I please scroll through the list of psych practices and add Mr. C to my patient list to view. They transferred him from a jail in another county to the jail where he worked, where he had never been before, and asked me to see him for a psychiatric evaluation.
As I review your chart, a pattern slowly emerges. Mr. C, an older black man, has been arrested multiple times over the years, usually on vague charges such as trespassing or disorderly conduct that are difficult to interpret. Is he really threatening to the people around him, or is he just trying to survive while he lives on the streets? He has little history of mental illness or substance use, except for one problem that seems to crop up every time he’s taken to jail: he starts screaming that he doesn’t want to live anymore.
When incarcerated, Mr. C becomes so distraught that he tears his clothes or cries loudly throughout the night, to the point where other incarcerated persons or custodial staff become angry with him. You have been placed on suicide watch in padded jail cells, sent to emergency departments, and seen by various mental health professionals, and these symptoms typically resolve within a few days after you enter jail or when you are released. on freedom.
I sigh, reading in his records the same diagnosis over and over again, one with which I have become both familiar and disillusioned: “adjustment disorder.”
According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, an adjustment disorder manifests as emotional or behavioral symptoms that arise in conjunction with an identifiable stressor and usually resolve when the stressor disappears.
There are several criteria for the diagnosis of an adjustment disorder, and the process includes consideration of cultural and contextual factors that may shape patients’ symptoms. However, health professionals tend to make this diagnosis when someone whose condition does not meet the criteria for another mental disorder demonstrates “marked distress out of proportion to the severity or intensity of the stressor.” I remember studying classic adjustment disorder cases in medical school, for example, the case of a person who has difficulty functioning due to depression or anxiety after a divorce.
During medical school and residency, I learned that this diagnosis can sometimes be helpful to clinicians, allowing us to name patients’ distress and use common language to characterize their clinical presentations after stressful life events. But in caring for incarcerated patients as a trainee and now as an attending physician, I have been concerned about the use of this diagnosis, among others. What does it mean to have a reaction that is “out of proportion” to being shackled? Is there a “normal” way of behaving for a person deprived of their freedom and locked up in a cell?
If an older black man living in poverty on the streets, surrounded by a society that gives him little help and doesn’t seem to care about him, becomes distraught when handcuffed, does he have a mental disorder? Must he “adjust” to this unfair reality, or does the disorder lie in the systems that surround him?
Much has been written about the dehumanizing nature of imprisonment. Less attention has been paid to the ways in which healthcare professionals and the diagnoses we make can compound the trauma experienced by people who have been incarcerated in jails and prisons. A woman locked in a cell for 23 or 24 hours a day can fall into such loneliness and despair that she cuts herself out of her cell and is sent to the hospital, where the doctors and nurses label her “faking” and give her up. high immediately. her back to shackles and chains. When a man repeatedly misbehaves, yelling at staff or kicking in his cell door, in protest against the conditions of his confinement, all too often he will end up with a medical file littered with references to a “personality disorder” and notes about what challenging it is. is treat.
The language we use in medicine often does not do justice to people who are caged. Incarcerated people have high rates of mental disorders, substance use disorders, and other general medical conditions, but they are generally not included in the research that guides diagnostic and treatment practices in the US. The field trials used to study the reliability of psychiatric diagnoses have generally not included people in jails or prisons.
The National Survey on Drug Use and Health, which provides estimates of the national prevalence of mental and substance use disorders, does not include prison and prison populations in its data. As long as national medical organizations and government agencies exclude incarcerated people from this type of research, the language and statistics used by health professionals, legislators, and others will not accurately reflect the public health needs of American communities. . It is essential to include people deprived of their liberty in the studies and surveys that shape national health policies and health care practices.
Beyond this additional research, health professionals need to consider not only the ways in which jails and prisons can affect people’s lives, but also the potential role of physicians in exacerbating the traumatic effects of mass incarceration, poverty, racism and other social injustices. Clinicians must recognize that while diagnostic labels can help characterize patients’ health needs and guide treatment approaches, diagnoses can also be harmful, especially when applied haphazardly and without careful consideration of the life circumstances of the patients.
Meeting the health needs of patients, whether incarcerated or not, often requires more than just medical diagnosis and treatment. Health professionals must also explore and address the social determinants of health that led to those health needs, in part by using our roles as trusted professionals to speak out against the social injustices that plague the lives and health of our patients.
When I meet Mr. C, he is calm and friendly, and we talk about his experiences with incarceration. He explains that he doesn’t belong in jail, which is why he gets so upset every time he ends up in one. We talked for some time about his life, discussing suicide safety planning, communication with his attorney, and housing resources. He tells me that he doesn’t feel suicidal anymore and that since he’s heard that he might be going home soon, we agree not to start any medication for now. I offer to continue to monitor him and ask that he send a medical note if he is experiencing similar distress before our next appointment.
As I see other patients and then go back to my desk to write notes, I think about what to document as my diagnostic impression of Mr. C. “Adjustment Disorder” still feels off, like we’re waiting for him to accept his lot in life and adjust to a cycle of homelessness and incarceration. He could write “deferred diagnosis” but that feels pointless and incomplete. Perhaps you could write “incarceration-related distress,” which is not a mental disorder but seems like a more accurate and humane description of Mr. C’s circumstances.
I go back to my desk and connect to the electronic medical record. When I click on Mr. C’s history, his meeting status has changed to discharged. He has already been released, and it remains for me to update the “problem list” in his history, where as many problems are listed as if they were only his.
This piece was originally published on The New England Journal of Medicine. Reprinted with permission of the Massachusetts Medical Society.