I love a good diagnostic challenge

One of the most interesting ever was a guy who had some weird kind of seizure/sleep thing going on that a couple of medical types had ruled was hysterical. Not funny, I mean, but entirely in his own mind. That didn't fit with the history, though, or with his presentation either, so we did some psychological testing, and the resulting personality profile clearly didn't fit with any of the somatoform, histrionic, or factitious-type disorders. So, not being a physician, I didn't get to say what the guy really had, but I could say I was about 99.99% sure it wasn't psychogenic, and that was cool. I love it when I get to say something definitive, clarifying, and helpful.

Recently, I had a young lady come in with three diagnoses from her previous therapy. But while I'm sitting with her, I'm thinking this isn't right. For one thing, the history doesn't quite fit, e.g., onset of symptoms in late adolescence for one diagnosis that is pretty firmly in place by early childhood, and for another that usually presents earlier or later. For another, the symptoms don't all quite mesh. And again, there's the presentation: She just doesn't feel like A, B, and C. So, I'm thinking, instead of A, B, and C, maybe her problems are X, Y, and/or Z. Then at the end of the session she tells me how much she's been drinking and drugging. And here beginneth the lesson.

When presented with a client who uses frequently and heavily, it's important essential to your differential to look at the onset of the symptoms. Somebody who starts having symptoms of a mental illness at about the time he started drinking could be drinking to cope with the illness. More likely, he doesn't have the illness at all, but the symptoms are a reflection of the intoxication/withdrawal cycle of the addiction. This is absolutely going to be the case if the symptoms of the supposed mental illness began after the alcohol and drug abuse. So unless you know different, the primary diagnosis and what you will treat first should be the addiction, people.

If, on the other hand, from the history you can clearly see that the symptoms predate the addiction by many years, then by all means go ahead and give a diagnosis of bipolar or borderline or whatever. Otherwise, you would be well-advised to get the client clean and sober and see if, 90 days or so later, they are still having symptoms before you give a diagnosis. Especially before you slap something as pejorative as a character disorder on 'em.

Regardless of which comes first, you can't do therapy with someone who is actively abusing substances. At a minimum, they need to not drink/drug 24 hours before and after a session. This allows them to not be anesthetized when they show up for therapy, so they will have some affect to drive the work, and it gives them a bit after the session to metabolize the work they've done. It's a minimum.

But as far as I'm aware, therapy never got anybody clean and sober, and therapists who think that working on the "root" of the problem (addiction is its own root, people, I'm here to tell ya) is going to help their patients proceed at great risk to the patient. Addiction is a progressive, lethal disease. And even if the person is "just" self-medicating, it can still kill them before you get to the root of whatever it is that you think is the real problem. So let's clean 'em up, if not first, then early in the treatment. You could save a life.

But I digress. We were talking about diagnosis, not treatment. Let's get back to that. Flip side is, if you have somebody come in who's in recovery and still having terrible anxiety or depression 90 days or more after her sobriety date, you have somebody with a free-standing mental illness. For the love o' Mike, diagnose it and treat it. Un-and under-treated depression, just as an example, is a notorious trigger for relapse. And remember, addiction is a relapsing, progressive, terminal disease.

And if you have somebody who's well-advanced in recovery, they've worked all the Steps, they have a sponsor and are going to meetings and working a good Program, and they still have character flaws left, right and Sundays too, then please feel free to give an Axis II diagnosis. And treat it. It's the only humane thing to do.

Regardless of what you do or don't diagnose, and decide to treat or not to treat, if you are a psychiatrist, don't give medications with abuse potential to clients who are drinking and drugging. You tryin' to kill 'em, or what? You are certainly aging me prematurely when you do that.

There endeth the lesson.