At the recent AACC conference Dr. Michael Lyles, a board member of AACC and practicing psychiatrist, stated the following,
A diagnosis is only a word on a page if it doesn’t serve a function.
What kind of function was he thinking about?
- Does it explain a set of symptoms?
- Does it point to a treatment plan?
- Does is help differentiate between overlapping symptoms?
I’m a firm believer that our current DSM diagnostic system is at once both flawed and useful. It is flawed in that DSM diagnoses don’t address causes or do much to point to treatment. It is useful when used carefully to help differentiate between overlapping sets of symptoms–even as it needs considerable overhaul to do a better job. Take differentiating between Major Depression and hypothyroidism instigated depression. The two look identical. But using a multiaxial diagnosis, a person could rule out Major Depression if they were able to make a positive diagnosis of low/inactive thyroid function.
So, until we have a better nosological system (i.e., a replacement for the DSM), I will continue to use it. In years to come we will, however, recognize it for the blunt instrument that it is.
Right Diagnosis…Wrong Focus?
Consider the following case study (not a real person, devised from several stories) as an illustration for the problems we have moving from current diagnostic categories to proper treatment.
Tom is 27, married, father to one young daughter, working part-time as a youth pastor and going to seminary full-time. He comes to counseling on the encouragement of his primary care doctor. One month ago during final exams and an overly busy ministry schedule, Tom began experiencing rapid heartbeat, shortness of breath, feelings that he was losing his mind, and chronic fear of dying. After experiencing 4 panic attacks in rapid succession, he began worrying that something was terribly wrong and that he was about to die. His doctor first ruled out a physical origin for these symptoms, taught him breathing and distraction exercises to interrupt the buildup of panic, prescribed an anti-anxiety medication, and recommended he make an appointment with a therapist. During the first session, Tom details his history of stress, reports he has been able to forestall 2 more panic attacks but admits he still struggles with fears of dying, lacks assurance of salvation, and feels flooded with guilt that he worries so much. Upon further exploration, Tom believes the bible teaches him that he should not fear if he has “perfect love”. He has read all of the verses about anxiety and feels condemned for his struggle.
Tom meets criteria for Panic Disorder, without Agoraphobia. This is a highly treatable problem and within a few short sessions, Tom is likely to gain mastery over his body in that he will no longer evidence panic attacks. This, of course, is not the same as saying he will stop experiencing worry, guilt over his chronic worry, or start having assurance of his salvation. Logic, disputing worries, distractions, exploring and altering core beliefs may help reduce the symptoms that brought Tom to his doctor and counselor. A good Christian counselor may also be able to reconnect Tom to Scripture in ways that help him experience God’s care for him in spite of his fears (e.g., hearing the gentle voice of Luke 12 vs. a harsh rebuke).
But has the diagnosis been properly made? Yes. Tom met the criteria for an anxiety disorder. No. Tom’s counselor also helped him discover a deep layer of shame that may have been the source of his anxiety. Without the latter, the former is not altogether helpful.
So, should the diagnosis be an anxiety disorder or shame? Until we have shame as some form of a diagnosis, I’m okay with maintaining the anxiety disorder as a good description of external symptoms. But, Tom and others like him will need wise counselors who can dig a bit to discover diverse multiple shaping factors (e.g., biopsychosociospirtual) that lead to a common expression of symptoms.
What good is a diagnosis? I concur with Dr. Lyles: not much.