D is for Distal Contextual Affordances (ha ha, just kidding). D is for Diagnosis and DSM 5

Each quarter, as I take new classes and learn new material, I analyze and diagnose myself accordingly. I generally text a friend of mine who is a marriage and family therapist (MFT) during class. Our exchange goes something like this:

Me: OMG, I so have this.
MFT: what?
Me: I wasn’t properly attuned to as a baby. That’s why I’m so fucked up.
MFT: gawd
Me: well, it could be that or it could be that I experienced a trauma as an infant.narcissist chicken
MFT: maybe
Me: I was dropped on my head once.
MFT: well, that explains it.
Me: I know, right?
MFT: it’s just one lens, Pam. A theory.
Me: oh. Sorry for being so narcissistic.
MFT: You’re not a narcissist.
Me: borderline?
MFT: ugh.

And so it goes. Each quarter I learn new and fascinating ways to make sense of human behavior.

A few years ago, when I began working on my memoir, I asked my (by then former) psychologist if I could have access to my records. I wanted to reconstruct a timeline of events and double-check my memories. Since she had seen me through some of my darkest hours I figured I would find a good record of events that I had been too depressed and distraught to remember. And I did. But I also discovered how I had been diagnosed, and I found it all a bit unsettling to see the DSM codes next to the list of my symptoms.

If you read yesterday’s blog, Dear Reader, you know that I was depressed. So it came as no surprise when I decoded the DSM codes to find variations on that theme: major depressive disorder, recurrent episode; major depressive disorder, recurrent episode in partial remission; major depressive disorder, severe. And so on. I was fine with these diagnoses and also with the occasional Adjustment Disorder diagnosis that I found. I knew enough by then to know that when a mental health provider doesn’t know what else to use, when a client just needs to chat a bit to clear things up, they use the somewhat ambiguous 309.9 (Adjustment Disorder, Unspecified).

Diagnosing someone with an illness or disorder that appears in the DSM 5 is an art, not a hard science. This latest version of the Diagnostic and Statistical Manual is arranged quite differently from its predecessors with disorders arranged according to lifespan. So, disorders that affect children come first—neurodevelopmental disorders, followed by illnesses that appear in adolescence and early adulthood: schizophrenia and psychosis, depression, anxiety, OCD. These are followed by trauma related disorders, dissociative disorders, somatic (body disorders), feeding and eating disorders, elimination disorders, sexual dysfunctions, substance abuse issues, personality disorders, and paraphilia.

Gone are Axis I, II, III, IV, and V. Used to be that the most acute and familiar disorders—those requiring immediate attention fell under Axis I: schizophrenia, major depressive disorder, panic attacks; ongoing personality issues—narcissism, borderline personality disorder, intellectual disabilities, obsessive/compulsive disorder—fell under Axis II. Axis III was reserved for related medical conditions such as terminal cancer, which might contribute to a client’s depression. Axis IV diagnoses included life events: marriage, job loss, promotions, divorce, death of a parent or child, and Axis V is used for the Global Assessment of Functioning Scale, a 100 point questionnaire evaluating the client’s ability to function in daily life.

What we CMHC (clinical mental health counseling) students all learn early on in our clinical program is that diagnosis is a necessary evil if a mental health care provider wants to take insurance. Insurance companies will not pay if we don’t attach a diagnosis to our clients. At the same time we learn that our clients are much more than walking bundles of diagnoses.

The bottom line is that when a person presents in my office and tells me what’s going on in their life, how they are coping day-to-day, and want to pay for their sessions with insurance, I have to give them a diagnosis. One counselor I’ve talked to diagnoses everyone with PTSD. After all, she says, we have all had trauma in our lives. Others consult the DSM and match the client’s presentation with the best diagnosis.

Failure to attend to details? Difficulty sustaining attention with tasks? Often lose things? Easily distracted? Often forgetful? ADHD 314.

Heart palpitations? Sweating? Trembling and/or shaking? Shortness of breath? Nausea? Choking feelings? Fear of losing control? Fear of dying? Panic Disorder 300.01

Marked distress? Significant impairment in social, occupational or other areas but doesn’t meet the criteria for another mental disorder? Adjustment Disorder 309

When I left the psychologist and started seeing the counselor, I stopped feeling like a hopelessly troubled person and more like a person with some troubles that could be resolved. Instead of being treated for my “mental illness,” I was treated like a person and we looked together at why I might be feeling depressed or anxious or sad or worried. I began to see that my inability to come off my meds for depression had more to do with the fact that in my case, I had been treating the symptoms, but not the root of the issue.

Over time, I came to understand that my behaviors, moods, and thought patterns had more to do with how I had learned, over the course of the last few decades, to deal with the world. Starting in infancy we all learn how to get our needs met. Some of us learn to trust that we will be taken care of, that our needs are important, that our voices are valued. Others not so much.

There are many lenses through which to evaluate human behavior: family systems, attachment theory, behaviorism, post-modernism, Jungian. There are many schools of thought on how to best help people: cognitive behavior therapy, exposure therapy, psychoanalysis, narrative therapy, play therapy, art therapy, drama therapy.

There are a multitude of diagnoses I could apply to my future clients, but my clients deserve more than a label and to be compared against a checklist of criteria.

I must to remember Carl Rogers and not ask, ”How can I treat, or cure, or change this person?” But instead,“How can I provide a relationship which this person may use for [her] own personal growth?”

10 thoughts on “D is for Distal Contextual Affordances (ha ha, just kidding). D is for Diagnosis and DSM 5

  1. The key is that each person encounters wayward, unsafe bridges . One walks them with difficulty and peril. Counseling should act as a navigator not as a pharmacist. Nice work here. L

    Sent from my iPad

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  2. Two things. 1) I thought I’d had a total revelation when I walked into my therapist’s office and said, “I’ve realized I’m a little bit bipolar.” She said, “Ya think?”

    2) A friend of mine who has really struggled with depression the last several years told me she had PTSD about her grandfather’s death, which I thought seemed like an odd conclusion. Maybe she had a therapist who diagnoses everyone with PTSD. Troubling.

    • Good points. Let me clarify.

      Two: That’s just what she sends to the insurance company. Because she has to. It’s an imperfect system. Interestingly, most people don’t know what their diagnosis is or that they even have one. I didn’t until I requested my files long after I changed therapists.

      One: I think we all know ourselves better than anyone else, therapist or doctor. That’s my point. We should listen to our clients, and sometimes it takes awhile for the client to realize what we may have initially suspected. My therapist says that clients usually come in holding a metaphorical dead fish but have no idea. The therapist can see and smell the fish, but the client has not yet noticed it. Eventually, if we listen, the client will discover it. It doesn’t work it we point it out. That’s the art of it.

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  3. J here, stopping by from the #atozchallenge – where I am part of Arlee Bird’s A to Z Ambassador Team.
    April is here and I’m excited about it. Best of luck to us both on meeting our goals of posting and hopping to other blogs.
    My blog has a giveaway. There’s a bonus a to z challenge each day to encourage people to visit more stops.
    http://jlennidornerblog.what-are-they.com
    I’ve followed your listed social media.

    Very interesting. I never knew about the codes, or much of this, really. The comic was funny, also.

  4. The PTSD thing explains a lot…when they switched to the open-office plan in my old workplace, several people said they had PTSD and couldn’t work like that. They were moved to corners. I often joke about having PTSD about working in an office in general, actually! I minored in psychology in college, so I only got a small taste of it, but I remember applying so much of what I was learning to myself!

    Stephanie
    http://stephie5741.blogspot.com

  5. Thanks, Victoria. Hope Good to know I didn’t geek out too much for the non-counselors out there. Interesting is good. Insightful=high praise 🙂

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