When psychogenic symptomatology is at play, a spectrum of ethical problems and considerations arise when patients want, and at times, insist on being given an inaccurate neurologic diagnosis. They use the example of MS to highlight the value considerations for clinicians when they face these types of cases. Given the ambiguities involved in its diagnosis and the significant risks of its treatment, MS represents a rich case study. This discussion highlights the potential harms of mislabeling such patients with MS when the neurologist is confident they do not have MS and offers suggestions about how to approach and manage these patients. Despite being expedient and well-intentioned, labeling psychogenic symptoms with a medically inaccurate diagnosis, such as a “touch of MS,” constitutes a “therapeutic mislabeling” and sacrifices ethically important values incommensurate with the benefits gained.
Adrienne et al A touch of MS: Therapeutic mislabeling Neurology WNL.0b013e318259e0ec; published ahead of print May 11
“We have a category called medically unexplained symptoms to label these people. In other words we can’t make a diagnosis and all our investigations are non-specific of normal. In fact, this is quite a common problem in neurology. A lot of people want a disease; this could be due to psychological factors and we refer to this as a somatization disorder or people may need a diagnosis for gain. The latter would include insurance claims, disability benefit, to get out of the military, to change their work, etc. The latter is called malingering; malingering differs from somatization in that there is secondary gain the subject is fully aware that their symptoms are not real.”
“A diagnosis of somatization disorder should be made by a psychiatrist. It is a difficult diagnosis to make as you have to be sure that there is no underlying disease. This can be very difficult.”
“Misdiagnosis also occurs due to mimics; in other words other diseases present like MS. A good neurologist should rarely make this mistake as the mimics usually have clinical features or investigations that allow them to be diagnosed accurately. If in doubt don’t make a diagnosis of MS and wait. Time is often a very good diagnostician and if someone has MS it usually declares itself quite quickly.”
“A good clinician should never be forced into making an incorrect diagnosis. Our reputations depend on being good diagnosticians.”