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Allan Schwartz, Ph.D.Allan Schwartz, Ph.D.
Dr. Schwartz's Weblog

Diagnoses, Some Thoughts to Consider

Allan Schwartz, LCSW, Ph.D. Updated: Jul 2nd 2009

a set of color bars on a black backgroundMost practitioners in the field of mental health would agree that it is important to have diagnostic categories and criteria, as presented in the Diagnostic and Statistical Manual 1V. Diagnosis is necessary for psychiatrists to decide the best use of medications for such acute and chronic illnesses as Schizophrenia, Bipolar Disorder, Major Depression and other Axis I disorders.

However, when it comes to the Personality Disorders, and they are Axis II, how helpful to a patient or therapist is it to diagnose someone with a Borderline, Dependent, Avoidant, Paranoid, Obsessional, or any Personality Disorder? Medications do not relieve or cure symptoms in the diagnostic category of Personality Disorders. Too frequently, the diagnosis becomes part of the self identity of the patient.

Very recently someone E. Mailed me with a question about psychotherapy and wrote that they are "a Borderline Personality." I always find this to be a very curious way for people to define themselves and therein, in my opinion, lies the problem.

When you have the flu, do you describe yourself as "I'm Flu?" No, you state that you have the flu or that you are fighting a virus. Can you imagine that, if you had a bout with the recent swine flu, that you would call yourself a swine? I certainly hope not, and we all realize that it would be downright silly for anyone to refer to himself that way. Yet, when it comes to the mental illnesses I often hear or read about someone "being schizophrenic, bipolar, borderline," or any variety of mental illness with which they have been diagnosed. The worst possible statement is when I hear someone say, "I am crazy!"

We often speak about the stigma attached to having a mental illness. There are  well founded fears of rejection if someone else learns that we are depressed, schizphrenic, bipolar, etc. Even today, society does not look kindly upon mental illness and continues to cling to stereotypes of those who suffer from these.

I want to emphasize some points about diagnosis in psychiatry:

1. By continuing to use such language as, I am: a depressive, bipolar, avoidant personality, and so on, we are unwittingly contributing to the problem of stigma.

2. In this area of human behavior, there is no such thing as "we and them." "We" refers to those of us who have mental problems, and "They," refers to those who do not have mental problems.

What I want to urge upon the reader is that there is no such thing as "we and them" in this area. We are them and they are us. What do I mean?

Some examples of what I mean by "we are them and they are us,"

1. Psychiatrists, Psychologists, Clinical Social Workers, Medical Doctors, all struggle with the difficult issues of life, depression, family problems, ADHD, Anxiety and all the other emotional ailments. They are not immune simply because they are the experts. That is why it is so important for mental health professionals, from Psychiatrists to Family Therapists, to attend psychotherapy for themselves.

2. All the mental illnesses fall on a spectrum and that spectrum includes everyone. In other words, it is entirely possible for any human being, under certain types of pressure and trauma, to experience an hallucination, delusion or any other type symptom. Here, too, no one is immune. It might be that the symptoms are transitory or they clear up once the crisis passes, but, the experience is that of a real symptom, nevertheless.

Therefore, what I would like the reader to think about is this: that you no longer allow some diagnosis to define who you are. You may feel depressed but you are not a depressive.

Your opinions, questions and experiences are welcome and encouraged.

Allan N. Schwartz, PhD

Allan Schwartz, LCSW, Ph.D.

Readers who live in the Boulder, Colorado metro area, or in Southwest Florida may contact Dr. Schwartz for face-to-face consultation. He is also available for psychotherapy through Skype video for those who are not in Florida or Colorado. He can be reached via email at dransphd@aol.com for details.

    Reader Comments
    Discuss this issue below or in our forums.

    HAVING certain things that I cannot help - Cori - Jan 29th 2010

    I was reading this, and wanted to explain a little on why I refered to myself as Borderline. Now, I was never diagnosed with BPD, but almost like another commenter, I had found out a few doctors and therapists of mine previously thought I had it. Now, growing up, I was always told I was mentally ill. So, I guess eventually I just started to believe I am what I am diagnosed with. But finding out either I have BPD, or at least the symptoms, was a relief to me. I always thought that everything I was experiencing and doing was just "normal", or that I was just nuts. Also, with the amount of confusion I have on knowing who I am, I don't really know how to describe myself, because I am kind of who I talk to at the moment, so I end up just saying "Here, read this, it's what I am." I now try to refer to myself as HAVING certain things that I cannot help, but sometimes I feel like I can't help but just say I am Borderline, or I am Obessive-Compulsive. Reading this has made me really think about how I am saying things, and how people take it. Thank you for saying this kindly, and for all of your posts.

    Labels do much harm, while they are too rather needed - Dr.T - Jul 4th 2009

    While I do agree that diagnostic labels are essential to understanding the nature of a disorder or mental illness, I also agree that these terms are over-used and provide a new "name" for the person being diagnosed. There is great psychology to "knowing" you are autistic, schizophrenic, or bipolar, and it seems to provide, for some, characteristics that the person may learn to exhibit or live up to. Perhaps there is some learned helplessness that is to blame for this as well.
    Professionals using terms to refer to someone as "bipolar," "autistic," or "schizophrenic" seems to decrease the professionalism of the individual. Anyone in the helping professions should truly learn to re-word how they speak about individuals suffering from mental disorders. I too am in the process of learning.
     
    In addition, diagnostic labels I agree probably do not really mean anything to the person who is experiencing the problems; however, they seem to have more meaning for those of us who are not experiencing the problems. It sort of helps us define that person and his or her behavior.
         Labels may not only cause stigma, but also a person who uses his or her new label to gain sympathy, to deceive (especially with sociopaths), and to blame wayword behavior on something besides a lack of inhibition, a character flaw, evironmental influences, etc.
     
    There is a video of a child named Jani (short for January) who supposedly experiences schizophrenia. One of the things that bothered me about her story is that her parents relate to her in a way that reinforces to her psyche that she is in fact mentally ill. What this does to her as a person, as a growing child, remains open to interpretation. But I don't think it's healthy for her to engage in conversations that reinfornce to her mind that she's schizophrenic. The link below will provide the documentary video for you.
     
    The mother, during the beginning of the clip, asks Jani if "she thinks she is schizophrenic," the child says "yes." The father later says "I know what you need, you need a Thorazine." These behaviors (and perhaps behaviors that were not exhibited through the documentary) can negatively reinforce the situation. Although I'm sure there is probably not much this child can do about her behavior, and keeping her mental struggles away from her may be unrealistic/difficult, to keep reminding her that she is ill can create a sort of learned helplessness and unstable view of herself that may influence (negatively, that is) her ability to try to grow and live as normally as possible.
     
     
     
    NOTE: I am by no means trying to decrease the significance of using diagnostic labels, but I am trying to show where labels can certainly be problematic.

    One Human with a Few Bad Tendencies - CB - Jul 2nd 2009

    My psychologist did not tell me directly I "have" BPD.  I figured it out after he and my psychiatrist recommended DBT.   When I saw the 9 critera for BPD I was amazed at the accuracy of the symtoms with how I felt since being a small child.   I felt overwhelming grief for all the suffering I've experienced over the years and the absolute torture I caused my husband.   I at the same time was happy because there was a reason for the emotional turmoil and better yet, a plan of attack for improving the behaviors. 

    In the future I will refer to myself as having BPD, not being BPD.  Thanks for the article.

    A powerful and positive message - Julian P - Jul 2nd 2009

    Dr. Schwartz,

    I could write at least one hundred pages about the power and value of the message in your article.  To spare yourself and the readers my 100 pages, for now I will just say that my hat is off to you for having the wisdom, humility, compassion and vast understanding in order to recognize the hazards, false permanence, and obstructions that can be imposed from the acceptance of "labels" or certain diagnosis.  For many, identifying so strongly with "X" disorder becomes precisely the thing that stands in the way of working through it and moving passed it.  

    Thank you,

    JP

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