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Sporadic photos and notes from a Psyche-midwife, cheerleader, anthropologist--aka clinical social worker in therapy practice. Photos are usually mine except for those of historical events/famous people. Music relevant to the daily topic is often included in a web video embedded below the blog. Click on highlighted links in the copy to get to source or supplemental material. For contact information, see my website @ janasvoboda.com or click on the button to the right below. Join in the conversation.

Wednesday, May 19, 2010

What's in a name? Diagnostic dilemmas

One the pleasures and pains of my job as a clinical social worker is to give a label to the variety of human experience that lead people to my office. If my clients choose to use--and are lucky enough to have-- therapy coverage, their insurance requires I give a diagnosis. It's a devil's deal: if you want to stay or get well, you better start off labeled sick. I've trained in diagnosis, both in school and through my many mentors and jobs. And I see the benefit shown, at times, in the relief of clients at having a name for what is ailing them. But it's a messy business.

Some of these diagnoses are reflective of the maladies that are standard to anyone who's lived long enough-- say, the ubiquitous "Adjustment Disorder" to a divorce, layoff, or newly emptied nest. Though considered a mild diagnosis, the "disorder" part rankles me. The experiences of life changes can be very disruptive, but being disrupted by them is too usual to qualify as an illness. However, the stress they invoke can and does cause real illness, the sort that costs insurance companies real money. It makes sense to attend to them. Somewhere in school or at a work conference you may have taken one of those "life stressor inventories" that gives a point value to experiences good, bad, anticipated and unintended. As your points increase, so do your chances of having a major medical event within the following year. Helping people find real tools to mitigate the damage is my job. And insurance requires a name for that damage.

But naming those names can be problematic. There's the very real stigma that media and individuals attach to it. If your gall bladder isn't working properly, you may be really uncomfortable; it's unlikely you're ashamed. But if your emotions, behavior or thinking is off it's a different story. Now it's REALLY personal. Our brains are organs--pretty complicated ones at that. Brain's function is dependent and reflective of a variety of processes: environmental (the nurture part, that is), biological, such as hormonal systems, oxygen levels etc and genetics. We are no more in charge of the DNA that regulates our innate response to stress than we are of the DNA that determines our eye color.

I've long believed that most things we call "disorders" are really just variations of genetics that have evolutionary function. Sometimes the side effects of those functions cause trouble, especially now that we are living much longer than is needed merely to reproduce and raise our young to a viable age. Sickle Cell Anemia is an example of that. Persons with this genetic mutation (read: random change) were much more resistant to childhood malaria, thus living long enough to reproduce. Reproduction passed that change along. When the average life span was 30-40, that was a real benefit to the population affected. Not so much when malaria is no longer an environmental threat for some with the mutation, and when life expectancy is much longer.

Genes that create a hypersensitivity to environmental risk-- or its opposite, a risk-taking, fearless approach to change-- both have reproductive advantage. Safety-conscious persons who are hyper-aware of their environment and actively avoid threats would have reproduced successfully in certain environments where their braver brothers and sisters walked into harm. Those same people would have been out-reproduced when factors required persons to disregard potential harm and immediate danger or discomfort in order to relocate for food, shelter, and so forth. We seem to have a reasonable minority of each of these groups still reproducing-- the anxious and the manic. Persons with hypomania, at least in its more benevolent form, can work for hours without sleep, be extremely creative, and take risks the rest of us deem unacceptable. Persons with anxiety, who can predict dangers unapparent to the hypomanic, mandate things like 8 hour shifts and OSHA rules.

Asperger "disorder" is another cultural definition of a spectrum of genetic variation that has its ups and downs. The Asperger variation probably is responsible for much of humanity's technological and engineering advances. The Asperger brain is often extremely skilled at spatial understanding, categorizing, ordering and patterning. It's not so hot at understanding emotional nuance. Which brain would be more useful to you in designing a building code to protect harm from earthquakes?

We get the brain we get. It's going to have quirks. It's going to have strengths and weaknesses. It is surprisingly more malleable at any age than we have ever previously understood. Within limits, we can challenge our innate tendencies and create new pathways of understanding that occur not just on a psychological but on a physical level.

I'll write more on that, and on diagnosis, in my next blog. Meanwhile, here's some additional readings on the profession's most fallible touchstone, the Diagnostic and Statistical Manual of Mental Disorders (aka DSM):

"81 Words" This American Life devotes the entire broadcast of episode 204 to the events surrounding the dissolution of the category homosexuality as a Certifiable Mental Disorder. It deserves to be heard as a cautionary tale of how popular, or at least powerful, opinion can be reified.

Opening Pandora's Box: The 19 Worst Suggestions for the DSM V Author Allen Frances, MD, was the chair for the DSM IV, and it's not surprising he might react to the revisionists. His bias is evident in this read-- a bit bitchy, even . Nevertheless, his article makes some good points about troublesome indications of pathologizing normal human experience and suffering.

DSM V Org: find the whole lollapalooza here, with highlighted changes and their rationales.

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