Tag Archives: Mental Health

Diagnosing Your Disorder. (It’s likely you’ve been misdiagnosed)

It is difficult to get a proper mental health diagnosis even with a knowledgeable and caring clinician

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One reason why it is crucial for us to understand the causes and symptoms of our disorder is the likelihood of misdiagnoses. It is time to recognize: we know more about the impact of our condition than our doctors. Psychiatrists may have extensive knowledge of medication, and psychologists, treatment programs, but that expertise is useless if the client is misdiagnosed and mismanaged. Mental health misdiagnosis is a cautionary phenomenon. Even mainstream medical authorities have begun to “criticize the poor reliability, validity, utility and humanity of conventional psychiatric diagnosis.” [i] A recent Canadian study reported, of 289 participants in 67 clinics meeting DSM-IV criteria for social anxiety disorder, 76.4% were improperly diagnosed.[ii] The Anxiety Institute in Phoenix reports an estimated 8.2% of clients had generalized anxiety, but just 0.5% were correctly diagnosed.[iii] Experts cite the mental health community’s difficulty distinguishing different disorders or identifying specific etiological risk factors due to the DSM’s failing reliability statistics. This failure in psychological diagnosis is like being hospitalized for strep throat and losing a leg. 

The DSM changes drastically from one edition to the next, even though the APA swears by its credibility. One study[iv] cites therapist Zimmerman’s[v] concern that criteria are “added, removed, and rewritten, without evidence that the new approach is better than the prior one.” [vi] A recent study points out that DSM-IV listed nine possible symptoms or traits for narcissistic personality disorder; DSM-V contains only two.[vii]  

The massive number of revisions, substitutions, and changes from one DSM to the next is never universally accepted. Psychiatrists, psychologists, and researchers who specialize or survive by funding are justifiably protective of their territory. Even under the best circumstance with a knowledgeable and caring clinician, it is difficult to get a proper diagnosis. Currently there are eight or nine types of depression, four or five different anxiety disorders, five types of stress response (three of them are PTSD), nine forms of obsessive-compulsive disorders, and ten personality disorders.

Bipolar personality disorder, a psychosis, shares characteristics and symptoms with avoidant, social anxiety, obsessive-compulsive, and post-traumatic stress disorders (neuroses). Psychologists cite the “substantial discrepancies and variation in definition, epidemiology, assessment, and treatment” of social anxiety.[viii] A researcher for this BLOG paper received three different depression diagnoses (including bipolar) and ADHD. Social anxiety was never considered, although he met nine of ten criteria for the disorder.

Adding to misdiagnosis is the prevalence of disorder comorbidity, which is especially concerning if the first diagnosis is inaccurate. The Anxiety and Depression Association of America [ix] reports many disorders are related to social anxiety, including major depression, panic disorder, alcohol abuse, PTSD,[x] avoidant personality disorder, generalized anxiety disorder, substance abuse, eating disorders,[xi] schizophrenia,[xii] ADHD, and agoraphobia.[xiii] Anxiety and depression are commonly comorbid. “Some estimates show that 60% of those with anxiety will also have symptoms of depression, and the numbers are similar for those with depression also experiencing anxiety.” [xiv] Three types or clusters categorize 10 personality disorders: 3 focus on the bizarre and eccentric, 4 on the dramatic; and 3 on the anxious and fearful; each cluster shares traits and symptoms. The diagnostic criteria for one disorder are common to others. For example, dependent personality has characteristics and symptoms mirroring social anxiety, avoidant personality, and histrionic personality disorders.[xv] One misdiagnosis is bad enough, not to mention two, resulting in “in worse treatment outcomes.” [xvi]

Thomas Insel,[xvii] director of the National Institute of Mental Health, has been “re-orienting [the organization’s] research away from DSM categories,” declaring that traditional psychiatric diagnoses have outlived their usefulness,  A program of recovery cannot be entertained if the problem is misdiagnosed. A recent article in Scientific American[xviii] suggests replacing traditional diagnoses with easily understandable descriptions of the issues. 

A simple list of people’s problems (properly defined) would have greater scientific validity and would be more than sufficient as a basis for individual care planning and the design and planning of services. However, this BLOG balks at throwing out the baby with the bathwater, positing that the DSM could be utilized as a part of a more thorough analysis focusing on the character strengths that generate motivation and persistence/perseverance towards recovery-remission. 

Etiology and diagnosis drive the disease model. Which disorder do people find most repulsive, and which poses the most threat? What behaviors contribute to the disorder? How progressive is it? How effective are treatments? It is important to recognize how these attributions affect public perception, treatment options, and self-belief and image. Imagine being treated for the wrong condition. Not only does it defeat the purpose of the treatment, but it is also potentially dangerous. Firsthand, we know the impact of our disorder on our emotional wellbeing and quality of life far better than the clinician, whose relationship is one of power over communication. Self-diagnosis is a slippery slope, but a client armed with the knowledge of the traits and characteristics of their disorder, and its impact would have a far better possibility of appropriate diagnosis and treatment. Equally important is recognizing the extent of our strengths and abilities to counter and defeat the symptoms of our disorder. The disease model of mental health tells us the problem; the wellness model emphasizes the solution.


[i] Kinderman, P. (2014). Why We Need to Abandon the Disease-Model of Mental Health Care. [Online.] Scientific American. https://blogs.scientificamerican.com/mind-guest-blog/why-we-need-to-abandon-the-disease-model-of-mental-health-care/  .

[ii] Chapdelaine A., Carrier J-D., Fournier L., Duhoux A. Roberge P. (2018) Treatment adequacy for social anxiety disorder in primary care patients. PLoS ONE 13(11) (2018). doi.org/ 10.1371/journal.pone.0206357.

[iii] Richards, T.A. (2014). Overcoming Social Anxiety Disorder: Step by Step. [Online.] Phoenix, AZ: The Social Anxiety Institute Press.

[iv] Lynam, D. R. & Vachon, D. D. (2012). Antisocial Personality Disorder in DSM-5: Missteps and Missed Opportunities. Personality Disorders: Theory, Research, and Treatment, 3(4) 483– 495 (2012). doi:10.1037/per0000006

[v] Zimmerman, M. (2011). Is there adequate empirical justification for radically revising the personality disorders section for DSM-5? Personality Disorders: Theory, Research, and Treatment. Advance online publication. doi:10.1037/a0022108

[vi] Stein, D. J., Fineberg, N. A., Bienvenu, O. J., Denys, D., Lochner, C., Nestadt, G., Leckman, J. F., Rauch, S. L., & Phillips, K. A. (2010). Should OCD be classified as an anxiety disorder in DSM-V? Depression and Anxiety, 6:495-506 (2010). doi:10.1002/da.20699.

[vii] Lynam, D. R. & Vachon, D. D. (2012). Antisocial Personality Disorder in DSM-5: Missteps and Missed Opportunities. Personality Disorders: Theory, Research, and Treatment, 3(4) 483– 495 (2012). doi:10.1037/per0000006

[viii] Nagata, T., Suzuki, F., Teo, A.R. (2015).Generalized Social Anxiety Disorder: A still‐neglected anxiety disorder 3 decades since Liebowitz’s review. Psychiatry and Clinical Neurosciences, 69(12): 724-740 (2015).  doi.org/10.1111/pcn.12327

[ix] ADAA (Anxiety and Depression Association of America). (2019). [Online.] Facts and Statistics. https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/understanding-anxiety-and-depression-lgbtq.

[x] Koyuncu, A., İnce, E. , Ertekin, E., & Tükel R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in Context 2019, 8. doi:10.7573/dic.212573; Lyliard, R. B. (2001). Social anxiety disorder: comorbidity and its implications. Journal of Clinical Psychiatry, 62(Suppl1): 17-24 (2001).

[xi] Cuncic, A. (2018). How Social Anxiety Affects Dating and Intimate Relationships. [Online.] verywellmind. https://www.verywellmind.com/adaa-survey-results-romantic-relationships-3024769; Koyuncu, A., İnce, E. , Ertekin, E., & Tükel R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in Context 2019, 8. doi:10.7573/dic.212573

[xii] Cuncic, A. (2018). How Social Anxiety Affects Dating and Intimate Relationships. [Online,] verywellmind. https://www.verywellmind.com/adaa survey-results-romantic-relationships-3024769; Vrbova, K., Prasko, J., Ociskova, M., & Holubova, M. (2017). Comorbidity of schizophrenia and social phobia – impact on quality of life, hope, and personality traits: a cross sectional study. Neuropsychiatric Disease and Treatment, 13: 2073-2083. doi: 10.2147/NDT.S141749

[xiii] Koyuncu, A., İnce, E. , Ertekin, E., & Tükel R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in Context 2019, 8. doi:10.7573/dic.212573

[xiv] Salcedo, B. (2018). The Comorbidity of Anxiety and Depression. (Online). National Alliance on Mental Illness.  https://www.nami.org/Blogs/NAMI-Blog/January-2018/The-Comorbidity-of-Anxiety-and-Depression 

[xv] DPD. (2007). Dependent personality disorder.  [Online.] Harvard Health Online.

[xvi] Koyuncu, A., İnce, E. , Ertekin, E., & Tükel R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in Context 2019, 8. doi:10.7573/dic.212573

[xvii]  Insel, T. (2013). Post by Former NIMH Director Thomas Insel: Transforming Diagnosis. [Online.] Washington, DC: National Institute of Mental Health. https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

[xviii] Kinderman, P. (2014). Why We Need to Abandon the Disease-Model of Mental Health Care. [Online] Scientific American. https://blogs.scientificamerican.com/mind-guest-blog/why-we-need-to-abandon-the-disease-model-of-mental-health-care/ 

Our Role in Recovery

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The fact that we are not accountable for the childhood/adolescent exploitation that led to our psychophysiological malfunction does not absolve us of the adult responsibility to do something about it.

Many of us avoid learning about the causes and symptoms of our disorder as if ignoring it will make it go away. When we see evidence that the traits and characterizations of the disorder match our own, it somehow makes it more concrete, more real. It makes us accountable. Although all the relevant data is readily available from credible sources, including the National Institute of Mental Health, Johns Hopkins, the Mayo Clinic, remaining uninformed perceptually abrogates responsibility.

When something is broken, it is deconstructed to analyze the problem. We isolate the components and acquaint ourselves with their objectives. Equal effort is required for the brokenness in us. We must study the traits and symptoms of our disorder, and recognize how they affect our thoughts and behaviors. For us to have any chance at recovery, we need to know what we are recovering from. Replacing or repairing defects is fruitless without knowing what those defects are and how they function. Before a football team faces their opponent, they watch hours of film, review stats, and practice. If an actor wishes to give a good performance, it is prudent to learn the character’s lines before getting on stage. Our disorder is our enemy; it is unhealthy, and it hurts us. Our deliberate ignorance is denial, and that is a deal-breaker. Our disorder will continue to impact our emotional wellbeing and quality of life until we recognize, accept, and confront it.

Recovery-remission is a psychological construct. The revelation we are not responsible for the disorder sets the foundation for recovery. Understanding that we alone are the agents of change begins the construct. Counselors and programs provide the blueprint, but we erect the edifice. The disease model tells us what is wrong with us. We do not need to hear that. Our disorder is not something that can be excised like a tumor, so what is the point of telling us what is wrong with us? The wellness model’s focus and by extension, positive psychology and other optimistic approaches, is on our virtues and strengths.

One group of psychologists describes recovery as “people (re-) engaging in their life on the basis of their own goals and strengths, and finding meaning and purpose through constructing and reclaiming a valued identity and valued social roles.” [i] Enduring recovery grounds itself on our knowledge of our disorder and the implementation of our character strengths and virtues to recover from it.


[i] Schrank, B., Brownell, T., Tylee, A., & Slade, M. (2014). Psychology: An Approach to Supporting Recovery in Mental Illness. East Asian Arch Psychiatry, 24, 95-103 (2014).

The Wellness Model versus the Disease Model of Recovery

The Disease Model tells us the problem; the Wellness Model emphasizes the solution.

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Establishing new parameters of wellness in mental health calls for nothing less than a reformation of thought and concept. In 2004, the World Health Organization (WHO, 2004) began promoting the advantages of a wellness over disease perspective, declaring health, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (Slade, 2010, p. 1). The World Psychiatric Association has aligned with the wellness model, submitting that “the promotion of well-being is among the goals of the mental health system” (Schrank et al., 2014, p. 98). Wellbeing has become a central focus of international policy (Slade, 2010). Concurrently, some psychological approaches have become bellwethers for research and study of the positive character strengths that facilitate the motivation and persistence/perseverance helpful to persons with mental illness who aspire towards recovery-remission. Wellbeing must become the central focus of mental health for the simple reason that the disease model has provided grossly insufficient results. As clinical psychologist Kinderman (2014) writes in Scientific American “We need wholesale and radical change, not only in how we understand mental health problems, but also in how we design and commission mental health services” (p. 1). This radical change, however, should not be a dissolution of approaches but an intense review of their efficacy, and repudiation of the one-size-fits-all stance within the mental health community. Certain fundamentals like language, perspective, and diagnosis demand drastic adjustment.

The hurdles are formidable, beginning with a consensus definition of mental illness and its origins. The Diagnostic and Statistical Manual of Mental Disorders (DSM) abandoned the word neurosis in 1980 but it remains the go-to term in the mental health community. One only needs the American Psychological Association (APA, 2020) definition of neurosis to comprehend the pathographic focus of the disease model. Neurosis is,

any one of a variety of mental disorders characterized by significant anxiety or other distressing emotional symptoms, such as persistent and irrational fears, obsessive thoughts, compulsive acts, dissociative states, and somatic and depressive reactions. The symptoms do not involve gross personality disorganization, total lack of insight, or loss of contact with reality (compare psychosis). In psychoanalysis, neuroses are generally viewed as exaggerated, unconscious methods of coping with internal conflicts and the anxiety they produce. Most of the disorders that used to be called neuroses are now classified as anxiety disorders.

Health experts define mental illness as a “diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria” that can “result in functional impairment which substantially interferes with or limits one or more major life activities” (Salzer et al., 2018, p. 3; SAMSHA, 2017). Any disorder that results in 30 or more days of role impairment at work, home, or in social relationships seriously impacts one’s emotional wellbeing and quality of life. Congress defines serious mental illness as a “functional impairment that substantially interferes with or limits one or more major life activities.” The two mental illnesses called psychosis are borderline personality disorder and forms of schizophrenia. Everything else is a neurosis or disorder. 

The pathographic or disease model of mental healthcare has been the modus operandi of society for centuries. Granted, there have been interruptions in the disease perspective philosophically and culturally. However, it has been the overriding psychological perspective for over a century, remerging with Freud and continuing through medical models with insular focuses on biological and neurological origins of mental illness. The chief propagator of the wellness model has been positive psychology which originated with Maslow’s (1943) seminal text on humanism and was legitimatized by Seligman as APA president in 1998. The study and research of the character strengths that generate the motivation and persistence/perseverance of a mentally ill individual in recovery-remission is of enormous benefit to psychology and individual mental health.

References

APA. (2020). Neurosis. Dictionary of Psychology. American Psychological Association. Washington, DC: American Psychological Association.  https://dictionary.apa.org/neurosis  Accessed 05 April 2020.

Kinderman, P. (2014). Why We Need to Abandon the Disease-Model of Mental Health Care. [Online Article.] Scientific American. https://blogs.scientificamerican.com/mind-guest-blog/why-we-need-to-abandon-the-disease-model-of-mental-health-care/ 

Maslow, A. (1943). A Theory of Human Motivation. Psychological Review, 50 (4), 370–396 (1943).

Salzer, M. S., Brusilovskiy, E., & Townley, G. (2018). National Estimates of Recovery-Remission from Serious Mental Illness. Psychiatric Services, 69(5) 523-528 (2018). https://doi.org/10.1176/appi.ps.201700401

SAMSHA. (2017).  2017 National Survey on Drug Use and Health (NSDUH) by the Substance Abuse and Mental Health Services Administration.  (Rockville, MD: SAMHSA. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#:~:text=Serious%20 mental%20illness%20(SMI)%20is,or%20more%20major%20life%20activities.

Schrank, B., Brownell, T., Tylee, A., & Slade, M. (2014). Psychology: An Approach to Supporting Recovery in Mental Illness. East Asian Arch Psychiatry, 24, 95-103 (2014).

Slade, M. (2010). Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC Health Service Research 10 (26), 1-17 (2010). https://doi.org/10.1186/1472-6963-10-26 10(26)

Personality

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We talk a lot about personality in this Blog as it directly impacts and is impacted by our dysfunction and recovery methods. Freud argued that our personality is formed through conflicts among the id, ego, and superego. Since then, there have been as many definitions of personality as there are psychoanalytic theories. For purposes of this Blog, let us simplify what we mean by personality.

Our personality is generated by everything and anything experienced by us in our lifetime. Our reaction to every teaching, opinion, belief, and influence develops our personality. It is our current being and our expression of that being. It reflects our self-qualities, character strengths, and weaknesses. It is formed by our core-beliefs and developed by our social, cultural, and environmental experiences. It is constant yet fluid, singular yet multiple. It is our inimitable way of thinking, feeling, and behaving. It is who we are, who we think we are, and who we are trying to become. We are our personalities.