When the Diagnosis is : All of the Above

Most of us aren't Diagnostic and Statistical Manual (DSM) experts, but are aware of this thing we call the DSM-5, or Diagnostic and Statistical Manual of Mental Disorders that therapists memorize. The bullet-point system of features at the corner of the desk is likely a well ear-marked spiral-bound copy of the bible. Docs flip easily to a suspected disorder.

"See?" we declare knowingly. "That's you."  Or more likely, "That's her."

Some of us read the patient right away. He belongs to either the anxiety disorder family, or the affective (depressive-manic) disorder tree, because so many of us do. The lucky belong to both. The experienced professional also recognizes substance abuse, eating and gambling disorders, personality disorders, everything.

Still, we work at that differential diagnosis, want to narrow the problem down, if there even is a real disorder, one that has met the full DSM criterion. Not everyone has a particular disorder, but we live in a world replete with mental and behavioral messiness, so a typical therapy visit also means someone else, someone who is not in the room, is the subject of that "See? That's her." Yes, you should worry when your partner gets a therapist.

All well and good. But what's a therapist to do when the patient begins by saying, for example, that as a kid he had an addiction to pot, and can't remember being depressed as it presents in the books, but knows he had suicidal thoughts. He will continue to say that he treated teachers as inferior beings and passive-aggressively refused to answer questions, yet never scored lower than an 90 on a test without studying. She'll tell you, too, change the gender, that she binged and purged before even knowing it would be popular in college, and that by the age of twenty started having obsessive thoughts when she saw a knife, visualizing the knife slashing her of its own accord. Or she might irrepressibly slash herself. Add to this a social network disorder that culminated in job loss, and compulsive sexual relationships on the internet. Oh, and she has a new job and she hates it.

All this without any family history, as if to say, It is my genetics that made me do it. I have a mental disorder and none of the doctors in the past have managed to narrow it down. Would you do that for me please? I'm under a lot of stress.

I look at you, do my best to read you. You return the favor, read me. I ask, How did you find me? Why me? This yields wonderful diagnostic information. Another question: What does your primary care doctor think?

Inevitably, assuming the pri-care is a family physician, the answer is: That I need counseling. I need to talk to someone like you.

Those of us who have helped people in one or two visits, who specialize in "only evaluations" or are in a hurry or don't have evening appointments might want to pass him on to another therapist. Our patient with a million symptoms and as many diagnoses and problems likely had a very messy childhood. One of my mentors once told me that if a person has been incested, that means twice a week for years.

Makes sense, right?  There are so many forms of incest, is the thing, and indeed, twice a week on the couch for years is an incredible luxury. And it usually isn't necessary, all due respect. Who has that kind of time? Job stress is at the top of the list. There is a V-code, I think, for that.

Upshot: If the patient with All of the Above* is your new patient, then settle back and relax. Feet up on the ottoman. Do the therapy that the primary care doctor has asked you to do. And don't worry about the diagnosis, the medication, or even who else you think should be in therapy. This one's yours. Embrace it.


therapydoc

All of the Above*: Not to say that there aren't a few diagnoses, but usually there are a few features of several diagnoses. One does have to go through that process, vetting those features, finding illness. All I'm saying is, don't let the diagnostic process get in the way of the therapy. Because it really can, seductive monster that it is.

Don't Super-Size Me: The push for calories on menus

I didn't see the movie Super Size Me, to tell you the truth. The thought of watching someone gorge on super-sized portions just didn't appeal.

IMDb (where I get all of my movie facts) tells us that movie filmmaker Morgan Spurlock embarks on the most perilous journey of his life. He can't eat or drink anything that isn't on McDonald's menu; he must wolf down three squares a day. He must consume everything on the menu at least once and super size his meal if asked.

Just not pretty.

In my two dozen plus years as a therapist, I've shied away from specializing in eating disorders. By not specializing, I do very well in this area, weirdly enough. I won't specialize because frankly, everyone is sensitive about weight (everyone). And weight is very hard to treat, even with "specialist" written before or after your name.

Because it's such a universal, when people tell me that they want to work on their eating I say, "You'll have to find another therapist if that's all you want to work on. I'll work with you on everything else, your behavior, your thoughts, your relationships, your organizational skill, your emotional management, anything almost, except for eating, and certainly not eating disorders. I won't set out to treat those. If they happen to change over our time together, great, but we're not setting out to cure them."

Why? (a) I like success in my work, prefer to see change fast, and (b) These are the hardest disorders to "cure." So put (a) together with (b) and you get my drift. Oh, and did I mention the paradox in all this?*

The truth? Eating really is an emotional affair. How can it not be emotional? It's about how we look and feel; it's so emotional that no matter how you slice it (all puns in this post may be intentional, I'm not sure yet) until you get yourself emotionally grounded, which can take years, it can be very hard, excruciatingly hard to control one's eating.

This is the essence of anorexia, by the way, control. You can't make anybody eat.

And far be it from me to try.

And you can't make anyone lose weight, either.

My patients lose weight, there's no question about it, without focusing on food as a therapeutic issue, perhaps by not focusing on food as an issue. When we spend a year (okay, more) on the emotional stuff, the pounds tend to peel off slowly, but still. It is a lovely thing to see. Two of my patients in the past year have lost over a hundred pounds each. Both had seen me for nearly three years before they started to lose.

No, it's not science, but it does seem to be a pattern in my practice, maybe is for others, too. Get therapy, take it seriously, and you'll get a handle on your life. Eating is a part of life.

I haven't tackled this topic on the blog until now because it's so huge, and I have so much to say about it. The only way is to begin a discussion is to focus on something in particular, and since WSJ offered me the perfect entree, let's start with Page 2, July 10, 2008, The Wall Street Journal, The Push for Calories on Menus.

Apparently some states are passing laws (or trying) to force restaurant chains to list the caloric and nutritional value of items they serve on their menus. Stu Woo tells us that the California and New York state legislatures have joined a movement approved by health advocacy groups such as the Center for Science in the Public Interest. Other advocates for content disclosure include the American Cancer Society and the American Heart Association.

These organizations agree that if we tell consumers what they're eating, they'll be less likely to eat as much.

Menus with caloric and nutritional information might make some foods less tempting, obviously, something restaurateurs are leery about. And they pay taxes, too, which is why state legislatures are keeping their sights low, only targeting large chains with 8 or more restaurants. Advocates believe these measures, posting calories on walls and menus, are a step towards addressing the country's obesity problems.

A May report by the Los Angeles County Department of Health indicates, based upon "conservative assumptions" that posting calories on menus might result in approximately 10% of restaurant patrons ordering reduced-calorie meals. Changing the eating habits of ten percent of anything is amazing.

And it sounds cheaper than years of therapy, so I'm all for it.

Because at the end of the day, weight control is all about calories in, calories out. If you eat more food than you use in a day, the rest goes to the thighs; or wherever your body feels most comfortable storing it.

But wait a minute! Here's another novel idea (not so novel, okay). What about learning the caloric content of food, cooking for yourself, eating from your own kitchen?

I realize it's easier to pick up the Weight Watchers meals (the only diet I ever recommend when pushed to opine). But there's really something very satisfying about seasoning your own food, sauteing those lean meats or vegetables in just a little olive oil, tossing out the egg yokes. Who cares how rich they are in vitamins?

But when I talk like this in therapy, when patients get me to talk weight control, to talk about exercise (they see my bike) and healthy eating (my sandwich), all I get back are blank looks that say, Why would I ever do that?!

Exercise regularly? Cook? Prepare food? Insane!

Which is why I don't treat eating disorders. Although I could steer away conversation about my bicycle, it would be impossible for me to not talk food, not to impose my palate, not to suggest the ideal sandwich. And a patient might think I'm not empathetic to the situation, which is totally not true, patently unfair.

And yet, just a little olive oil and some garlic, throw in a half-inch of fresh ginger, but don't forget to discard it before you eat. . .it's such a good thing. . .


therapydoc
*a paradox works paradoxically, meaning if I say I refuse to work on this with you, you're probably really going to want me to work on this with you.