November 16, 2015

The Diagnostic Mystery Movie of Robin Williams

By H. Steven Moffic, MD

EDITOR’S NOTE: The following is an excerpt from Dr. Moffic’s appearance on the Talk Ten Tuesdays broadcast that took place on Nov. 10, 2015. 

For all he gave to us, I bet Robin Williams never imagined providing a justification for the importance of ICD-10 and the advances in our diagnostic classification of diseases.

To see that, let’s start from the beginning, which is really the end. To the dismay of his fans and family, he committed suicide a little over a year ago. It left many diagnostic questions. Was his known history of some type of depression a crucial factor? Probably not, as that seemed to be in remission. Not his substance abuse, either, for that was apparently in remission, too.

What about his recent diagnosis of Parkinson’s disease? That is usually treatable for a good bit of time, even with boxing therapy. And his new marriage seemed to be a happy one.

So let’s call in the best medical diagnostic sleuth to do an autopsy. But before the coroner’s report is released, let’s flash back to his last doctor’s visit, as reported by his wife. Because of his memory problems, he asked his doctor if he had Alzheimer’s disease, and the doctor answered “no.” Because of his visual hallucinations, he asked if had schizophrenia, and the doctor answered “no.” Then he asked if he had “dementia” and the doctor answered, “absolutely not!” Now, maybe he wasn’t suspicious enough of all the possibilities in ICD-10 of what diagnosis could cause dementia. We call them rule-outs!

His psychiatrist suggested hospitalization in order to get further neuro-cognitive testing. Robin declined and actually seemed to be doing better in the last week of his life, but that is a common camouflage for the relief of an internal decision to commit suicide, and why loved ones are sometimes surprised by it.

So, why the suicide then? Back to the coroner. He indeed finds a dementia, but a much rarer and harder-to-diagnose kind than Alzheimer’s, and one that often has symptoms that overlap all the other considerations. He finds the definitive microscopic protein bodies of Lewy body dementia, G31.83 in ICD-10. What could have uniquely suggested LBD while he was still alive was relative maintenance of short-term memory, rapid fluctuations in awareness, spontaneous motor symptoms, and recurrent visual hallucinations, all of which his wife apparently noticed.

It is not currently treatable, but it can be manageable to some extent, though of course Mr. Williams didn’t know that. The diagnostic mystery is solved, but not the suicide mystery.

For that, we need to speculate with a psychological autopsy, which is sometimes done after a suicide to examine the mind like a pathologist would examine the brain.

It seems like he was in the most distressing period of any kind of dementia, after you think that you just have normal aging problems and before your memory becomes so bad that you don’t know you have a bad memory. In this interval, you actually can realize that you are losing your mind, or more accurately, your brain.

Was it a rational suicide? Perhaps. If he had known he had Lewy body dementia, eliminating the anguish of uncertainty might have changed his decision and the assumptions about what was wrong. It certainly leaves us with a better understanding of his decision. 

About the Author

H. Steven Moffic, MD, is an editorial board member and regular contributor for Psychiatric Times. After an award-filled career focusing on the underserved, he retired from clinical work and his tenured professorship at the Medical College of Wisconsin on June 30, 2012. He continues to write, present, and serve on boards devoted to this and related ethical concerns. Dr Moffic’s book, The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare (Jossey-Bass, 1997), was the first on the subject. He is a popular guest on Talk Ten Tuesdays. 

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