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DSM Labels: Are They Helpful?

Posted May 05 2009 5:01pm

Dr. Rob,

Over the past few years I had noticed my mood taking a subtle nose dive and I decided to see a therapist. After asking me millions of questions about myself, my parents, my wife and kids and everything else she could think of, she told me that I had Dysthymic Disorder. I had never heard the term before and it kind of scared me. I knew that I might have some mild depression but didn't think I qualified for anything in the DSM. When the therapist explained to me that Dysthymic Disorder is basically a low-grade depression that lasts a long time I was slightly relieved but still felt a little uncomfortable because I now had this 'label' attached to me. My question to you is do you agree with psychological diagnoses and why?

J.C.

A lot of people have very serious concerns about DSM labels, especially since psychology/psychiatry are soft sciences. We can't put a dipstick into someone's head and measure how anxious or sad he is, so how do we definitively label someone with an illness we can't even really see? And I've bashed the DSM-IV before so I can't turn around now and be its best friend. It's a flawed tool used by shrinks, no doubt about that. However, part of the problem with the criticisms is the undue significance people place on mental health diagnoses.

In the simplest terms, a 'diagnosis' is a social construct. It's a collection of 'symptoms' that shrinks pull together to create a system for communication. Life becomes remarkably easier when you can say 'this person suffers from schizophrenia' and have another professional know to some degree what you are talking about. In many ways, diagnoses are simply shorthand. Today diagnoses are also required for insurance companies but that wasn't the original plan when they were developed.

The problem is that rarely, if ever, does one person's schizophrenia diagnosis look like another's. The same is true for Major Depressive Disorder, Generalized Anxiety Disorder, Panic Disorder and any other listing in the DSM-IV. Diagnoses are models but the actual problem hardly ever manifests itself exactly the way the book describes. This makes mental health simultaneously frustrating and fascinating, because it's essentially impossible to accurately quantify and compartmentalize human experience.

In my work I often (although not always) share the diagnostic label I've assigned with the client. The cardinal question I ask myself is "will the person benefit from this information?" More often than not the answer is affirmative because knowledge is power. If a client and I are speaking the same language and he knows what this label and its limitations mean he is more empowered with what the condition is and what can be done about it. We're on the same page now and a treatment team.

There's another, more subtle benefit to diagnoses that I wasn't aware of until a client educated me. When I was in graduate school a young woman came into our clinic who had been mugged about nine months earlier. She couldn't bring herself to go near the street where the offense had occurred, was having flashbacks of the incident, regular nightmares about the attack and an overall heightened sense of vigilance about the world around her. She told me that she knew that after the assault she would be distressed for awhile, but she had no idea that her life would be impacted so drastically and for so long. After about three months she was surprised she wasn't feeling better and was outright shocked that she couldn't even talk about the incident six months later.

When I explained to her that she was suffering from what sounded like Post-Traumatic Stress Disorder (PTSD) she immediately wanted to know everything I could tell her about the disorder. I was 24 and a first-year graduate student at the time and as ignorant as a bag of rocks so I actually had to refer to my textbooks with her sitting there in the therapy room. However, in addition to providing her with a laugh due to my red, professionally naïve face, she learned something else. "If there's a name for this," she said, "that's means that other people have it. I'm not alone." This is a psychological concept known as Universality and - provided that the clinician doesn't invalidate someone's personal experience by lumping her in with everyone else who has come through the door - can be a powerful therapeutic tool.

"Thank you," she said. "This helps a lot."

"Therapy can be very helpful for PTSD. I hope you'll consider it."

"I will. Would you be my therapist?"

"No, as a first year student I only do the diagnostic interviews. But I'll get you a very good therapist."

"That's probably for the best," she said. "You seem kind of clueless without your textbooks."

As a seasoned professional I know now that what she really meant by that was you are far too attractive a man to be my therapist. I wouldn't even be able to focus with that cute red face of yours looking at me all day! Please say you're not married! But let's just take what she said at face value for the purposes of this discussion.

Rereading this I'm not even sure I answered J.C.'s question directly but I think you get where I'm coming from. No diagnostic system is perfect and it will never be to everyone's satisfaction. But if used in the proper way, in the spirit in which it was intended, mental health diagnoses can actually be a useful, therapeutic tool.

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