Tag Archives: Diagnosis

October 3, 2012 · 4:39 pm

What good is a diagnosis?


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?

  1. Does it explain a set of symptoms?
  2. Does it point to a treatment plan?
  3. 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.

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May 15, 2012 · 2:46 pm

2 reasons why finding the root problem may not be a good goal for counselors


How important is it for a counselor to diagnose the client’s root problem? Consider these analogies:

Imagine being diagnosed with cancer in one part of your body but having your doctor tell you that it isn’t important to discover whether the source of that cancer lies elsewhere. You wouldn’t be happy and you would likely seek another opinion. Or, consider this analogy: you keep cutting off the tops of dandelions only to find that they keep coming back. Not a very wise decision. Instead, you find the tap-root and remove it if you really want to stop the weed from growing.

In the last week I have had three conversations about identifying the source or primary cause of someone’s emotional struggle. In each case I was asked questions about the source of the problem.

Is it a chemical imbalance? Is it the result of childhood trauma? Is the primary problem his sin?

I understand these questions. They are reasonable and important to ask. As a counselor, I am trying to assess how a particular psychological problem develops in an individual. But, maybe these questions aren’t as helpful as they first appear. Here are two reasons why we ought not put too much stock into seeking out the root problem and a suggestion for a different approach than the “why” question.

  1. “Why” questions almost always lead to a simplistic/categorical answer. Most psychological (or spiritual) problems have multi-factored roots. There are biological predispositions, experiences, behavioral choices/habits, perceptions, beliefs, etc. all working together to “allow” the problem to develop. Usually, we do not find this kind of complexity very helpful. We like to narrow things down to single or primary problems. Narrowing down to either/or categories helps us “understand” the problem and exert energy towards a single solution. However, when we demand a primary cause, we will almost always misrepresent the problem and may communicate to others a distorted image of what is taking place. Saying that a psychological problem is the result of sin or neurochemicals or family upbringing ALWAYS flattens the problem and as a result puts too much hope in any intervention.
  2. “Why” rarely leads to the most important question, “so, now what?” Let’s say that we can figure out why you struggle with Obsessive-Compulsive Disorder (OCD). Your mother contracted a virus during the 7th month of her pregnancy and that virus altered your prenatal brain and caused your OCD. Okay…so now what? Notice how the why question provides interesting information and possibly helpful in eliminating the problem in future expecting mothers…but as enticing as it is, the diagnosis doesn’t help much with the, “so now what do I do about it.” In fact the desire to figure out the “why” never is as clear and easy as I have just made it in the virus example and so the search for “why” doesn’t lead to the “so now what” question at all. Now, I don’t want you to think that I care little for historical data gathering. The multifactorial etiology of our problems are worth exploring. We ought to take a look at how early childhood experiences shape our current behavior. We ought to explore the possibility of a biological predisposition to our anxiety. We ought to examine how our beliefs about self, other, and God influence our current problems. However, we explore these historical facets not because they answer the “why” question but because they help us understand “how” we function and whether we want to alter some of these shaping influences.

An Alternative Approach?

I’ve just tipped my hand in the last point. How is a better question. Finding out how a particular feature (belief, habit, experience, perception, biological process, etc.) influences current life and how a person might respond to or engage differently over a problematic emotional expression is more likely to bear good fruit. Consider these examples:

  1. How does your history with pornography and secret shame influence your seeking accountability from your other men in the church?
  2. How do you react to trauma triggers and what different responses to triggers might you want to practice?
  3. How do you want to think about or assess your unwanted sexual desires and feelings?

So, asking why we do what we do or why we are the way we are is interesting but not always the most helpful question from a counselor. Instead, explore your perceptions, reactions, thoughts about what is happening and explore how you might come to feel, think, or engage the problem from a different perspective or with a different goal in mind.

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May 5, 2012 · 8:15 am

Do your labels help or hurt?


I have a post over at the Seminary’s faculty blog today. You can find it here.

Counselors label all the time. Even when we don’t offer official DSM diagnoses, we label things as good, bad, healthy, unhealthy, dysfunctional, sinful, etc. The key question counselors face is WHEN and HOW to share their views on a subject. Just because we can see something is wrong doesn’t mean we ought to share it yet. While you may wish your family doctor to share suspicions of Lyme’s disease with you on the first visit, your counselor may need to earn the right to say, “I think you have become embittered over your husband’s insensitivity.”

If you are in a position of authority (parent, teacher, boss, counselor, leader, etc.) consider how quickly you use labels and whether or not they invite dialogue and action. If the result of our labeling is increased passivity in the one being labeled, then maybe we need to consider that our labeling is part of the problem.

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February 14, 2011 · 5:59 am

Resources about narcissism?


Cover of "The Drama of the Gifted Child"

Cover of The Drama of the Gifted Child

A few weeks ago I was asked about resources on the topic of narcissism, things a person struggling with some of the features might read to better understand their inner world. I didn’t have any really great “lay” materials on the topic so I’m going to poll the audience. A perfect entry for Valentine’s Day when we celebrate those people who make us feel special!

Narcissism is an ugly word if it is used about you, as in, “you’re so narcissistic!” This usually means someone sees us as being self-centered.

The truth is…most of us have a touch of it at times. We desire affirmation, we fantasize about being recognized for our achievements, we want to be special (or at least seen that way), we have times of feeling entitled and may even manipulate the feelings of others to get what we want. Our focus on self may limit our empathy towards others. We may be haughty. All of have some of these features some of the time. Some of us have these features most of the time.

Having these feelings doesn’t mean we are personality disordered. But, our willingness to acknowledge and work on being more other centered MAY reveal whether we meet diagnostic criteria. Meaning, if you can admit to the problem and improve your capacity for empathy then you probably aren’t meeting criteria for a personality disorder.

What causes narcissism?

The simple Christian answer is sinful self-focus. But since ALL of us are sinners and flawed…can we be more specific why some people seem to struggle more with the problem, why some have an enduring bent  or a fixed pattern of relating to the world? One theory suggests that narcissistic features arise out of a lack of mirroring which results in a deep fear that we aren’t special…or worse, are worthless. There is likely some truth to this. However, it seems that some narcissism is encouraged in a me-first culture.

Resources?

So, what resources do you know that get at some of these experiences, desires, feelings of narcissism that could help a person be more aware of their impact on others.

Here’s a few reads I know about:

1. Drama of the Gifted Child, by Alice Miller. A classic psychodynamic read about our emotions. She does a nice job illustrating the fears/cravings of narcissism and borderline features and how we all have a touch of these. Not necessarily helpful in what to do about the experience but good to delve into the experiences of depression, grandiosity, denial, and self-contempt and what these do for us.

2. Re-inventing Your Life, by Jeffrey Young. In particular, look at chapter 16. In fact, if you follow the link, you can search “entitlement” in the “search inside” box on the left and once you get results, scroll down to the one on p. 314. You can read a bit of the chapter to see how the authors do a good job describing the common symptoms of narcissism.

3. Anatomy of Secret Sins, by Obadiah Sedgwick. Well, not exactly about narcissism but definitely about uncovering our true self-centeredness. Sedgwick lived between 1600 and 1658! Excellent read on the problem of self-deception.

If you try to search for books on this topic, you will discover (not surprisingly) most are written to those who either have to live with the person or are trying to get free of them. Few are written to the person with the problem.

Any resources you might add to the list?

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January 18, 2011 · 7:48 pm

Adult Asperger’s?


DSM-IV-TR, the current DSM edition

Image via Wikipedia

In last night’s Psychopathology class I was discussing the significant changes throughout the history and editions of the Diagnostic & Statistical Manual (I-VI), especially in regard to the growth of mental health diagnoses. That led us to talk about a couple of diagnoses, once added, that have become “popular.” By popular I don’t mean en vogue or fun or the like. What I mean is that there has been a significant increase in the usage of that diagnosis.

What diagnosis? Asperger’s Syndrome.

Why? Some feel it is because the diagnosis is known and now those who went undiagnosed now are more likely to receive a correct diagnosis. Others feel that therapists are over diagnosing–lumping in every kid who has any hint of a social quirk.

It will be interesting to see what happens to the numbers being diagnosed when DSM5 comes out (2013?) and Asperger’s is subsumed into a generic Autistic Spectrum Disorder. I’d be willing to bet that fewer people will get the diagnosis because of stigma alone.

Whether over or under used, there are adults who meet criteria for this diagnosis and who might be helped (along with their spouses) if they had some hooks to use to understand what was happening in their relationships. If you are involved in counseling folks who meet criteria for this diagnosis…or think you might, check out the this website.

Click the link “tests” and check out a couple of the free adult forms you might use in the diagnostic process. They may not be quite as robust in their statistical properties, but they do give you a good way to narrow the conversation with your clients.

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