Wow. Those last two posts really resonate with me. First of all, we do pathologize the rat and the monkey. Sometimes in very pejorative ways that can be more harmful than helpful. But we are quick to justify ourselves. I am very cautious about giving certain diagnoses and will do a thorough psychological assessment using clinical interview, collateral information, and assessment tools, particularly for things like bpd because it is so stigmatizing. I know therapists who give this diagnosis to people because they are difficult. A lot of therapists I know are poorly trained in making this diagnosis. They hear someone say they think think their husband is having an affair and is going to leave them, and they check the box “fear of abandonment”. I just had a big discussion about that in a collaborative group I am in. I asked if the client was making frantic attempts to avoid abandonment. I mean, I only check that box if people are so fearful of being left, abandoned, rejected, that they cry hysterically, have meltdowns, hurt themselves, threaten suicide etc etc in order to try to manipulate the person or prevent them from leaving. I’m sure that my take on that criteria is more on the extreme end. But like I said, I’m very cautious.
I see people interpret the Phq-9 without considering the clients presentation and gathering more information. Someone might give all 3’s for answers, but when you talk with them about it, you find out that their 3 isn’t really a clinical 3. It’s kind of like the pain scale. Some people rate their pain as 10 out of 10 and are sitting comfortably eating a sandwich, contemplating going to Walmart after the session. That’s not a 10 out of 10. But also, I have had people fill out the phq-9 before a session completely within the normal range. They look like hell and when I start talking with them, I realize that they are in significant distress due to depressive symptoms. Also, the phq-9 measures some things that can be related to depression but also can fit other things. For example, attention and concentration difficulties can be caused by a lot of things, not just depression. And finally on my monologue about diagnosing depression, almost no one that is my peer also evaluated for symptoms of hypomania or evidence of a previous manic episode. If they do, they ask yes no questions, but don’t ask for examples. So sometimes I get patients with bipolar diagnoses and when I interview the patient and ask detailed questions about their hypomanic episodes they tell me things like “I went into Walmart and was in the checkout line. I was so excited that so happy that I started jumping up and down. Then I got to my car and I felt depressed.” Actually. Ummm. No. Tell me about a hypomanic episode. I very unapologetically wrote that report and did a review of all symptoms and in my summary detailed why they do not qualify for a bipolar diagnosis. Might be bad style to do that, but I sent that report to the diagnosing and prescribing physician and I hope that patient isn’t still taking lithium, Risperdal, and Lamotragine. But I bet they are.
Also, the PCL-5 is like a screener for ptsd. There are much more appropriate and accepted instruments to evaluate for the presence of ptsd. But I see patients regularly who come for an assessment with diagnoses of ptsd and cptsd and when I start inquiring about their trauma it’s something like “I had to move and change schools in the ninth grade” or “my fiancé left me at the alter” and I’m sitting their like I’m sure that was very difficult for you, but I’m looking for a criterion A trauma. When I read therapist notes or assessments that give out ptsd diagnoses like stubbing your toe is a trauma, I want to get back to them and tell them to do some continuing education.
Last week, I had a client present for clinical interview for an autism evaluation. They have a diagnosis of ADHD. I had her upload all psychological assessments to my platform. She had 2 adhd evaluations done in a 6 month time period. On her first assessment, she was not diagnosed with ADHD because her cat-a childhood symptoms index was normal, she reported not having symptoms until college, and her mother reported no childhood symptoms of adhd. So she just made a new assessment appointment with someone else, did not use collateral, and reported childhood symptoms in the very significant clinical range. So she got her adhd diagnosis. I just wondered if the second clinician had asked to look at her previous assessment, hadn’t been told about it? It was a referral from her psychiatrist and I just couldn’t help myself. When I wrote the report, I reviewed previous assessments in detail like I always do, but this time, I made comparisons between her two assessments, pointed out the discrepancy between self and collateral reports between the sessions, intimating that basically she was diagnosis shopping and that the diagnosis should be scrutinized.
I sound like I think I know everything right now, but I know I don’t. I make mistakes and that I have to learn too. I’ve just these few frustrating evaluations and reports Ibhad to write and I’ve been on bedrest for 3 days, so I’m here talking to myself. If someone actually read this, thanks for listening to the very self indulgent ramblings of a very bored person!
pubmed.ncbi.nlm.nih.gov
