REWRITING PSYCHIATRIC DIAGNOSIS: In Narrative Form

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In previous posts, I have expressed my reservations about using a checkbox approach to diagnosing.  In this post, I will present my answer to the checkbox.  Briefly reviewing, it is my point of view that most physicians go to the Diagnostic Manual (DSM) to make a diagnosis with their glasses on the end of their collective noses, peering at you.  “So, you can’t sleep?  Your mind races?  You can’t turn off your thoughts?  You have mood swings, too?  You have Bipolar.  I’ll write you a prescription.  Come back in three months and we’ll see if the symptoms have gone away.”

From this type of encounter, an initial office visit, a patient leaves with a diagnosis, a sense of relief that the symptoms are caused by something, and a prescription that will take the symptoms away if the diagnosis is correct.  Moreover, the solution is the product of years of science, hard science that was put into a scientific manual, then into a pill to treat the symptoms.  At the point of diagnosis, in the initial interview, the goal is to identify symptoms that are related and that now can fit into a statistically derived pattern as described by the most current research in the DSM5.  This is not much different than looking for a complex of symptoms that are indicators of circulatory problems that can lead to heart attack or certain other symptoms that can indicate cancer or any other physical illness.  But, with physical medicine there are often techniques to confirm diagnosis, mostly involving machines and knives to enter an area to have a direct look at what is going on, sort of like diagnosing a broken automobile, but much more sophisticated.  Medicine looks at the body as a complex machine, after all.

In psycho-diagnostics, however, I don’t care what kind of practitioner you are—psychiatrist, psychologist, social worker, counselor whatever—you have to rely almost exclusively on interview.  You will learn nothing by opening the brain cap.  You won’t even see that electro-chemical activity is occurring, although you may see tumors or brain injury on the surface.  Dig further and you’ll kill the patient.  There are machines to see tumors and electrochemical activity but none to detect feelings and thoughts, or most behaviors.  This leaves us to rely entirely on what the client/patient tells us.

“So, you say you are depressed?  Who am I to say otherwise?  You know how you feel.  I don’t.”  Then, we check the box marked depressed mood.  We might also want to check the box that says depressed affect, the physical expression of a mood, but that is sometimes not done because the doctor assumes that, if the patient is saying s/he is depressed, then a depressed affect is to be expected.  Although, truth to tell, there are people who report depression, but their affect is neutral.  “Depression?  That’s just how I feel, all the time.  I don’t care what I look like to you.”

This is just one small example of how the diagnostic system can break down as the doc says, “Who am I to disagree with you?”  From this we derive a diagnosis and a treatment that practically speaking is the result of a patient diagnosing him/herself.  This type of thing occurs most of the time.  And if, like me, you try to dig a little deeper to find causes for depression, you may find the client gets irritable, even angry that you don’t agree.  “After all, my psychiatrist believed me.  Why don’t you?  Why are you asking me all these questions?  My psychiatrist didn’t and (s)he’s better educated and smarter than you are.”

The goal of medications is to relieve symptoms, but does not address causes, unless they happen to be chemically based.  It is from this that we ended up with a generation of patients who would declare that they have a chemical imbalance.  The problem is, as I have previously said, that nobody knows what chemical balance is anymore than we know what a “healthy personality” is.  We have to assume that, if you feel good mentally and emotionally, then you must be healthy.  The same can be said of depression, bipolar and other mental disorders.  If you think you have the symptoms, the diagnosis of them is very likely to follow.

From this, I would say that there is an element of myth involved in any treatment, chemical or talking.  It really depends on what you think will work and what you are prepared to do to make it happen.  It’s a lot easier to take a pill than to look at the cause of symptoms based on history and experience.  It can be a lot of work.  It can rekindle traumatic memories, although just as in medicine, in some cases, it may not work.  And it won’t work especially if the client is too fragile, if they don’t feel safe in the therapy, or the therapist doesn’t know what to do with the information they are given by the client.

Getting back to diagnosis, if we don’t use checkboxes and sophisticated statistics to diagnose, what remains?  For those who like theory, I would like to reintroduce an old one that makes sense.  Gestalt Psychology (not Gestalt Therapy, which is a technique not a theory) is a Cognitive Theory that has generated a lot of laboratory research, although as a theory it offers much promise for diagnosing and doing therapy because it can bring a person and that person's experience closer together.  The theory introduces the idea of Figure and Ground, that is, Figure (person) within Ground (the situation in which he or she finds him or herself).  The two are not easily separated and perhaps cannot be if you analyze all areas of connectedness, but they can be worked with, creating a therapy based on history and experience.

Going back to the DSM-II, diagnosis was based mostly on Freudian theory and symptoms.  With the advent of psychopharmacology, it made far more sense and was more scientific to treat behaviors, rather than hypothetical psychic structures, because behaviors are observable and can be quantified and analyzed as responses to treatment.  From this, the DSM-III evolved which is the earliest diagnostic system in the US that took a person’s internal life out of it, but instead looked only at behaviors with the addition that thoughts and feelings were analyzed as behaviors also.  As we know now, it doesn’t really work that way.  That is, we have never really kept a person’s internal experience entirely out of the equation, but instead ask for a report on how the person feels as a way to diagnose and to check the effectiveness of the medicine, leading to such reports as, “Doctor, I don’t like the side effects and I am still depressed.”

Metaphorically, it is as if the person’s inner life is locked away inside a black box and the person’s report of what's in the box is what’s to be investigated, that is as behavior to change and make better.  We'll pretend this doesn't violate the spirit of what a behavioral diagnostic system is intended to do, that is diagnose by direct behavioral observation.  (Imagine doing the same thing with a lab rat.  “Mr. Rat, now that we’ve given you the medication, how are you feeling today?)  And, lest we forget it, when research is generated from this, the statistics are influenced by this practice with results that are skewed to favor the patient’s report—don’t forget placebo effects!—and are therefore less objective and less scientific than one would hope.  Unlike in physical medicine where the doctor uses tools to learn what is wrong, in psycho-diagnostics patients do most of the work themselves and know the end-product before the practitioner does.  They’ll even say it.  It would be an understatement to say that medication trials may be skewed under these conditions and one can easily wonder if those researching a new drug take results seriously themselves because patients' reports can be so easily influenced by what is happening in their lives or, for example, whether they might have slept well.

So, for a future DSM6, I propose going back to Cognitive Psychology to diagnose.  Let’s put the science back in mental health and treatment.  Let’s go back to Figure-Ground as the only theory that makes sense for diagnosis and treatment.

There is an old expression that I heard growing up that captures the essence of this.  “You can take the kid out of the city, but you can’t take the city out of the kid.”  As it turns out, this is a dynamic expression of Figure-Ground.  When applied to diagnosis, this means that, like the rings of a tree, people have layers of experience and responses to that experience that are the result of past influences on them, just as current experience influences them now.  Without taking these influences into account when formulating a diagnostic system and without considering it at every step in a treatment, the essence of an individual’s experience and what it means to be human are lost.  By just looking at behaviors, diagnostics appears to just be looking at people in two dimensions.  Add a careful analysis of current experience and you add a third dimension.  But, if you take an in-depth look at a person’s history and experience, you add the fourth-dimension of time, space-time as the person internalized it, which is the stage on which current symptoms and experience occur.  This is the basis of people’s understanding of what is happening to them now.  This should also be the primary focus of diagnosis and treatment.  It is also the only way that another person, a person other than ourselves, can be understood.  I suggest that, however difficult, all this must be taken into account in order to diagnose accurately and to formulate a treatment, whether behavioral or medicinal.  I offer this as a supplement for sophisticated statistical analysis of an otherwise linear experience based primarily on a subject’s report of current symptoms.