicle fracture, and left rib fracture.
She made a full recovery in three months.
During her prolonged hospitalization, she lost confidence in her recovery and sometimes felt anxious about living on her own when she left the hospital.
Two months before coming to the doctor in the report, she started vomiting, became increasingly depressed, and experienced loss of appetite. She refrained from eating food for fear of vomiting and lost weight. An upper gastrointestinal endoscopy was performed at another clinic, which showed normal findings.
She was referred to our clinic with the diagnosis of psychogenic vomiting or eating disorder due to depression.
Chest X-ray and CT scan showed a left diaphragmatic hernia, and upper gastrointestinal radiographs showed gastric torsion with adhesions of the gastric body above the gastric fundus. Upper gastrointestinal endoscopy showed that the mucosa was mostly normal, but there was a slight reddish color and edema.
Gastrointestinal endoscopy to reposition the stomach was
impossible because of the close contact between the gastric body and the left diaphragm, and also because of the gastrostomy.
Radical surgery for diaphragmatic hernia was performed to normalize the gastric axis and position. After the surgery, she recovered her appetite without vomiting and was discharged on the 23rd day.
Final diagnosis: "Gastric torsion".
Case Report 2)
Initial diagnosis: Eating disorder
A 24-year-old male presents with symptoms of nausea, vomiting, and weight loss.
Over the last year he has suffered from occasional nausea and vomiting and has lost 15 kg (82 to 67 kg) despite having a normal appetite.
His height is 170.7 cm.
At first, he wanted to lose weight to improve his obesity.
He stated that his ideal weight is 65 kg.
He had an upper gastrointestinal endoscopy done at another clinic.
It revealed normal findings, and gastrointestinal motility medication did not improve his symptoms. He was referred to the authors and other physicians with a diagnosis of an eating disorder. Under observation after hospitalization, it was not self-induced vomiting as he sometimes vomited unexpectedly and at other times successfully swallowed food. Esophageal radiography showed esophageal achalasia.
Transendoscopic myotomy relieved his symptoms.
Final diagnosis: "esophageal achalasia.
Conclusion
Why is there such a misdiagnosis?
The authors of this paper believed that this is what happens because of the way we think about the diagnostic system. The authors of this paper believed that this is what happens because of this way of thinking about diagnostic systems.
Comparison of System 1 and System 2: Types of Clinical Reasoning
Intuitive process Analytic process
System 1 System 2
Example Heuristic Algorithm
Pattern recognition Hypothetical reasoning
Feature Snapshot Diagnosis Overall Diagnosis
Fickle Conscientious
Advantages Faster Scientific
Efficient Analytical
Disadvantages Biases More slowly
It is said in psychology that there are two systems for judging things, System 1 and 2. System 1 is said to be intuitive and System 2 is said to be theoretical.
These two systems are at work in human judgment, and it is not necessarily the case that one is better than the other. In terms of diagnosis, diagnosis made by System 1 may be more accurate in proportion to the number of diagnoses made by doctors and the number of clinical trials, but on the other hand, it is also easier to make assumptions due to bias. On the other hand, System 1 diagnoses are quicker and more reliable, so they tend to be favored.
System 2 diagnosis requires more time for more tests and more accuracy. Therefore, it is easy to get a highly accurate diagnosis by probing from various perspectives, but However, the slow response time can also be seen as a problem.
The authors also propose six measures to prevent misdiagnosis.
Because it is impossible to diagnose a disease that is unknown, it is necessary to understand the characteristics of even rare diseases and to have the knowledge to differentiate them.
1. It is necessary to understand the characteristics of even rare diseases and have the knowledge to differentiate them.
2. Do not overlook abnormal findings that can be considered trivial.
3. It is necessary to recognize that true diagnosis takes time.
4. We should not easily make a diagnosis such as "psychogenic" or "depressive".
It also means that there is a lack of understanding of mental illness.
5. If no organic abnormality is found, consider a functional abnormality.
6. Doctors' arrogant attitude, overconfidence, and emotional diagnosis are leading to misdiagnosis.
The voice of the patient and examining the patient's point of view as well are linked to accurate diagnosis and what is required by the patient. If you are in the position of a patient and are about to encounter such an example, maybe you should discuss it or turn to someone else.
Koyama A, Ohtake Y, Yasuda K, et al. Avoiding misdiagnosis in psychosomatic medicine: a case series study Biopsychosoc Med. 2018; 12: 4. Published March 13, 2018. doi: 10.1186 / s13030-018-0122-3
