Ignorant of psychology

[Brombadil]

I'm curious about how mental health specialists and psychologists accurately diagnose patients. It seems like unless there is an extreme clear cut case of a mental disorder that could be indentified by anyone then it becomes almost impossible to actually tell if someone is suffering a deficiency of any kind.

Bear with me I'm trying to organize my thoughts about this as best I can.

I want to start with common examples of "disorders" that people seem to easily make claims to that dont seem to be based on anything empirical.

Depression.
What is it? You wake up and dont feel like going to work? Your upset about things? You have conflict in your life? There is many different kinds of depressions but it seems that the symptoms are so generalized that it could almost apply to anyone at some point.

A lot of people immedietly put forth "a chemical imbalance" like its a matter of fact. A chemical imbalance of what? How? If this is some measurable inadequacy, why does the final diagnosis lie with yourself?

During psych evaluations at work, I sit down with these people and talk about whatever they want. The conversation kind of goes like this:

"X,Y,Z Upsets me or pisses me off."
"Do you think you might be depressed?"
"Define depression. If things upset me then I suppose the answer is yes.
"Well depression is a chemical imbalance that causes you to feel down etc etc"
"Ok so why are you asking me if im upset if you can just figure out if I have a chemical imbalance or not. You have the mechanism of why it occurs, so why dont we just run a test of some sort to see if thats occuring? Why does what I think about it have anything to do with whether I am or not if this is a measurable deficiency in the brain?"

The difference between me being depressed or not depressed seems to be me saying so. Is this sound science or conjecture?

Basically unless you have a severe case of depression that involves trying to off yourself several times a day, completely void of good feelings and being unable to get out of bed in the morning, I dont see how people can discern this.

How does mild or moderate depression differ from being upset, angry, or annoyed with someone or something?


Obsessive Compulsive Disorder.

Riding with a friend in the car.
"Yeah I got diagnosed with OCD. If I come home and the house is messy I freak out."
"I like it when my apartment is clean. I'd probably be upset if I came home and someone had trashed it. Do I have OCD?"
"Well no cause like you need to get really upset"
"So unless you are on the verge of a heart attack and start profusely sweating if your book shelf is unorganized, how do you discern a preference for order and cleanliness over OCD?"
"...."


ADD/ADHD

Kid wont learn his ABCs? ADD
Kid failing math? ADD
Kid talks too much? ADD

Your kids not unruly, energetic or would rather be at home playing with batman toys, he has a mental illness! Take this ritalin and your kid will become a normal 5 year old human being with tremendous amounts of discipline, focus and drive.

Again, unless you have a kid that runs around at mach 2 all day, cant sit still for 3 seconds, cant finish a single thing he starts, then how do you know he has a deficiency at all?


I guess all im saying is if its not obviously apparant, it seems non existant.
How can anyone determine mild and moderate forms of these cases with any kind of certainty?

[Dancing David]

I have done over 700 mental health assesments, all based upon a 16 pt structured interview as required by Illinois DHS, a good assesment will take about 4 hours but usually 2 is all you get.

The main thing that people do not understand in the DSM is qualifiers about persistence and severity.

Take the criteria for ADHD

And note the 'often' in this context means 'more often then not', IMO

Quote:

DSM-IV Criteria for ADHD
I. Either A or B:

A.Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention

1.Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2.Often has trouble keeping attention on tasks or play activities.

3.Often does not seem to listen when spoken to directly.

4.Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5.Often has trouble organizing activities.

6.Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7.Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

8.Is often easily distracted.

9.Is often forgetful in daily activities.

B.Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1.Often fidgets with hands or feet or squirms in seat.

2.Often gets up from seat when remaining in seat is expected.

3.Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4.Often has trouble playing or enjoying leisure activities quietly.

5.Is often "on the go" or often acts as if "driven by a motor".

6.Often talks excessively.

Impulsivity

1.Often blurts out answers before questions have been finished.

2.Often has trouble waiting one's turn.

3.Often interrupts or intrudes on others (e.g., butts into conversations or games).

II.Some symptoms that cause impairment were present before age 7 years.

III.Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

IV.There must be clear evidence of significant impairment in social, school, or work functioning.

V.The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

1.ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months

2.ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months

3.ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

[mijopaalmc]

Originally Posted by Brombadil

I'm curious about how mental health specialists and psychologists accurately diagnose patients. It seems like unless there is an extreme clear cut case of a mental disorder that could be indentified by anyone then it becomes almost impossible to actually tell if someone is suffering a deficiency of any kind.

Bear with me I'm trying to organize my thoughts about this as best I can.

I want to start with common examples of "disorders" that people seem to easily make claims to that dont seem to be based on anything empirical.

Depression.
What is it? You wake up and dont feel like going to work? Your upset about things? You have conflict in your life? There is many different kinds of depressions but it seems that the symptoms are so generalized that it could almost apply to anyone at some point.

A lot of people immedietly put forth "a chemical imbalance" like its a matter of fact. A chemical imbalance of what? How? If this is some measurable inadequacy, why does the final diagnosis lie with yourself?

During psych evaluations at work, I sit down with these people and talk about whatever they want. The conversation kind of goes like this:

"X,Y,Z Upsets me or pisses me off."
"Do you think you might be depressed?"
"Define depression. If things upset me then I suppose the answer is yes.
"Well depression is a chemical imbalance that causes you to feel down etc etc"
"Ok so why are you asking me if im upset if you can just figure out if I have a chemical imbalance or not. You have the mechanism of why it occurs, so why dont we just run a test of some sort to see if thats occuring? Why does what I think about it have anything to do with whether I am or not if this is a measurable deficiency in the brain?"

The difference between me being depressed or not depressed seems to be me saying so. Is this sound science or conjecture?

Basically unless you have a severe case of depression that involves trying to off yourself several times a day, completely void of good feelings and being unable to get out of bed in the morning, I dont see how people can discern this.

How does mild or moderate depression differ from being upset, angry, or annoyed with someone or something?


Obsessive Compulsive Disorder.

Riding with a friend in the car.
"Yeah I got diagnosed with OCD. If I come home and the house is messy I freak out."
"I like it when my apartment is clean. I'd probably be upset if I came home and someone had trashed it. Do I have OCD?"
"Well no cause like you need to get really upset"
"So unless you are on the verge of a heart attack and start profusely sweating if your book shelf is unorganized, how do you discern a preference for order and cleanliness over OCD?"
"...."


ADD/ADHD

Kid wont learn his ABCs? ADD
Kid failing math? ADD
Kid talks too much? ADD

Your kids not unruly, energetic or would rather be at home playing with batman toys, he has a mental illness! Take this ritalin and your kid will become a normal 5 year old human being with tremendous amounts of discipline, focus and drive.

Again, unless you have a kid that runs around at mach 2 all day, cant sit still for 3 seconds, cant finish a single thing he starts, then how do you know he has a deficiency at all?


I guess all im saying is if its not obviously apparant, it seems non existant.
How can anyone determine mild and moderate forms of these cases with any kind of certainty?

One way mental health professionals diagnose disorder is with the SCID (Structured Clinical Interview for the DSM-IV). The SCID-I is used for Axis I disorders, such as ADHD and OCD, and the SCID-II is used for Axis II disorders, such borderline personality disorder. There are also SCIDs for specific types of disorders, such as the SCID-D, which is specifically for dissociative disorders.

Clinicians can also conduct semi-structured or unstructured clinical interviews, but the result of these types of interviews seem like they would be harder to interpret because the questions asked are not necessarily aimed at the DSM criteria for the disorder.

There are also tests that measure cognitive and motor skills like the WAIS that help give a much more detailed break-down of developmental issues to discern learning disabilities more clearly.

[Brombadil]

Originally Posted by Dancing David

I have done over 700 mental health assesments, all based upon a 16 pt structured interview as required by Illinois DHS, a good assesment will take about 4 hours but usually 2 is all you get.

The main thing that people do not understand in the DSM is qualifiers about persistence and severity.

Take the criteria for ADHD

And note the 'often' in this context means 'more often then not', IMO

Im glad you addressed the word often, as its the most glaring thing in your quote for me. Seems to be pretty subjective and can easily fall into some form of selection bias unless your incredibly thorough. Can you trust the patient to give these questions a 1 out of 10? Is it up to observers like teachers and parents to decide? What if Billy cant focus on his science book but can listen all day to the problems little Suzy has with learning how to ride a bike? What if billy cant learn how to solve math problems because his mind is occupied with solving how he can get suzy to like him more?

What im taking from this is its not so much mathematical certainty as it is trying to figure things out beyond a reasonable doubt.

As for depression, how could anyone define mild or moderate without fitting the bill of "Life has problems and things that will upset you"

[Paul W]

Oh, dear.

Why don't we just go back to Szasz: "The Myth of Mental Illness".

I once set a final degree exam question in a paper on a course I taught on "Rational Behaviour", based on the idea that "to be rational" is an irregular verb.

"I am rational. You are peculiar. They should be locked up. Discuss."

Nobody answered it.

I freely admit that this was copied from a "Yes Minister" episode which ran, "I brief, you leak, he is prosecuted under the Official Secrets Act."

[Brombadil]

Originally Posted by Paul W

Oh, dear.

Why don't we just go back to Szasz: "The Myth of Mental Illness".

I once set a final degree exam question in a paper on a course I taught on "Rational Behaviour", based on the idea that "to be rational" is an irregular verb.

"I am rational. You are peculiar. They should be locked up. Discuss."

Nobody answered it.

I completely agree that people can be mentally ill in any painfully obvious case as I mentioned above, I would like to know how people justify mild or moderate forms of these conditions in contrast to the reality of hardships.

[Sabretooth]

Originally Posted by Dancing David

I have done over 700 mental health assesments, all based upon a 16 pt structured interview as required by Illinois DHS, a good assesment will take about 4 hours but usually 2 is all you get.

The main thing that people do not understand in the DSM is qualifiers about persistence and severity.

Take the criteria for ADHD

And note the 'often' in this context means 'more often then not', IMO

When I was growing up, I had a lot of these issues. Most everyone just figured I was bored. Now they define it as ADD.

My perspective? I think they nailed it the first time around. Kids don't want to be hunkered down, learning about maths and all that jazz...they want to be doing something fun.

But, I'm not a doctor...

[Dancing David]

Originally Posted by Brombadil

Im glad you addressed the word often, as its the most glaring thing in your quote for me. Seems to be pretty subjective and can easily fall into some form of selection bias unless your incredibly thorough.

Which is why observation and metrics are important, non medical behavioral interventions are the place to start with ADHD.

Quote:

Can you trust the patient to give these questions a 1 out of 10? Is it up to observers like teachers and parents to decide?

No, it is up to them to ask, then there should be an evaluation. A child that has a chaotic home live is going to have similar issues.

then are they persistent across all classes and at home.


Then behavioral interventions first.

Quote:

What if Billy cant focus on his science book but can listen all day to the problems little Suzy has with learning how to ride a bike?

that really depends on how you determine his attention to what Suzy says.

Quote:

What if billy cant learn how to solve math problems because his mind is occupied with solving how he can get suzy to like him more?

What im taking from this is its not so much mathematical certainty as it is trying to figure things out beyond a reasonable doubt.

As do most mental health professionals.

Quote:

As for depression, how could anyone define mild or moderate without fitting the bill of "Life has problems and things that will upset you"

People with moderate symptoms will usually have some major sleep disturbances, and distorted thinking.

People with mild symptoms rarely seek treatment.

[Dancing David]

Originally Posted by Brombadil

I completely agree that people can be mentally ill in any painfully obvious case as I mentioned above, I would like to know how people justify mild or moderate forms of these conditions in contrast to the reality of hardships.

One can develop symptoms in response to stress.

[Dancing David]

Originally Posted by Sabretooth

When I was growing up, I had a lot of these issues. Most everyone just figured I was bored. Now they define it as ADD.

My perspective? I think they nailed it the first time around. Kids don't want to be hunkered down, learning about maths and all that jazz...they want to be doing something fun.

But, I'm not a doctor...

I understand but school, at least in my school district is very different now a days, what with centers and desk work.

The question is not 'do you have x, y and z' the questions is 'does it impair your functioning significantly'.

Schools are much looser than they used to be, but some kids stills eem to have issues.

Boredom is not ADHD,.

Did you act that way at home?

one of teh questions I used to ask people about their kids was -

How long can they watch a TV show?
What kind of TV show?
Do they read?
How long do they read?
What do they read?
Can they play board games?
What happens during the game?

You have to look at the whole picture, a kid how may normally watch TV for five minutes will watch a TV show for 15 when it is stimulating.

My son hates reading, but when he wants to read he will sit down and read for long periods.

Structured board games are a real give away. It is the consistency of behavior that you want to look at.

And you have to look at their peers, what happens in kindergarten is different than third grade.

[Safe-Keeper]

To the OP
Your problem is a lot of your arguments apply just as well to physical illnesses. The fact that your arguments seem to consist nearly entirely of strawmen doesn't help either.

Ie. "I don't believe asthma exists, all of us get short on breath during jogging".

Quote:

My perspective? I think they nailed it the first time around. Kids don't want to be hunkered down, learning about maths and all that jazz...they want to be doing something fun.

Yeah, and bedridden children aren't really bedridden, they just don't want to go to school.

[Sabretooth]

Originally Posted by Safe-Keeper

To the OP
Your problem is a lot of your arguments apply just as well to physical illnesses. The fact that your arguments seem to consist nearly entirely of strawmen doesn't help either.

Ie. "I don't believe asthma exists, all of us get short on breath during jogging".

Yeah, and bedridden children aren't really bedridden, they just don't want to go to school.

That's not what I meant. I just believe doctors/parents are far too quick to hand out the ADHD card. Kids tend to get bored with things they don't enjoy...just like everyone else.

Let's say that Johnny can't concentrate on his math homework for more than a few minutes at a time. But, he'll play with Lego bricks for several hours without a hint of losing attention. Is his inattention to math an ADHD qualifier?

Now, if a child can't do anything for 5 minutes without switching gears, despite what the chore/game/project/fun is, then you may be on to something.

[Dancing David]

Originally Posted by Sabretooth

That's not what I meant. I just believe doctors/parents are far too quick to hand out the ADHD card. Kids tend to get bored with things they don't enjoy...just like everyone else.

Let's say that Johnny can't concentrate on his math homework for more than a few minutes at a time. But, he'll play with Lego bricks for several hours without a hint of losing attention. Is his inattention to math an ADHD qualifier?

nope, you just said that they can focus their attention for hours.

Quote:

Now, if a child can't do anything for 5 minutes without switching gears, despite what the chore/game/project/fun is, then you may be on to something.

Now I have seen parents shop around for solutions...

[crimresearch]

Originally Posted by Brombadil

I'm curious about how mental health specialists and psychologists accurately diagnose patients. It seems like unless there is an extreme clear cut case of a mental disorder that could be indentified by anyone then it becomes almost impossible to actually tell if someone is suffering a deficiency of any kind.

Bear with me I'm trying to organize my thoughts about this as best I can.

I want to start with common examples of "disorders" that people seem to easily make claims to that dont seem to be based on anything empirical.

Depression.
What is it? You wake up and dont feel like going to work? Your upset about things? You have conflict in your life? There is many different kinds of depressions but it seems that the symptoms are so generalized that it could almost apply to anyone at some point.

When I was running rescue squad, we had regular training sessions to stay qualified.

At one of these, a paramedic with the regional trauma center told us about an ambulance call that arrived on the scene to find an adult male sitting on a parking bumper holding his head.
The crew went down the checklist, 'how old are you any meds etc.', and of course 'What's wrong'? He replied that his head *really* hurt.

So they carted him to the ER, where the neuro people flashed shiny things, the internal people took blood, etc. Then they started lining him up for scans and such...

Almost 2 hours later, someone finally asked him 'What happened?

He removed his hand from his head and calmly told them that he had been shot.

Sure enough, a bullet was lodged behind his ear.


And the process of diagnosis for mental health issues starts with questions and a checklist as well.

[quarky]

Soon enough, we'll all be mentally ill.

Or possibly exert our sanity.

[Safe-Keeper]

Quote:

Soon enough, we'll all be mentally ill.

F'thagn.

Quote:

That's not what I meant. I just believe doctors/parents are far too quick to hand out the ADHD card. Kids tend to get bored with things they don't enjoy...just like everyone else.

Let's say that Johnny can't concentrate on his math homework for more than a few minutes at a time. But, he'll play with Lego bricks for several hours without a hint of losing attention. Is his inattention to math an ADHD qualifier?

Now, if a child can't do anything for 5 minutes without switching gears, despite what the chore/game/project/fun is, then you may be on to something.

Sorry. I misunderstood you. Think I need to get a little better at not jumping the gun on this forum.

[Lamuella]

if only we had some kind of guide to observable behaviours to help mental health professionals diagnose...

[curious pheonix]

i agree that sometimes we are quick to diagnose and i know sometimes people may use their diagnosis as an excuse - but i also think it is handy to be able to diagnose to things that are solvable - i.e. there are solutions to ADD and Depression, Disassociation ... i guess maybe its a good starting point for solving a neuro/psychological/cognitive/physical/behavioural disorder, particularly if it is affecting the quality of one's life.

[Safe-Keeper]

I think that's a good summary of the topic, yeah.