On Wednesday, we explored the utility of disclosing a diagnosis to psychotherapy patients. More often than not, discussing the diagnosis goes a long way in setting the stage for someone’s treatment. However, it cannot be a “by the way” commentary if we are to put them at ease and foster patients’ curiosity about their mental health, which can accelerate treatment. To be effective, the practitioner must present a digestible understanding to the patient, and what it means for their care. This means that practitioners must be well-versed in diagnoses. While speculative, I wonder if there is a correlation between the practitioners mentioned in previous posts who don’t believe that diagnostic accuracy is hugely important so long as you can recognize symptoms. As we know, that’s not enough, because symptoms are often diagnostically cross-cutting. Many diagnoses can share some symptoms, but that doesn’t mean they’re treated the same. Have a look at this improving diagnostic accuracy post from a couple of months ago for a refresher.
Today, we’ll bring the skill of therapeutically disclosing a diagnosis to life with some examples.
Robin called for an appointment complaining of anxiety; “I’ve been getting panicky and feel out of sorts,” he said. At his appointment, I asked him to describe the anxiety in detail, and when it began. He noted he would get panicky when he felt he was “living in a dream.” “It’s scary, like I’m able to function but I feel like I’m removed from everyone and everything,” Robin finished. Of course, I asked him to expand on this, and Robin detailed that a few months earlier he tried marijuana for the first time and ever since had bouts of this “dream state.” Tearful on my couch, he feared the drug experimentation may have altered the course of his life for the worse. Outside of trauma/stressors and some personality disorders, cannabis is a common culprit in unlocking such dissociative states. Robin denied any further use of marijuana because of what happened. When it was clear Robin was experiencing Depersonalization/Derealization Disorder, my first inclination was to put him at ease.
“Great job explaining that experience to me,” I told him. “I can definitely see why you’ve been anxious about it. Rest assured, though, you’re not the first person I’ve met with to describe it.” This piqued Robin’s attention, as it was so weird to him he figured he was the only living person experiencing such a thing. Panic he understood, the dissociation he didn’t. I continued, “You’re experiencing what’s called Depersonalization-Derealization Disorder. This is a fancy way of saying that things can seem super-surreal or even like an out-of-body experience. It’s not unusual for someone to develop the symptoms after a stressor or sometimes after using marijuana if it doesn’t agree with them. I know it’s scary, but the good news is, I can help you learn to manage it, and chances are, as that gets better, the panic will subside too. It’s often exacerbated by stress, so keeping stress down, and learning to ground yourself to feel more in touch when it happens are key things we’ll explore to get you back on track.”
Borderline Personality Disorder
Stacy called for an appointment because of anxiety and irritation around her inability to maintain successful romantic relationships. After learning about her patterns and the long-standing battle with maintaining relationships, it was clear Stacy met criteria for Borderline Personality Disorder. I summarized, “This has been ongoing since middle school, and has been getting more intense for you. Lately it seems you just have to have someone to be with or you feel really empty, sometimes even physically numb it’s so bad. When relationships do happen, they’re intense, short-lived scenarios ending in blow ups or people telling you they feel smothered by you. Does that all sound accurate?”
Stacy sheepishly looked up and nodded; “What’s wrong with me!? Why does everyone give me a hard time in relationships!?” she demanded. I began, “If it’s any reassurance, Stacy, you’re not alone in this battle. It’s called Borderline Personality Disorder.” Familiar with the movie Fatal Attraction, and the press that Glenn Close received for playing a particularly vicious Borderline, she stared at me. “I’m turning into that psychotic whacko who ruined that guy’s life!?” Stacy fumed. “Not so fast,” I reassured her; “That was more like a Hollywood caricature of the condition to make an entertaining movie. Hollywood usually embellishes mental illness.”
Making the diagnosis relevant to Stacy, I informed her, “Essentially, what Borderline Personality means is that you have a lot of anxiety about relationships and it makes them difficult to manage. If you perceive things as going south, that frustration turns to anger, which can be intense, and pushes people away. It’s almost like making a self-fulfilling prophecy that no one likes you when that’s not true. It’s just tough for them and you, to handle that level of emotion. Things don’t get dealt with constructively.”
Wrapping it up to move forward, I finished, “Thankfully, we know that working on learning to be responsive and not reactive, and changing the lens you look at relationships through, people with Borderline Personality can do pretty well and work towards those more stable relationships they really want and deserve. If that sounds like something you’d like to explore with me, I can help with that.”
Major Depressive Disorder
Alexis complained, “I’ve just been in these funks. They last longer each time.” Tearfully, she continued, “A couple of times a year I crawl under a rock and wait for it to pass. It’s tough with a family.” Alexis was feeling crushed, and had an air of hopelessness about it be manageable. Her history and presentation in the office aligned with recurrent Major Depressive Disorder episodes.
“Thanks for being so thorough about your background and letting me in on how you’re currently feeling,” I began. I continued, “From what you described and what I’m seeing, that ‘funk’ sounds like depression. In particular, what is called Major Depressive Disorder.” Alexis chimed in, “So ‘major’ like ‘big problem’? A black hole I’ll keep getting pulled into?”
“Well, clearly it’s been problematic, but it doesn’t have to remain so. A lot of people experience it, so we know a lot about treating the condition,” I replied. “‘Major Depression’ is psychology speak for ‘way beyond feeling blue,’ and the symptoms really taking away from your quality of life,” I explained.
“The positive thing here,” I continued, “is that by exploring and cultivating your strengths, learning to undercut the thoughts that contribute to the bad mood, and making lifestyle changes like in diet and exercise habits, we more often than not gain control over the depression. Also, if you’re interested, antidepressant medications often accelerate progress, too.”
Finishing, I offered, “Once you’re feeling better, we work on prevention and learning to recognize sings an episode might be coming on, so we can cut it off at the pass.”
Therapist Checklist for Reviewing Diagnoses with Patients
- If it is to be constructive, providing a diagnosis can’t be like dropping a bomb (i.e., “I think your problem is Major Depression. Now, let’s set up our next appointment…)
- Being prepared to answer questions for the patient goes a long way in helping them understand their diagnosis, and feeling more hopeful about improving.
- Become intimately familiar with more common diagnoses, and/or ones you may encounter in specialty settings. Then practice how you might convey the material in a compassionate and informative manner.
- Don’t just provide an understanding of the diagnosis. They’ll want to know what that means for treatment. Be sure information is conveyed about treatment being possible and what it looks like.
Discussing a diagnosis may be anxiety-provoking for therapist and patient alike. Framed like the above, diagnostic disclosure doesn’t have to be complicated. It can be a foundational, rapport-building discussion that may provide not only relief in putting a name to their struggle, but generate hope about managing it.