The Correct Diagnosis Isn't Made Online
The internet is now the first place most of us go to answer a question about almost anything. It’s almost a necessity, and websites like Reddit, and Quora, have become ubiquitous. There are too many health and wellness sites to name, and many that allow you to ask a “real doctor” a question about what ails you. They’re great if your a curious person, who wants to explore and get ideas, but they aren’t reliable sources to give a definitive answer about your health.
When it comes to mental health, therapists and psychiatrists often make mistakes. Is it because there lots of terrible ones? Sure, just as there are lots of terrible dentists, doctors, lawyers, etc... But that’s not the biggest reason. It’s because we are, generally speaking, terrible reporters of symptoms, and professionals don’t always question our words. We don’t understand the nuances of symptoms, and we tend to go mining for evidence to support our belief that we have X condition. Treating a condition you don’t actually have is potentially harmful, creating new problems, and prevents healing. Too many people are given antidepressants and mood stabilizers, to treat symptoms that are not truly due to anxiety, depression, or the overdiagnosed, bipolar disorder. It’s ironic that ADHD is considered to be the most overdiagnosed disorder, but in my experience, it’s the one that most often gets missed or mistaken for something else. Here are some recent, real life examples of what I’m talking about.
Homer has a clear diagnosis of OCD. He was in therapy with me twice a week. He wants to go back on medication he took when he was a teenager, and sees a psychiatrist. The psychiatrist provides the prescription, and then retires before his second appointment. Homer has a 3 month prescription for medication, and while in therapy with me, enters a 4 week program for OCD. There he meets a new psychiatrist, who provides the next 3 months of prescriptions for OCD symptoms. Homer has intrusive thoughts, and those thoughts make him angry, and sometimes, he doesn’t recognize this as part of OCD. We’d been talking about the thoughts and anger for months, but lately, he’d been relatively symptom free, or rather, he wasn’t reporting symptoms, and was focused on his marriage. He left the program, and he needs a refill of his medication, so he makes an appointment to see a new psychiatrist. When the psychiatrist asked him what he needs help with, he said he has trouble with inappropriate anger. Homer said he needs help with anger management. The psychiatrist didn’t ask probing questions, or for a description of the angry episodes. The psychiatrist didn’t even know that Homer has OCD. Homer didn’t mention it, he was too focused on this “anger” symptom. The psychiatrist told Homer, he has bipolar disorder, and wrote a prescription for an entirely different medication than Homer has been taking. Why didn’t I recognize that Homer has bipolar? Because he doesn’t. He’s a crappy reporter of symptoms, and in this case, the psychiatrist was an idiot, too.
Lisa is a graduate student. She has signs and symptoms of depression, and is often tearful when we meet. She has a prescription for an SSRI, but hasn’t found it helpful, and has stopped taking it consistently. Some of the sadness she is feeling is due to a failed relationship, and difficulties with her family. Over time, the primary symptoms she reports are feeling overwhelmed, anxious, and panicked about school. The average psychiatrist would diagnose her with generalized anxiety disorder, and write a prescription for another SSRI, and a benzodiazepine like Xanax, and send her on her way. By asking her the right questions, and taking a comprehensive history, Lisa was able to describe her symptoms more accurately, patterns emerged, and a correct diagnosis of ADHD was made. She wanted to try medication to see if it would help her, and went to see a doctor who advertises himself as a “specialist” in diagnosing ADHD. He told she has bipolar disorder. She has zero symptoms to support that diagnosis, yet there it was again, because she told the doctor she doesn’t sleep a lot. He didn’t listen to her protests, or allow her to explain the reason she is missing sleep. She left the appointment feeling angry and misunderstood. Ultimately, her family physician worked with me and her. He provided a trial of medication, which has made a significant and positive difference in her daily functioning. Symptoms of anxiety, panic, and overwhelm have resolved. The symptoms of depression have also lifted, and she’s addressing the environmental issues in her life that she wants to work on.
Bart has been feeling down, and recently got angry with a friend. He looked online and did a screener which told him he has depression, he did another screener, which told him he has bipolar disorder. As we talked for the first time, a pattern emerged. Each time he’s gotten angry, he was drinking alcohol, in the company of the same friend. Each time, his anger was in response to something that would anger most people. If he lost sleep, focused on a project for work, he was exhausted the following day. He is not irritable, he doesn’t have feelings of euphoria, or a lot of energy, or anything else to hint at hypomania or mania. He has a jerky friend, and if he’s drunk, his impulse control is weakened, and he reacts more strongly than he would otherwise to his friend’s inconsiderate behavior. That’s not bipolar disorder. He may have depression, but to make that diagnosis, I’d devote at least one entire meeting to that alone.
Marge tells me she has anxiety, and has a binge eating disorder. Her weight appears healthy, and she has a reasonable and established exercise routine. When she describes the anxiety, it’s not the combination of unbearable physical sensations and fearful, racing thoughts that are typical. She describes a positive energy, that makes her want to move around. If she can’t get up from her desk, she sings to herself or engages her coworkers in conversation. She feels like she never has enough time for everything, and it’s hard to gather her thoughts to speak articulately. Marge had difficulties in school, but she is smart, and was able to earn a graduate degree, and is successful at work. She takes medication for depression, which was diagnosed correctly, several years ago. She doesn’t report symptoms now, and feels good on the medication. Does Marge have anxiety, as she believes? She doesn’t. An accurate diagnosis of ADHD was confirmed, and she notices a very positive difference since taking medication. The inner restlessness is replaced by a feeling of calm, she can gather her thoughts easily, and is able to maintain her focus, and control her impulse to eat from boredom.
A good therapist or doctor takes the time to get a clear picture of reported symptoms, and looks for signs that are hallmarks of certain disorders. I can’t stress enough, the importance of working with an experienced professional, who will listen to you, answer your questions and concerns, provide you with accurate information, and informed consent before recommending any treatment.