Tag Archives: Diagnosis

More Musings on Donald Trump’s Personality: Spoiler Alert, We’re Not Talking Narcissism Anymore . . . Because it’s Worse than That

Irrigation SunriseAs I mentioned in Part One, much of the focus on DJT has been on whether he meets the diagnostic criteria for Narcissistic Personality Disorder. Allen Francis, who helped write the personality disorder criteria, has expressed many times that DJT is “bad, not mad.” His reasoning is that DJT’s narcissistic traits don’t cause Trump personal distress and haven’t adversely affected his functioning; in fact, DJT was elected president! In diagnostic terminology, Dr. Frances is saying that DJT doesn’t meet either the distress or impairment criteria, at least one of which is needed to make a formal diagnosis.

Despite the objections of Dr. Francis, if you look at the DSM-5 criteria for NPD, it’s easy to see that DJT’s public behaviors could have served as the prototype for the DSM’s authors as they developed the NPD diagnostic criteria. But it still doesn’t mean DJT has NPD. In addition to not meeting the distress or impairment criteria, individuals (even DJT) cannot be diagnosed without a clinical interview, principally because all behaviors occur in context (or within a subculture). What’s even more interesting is that given DJT’s context of being a reality television star, running for president, and being elected president, who are we to say whether his apparent NPD characteristics are diagnosable. In those contexts, having NPD behaviors might be adaptive (at least sometimes).

In particular, the context of U.S. President is of special intrigue. Generally, anyone who runs for president probably has some (or many) narcissistic traits. I’m not saying that all U.S. Presidential candidates are, by definition, narcissistic. I am saying that narcissistic traits in a U.S. President are not especially distinguishing features. It’s sort of like saying, “Hey, I found this fish and I also discovered that it can swim!!” Narcissistic traits in a U.S. President does not a news-flash make.

Besides . . . and here’s where I go down a more frightening path. My sense is that what’s unique and distinguishing about DJT isn’t his narcissism (although his narcissism is palpable, but not diagnosable); instead, I think he behaves in ways consistent with individuals who have antisocial personalities. Again, I’m not making the claim here that DJT should be diagnosed with Antisocial Personality Disorder (APD). Below, I’ll elaborate on my thinking about this.

As I explore how DJT manifests an antisocial personality style (not APD), I’ll be quoting liberally from the amazing work of the late Theodore Millon (see: Disorders of Personality, 3rd ed., 2011). Millon was a psychologist famous for his writings on personology in general, and personality disorders, in particular.

Just FYI: The following quotations and comments don’t refer to APD diagnostic criteria. Millon (2011) believed those criteria were too concrete and simple and therefore inconsistent with the concept of personality. Instead, my focus is on individuals who think and behave in ways consistent with Millon’s formulation of “Aggrandizing-Devious-Antisocial Personality.” These individuals, although not necessarily diagnosable in the DSM or ICD sense, exhibit a style consistent with antisocial psychological and interpersonal dynamics.

Before I dive into Millon’s descriptions, which are fantastic, by the way, let’s take a brief historical tour.

Way back in Aristotle’s time, his student, Theophrastus (371 – 287 B.C.), wrote about specific personalities, one of which was “The Unscrupulous Man.” Here’s one of Theophrastus’s descriptions.

The Unscrupulous Man will go and borrow more money from a creditor he has never paid . . . . When marketing he reminds the butcher of some service he has rendered him and, standing near the scales, throws in some meat, if he can, and a soup-bone. If he succeeds, so much the better; if not, he will snatch a piece of tripe and go off laughing (from Widiger, Corbitt, & Millon, p. 63).

If you recall Aristotelian philosophy, Aristotle was big into virtues or virtuous behaviors. Here we have his student describing someone who isn’t especially virtuous. Theophrastus’s description involves a pattern of taking from others; The Unscrupulous Man apparently thinks that theft of others’ goods and property is acceptable, and perhaps laudable. Serendipitously, I’m reminded of a few examples of this attitude and unscrupulous behaviors in DJT. Specifically, there are well-publicized bankruptcies, reports of non-payment to contracted employees, and a statement in one of his debates with Hillary Clinton that not paying any federal income taxes “makes me smart.” Hardly anyone (other than Sarah Huckabee Sanders) would step up and contend that DJT is neglecting himself because of his interest and focus on the welfare of others. That DJT frequently works systems and people to his advantage is relatively unarguable.

About 2000 years later, interest in The Unscrupulous Man re-emerged. The famous American physician, Benjamin Rush wrote about “perplexing cases characterized by lucidity of thought combined with socially deranged behavior. He spoke of these individuals as possessing an ‘innate, preternatural moral depravity’” (p. 425). Millon summarized Rush’s description: “He claimed that a lifelong pattern of irresponsibility was displayed by these individuals without a corresponding feeling of shame or hesitation over the . . . destructive consequences of their actions” (p. 425). Rush himself wrote: “Persons thus diseased cannot speak the truth upon any subject” (1812, p. 124).

Earlier this year, the Washington Post (May 31, 2018) reported, “President Trump has made 3,251 false or misleading claims in 497 days.” Of course, the Post limited their analysis to public statements, so their estimate is probably low. Rush’s description of someone who “cannot speak the truth on any subject,” has some surface validity in that it sometimes seems that DJT tells unnecessary lies. Given an opportunity to speak freely, it’s not unusual to hear DJT begin exaggerating about inaugural (or other) crowd sizes or to completely dissemble, “I never fired James Comey because of Russia!” or “I’m the only politician that produced more than I said I was going to produce, and we’re only 1 1/2 years in” or ________________. You can fill in the blank, I’m sure.

The history of APD as an entity is peppered with commentary of astonishment (an astonishment similar to the mainstream press) and their repeated surprise that DJT was behaving in ways that were unprecedented, over and over, and in a sense, normalizing combat between the  Office of the President and the Press Corps, who were quickly labeled as “the enemy of the people.” Historically, there was a similar repeated surprise over discovering (and rediscovering) that there was a “type” of mental patient who, in many ways seemed perfectly normal, but in the place where moral values existed for others, there was only emptiness. The usual signs of insanity were missing, but constructs of ethics and morals were viewed as quaint ideas existing only on other planets or in alternative universes. Given this moral lacunae, early on, the condition was referred to as “moral insanity.” This term emphasized the consistent observation that these people appeared sane in all other respects—and often charming. Henry Maudsley (1874), put it this way:

“As there are persons who cannot distinguish certain colours, having what is called colour blindness, so there are some who are congenitally deprived of moral sense” (p. 11).

In the early 1900s, Emil Kraepelin, upon whose work forms the foundation for modern diagnostic systems, described a personality type that he referred to as “morbid liars and swindlers.” These types “were glib and charming, but lacking in inner morality and as sense of responsibility to others; they made frequent use of aliases, were inclined to be fraudulent con men, and often accumulated heavy debts that were invariably unpaid” (Millon, 2011, p. 428). One of Kraepelin’s disciples, a German physician, later added, “. . . that many of these individuals were unusually successful in positions of either political or material power” (Millon, p. 429)

Obviously, DJT has been “unusually successful” both politically and materially. Of greater prescience is a quotation from Jimmy Kimmel Live (May 25, 2016) where DJT described his used of aliases. “Over the years I’ve used alias (sic), and when I’m in real estate and especially when I was out in Brooklyn with my father and I’d want to buy something . . . I would never want to use my name because you’d have to pay more money for the land. If you’re trying to buy land, you use different names.”

Also in 2016, but on a less grand stage, consistent with Kraepelin’s formulation of morbid liars and swindlers, my 90-year-old poker-playing father quickly identified DJT as “a con man” (https://johnsommersflanagan.com/2016/11/05/what-my-card-playing-genius-father-says-about-donald-trump/).

One final note before ending Part Two.

A Kraepelin disciple from Germany made an interesting point . . . and one that Millon repeatedly emphasizes. Not only is it that individuals with antisocial characteristics may not be disordered, in fact, they may be very successful: “Schneider observed that many of these individuals were unusually successful in positions of either political or material power.” (Millon, p. 429).

Part Three is coming . . . although I’m hoping that my Slate Magazine article is coming sooner.

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On Psychiatric Diagnosis and Whether Donald J. Trump has a Personality Disorder

IMG_3063Note — This is a three or four part series focusing on complexities of psychiatric diagnosis; then I ramble into an exploration of what specific psychological and interpersonal dynamics might be driving Donald Trump’s behaviors. This piece and the next two or three are a lead-up to an essay I’m doing for Slate Magazine.

Psychiatric diagnosis looks easy.

All you need is a diagnostic manual. In the U.S., you can use the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; published by the American Psychiatric Association) or the 10th edition of the International Classification of Diseases (ICD-10; published by the World Health Organization). Even easier, you can search for and find online diagnostic criteria for virtually every mental disorder. The power to diagnose is at your fingertips.

If you think your friend has panic disorder, you can type “panic disorder” into your favorite search engine, find the criteria, and confirm your suspicions. The same goes for diagnosing children. Finding the criteria for attention-deficit/hyperactivity disorder (ADHD) is simple. Of special convenience is the fact that if you look at the ADHD criteria, you’ll discover that nearly every child on the planet has ADHD. Odds are, if you look closely at the ADHD criteria, you’ll end up diagnosing yourself. I mean, who really likes waiting in lines?

Technically, you should study the different diagnostic categories and the various checklists of symptoms for each disorder, do a formal observation or interview with the person you want to diagnose, match their behaviors to the checklist, and come to your diagnostic conclusion. But we’re living in a fast-paced world where, like our president, whatever you think must be true because you thought it; never mind that you should recuse yourself from diagnosing your friends, your family, and yourself. Who has time to fact check? Besides, you can just ask, “Siri, do I have obsessive-compulsive disorder?”

Contrary to popular solipsistic fantasies and what you’ll learn from Siri, psychiatric diagnosis may look easy, but in the real world, it’s complex and sticky.

Not only are there 300 different diagnoses (and 947 pages in the DSM-5), many psychiatric conditions overlap, meaning one symptom could be associated with several different diagnoses. For example, having a depressed or irritable mood could qualify your or your romantic partner for bipolar disorder or various depressive disorders, but because bad moods are also associated with ADHD, oppositional defiant disorder, substance use disorders, and many different physical/medical conditions, you’ll need to assess for and rule out these other possible disorders. Then again, there’s the likely chance that you and your romantic partner are bugging the hell out of each other and so your depressed and irritable moods are simply a natural product of your poor judgment, incompatibility, or desperate need for couple counseling.

Sorting out diagnostic signs and symptoms is especially difficult because people will often intentionally or unintentionally minimize or exaggerate their symptoms, depending on the setting and their motivation. Think about your son. He’s a hellion at home, but when you take him to the pediatrician, you come unglued trying to tell the doctor about your hyperactive child. All the while, he sits there, hands folded like a little cherub. You leave the office with a new prescription for valium for yourself.

If you make an effort to go beyond using the diagnosis-is-easy approach, in the end, or in the middle, or somewhere in the diagnostic process you may find the symptoms have changed. You mother may have seemed bipolar and you were closing in on a diagnosis of intermittent explosive disorder for your father, but suddenly, right after you move out, their symptoms vanish. Or maybe they just aged and became more mature or maybe they got out of their miserable jobs, and consequently became less emotionally volatile? This is the nature of working with humans; as much as you’d like them to hold still for a clear snapshot, they move, their relationships change, their employment situation shifts, and you end up with what the venerable psychologist Paul Meehl might have called, a fuzzy notion, rather than diagnostic certainty. Looking back, Meehl might have added that diagnosis is also a sticky notion because, once applied, psychiatric diagnoses are difficult to remove. This is why psychiatric diagnosis is best left to trained professionals. This is also why professionals often get it wrong, and someone ends up labeled with a sticky diagnosis that follows them into the future despite new and contradictory diagnostic information.

As an example, many people and some professionals have concluded that Donald J. Trump has a mental disorder called narcissistic personality disorder (NPD). As satisfying as it might feel to diagnose Donald Trump with NPD, the NPD conclusion is erroneous on two counts. First, no one can or should diagnose Trump without conducting a diagnostic interview. Even then, diagnosing him would be difficult. As Allen Francis, Chair of the DSM-IV Task Force wrote, diagnosticians should “be patient,” because accurate psychiatric diagnosis may take five minutes, five hours, five months, or five years. In the real world of psychiatric diagnosis, accurate and useful diagnoses take much longer and are much more involved than a 5 minute armchair social media diagnosis. Competent and ethical mental health professionals always go beyond diagnostic checklists.

Now, don’t get me wrong, labeling Trump with NPD feels good and feels right. Check it out. There are many, many obvious examples of how Trump fits the NPD criteria. However, other than being fun, entertaining, and gratifying (not to mention offensive), the process and outcome of armchair social media diagnosis is neither fair nor honest.

Beyond simply matching DJT’s behaviors with the NPD diagnostic criteria, over the past two years, many articles and books have been written about Donald J. Trump’s mental health. For some odd reason, I’ve been preoccupied with reading many of these articles and books lately. Although not “fun” content, reading about DJT’s mental state was a welcome shift away from my first impulse after his election—which was to start reading about the death instinct in Freud’s Civilization and It’s Discontents. I’m having way more fun now.

For another odd reason, after reading about DJT’s mental health, I found myself fantasizing that I might have something to add to the conversation.

To be continued . . .

Mental Health or Mental Illness: Defining Mental Disorders

East Rosebud

For a while, I’ve been engaged in a debate (sometimes just with myself) about the use of the term “mental illness.” [More on this at a later date]. Civil debates are good for the brain. There doesn’t have to be a winner or loser. Recently I remembered that we addressed this issue briefly in our 2017 revision (6th edition) of Clinical Interviewing. Here’s an excerpt, beginning on page 396:

Defining Mental Disorders

The concept of mental disorder, like many other concepts in medicine and science, lacks a consistent operational definition that covers all situations. From the DSM-IV-TR (American Psychiatric Association, 2000, p. xxx)

It’s often difficult to draw a clear line between mental problems and physical illness. When you become physically ill, it’s obvious that stress, lack of sleep, or mental state may be contributing factors. Other times, when experiencing psychological distress, your physical state can be making things worse (Witvliet et al., 2008).

Why Mental Disorder and not Mental Illness?

Many professionals, organizations, and media sources routinely use “mental illness” to describe diagnostic entities included in the ICD and DSM classification systems. This practice, although popular, is inconsistent with the ICD and DSM. Both manuals explicitly and intentionally use and plan to continue using the term mental disorder. From the ICD-10:

The term “disorder” is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as “disease” and “illness”. “Disorder” is not an exact term, but it is used here to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions. (1992, p. 11)

The ICD and DSM systems are descriptive, atheoretical classification systems. They rely on the presence or absence of specific signs (observable indicators) and symptoms (subjective indicators) to establish diagnoses. Other than disorders in the F00-F09 ICD-10 block (e.g., F00: Dementia in Alzheimer’s disease, F01: Vascular Dementia, etc.), there is no assumption of any physical, organic, or genetic etiology among ICD mental disorders.

Consistent with the ICD and DSM, we don’t use the term mental illness in this text. We also believe mental illness to be a more problematic term than mental disorder. In fact, often we step even further away from an illness perspective and use the phrase “mental health problems” instead. However, in the end, no matter what we call them, mental disorders are fairly robust, cross-cultural concepts that can be identified and often treated effectively.

General Criteria for Mental Disorders

The DSM-5 includes a general definition of mental disorder:

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. (American Psychiatric Association, 2013, p. 20)

This definition is consistent with ICD-10-CM. Nevertheless, significant vagueness remains. If you go back and read through the DSM-5 definition of mental disorder several times, you’ll find substantial lack of clarity. There’s room for debate regarding what constitutes “a clinically significant disturbance.” Additionally, how can it be determined if human behavior “reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (p. 20)? Perhaps the clearest components of mental disorder include one of two relatively observable phenomena:

  1. Subjective distress: Individuals themselves must feel distressed.
  2. Disability in social, occupational, or other important activities: The cognitive, emotional regulation, or behavioral disturbance must cause impairment.

Over the years the DSM system has received criticism for being socially and culturally oppressive (Eriksen & Kress, 2005; Horwitz & Wakefield, 2007). Beginning in the 1960s Thomas Szasz claimed that mental illness was a myth perpetuated by the psychiatric establishment. He wrote:

Which kinds of social deviance are regarded as mental illnesses? The answer is, those that entail personal conduct not conforming to psychiatrically defined and enforced rules of mental health. If narcotics-avoidance is a rule of mental health, narcotics ingestion will be a sign of mental illness; if even-temperedness is a rule of mental health, depression and elation will be signs of mental illness; and so forth. (1970, p. xxvi)

Szasz’s point is well taken. But what’s most fascinating is that the ICD and DSM systems basically agree with Szasz. The ICD includes this statement: “Social deviance or conflict alone, without personal dysfunction, should not be included in mental disorder as defined here” (p. 11). And the DSM-5 authors wrote:

Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual . . . . (p. 20)

The ICD’s and DSM’s general definitions of mental disorder and criteria for each individual mental disorder consist of carefully studied, meticulously outlined, and politically influenced subjective judgments. Science, logic, philosophy, and politics are involved. This is an important perspective to keep in mind as we continue down the road toward clinical interviewing as a method for diagnosis and treatment planning.

Why Diagnose?

Like Szasz (1961, 1970), many of our students want to reject diagnosis. They’re critical of and cynical about diagnostic systems and believe that applying diagnoses dehumanizes clients, ignoring their individual qualities. We empathize with our students’ complaints, commiserate about problems associated with diagnosing unique individuals, and criticize inappropriate diagnostic proliferation (e.g., bipolar disorder in young people). But, in the end, we continue to value and teach diagnostic assessment strategies and procedures, justifying ourselves with both philosophical and practical arguments.

Some of the benefits of education and training in diagnosis follow:

  • Clinicians are encouraged to closely observe and monitor specific client symptoms and diagnostic indicators
  • Accurate diagnosis improves prediction of client prognosis
  • Treatments can be developed for specific diagnoses
  • Communication with other professionals and third-party payers can be more efficient
  • Research on the detection, prevention, and treatment of mental disorders is facilitated

Although we advise maintaining skepticism regarding diagnostic labels, having knowledge about mental disorders is a professional requirement.

It seems ironic, but sometimes labels are a great relief for clients. When clients experience confusing and frightening symptoms, they often feel alone and uniquely troubled. It can be a big relief to be diagnosed, to have their problems named, categorized, and defined. It can be comforting to realize that others—many others—have reacted to trauma in similar ways, experienced depression in similar ways, or developed similar irrational thoughts or problematic compulsions. Diagnosis can imply hope (Mulligan, MacCulloch, Good, & Nicholas, 2012).

 

The Diagnostic Clinical Interview: Tips and Strategies

CI6 Cover

The clinical interview is 40% assessment, 40% therapy, 25% relational, and 20% technical. What I’m trying to say (other than I wasn’t a math major) is that, as the headwaters from which all counseling and psychotherapy flow, the clinical interview is a flexible tool that many researchers and practitioners use to achieve many different goals. Although I’m a big fan of the clinical interview as a means through which clinicians interpersonally connect with clients to begin therapeutic collaboration, I also recognize that interviews can be a highly structured procedure for collecting data and establishing mental disorder diagnoses.

Recently, I came across a nice “eight minute” diagnostic interviewing article by Allen Frances. Dr. Frances was deeply involved in the development of DSM-IV. Here’s a link to his excellent article: https://pro.psychcentral.com/14-tips-for-the-diagnostic-interview-of-mental-disorders/

Reading the 14 tips from Dr. Frances reminded me of a similar section in our Clinical Interviewing textbook, and so I’ve pasted it below. As always our emphasis is on making sure that technical tasks during an interview don’t overshadow essential relational components. In fact, as I write this, I’m aware that even using the term “relational components” is bad form. It’s bad form because it misses the deep human connection, the non-verbal signals, the first impressions, and the whole interpersonal dance that is de rigueur in every unique clinical encounter. Words cannot adequately express what can and does happen during a clinical interview. Nevertheless, here are a few words from the Clinical Interviewing text anyway. We start with short lists of the advantages and disadvantages of structured diagnostic interviews and then move on to a less structure diagnostic interviewing model. Here’s a link to the 6th edition of Clinical Interviewing on Amazon: https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=sr_1_1?ie=UTF8&qid=1519745757&sr=8-1&keywords=clinical+interviewing+sommers-flanagan

Advantages Associated with Structured Diagnostic Interviewing

Advantages associated with structured diagnostic interviewing include the following:

  • Structured diagnostic interview schedules are standardized. Therapists systematically ask clients a menu of diagnostically relevant questions.
  • Diagnostic interview schedules generally produce a diagnosis, consequently relieving clinicians of subjectively weighing many alternative diagnoses.
  • Diagnostic interview schedules show better diagnostic reliability and validity than less structured methods.
  • Diagnostic interviews are well suited for scientific research. Valid and reliable diagnoses support research on the nature, course, prognosis, and treatment responsiveness of particular disorders.

Structured and semi-structured diagnostic interviews are a part of the scientific foundation of psychology and counseling. Current systems are always in revision; realistically, progress (not a perfect system) is the goal. The diagnostic criteria from DSM-III and -IV and ICD-9 and -10 were improvements on previous versions, and there’s hope that the DSM-5 and ICD-11 will show further improvements in reliability, validity, and clinical utility (Keeley et al., 2016).

Disadvantages Associated with Structured Diagnostic Interviewing

There are also disadvantages associated with structured diagnostic interviewing:

  • Many diagnostic interviews require considerable time for administration. For example, the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Puig-Antich, Chambers, & Tabrizi, 1983) may take one to four hours to administer, depending on whether both parent and child are interviewed.
  • Diagnostic interviews don’t allow experienced diagnosticians to take shortcuts. This is cumbersome because experts in psychiatric diagnosis might require less information to accurately diagnose clients than would beginning therapists.
  • Some clinicians complain that diagnostic interviews are too structured and rigid, de-emphasizing rapport building and basic interpersonal communication between client and therapist. Extensive structure may not be acceptable for practitioners who prefer using intuition and who emphasize relationship development.
  • Although structured diagnostic interviews have demonstrated reliability, some clinicians question their validity. All diagnostic interviews are limited and leave out important information about clients’ personal history, personality style, and other contextual variables. As noted earlier, two different therapists may administer the same interview schedule and consistently come up with the same incorrect diagnosis.

Given their time-intensive requirements in combination with the need of mental health providers for time-efficient evaluation, it’s not surprising that diagnostic interviewing procedures are underutilized and sometimes unutilized in clinical practice. Critics contend that even the diagnostic criteria themselves are more oriented toward researchers than clinicians (Phillips et al., 2012):

It is difficult to avoid the conclusion that the diagnostic criteria are mainly useful for researchers, who are obligated to insure a uniform research population. (p. 2)

Researchers and academics are far and away the primary users of contemporary structured diagnostic interviewing procedures.

Less Structured Diagnostic Clinical Interviews

If your goal is to conduct a state-of-the-science diagnostic clinical interview, then you’ll use a structured or semi-structured format. But not all clinicians choose that approach. The features of a less structured approach include the following:

  1. An introduction to the assessment process (aka role induction) characterized by culturally sensitive warmth and active listening. Depending on the situation and clinician preference, clinicians may employ culturally appropriate standardized questionnaires and intake/referral information (for example, MMPI-2-RC; BDI-2; OQ-45).
  2. An extensive review of client problems and associated goals, and a detailed analysis of the client’s primary problem and goal. This could include questions about the client’s symptoms using the ICD-10-CM or DSM-5 as a guide, or a circumscribed, symptom-oriented diagnostic interview protocol (the HAM-D, for example).
  3. A brief discussion of experiences (personal history) relevant to the client’s primary problem, including a history of the presenting problem if such a history hasn’t already been conducted.
  4. If appropriate, a brief mental status examination could be included, but more likely you’ll review the client’s current situation, including his or her social support network, coping skills, physical health, and personal strengths.

Introduction and Role Induction

The goal of developing a diagnosis and treatment plan shouldn’t change the therapist’s interest in the client as a unique individual. After reviewing confidentiality limits, you should introduce diagnostic interviews to clients using a statement similar to the following:

Today, we’ll be working together to try to understand what has been troubling you. This means I want you to talk freely with me, but also, I’ll be asking lots of questions to clarify as precisely as possible what you’ve been experiencing. If we can identify your main concerns, we’ll be able to come up with a plan for resolving them. Does that sound OK to you?

This statement emphasizes collaboration and de-emphasizes pathology. The language “try to understand” and “main concerns” are client-friendly ways of talking about diagnostic issues. This statement is a role induction that educates clients about the interview process.

Beginning therapists often become too structured, excluding client spontaneity, or too unstructured, allowing clients to ramble. Remember to integrate active listening and diagnostic questioning throughout your diagnostic interview.

Reviewing Client Problems

While reviewing client problems, consider the following.

Respect Your Client’s Perspective, but Don’t Automatically Accept Your Client’s Self-Diagnosis as Valid

Diagnostic information is available to the general public. This leads many clients to offer their own diagnosis at the beginning of interviews:

  • I’m so depressed. It’s really getting to me.
  • I think my child has ADHD.
  • I took an online quiz and found out that I’m bipolar.
  • I have a problem with compulsive behavior.
  • My main problem is panic. Whenever I’m in public, I just freeze.

Some diagnostic terminology has been so popularized that its specificity has been lost. This is especially true with the term depression. Many people use the word depression to describe sadness. The astute diagnostician recognizes that depression is a syndrome and not a mood state. When clients report “being depressed,” further questioning about sleep dysfunction, appetite or weight changes, and concentration problems are necessary. Research has shown that using the single question “Are you depressed?” isn’t an adequate substitute for an appropriate diagnostic interview (Kawase et al., 2006; Vahter, Kreegipuu, Talvik, & Gross-Paju, 2007).

Similarly, the lay public overuses the terms compulsive, panic, hyperactive, and bipolar. In diagnostic circles, compulsive behavior generally alerts the clinician to symptoms associated with either obsessive-compulsive disorder or obsessive-compulsive personality disorder. In contrast, many individuals with eating disorders and substance abuse disorders refer to their behaviors as compulsive. Similarly, panic disorder is a specific syndrome in the ICD-10-CM and DSM-5. However, many individuals with social phobias, agoraphobia, or public speaking anxiety refer to panic. Therefore, when clients say they have panic, it should alert you to gather additional information about a range of different anxiety disorders. Finally, diagnostic rates of bipolar disorder in both youth and adults have skyrocketed (Blader & Carlson, 2007; Moreno et al., 2007). As a result, the lay public (and some mental health professionals) quickly attribute irritability and/or mood swings to bipolar disorder. Nevertheless, we recommend using established diagnostic criteria.

Keep Diagnostic Checklists Available

When questioning clients about problems, keep diagnostic criteria in mind, but don’t expect to have perfectly memorized diagnostic criteria from the ICD or DSM systems. Using checklists to aid in recalling specific diagnostic criteria helps. But don’t reduce your diagnostic musing to a simple checklist.

Don’t Expect to Accurately Diagnose Clients after a Single Interview

It’s good to have lofty goals, but in many cases, you won’t be able to assign an accurate diagnosis to a client after a single interview. In fact, you may leave the first interview more confused than when you began. Fear not. The ICD-10-CM and DSM-5 provide practitioners with procedures for handling diagnostic uncertainty. These include the following:

V codes (DSM-5) and Z codes (ICD-10-CM): V codes and Z codes are used to indicate that treatment is focusing on a problem that doesn’t meet diagnostic criteria for a mental disorder.

F99: This code refers to Unspecified Mental Disorder. It’s used when the clinician determines that symptoms are present, but full criteria for a specific mental disorder are not met. Also, the clinician doesn’t specify why the criteria aren’t met.

Provisional diagnosis: When a specific diagnosis is followed by the word provisional in parentheses, it communicates a degree of uncertainty. A provisional diagnosis is a working diagnosis, indicating that additional information may modify the diagnosis. The ICD-10-CM also allows for using the word tentative, meaning there is uncertainty but that “more information is unlikely to become available” (p. 8)

Being uncertain about your client’s diagnosis after an intake interview should be an excellent stimulus for you to do some extra reading before meeting for a second appointment.

Client Personal History

Even when time is limited, social-developmental history information helps ensure accurate diagnosis. For example, the DSM-5 lists numerous disorders that have depressive symptoms as one of their primary features, including (1) persistent depressive disorder, (2) major depressive disorder, (3) various adjustment disorders, (4) bipolar I disorder, (5) bipolar II disorder, and (6) cyclothymic disorder. Many other disorders include depressive symptoms or symptoms that are comorbid with one of the previously listed depressive disorders. Among others, these include (1) posttraumatic stress disorder, (2) generalized anxiety disorder, (3) anorexia nervosa, (4) bulimia nervosa, and (5) conduct disorder. The question is not whether depressive symptoms exist in a particular client but rather which depressive symptoms exist, in what context, and for how long. Without adequate historical information, you can’t discriminate between various depressive disorders and comorbid conditions.

In some cases, accurate diagnosis is directly linked to client history. For example, a panic disorder diagnosis requires information about previous panic attacks. Similarly, posttraumatic stress disorder, by definition, requires a trauma history; and for AD/HD (in DSM-5) and hyperkinetic disorders (in ICD-10-CM), the diagnosis can’t be given unless there is evidence that symptoms existed prior to age twelve (DSM) or age six (ICD-10-CM).

Current Situation

Obtaining information about a client’s current functioning is a standard part of the intake interview. A few significant issues should be reviewed and emphasized.

A detailed review of your client’s current situation includes an evaluation of his or her typical day, social support network, coping skills, physical health (if this area hasn’t been covered during a medical history), and personal strengths. Each of these areas can provide information crucial to the diagnostic process.

The Usual or Typical Day

Yalom (2002) has written that he believes an inquiry into the “patient’s daily schedule” is especially revealing. He wrote:

In recent initial interviews this inquiry allowed me to learn of activities I might not otherwise have known for months: two hours a day of computer solitaire; three hours a night in Internet sex chat rooms under a different identity; massive procrastination at work and ensuing shame; a daily schedule so demanding that I was exhausted listening to it; a middle-aged woman’s extended daily (sometimes hourly) phone calls with her father; a gay woman’s long daily phone conversations with an ex-lover whom she disliked but from whom she felt unable to separate. (pp. 208–209)

Asking about the client’s typical day can open up a cache of diagnostically rich data that moves you toward identifying appropriate treatment goals and an associated treatment plan.

Client Social Support Network

In some cases, it can be critical to obtain diagnostic information from people other than the client, especially when interviewing young clients. Parents are often interviewed as part of the diagnostic work-up (see Chapter 13). However, even when interviewing adults, you may need outside information:

Adults can also be unaware of their family histories or details about their own development. Patients with psychosis or personality disorder may not have enough perspective to judge accurately many of their own symptoms. In any of these situations, the history you obtain from people who know your patient well may strongly influence your diagnosis. (Morrison, 2007, p. 203)

Whether you need to interview a collateral informant to obtain diagnostic information should be determined on a case-by-case basis.

Assessment of Client Coping Skills

Client coping skills may be related to diagnosis and can facilitate treatment planning. For example, clients with anxiety disorders frequently use avoidance strategies to reduce anxiety (people with agoraphobia don’t leave their homes; individuals with claustrophobia stay away from enclosed spaces). It’s important to examine whether clients are coping with their problems and moving toward mastery or reacting to problems and exacerbating symptoms and/or restricting themselves from social or vocational activities.

Coping skills also may be assessed by using projective techniques or behavior observation. You might try having clients imagine an especially stressful scenario (sometimes referred to as a simulation) and describe how they would handle it. Behavioral observations may be collected either in an office or in an outside setting (school, home, workplace). Collateral informants also may provide information regarding how clients cope when outside your office.

Physical Examination

Often, a conclusive mental disorder diagnosis can’t be achieved without a medical examination. When interviewing new clients, therapists should inquire about the most recent physical examination results. Some therapists ask for this information on their intake form and discuss it with clients.

Physical and mental states can have powerful and reciprocal influences on each other. For instance, a long-term illness or serious injury can contribute to anxiety and depression. Consider the following options when completing a diagnostic assessment:

  • Gather information about physical examination results.
  • Consult with the client’s primary care physician.
  • Refer clients for a physical examination.

Making sure that potential medical or physical causes or contributors to mental disorders are considered and noted is an ethical mandate.

Client Strengths

Clients who come for professional assistance may have lost sight of their personal strengths and positive qualities. Further, after experiencing an hour-long diagnostic interview, clients may feel even more sad or demoralized. As we’ve mentioned before, especially within the context of suicide assessment interviewing, it’s important to ask clients to identify and elaborate on positive personal qualities throughout the interview, but especially toward the end of an assessment/diagnostic process. For example:

I appreciate your telling me about your problems and symptoms. But I’d also like to hear more about your positive qualities. Like how you’ve managed to be a single parent and go to school and fight off those depressive feelings you’ve been talking about.

Exploring client strengths provides important diagnostic information. Clients who are more depressed and demoralized may not be able to identify their strengths. Nonetheless, be sure to provide support, reassurance, and positive feedback. In addition, as solution-oriented theorists emphasize, don’t forget that diagnosis and assessment procedures can—and should—include a consistent orientation toward the positive. Bertolino and O’Hanlon (2002) stated:

Formal assessment procedures are often viewed solely as a means of uncovering and discovering deficiencies and deviancies with clients and their lives. However, as we’ve learned, they can assist with learning about clients’ abilities, strength, and resources, and in searching for exceptions and differences. (p. 79)

Effective diagnostic interviewing isn’t exclusively a fact-finding process. Throughout the interview, skilled diagnosticians express compassion and support for a fellow human being in distress. The purpose of diagnostic interviewing goes beyond establishing a diagnosis or “pigeonhole” for clients. Instead, it’s an initial step in developing an individualized treatment plan.

 

 

 

Teenagers and Depression

Every year, every month, and every day, many teenagers complain of feeling down, depressed, or sad and some of them just act with immense irritability. You probably knew that. But, how many teens are experiencing symptoms of depression?

Estimates are wide ranging. The National Institute of Mental Health reported that approximately 12.5% of U.S. youth from 12-17 years-old experienced at least one episode of major depressive disorder. That’s a huge number of American teenagers (about 3 million).

Add to that the many more teenagers who complain of feeling depressed or down, but who don’t officially meet the diagnostic criteria for clinical depression. By some estimates, that brings the number to close to 50% of teens who are consistently bothered by sad, bad, and irritable feelings.

If you’re a parent of a teen, it’s easy to feel concerned about your teenager’s emotional health.

You may have questions like the following

  • Is my teenager clinically depressed or just going through the normal emotional ups and downs of adolescence?
  • Should I take my son or daughter to a mental health professional?
  • What about medications? Are any of the antidepressants safe and effective for teenagers?

The answers to these questions are complex. It’s hard to tell whether a teenager is in a normal emotional angst or experiencing something more insidious and chronic. And, the answer to the question about whether antidepressant medications are safe and effective with teens is a solid: “Maybe, but maybe not.”

In the latest Practically Perfect Parenting Podcast, Dr. Sara and I take on the serious topic of teenage depression. There are no laughs or giggles, but you’ll get to hear Sara ask me many questions about teen depression, and you’ll get to hear me try to answer them, which is sort of funny. You’ll hear the answer to my favorite trivia question: “What percent of children “recovered” from their depressive symptoms in the first-ever double-blind, placebo-controlled study of antidepressant medications?” And yes, once again, you’ll hear Sara find a way to mention sex during our podcast.

If you have teenagers yourself, or you know someone who has teenagers, or you’re a helping professional who works with teenagers, this podcast may be of interest or helpful to you. Check it out here on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

If you listen and like it, please share it, and then do us one little favor—rate the podcast on iTunes. That way Sara and I can keep climbing up the charts in reality—rather than just in our imaginations.

JSF Dance Party

Webinar Tomorrow: Diagnosis and Assessment of Oppositional Defiant Disorder and Conduct Disorder

Tomorrow at noon Mountain Time, Western Montana Addiction Services is sponsoring a one-hour webinar on the diagnosis and assessment of oppositional defiant disorder and conduct disorder. I’ll be the presenter. If you’re interested in tuning in, you’ll need to email Erin Wenner at: ewenner@wmmhc.org to get instructions on how to gain access. This month I’ll be focusing on very basic diagnosis and assessment issues related to ODD and CD. Next month on June 10th at noon, I’ll be focusing counseling or treatment issues.

DSM-5 and the Universal Diagnostic Exclusion Criteria

Sometimes, even when someone appears to meet all the diagnostic criteria for a mental disorder, assigning a psychiatric diagnosis is still not the right thing to do.

In the following excerpt from the forthcoming 5th edition of Clinical Interviewing, we offer an example of when and why psychiatric diagnosis is inappropriate (see: http://lp.wileypub.com/SommersFlanagan/). We refer to this as the “Three-Dimensional Universal Exclusion Criterion” which is our highly esoteric way of saying, “Whoa on psychiatric diagnosis until you’ve checked to see if there’s an alternative explanation for the observed behaviors!”

Multicultural Highlight 6.2

The Three-Dimensional Universal Exclusion Criterion: Is the Behavior Rationally or Culturally Justifiable or Caused by a Medical Condition?

Let’s say you meet with a client for an initial interview. During the interview the client describes an unusual belief (e.g., she believes she is possessed because someone has given her the “evil eye”). This belief is clearly dysfunctional or maladaptive because it has caused her to stop going out of her house due to fears that an evil spirit will overtake her and she will lose control in public. She also acknowledges substantial distress and her staying-at-home-and-being-anxious behavior is disturbing her family. In this case it appears you’ve got a solid diagnostic trifecta—her belief-behavior is (a) maladaptive, (b) distressing, and (c) disturbing to others. How could you conclude anything other than that she’s suffering from a psychiatric disorder?

This situation illustrates why diagnosis (see Chapter 10) is a fascinating part of mental health work. In fact, if the client has a rational justification for her belief-behavior . . . or if there’s a reasonable cultural explanation . . . or if the belief-behavior is caused by a medical condition—then it would be inappropriate to conclude that she has a mental disorder. One source of support for a universal exclusion criterion is the DSM-5. It includes the statement: “The level of severity and meaning of the distressing experiences should be assessed in relation to the norms of the individual’s cultural reference groups” (American Psychiatric Association, 2013, p. 750).

To explore our three-dimensional “universal” exclusion principle in greater depth, partner up with one or more classmates and discuss the following questions:

Can you think of any rational explanations for the client’s belief-behavior?

Can you think of any reasonable cultural explanations for the client’s belief-behavior?

Can you think of any underlying medical conditions that might explain her belief-behavior?

After you’ve finished discussing the preceding questions, see how many new examples you can think of where a client presents with symptoms that are (a) dysfunctional/maladaptive, (b) distressing, and (c) disturbing to others. Then discuss potential rational explanations, cultural explanations, and medical conditions that could produce the symptoms (e.g., you could even use something as simple as major depressive symptoms and explore how rational, cultural, or medical explanations might account for the symptoms, thereby causing you to defer the diagnosis.