So What’s the Deal with Diagnosing?

If you have been to a mental health professional before, you’ve likely heard the word “diagnosis”. Maybe you were told your diagnosis was “Major Depressive Disorder” or “Panic disorder” or “Bipolar Disorder”, to name a few. Depending on the type of practitioner, and their attitude towards diagnosing, you may or may not have received an explanation of what that diagnosis actually means. Additionally, you may have encountered paperwork from your therapist for your insurance company and saw a diagnosis code listed on it, since insurance requires you to be given one in order for them to pay for your treatment.

I want to take some time to discuss what diagnosis is and is not, and what to take away from the process. As I mentioned earlier, different practitioners approach diagnosing in different ways. For example, a psychiatrist (a doctor who prescribes mental health medications) likely will tend to tell you up front in your first appointment which diagnosis they have decided appropriately describes your symptoms. Therapists may tell you in your first or second appointment, or you may never hear the words “Your diagnosis is X” from them. Diagnosis can be regarded as controversial, even amongst professionals, for several reasons.

The Cons/Risks

One of the reasons a therapist may avoid applying a diagnosis to your symptoms, or avoid disclosing the diagnosis, is because diagnosis is highly subjective. Despite the Diagnostic & Statistical Manual of Mental Health Disorders Version 5 (DSM-5) existing for the purpose of outlining a vast array of currently recognized disorders and their criteria (aka symptoms), ultimately the therapist or provider makes the choice which diagnosis or diagnoses fit your symptoms best. For example, you may go see your Primary Care Physician and be diagnosed with Generalized Anxiety Disorder, after reporting to him that you have felt stressed over everything, worried constantly, preoccupied, etc. He then refers you to a Psychiatrist, because as a general physician he likely knows basic mental health concerns but wants to help you find a specialist in the subject. You have your initial appointment with this psychiatrist, report the same symptoms, and he tells you “Panic Disorder”. What the heck!

This is why diagnosing can be tricky. Keeping with the above example, Generalized Anxiety Disorder can look very similar to Panic Disorder, especially if the practitioner does not ask assessment questions in a way that obtains an accurate picture of what you are experiencing. Maybe your PCP did not know to ask about panic attacks, or he did not describe symptoms of a panic attack to you and so he missed some information and subsequently applied a diagnosis that may not be fully accurate. You may not have known that those times when you’ve felt intense chest pain, followed by heart palpitations, sweatiness, rapid breathing, and an intense fear of dying/having a heart attack are actually classic symptoms of “panic attacks”; thus, when he simply asked “do you get panic attacks?”, you simply stated “no” and the diagnosis was then overlooked.

Unfortunately, this happens more often than it should. That is why being honest with your practitioner is really important, and also why it is critical that therapists and providers receive adequate training on assessment and diagnosis.

You may wonder what receiving different diagnoses means for you as the client. The first answer that comes to mind is that there may be differences in treatment interventions your clinician may utilize with you. For example, if a client comes to me with symptoms of panic attacks, we will likely first be addressing breathing techniques and grounding strategies to help when the anxiety and fear start to rise. I also may create a '“fear hierarchy” with the client where we address situations a client will gradually expose themselves to over time to build up confidence and skill and reduce anxiety & fear. If the client denies experiencing panic attacks, and reports constant worrying about everything from social interactions to self-esteem, we will likely still address breathing and grounding techniques, but I may not need to introduce a fear hierarchy with this client.

Another example of how treatment may look different based on diagnosis is when there is trauma as an underlying cause in a client’s symptoms. Often times, at least in my experience and professional opinion, past trauma contributes to an individual’s present day symptoms. Someone may present with symptoms of Attention-Deficit/ Hyperactivity Disorder, have been diagnosed with this disorder for many years and received treatment on and off for it. However, if they have unaddressed trauma, they may find treatment has only seemed to provide benefits for several months or so then they begin to feel a relapse in symptoms (lack of focus, feeling disorganized, difficulty following through with tasks, issues with emotional stability, etc.). While “trauma” is not a DSM diagnosis itself, Post-Traumatic Stress Disorder is. Many clinicians, including myself, adopt a wider view of trauma as well, including “little t traumas” (don’t be fooled by the name, this type of trauma often has a profound effect on individuals; can include emotional abuse/neglect, loss of significant relationships) and “big T traumas” (serious injuries, war, tragic loss, sexual assault, life-threatening events). Many clinicians also examine “complex trauma”, which can be thought of as distressing events occurring back to back over several years; an example may be having a parent with mental health issues who struggles to be present, consistent, and supportive and who may seem to “switch” from loving to absent or irritable often. Another example of “complex trauma” may include a romantic relationship in which emotional abuse and neglect occur over the years, leaving one partner constantly feeling overwhelmed, on edge, and uncertain of their relationship status or their emotional safety. “Relational trauma” is also considered a type of trauma that usually begins in childhood with a parent who does not have a healthy sense of boundaries and often enmeshes themselves with the child (or abandons them) which can lead to issues and distress within the child well into adulthood. Additionally, “racial trauma” is becoming more and more recognized by clinicians to describe experiences of trauma in individuals of color; these experiences often involve micro-aggressions, racism, policy brutality, discrimination, persistent unequal access to healthcare or opportunities, lesser quality in healthcare services received, hate crimes, and more.

All of that to say, if there is trauma underlying a mental health issue or disorder, it needs to be recognized and addressed. Even if the individual’s symptoms do not meet the criteria listed in the DSM-5 for PTSD; lack of attention and treatment to the trauma can lead to only achieving temporary symptom relief through therapy or worst case, can cause more distress if the clinician is invalidating or dismissive towards the client’s trauma.

Many disorders can co-occur with trauma as well, meaning you may meet the criteria for ADHD and PTSD, or Bipolar Disorder and PTSD, as examples. As your clinician, I will be focusing your treatment differently based on if you have a trauma history or not. Bipolar disorder treatment often involves mood tracking, education about the disorder, medications (not prescribed by a therapist, that’s not in our scope), constructing a safety plan, practicing coping skills, and other talk therapy techniques. If there is a history of trauma as well as Bipolar disorder, trauma-specific treatments will be needed in addition to these. Trauma treatment can include experiential therapies, EMDR, psychodynamic and relational theories (focusing on exploring effects of early relationships in a supportive environment), mindfulness, and more.

Another reason the DSM-5 and its diagnoses may be considered controversial is because of racist undertones many have pointed out within the DSM-5. Our code of diagnosing has been accused of being based solely on white, western culture. It makes sense when you consider certain diagnoses such as those in the schizophrenia family. Hearing voices and seeing figures is considered by the DSM-5 to be a symptom of schizophrenic disorders or psychosis. However, many cultures outside the U.S. believe hearing and seeing things can be not only normal, but desired. It is often tied to their religious beliefs. Our DSM-5 poses an issue in this regard because we may be diagnosing people based on what we feel or believe is “acceptable” or “abnormal”, and in return we are excluding and mislabeling individuals of other cultures while simultaneously sending messages that promote Americanized views and cultural beliefs as superior. The DSM-5 also does not address racial or historical trauma, which again sends messages that white, westernized culture and values are most important and other traumatic experiences then go unrecognized and unvalidated, which can further compound the trauma that persons of color experience.

I think it’s also important to mention that sometimes when clients get diagnosed with something, a tendency to over-identify with that diagnosis can occur. For example, when someone hears their practitioner say “Major Depressive Disorder” they may begin to assume the identity of “I am depressed”, sometimes even on a unconscious level. This can be harmful for several reasons. For one, you are not just your mental health issue(s). You are a husband/wife/partner, a parent, a child, a sibling, a person enjoys dancing, a person is worthy of love and kindness, a pet owner, and more. We are dynamic beings, and limiting our personality to one or two words takes away from who we truly are and can trick us into believing we are just “depressed” or “anxious” or “bipolar” and nothing more. Additionally, over-identifying with a diagnosis given to us can lead to over-emphasis on that particular set of symptoms or issues. For example, someone living with Borderline Personality Disorder may begin to view everything they do as “a BPD thing”; they may then write others off (intentionally or even unconsciously) and get in the way of their own progress by using their diagnosis as an “excuse” or sole explanation for all of their behaviors. This can happen with any diagnosis; for example someone may become so attached to their diagnosis of ADHD that instead of trying to implement techniques such as using a timer for tasks, or taking their medications as prescribed, they may begin to assume they are “incapable” of progress because “my ADHD mind is just always too scattered”. This may result in not trying to open up in therapy or not giving new techniques a chance. I will discuss later how identification with diagnoses can also be beneficial, but I wanted to address this potential risk as well.

In summary, diagnoses are names for a set of symptoms one experiences. Different practitioners can apply different diagnoses to the same patient based on differences in professional experience, subjective opinion, interpretation of symptoms, their personal culture, and more. We try our best as clinicians to be as accurate as possible, but human subjectivity still manages to play a factor despite having an organized manual of disorders for reference. Furthermore, our current manual lacks inclusivity of other cultures and of the many different types of trauma. Finally, individuals may over-identify with a particular diagnosis which can lead to hindering their personal progress, self-esteem, and overall identity.

The Pros/Benefits

I’ve mentioned a lot about potential cons and issues. But what about the positives of diagnosing?

I believe one huge positive lies within an individual finally being able to put a name to an experience and the feelings they have. Hearing a practitioner say, “I think you’ve got ADHD” can actually feel incredibly validating and freeing for some people. For those individuals, they have often felt “abnormal”, “weird”, “lazy”, “stupid”, or “inadequate”. When a professional is able to say, “No, you’re not unintelligent or lazy. You have a disorder we clinically recognize, one we have studied enough to know brain structure differences and chemical imbalances exist in those living with it, and this disorder has been shown to be treatable with therapy or therapy and medications”, the feeling can be so empowering. A shift occurs from blaming the self to more of an understanding that “this is how I am wired and there are others just like me too”, or “I have lived through some really tough experiences and now there is a name to describe why I feel the way I do”.

It is really difficult to treat something if you don’t know what it is that you’re actually dealing with. Another way of saying this is that accurate language to describe our experiences is incredibly important. It helps us organize and categorize our experiences and it can help us learn to communicate better with others.

Another “pro” of diagnosing is more specialized treatment. If a client has a diagnosis assigned, the practitioner can use treatment modalities that are evidence-backed for that particular disorder. They can also communicate with colleagues and treatment teams with more clarity and direction when there is a diagnosis assigned. Imagine trying to explain your experience and symptoms to a whole team of individuals, from scratch, every time you met with them or even when you had one-on-one meetings with each one of them. It would take a lot of time, energy, effort, and attention to detail to make sure everyone was always understanding what was being said and to try and get everyone on the same page. With an identified diagnosis, clinicians can meet with case managers, doctors, psychiatrists, and other staff and be able to save time, shifting the focus more to how to help you, versus just describing your symptoms again and again.

Closing Remarks

You can see now how diagnosis is definitely not something that is cut-and-dry. There are many layers to it, both positive and negative. I recommend working with a practitioner who you feel uses terminology you are comfortable with, and that you feel accurately describes your experiences. If you do not trust the diagnosis assigned by one provider, I recommend getting a second opinion. Be mindful of the language you use to describe yourself as well. For example, refrain from saying “I am bipolar” or “I am depressed”; instead learn to say “I have bipolar disorder” or “I live with depression”. This can help ensure you don’t over-internalize diagnoses given to your symptoms. You also don’t have to have a diagnosis. Remember, at the end of the day- you are a human being. A diagnosis is just a word, not an identity. You are much more complex and important than just one word!