By David Joel Miller.
Ever wonder what is wrong with you?
Lots of clients ask me that question. Occasionally they want to know their diagnoses. Most of the time they are asking a whole lot more.
Discussing a diagnosis with a client is a controversial thing. Some clinicians feel that a diagnosis is a label and the client is a whole lot more than their label. What a client needs right now may have very little to do with their long-term diagnosis. Someone who has the symptoms of schizophrenia may come to see the counselor because they can’t get along with their spouse. The schizophrenia may make the situation more complicated but what they need right now is relationship counseling just like any other person. I see the point of avoiding labels but don’t always agree with holding the diagnosis.
Other people tell me that knowing their diagnosis is empowering. If you can put a name on your problem and you know there are treatments for this problem, then you have some hope of recovery. If the professionals can’t tell you what is wrong you may start to think there is no hope for you. Alcoholics Anonymous encourages its members to admit they are alcoholics. If you know that you have this disease then you know what or do. Don’t drink! But if you think you have a “lack of control” or poor will power you can keep on trying to control your drinking while racking up more DUI’s.
I take the approach that if the client asks me what the diagnosis is then I owe them an answer and an explanation. Personally, I don’t think “Why is it important for you to know that?” is an answer. It annoys me when clinicians do that. Lots of clients tell me it annoys them when their counselor says things like that. So how do therapists come up with these diagnoses that end up in client’s charts?
A warning here. Diagnosis is not a do it yourself program. What I am saying here is meant as general information, not a personal assessment. That said, if you have questions ask your provider. If you don’t like the answer ask for a second opinion.
Some basics first. The way in which mental illness is diagnosed keeps changing as research and our understanding changes. There are also some gray areas in which the clinician needs to make a judgment call.
Diagnosis of mental illness is most often made by using a book called the DSM-4-TR. This stands for the “Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision. The DSM-5 is due out soon but so far there is lots of disagreement about the changes that may be made. This book is published by the American Psychiatric Association (NOT the American Psychological Association type APA) so while we all have to go by their book, the psychiatrists get to write the book.
There are a lot of complicated rules about who gets to hand out Diagnoses and whether or not they need to be cosigned by a Psychiatrist. I won’t try to explain all that just now.
Therapists and counselors have to take at least one master’s level class, sometimes two in using the DSM and they get thousands of hours of supervised training while pursuing their license. You would think that would take all the guess-work out of diagnoses – it doesn’t. Let me explain why.
Diagnoses are categories. The client gets a named diagnosis like Depression. People don’t always come in nice discrete categories. Everyone gets sad or depressed sometimes. When is it severe enough that we say you have depression, not just normal sadness? We have 32 different shades of mood disorders (296.xx’s) plus specifiers for each and say 6 or more other flavors tucked away in other places. (Cyclothymic, Dysthymic, Adjustment Disorder with Depressed Mood etc.) See why your psychiatrist might have a headache even before you get to their office? See why we might each have a few “favorite diagnosis” that we use more than others? But the problem doesn’t end there.
Let’s take one diagnosis category – Major Depressive Disorder. To hand this one out the client must meet criteria A, B, C, D, and E. AND under criteria A there are 9 “Notes.” The client needs to have note one or two and at least four other of the noted characteristics. So we interview you and you sort of have note one but not note two. Then we see you have the three of the others, but we are just not sure if you have the fourth one or not. Now we have a problem.
If we say no to either of the maybe’s you are out. You do not have depression. But if we say yes to the two questionable calls you are in – you get the diagnosis. This makes me want to scream.
In research studies, they use “strict” criteria. Any doubt and they do not give out the diagnosis. In practice, if you come close and we think you need help and that you might get worse, then you are in. If you are suicidal, does it matter how many times a week you are able to feel pleasure or how much you sleep?
We should be done now but we are not. Not by a long shot. There is a hierarchy of diagnosis. Sometimes one diagnosis trumps and other, sometimes not. You can have depression and anxiety but not depression and Bipolar disorder.
Lots of people come in and tell me thy have been diagnosed with Depression, Manic Depression, and Bipolar. I nod my head yes and let it go.
Bipolar is the new name for manic depression, same thing, new name, mostly to confuse us. Bipolar may not be any better a name than manic depression. Both make it sound like you are either manic or depressed. Kay Redfield Jamison says, and I very much agree, that it is possible to have both at once, we call this mixed states. Some psychiatrists want to take it out of the next DSM. I think it needs to stay, but who am I to argue.
Why can’t you have depression and Bipolar? Because the description of bipolar includes having one manic or hypomanic episode! Most people start out diagnosed with depression but once you have even one teensy weensy bit of hypomanic episode we change the diagnosis to Bipolar.
I want to thank DeeDee whose post suggested the idea for this post. Her post on the GAF got me started about how we keep diagnosis a secret. It is now clear I will not get this all into one post. So watch for a future post in which we tackle the mysteries of five-axis diagnosis and other esoterica.
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For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog check out my Google+ page or the Facebook author’s page, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. A list of books I have read and can recommend is over at Recommended Books