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rachelmanija) wrote2016-01-18 03:10 pm
rachelmanija) wrote2016-01-18 03:10 pm
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Diagnosis Made Easier, by James Morrison
Morrison’s book is a textbook for mental health clinicians. It is exactly what it says on the tin. It’s easy reading and could be read by a layperson with some knowledge of psychology. He lays out a number of important principles. I’ll just note a few that I find particularly useful.
In my own practice, I don’t often find diagnosis challenging in the sense of “What official diagnosis could this person possibly have?” (It has to do with where I work. Most of our clients were recently traumatized or court-mandated, so their issues tend to be pretty obvious - PTSD, depression, anxiety, life stress, etc.)
But the principles are still useful. For instance, I often have clients who match the criteria for multiple disorders. It is not at all uncommon for one person to fit the criteria for PTSD, generalized anxiety disorder, major depression or dysthymia, agoraphobia, panic disorder, and social anxiety. Which one is the most important? Is one causing all the rest? Which should I treat first? Which treatment is best for this person, given that they could in theory benefit from treatments for all the disorders? Is there one treatment that would cover several?
Also, sometimes the initial diagnosis is wrong or incomplete, and they need additional or different treatment. For instance, the client comes in with a clear-cut case of PTSD. But maybe they’re also non-neurotypical and have never been diagnosed. Or they were bulimic before and didn’t tell me about it. Etc.
Prioritization by safety hierarchy.
Since tests and investigation take time, you need to immediately check into some things, and leave others for later investigation. First, check for issues which are potentially life-threatening but treatable and likely to have a good outcome; last, check for issues which are not immediately life-threatening, hard to treat, and not likely to have a good outcome. In the middle, look for things in between. For instance:
1. Suicidality, major depression, bipolar disorder, medical illness. All potentially very dangerous, all potentially very treatable.
2. Panic disorder, OCD. (Very treatable but not immediately dangerous.)
Substance abuse without suicidality. (Potentially very dangerous, but difficult to treat; practically speaking, you can put a hold on the person who is threatening suicide, but you can't put a hold on a heroin addict just because you worry that they might accidentally OD.)
4. Personality disorders, dementia (if the person has caretaker and isn’t in danger of wandering into traffic or some such). Not easily treatable; may be life-threatening (Alzheimer’s) but immediate intervention won’t change that.
History beats current appearance
If you’re talking to someone who was raped last month, they will usually appear to have major depression, generalized anxiety, etc. Find out if they ever had any of those symptoms before.
Someone with a history of depression or anxiety is a better candidate for a psychiatric referral than someone who was fine pre-trauma. If someone was depressed before, treating their PTSD may not cure their depression, so they should be getting a med consult ASAP. (They are also much more likely to be open to the possibility of taking medication.)
If they have no previous history of depression and are not suicidal, sending them to a psychiatrist is not a priority; by the time they found an anti-depressant that worked for them, their depression may have resolved anyway because it wasn't true depression; it was a depressed mood caused by trauma. Treat the PTSD, and the depression goes away. Also, these people frequently don't want to take meds. (In those cases, I bring it up again if their PTSD seems to be resolving but they have persistent symptoms of some kind that are not improving with talk therapy. I point out that they may just need a little extra help in this one area, since we've tried our best with non-medical means and, unlike their other issues, it's not going away.)
And along similar lines:
Be cautious about diagnosing mental illnesses in people actively abusing substances when they do not have a known previous history of mental illness. Especially if they appear to be psychotic.
Maybe they’re schizophrenic. Maybe they’re bipolar. Maybe they’re depressed. But it is really hard to tell if they’re also snorting coke and drinking a bottle of whiskey every day. Very likely they do have some mental illness, but which one? Defer diagnosis and refer for specialized treatment (unless you’re the specialist.)
Get a family history
This is useful in so many ways. For instance, if you have a client balking at medication, knowing that their father was a drug addict may open up a conversation about exactly what their concern is – maybe they don’t know that SSRIs are not addictive. On a more obvious note, if there’s a long family history of depression, that makes depression a more likely diagnosis. Many mental illnesses run in families. (Typically, both genetic and learned factors are in play.)
Look for horses before you look for zebras
The teenage girl who seems anxious and pulls at her hair might have trichotillomania (the compulsion to pull out her hair.) But I’d check for anxiety, depression, trauma, neuro-atypicality, or even OCD first. (I'd start by asking her what the hair-pulling is about.)
Keep an open mind
Don’t just assume that previous diagnoses are correct. That includes your previous diagnosis. That also goes for family history. The “alcoholic grandfather” may have been self-medicating something.
Consider medical causes, including environmental ones
I once correctly diagnosed a client’s “panic attacks” as caffeine withdrawal. Morrison once thought he was suffering from a panic attack (he was in combat at the time, so very understandable) but it was actually an electrolyte imbalance – he’d forgotten to take his salt tablets. Once he took them and drank some water, his symptoms vanished.
Clients with chest pains need to see a medical doctor to rule out heart problems if they haven't already, even when you’re 100% sure it’s panic/anxiety. Depressed, low-energy, overweight clients and anxious, skinny, eye-bulging ones should get their thyroid checked. If there is any reason to think there may be a medical issue going on, send them to a doctor.
Always about ask medications a patient is taking, and ask again if they present with new symptoms with no clear cause. Specifically include OTC meds, herbal meds and supplements, and recreational drugs. Also ask if they’ve recently given something up.
Similarly, ask if they’ve been recently diagnosed with a medical condition. Many medical drugs and some medical conditions can have psychiatric side effects.
Clients presenting with a completely new condition in middle age with no clear cause (ie, not PTSD from a recent trauma) should be strongly considered for a medical cause. Mental illnesses (again, other than PTSD) tend to have a history, and middle-aged people are more likely to be physically sick than young people.
"Undiagnosed" is a perfectly legitimate label to use when you don't know what's going on, or don't have enough info to go on. Don't be embarrassed to use it.
The rest of the book is about diagnosing specific illnesses, such as “How to diagnose OCD.” It’s quite helpful (especially the diagnosis trees) but I thought the general principles above were more interesting for a general audience.
Diagnosis Made Easier, Second Edition: Principles and Techniques for Mental Health Clinicians
In my own practice, I don’t often find diagnosis challenging in the sense of “What official diagnosis could this person possibly have?” (It has to do with where I work. Most of our clients were recently traumatized or court-mandated, so their issues tend to be pretty obvious - PTSD, depression, anxiety, life stress, etc.)
But the principles are still useful. For instance, I often have clients who match the criteria for multiple disorders. It is not at all uncommon for one person to fit the criteria for PTSD, generalized anxiety disorder, major depression or dysthymia, agoraphobia, panic disorder, and social anxiety. Which one is the most important? Is one causing all the rest? Which should I treat first? Which treatment is best for this person, given that they could in theory benefit from treatments for all the disorders? Is there one treatment that would cover several?
Also, sometimes the initial diagnosis is wrong or incomplete, and they need additional or different treatment. For instance, the client comes in with a clear-cut case of PTSD. But maybe they’re also non-neurotypical and have never been diagnosed. Or they were bulimic before and didn’t tell me about it. Etc.
Prioritization by safety hierarchy.
Since tests and investigation take time, you need to immediately check into some things, and leave others for later investigation. First, check for issues which are potentially life-threatening but treatable and likely to have a good outcome; last, check for issues which are not immediately life-threatening, hard to treat, and not likely to have a good outcome. In the middle, look for things in between. For instance:
1. Suicidality, major depression, bipolar disorder, medical illness. All potentially very dangerous, all potentially very treatable.
2. Panic disorder, OCD. (Very treatable but not immediately dangerous.)
Substance abuse without suicidality. (Potentially very dangerous, but difficult to treat; practically speaking, you can put a hold on the person who is threatening suicide, but you can't put a hold on a heroin addict just because you worry that they might accidentally OD.)
4. Personality disorders, dementia (if the person has caretaker and isn’t in danger of wandering into traffic or some such). Not easily treatable; may be life-threatening (Alzheimer’s) but immediate intervention won’t change that.
History beats current appearance
If you’re talking to someone who was raped last month, they will usually appear to have major depression, generalized anxiety, etc. Find out if they ever had any of those symptoms before.
Someone with a history of depression or anxiety is a better candidate for a psychiatric referral than someone who was fine pre-trauma. If someone was depressed before, treating their PTSD may not cure their depression, so they should be getting a med consult ASAP. (They are also much more likely to be open to the possibility of taking medication.)
If they have no previous history of depression and are not suicidal, sending them to a psychiatrist is not a priority; by the time they found an anti-depressant that worked for them, their depression may have resolved anyway because it wasn't true depression; it was a depressed mood caused by trauma. Treat the PTSD, and the depression goes away. Also, these people frequently don't want to take meds. (In those cases, I bring it up again if their PTSD seems to be resolving but they have persistent symptoms of some kind that are not improving with talk therapy. I point out that they may just need a little extra help in this one area, since we've tried our best with non-medical means and, unlike their other issues, it's not going away.)
And along similar lines:
Be cautious about diagnosing mental illnesses in people actively abusing substances when they do not have a known previous history of mental illness. Especially if they appear to be psychotic.
Maybe they’re schizophrenic. Maybe they’re bipolar. Maybe they’re depressed. But it is really hard to tell if they’re also snorting coke and drinking a bottle of whiskey every day. Very likely they do have some mental illness, but which one? Defer diagnosis and refer for specialized treatment (unless you’re the specialist.)
Get a family history
This is useful in so many ways. For instance, if you have a client balking at medication, knowing that their father was a drug addict may open up a conversation about exactly what their concern is – maybe they don’t know that SSRIs are not addictive. On a more obvious note, if there’s a long family history of depression, that makes depression a more likely diagnosis. Many mental illnesses run in families. (Typically, both genetic and learned factors are in play.)
Look for horses before you look for zebras
The teenage girl who seems anxious and pulls at her hair might have trichotillomania (the compulsion to pull out her hair.) But I’d check for anxiety, depression, trauma, neuro-atypicality, or even OCD first. (I'd start by asking her what the hair-pulling is about.)
Keep an open mind
Don’t just assume that previous diagnoses are correct. That includes your previous diagnosis. That also goes for family history. The “alcoholic grandfather” may have been self-medicating something.
Consider medical causes, including environmental ones
I once correctly diagnosed a client’s “panic attacks” as caffeine withdrawal. Morrison once thought he was suffering from a panic attack (he was in combat at the time, so very understandable) but it was actually an electrolyte imbalance – he’d forgotten to take his salt tablets. Once he took them and drank some water, his symptoms vanished.
Clients with chest pains need to see a medical doctor to rule out heart problems if they haven't already, even when you’re 100% sure it’s panic/anxiety. Depressed, low-energy, overweight clients and anxious, skinny, eye-bulging ones should get their thyroid checked. If there is any reason to think there may be a medical issue going on, send them to a doctor.
Always about ask medications a patient is taking, and ask again if they present with new symptoms with no clear cause. Specifically include OTC meds, herbal meds and supplements, and recreational drugs. Also ask if they’ve recently given something up.
Similarly, ask if they’ve been recently diagnosed with a medical condition. Many medical drugs and some medical conditions can have psychiatric side effects.
Clients presenting with a completely new condition in middle age with no clear cause (ie, not PTSD from a recent trauma) should be strongly considered for a medical cause. Mental illnesses (again, other than PTSD) tend to have a history, and middle-aged people are more likely to be physically sick than young people.
"Undiagnosed" is a perfectly legitimate label to use when you don't know what's going on, or don't have enough info to go on. Don't be embarrassed to use it.
The rest of the book is about diagnosing specific illnesses, such as “How to diagnose OCD.” It’s quite helpful (especially the diagnosis trees) but I thought the general principles above were more interesting for a general audience.
Diagnosis Made Easier, Second Edition: Principles and Techniques for Mental Health Clinicians
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Hah, yeeeeah. I've always known the ASD (and my sib's ADHD) comes from the paternal line because it's rife with it. I think we have exactly two adults alive in that family at this point who either don't have a diagnosis formally, or can't be immediately diagnosed by a trained monkey but for whatever reason it's not worth pursuing formally for one, the other, or both. Bipolar/cyclothymia may also be lurking in there, but we're not 100% sure those weren't misdiagnoses of ADHD+life crap (and desire on the part of both parties to have a more exotic diagnosis).
More recently, however, I've learned that "tendency to alcoholism" in my maternal line could be more accurately described as "huge, huge stripe of severe depression and anxiety which the men in the line tended to try to self-medicate by alcohol before giving up and suiciding and which curdled many of the women up into hateful knots."
Suddenly my own mental health makes perfect sense!
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Ye-eees. I mean there might be a genetic predisposition to that PARTICULAR addiction, at least when culture enabled drinking (thus the tendency to men)? Sure, maybe.
But the part where two of my grandmother’s brothers actively killed himself, as did one of her nephews, and the nephew never drank, and my mother was hospitalized for depression, and I swear one of my aunts has undiagnosed depression and my uncle definitely did, and then there’s me, and and and . . . it puts both the functional alcoholism of a couple other relatives and the other great-uncle “drinking himself to death” into a different kind of complexion, you know?
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Ha.
This is really interesting and cool. Even though I'm not going to be diagnosing anyone with anything anytime soon. I really like the practical approach to triage, and the thoughts on telling similar things apart.
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Thank you for doing these book reports--I don't always have anything useful to say, but I really appreciate reading them.
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It's so much easier, so much safer, so much cheaper, to just not try to get the addict brain unpickled out when the chemistry set we've got now isn't really up to the task yet.
Yeah, seriously. Did you read Gabor Mate's book, In the Realm of Hungry Ghosts? He's a Canadian doctor who write a lot about addiction and harm reuduction and he's great.
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Dr Drew is a narcissistic sociopathic motherfucker. Also, a sadist, a real one. He doesn't deserve to have a doctorship. I hate his guts.
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AHAHAHAHA ahem.
Dr Drew is a narcissistic sociopathic motherfucker. Also, a sadist, a real one.
I remember watching him on MTV's Loveline //carbon dates self and thinking Man, this guy is weird. THEN there was the shit with Celebrity Rehab, which I thought really went beyond the pale.
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Yeah, I was a binge drinker most of the time I was in therapy, and kept that from a lot of therapists -- not totally consciously, but I really didn't bring it up. Then when I saw one of them again after a long time I told them I was an alcoholic and had gone to meetings etc., etc., and felt a lot better and they were totally shocked. Poor thing. (If you think someone has a substance abuse problem and they _do_ admit to it, it's almost always accurate to multiply what they say they take by two or three.)
Another therapist of mine, after I sobered up, was shocked when I told him flat out I'd personally make it a requirement of an addict being in therapy that they were in some kind of program, complete with the signed slips. "But wouldn't it be better to first establish some -- " "No." Addicts tend to be much more hardass about that in my experience than mental health professionals, heh. But really, for an active addict, the addiction will always come first before absolutely anything else.
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I can definitely understand requiring that someone be *concurrently* in an addiction treatment programme in order to access therapy (as you recommend). But what usually happens is that people are required to be clean for a long period of time before they're allowed to access therapy at all. This model, to put it bluntly, sucks, and is one of the many reasons there are so many mentally ill addicts hanging around my church.
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Yeah, I personally think that's dumb. Someone with dual diagnosis (mental health/substance abuse issues) needs both counseling and specialist treatment. On the flip side I've known people who were in therapy for long periods of time who kept abusing drugs, and it really got in the way of their dealing with any other issues. Dual diagnosis also sucks.
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I totally believe that this happens lots, but I can honestly say I have never seen it in my context. It's probably partly about class -- if you're homeless or very poor, all the system can see is ADDICT, and you have no chance of accessing therapy privately. Double all this if you're a person of colour.
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It seems like maybe you didn't realize that some of the people in this conversation ARE very poor? That their experiences come, not from the side of being the helper, but from the side of the helpee?
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For the record, yes, I certainly do understand that many are participating in the conversation as helpees. Most of us are both at one time or another. Myself also in the area of mental health, although not addiction. And yes, I realize that undoubtedly some people in the conversation are very poor, and that different poor people have different experiences as well.
I think we all agree that everyone should be able to access both mental health and addiction treatment resources as needed. My own experience has been one of people with addictions being refused mental health treatment, frequently and persistently. I believe that Kore's experiences are also real and true, absolutely. I continue to try to understand the factors involved in people not getting the help they need, in whatever area, in the hope that maybe things can get better. I am sorry for handling that conversation badly.
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I personally wish that there were good, solid programs to help people develop coping skills, interpersonal skills, hell, just plain 'how to balance a checking account' skills, in high school or junior high. BEFORE addiction usually sets its claws in.
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But guess what? Depression meds don't make a trans person not trans anymore! Getting appropriate help with transition, however, did make me not depressed anymore, with no depression meds required.
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("Unless you're the specialist" also made me lol, because yes, and also because my trauma/crisis therapy prof this semester specializes in DD, especially in starting programs for high-risk-of-incarceration-or-reincarceration DD populations). He seems to be super freaking awesome, in that very, very down to earth way that the best kind of therapist professor is.
I expect with my internship at a youth partial hosp program I'm going to run into all the Kid Diagnosing Puzzle Problems, including a lot of "we don't know what the fuck this is, so we're calling it ODD." So if you or your readership have recs for awesome books on diagnosis with kids and adolescents, I would read the fuck out of them.
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My agency doesn't accept people who are actively abusing substances or who have been sober for less than four months, so for me that's an auto-refer out.
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It's one of the books I wish my parents had had when I was a kid, basically.
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From my own experience, I'd add "Don't automatically discount environmental influences as 'not sufficient to cause problems', especially if the patient brings them up". I've hallucinated from standard doses of pseudoephedrine, had systemic effects (drowsiness, etc.) from topical Benadryl, am psychotic and suicidal on standard therapeutic doses of Zoloft, have drastic mood reactions to antibiotics, need to consume caffeinated beverages one ounce at a time to prevent panic attacks, etc. (This is another thing that sometimes runs in families.) And an event that seems too minor to really affect someone can still be traumatic if it presses just the right button.
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btw, Why isn't there an "adverse reaction" section on in-take forms? To be on the safe side, I list the psued. and a couple other things I've had wonky reactions to under "allergies."
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Being allergic to Benadryl sounds like a total nightmare. My sympathies to that person. :/
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Morrison worked in some settings where clients were sometimes faking/denying/exaggerating their problems for various reasons, so he gets much more into that. Red flags include outside evidence contradicted by client (like the DUIs), claiming symptoms that pretty much nobody ever has (our standard trauma inventory has "red flag questions" that very few people in any situation endorse, such as "Sometimes the left side of my body becomes paralyzed for several hours" and "I have a hard time controlling the urge to set fire to public buildings,") claiming symptoms that are extremely unusual for their stated disorder, inconsistent stories, etc. These point to lying, denial, or simply a wrong diagnosis - like, the inconsistent story person might actually have dementia.
With the TSI, if someone seems otherwise normal but endorses the paralysis question, you send them to a doctor immediately. If they seem otherwise normal but endorse the fire question, you evaluate for psychosis, pyromania, or just extreme anger. If they endorse BOTH, they are probably scamming you. (This is simplified. There are about ten questions like that on the test.) Endorsing a lot of weird, unrelated stuff that almost no on ever endorses at all suggests scamming, psychosis, dementia, or randomly answering without reading the questions. It's a red flag for "Investigate this."
Inappropriate Ion Is Appropriate
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That's a classic problem with heart and respiratory issues. As a vast simplification, what will improve heart function will often decrease lung function, and vice versa. For a long time, it can be a maintainable balancing act, but at the end stage, there's no way to optimize both, and the patient goes into heart failure and/or respiratory arrest.