What’s Really Wrong With Me?

WWWM

For the past decade I have been conducting psychological testing for various reasons. Sometimes a person wants to know if they have ADHD or a learning disorder. Sometimes we are looking at career options and want to determine if college is a good choice, or maybe if a specific job fits their knowledge, skills, and abilities (KSA’s). Maybe it’s about a legal matter and making recommendations that are useful to an attorney or a probation department. Most often what I do is a diagnostic study to understand whatever is happening and make appropriate treatment recommendations. It’s the answer to the “what’s really wrong with me and what can I do about it” question.

In the course of hundreds of evaluations, something I’ve noticed is a lack of consistency and sometimes an outright lack of agreement among clinicians. Just this month I was beginning a therapy relationship with someone who disclosed every diagnosis along the Autism spectrum. Last month a client presented with “bipolar, major depression, anxiety, ADHD, PTSD, ADD, generalized anxiety, panic attacks, learning disorder.” What a laundry list! How is it possible for one person to have so many labels? How can one person run the gamut of an entire spectrum like Autism or psychosis? It’s more common than you think, and here are a few reasons why.

Point in Timesign
Any psychological evaluation represents a brief moment in time. Hopefully an evaluator thoroughly reviews your history, including medical and mental health records and prior evaluations. That’s certainly a best practice. It does give us more information (data points) to consider for diagnostic purposes. But even then, your evaluation a single slice in time of what that clinician observed or recorded (testing) on a specific day. Having a bad day? Testing might underestimate your best abilities. Forget your medication? Your mood might be a little more off kilter than usual. Or paying attention might be pretty hard. Leave your glasses at home? Probably going to make it hard to complete testing with speed and accuracy. Or the biggie…did you hold back some information? Sharing all the details is important for an accurate diagnosis.

Even if everything goes just as it should, it’s still entirely possible that a diagnosis can be right in that moment but not really accurate for your daily functioning. Or it might be accurate for problems lasting a few weeks or a few months, but not forever.

bullseyeMoving Targets
Another consideration is that diagnoses can be “moving targets.” There is a lot of overlap in symptoms for various disorders. For example, problems with attention and concretion can be related to ADHD, depression, psychosis, intellectual disability, learning disability, dementia….and on and on. Having mood swings? Could be a bipolar disorder, but it also could be a normal variation of depression or even personality traits. Behavior problems? Might be ADHD, depression, anxiety, Autism Spectrum Disorder, psychosis, personality-related, or a bona fide conduct disorder. See how easily this can all be confused? Yes, we get lots of training in diagnostics (psychopathology), but it takes good rapport and good investigative skills to understand what’s really going on.

This is never more true than with children and adolescents. Symptoms can look very different in young folks. Depression in a teenager often includes irritability, hostility, and acting out. Which can look like an oppositional defiant disorder. Some behaviors could be the result of medications affecting the developing brain. And, quite often, children and teens simply cannot verbalize what is going on the same way you and I can. They try, but they themselves might not understand it in order to explain it coherently.

Treatment = Change (hopefully)
Another consideration is that appropriate treatment really should change diagnostic labels over time. If you are taking medication and engaging in weekly therapy, your depression should get better and eventually that label should go away. Or perhaps your Major Depressive Disorder transitions to a Depressive Disorder NOS and then to nothing at all. ADHD frequently abates over time as the adolescent brain develops into adulthood. But not always, and more and more adults are given a label that traditionally had to be first diagnosed in children.improving together

The biggie here is Autism Spectrum Disorder. With appropriate and consistent treatment (social skills training, therapy, and possibly medication), it is very common for the more severe symptoms related to communication and social interaction to greatly improve to the point it really can be hard to see that a label is appropriate. The same is true for learning disorders. The schools refer to this as “response to intervention” and is now formally measured for those receiving special education services.

Arriving at the right diagnosis can sometimes be pretty straightforward. Other times it feels like I am a detective solving a mystery. The end result will depend on the available information, how willing people are to be open and honest, and the skills of the clinician. It is vitally important that you feel comfortable with the person evaluating you. You are far more likely to be open and honest if you feel safe and secure.

Feel free to contact my office if you keep asking “what’s wrong with me” and it seems like nobody can understand you.

Living behind masks

drama-masksWhen I was in high school I became enamored with a drama class. It was purely happenstance, as there was no other elective available for the last period of the day besides Spanish. In Arkansas two decades ago, I didn’t feel a great need to know Spanish. Drama won out.

I am secure enough to admit I was a horrible actor. I never got cast in any production. My projection was weak. My suspension of disbelief was lacking. Still, I was intrigued by the notion of disappearing into a character. Exploring a whole other world and living the life of another person. Being something other than I was. Something better, more interesting, more enjoyable. The drama masks, smiling and frowning, represented a world a possibility limited only by the imagination.

I forgot all about the drama masks until the mid 2000’s, when I met a drama therapist by the name of Lori Yates. She was a social worker at North Texas State Hospital, a maximum security forensic hospital. Lori is quite the therapist, willing to try anything and everything. Plus she is quite the cut up. Drama therapy obvious was a fit for her. One of her techniques was to have patients craft masks and then wear them during productions of their own creation and direction. Some of the masks at the hospital were extraordinarily beautiful, reminiscent of Mardi Gras or a masquerade ball. Others were dark and scary, and clearly represented pain and tragedy. All were intriguing.

Masks do serve a purpose. In sports, we wear masks and faceguards to protect delicate features and reduce the risk of injury. More often, though, masks are for hiding our identity…which can be a variation on protection if we think about it in terms of protecting ourselves from the ramifications of our choices. Superheroes were masks to protection their friends and family. Criminals and various bad guys where masks to keep from being caught. At Halloween we wear masks to be rewarded with candy…and as adults to (hopefully) hide some of our suboptimal behavior.

Wes Mask2This past New Year’s Eve, I myself wore a mask. The whole night I disappeared behind this mask, surrounded mostly by strangers who had no idea of my identity. It was quite liberating. I danced more freely than I had in years. I was not afraid to look around and see people. I didn’t shy away or avert my gaze. I observed. I witnessed. And then I imagined that probably most people wearing masks were having a more free experience than usual, just like me.

When I saw the pictures from NYE, I was struck by the thought that we live our lives behind masks. Physically invisible, but role-defining nonetheless. I “act” a certain way during therapy sessions. I’m different when playing softball. I’m more liberated when dining and drinking with friends. Somber and contemplative in church. At home with my partner and cats, I am probably something very few people have ever seen. Each role of my life is a variation on the core of who I am as a person. The physical masks may be gone, but still I live as different people depending who needs me and what I need.

I’m not sure I like this. As therapists, we frequently advise our clients to live genuine and authentic lives. We say this from an authoritative role of expertise based on training and experience. And quite likely there is the assumption that therapists live mostly perfect lives because of out training and experience. (If you only knew!) Who you are should be consistent in your life, or so we say. Imagine the shock and awe of having my best friend point out that I was willing to tolerate deplorable manipulative behavior from another friend because I was afraid to rock the boat. My bestie pointed out that this was not the first time, and I had tolerated similar behavior on the softball field. Though he did not make all the connections for me, I was well able to see it in myself. In my different roles, while wearing different masks, I had set up different standards of how I was to be treated.

Wes Mask1We all do it. Thinking about your roles. Think about the masks you wear. What do you expect as a wife or a husband? As a mother? As a child? How about as a manager or an employee? As a parishioner? Neighbor? What about as a friend? Now here’s the real question….are your expectations for how you are treated consistent across all those roles? Does it change depending on what mask you wear? Do you wear masks to hide from your own disappointment that you are not living your values? If I’m honest, this definitely applied to me. I didn’t realize it for a long time. And now that I think about what Lori was doing with those masks in the hospital, I see the real impact. Those patients had to express their needs wearing the masks so that they felt safe to build up to making healthy and assertive demands without the masks. Lori was teaching them to not hide behind roles and masks, and to see themselves as whole persons. Not broken and fragmented, and not having to play games to meet their needs Intellectually I get it; practically, I’ve been lacking in my own execution.

Removing a MaskToday I’m giving myself the same homework I’d give a client. I’m making a list of my core values and beliefs, what I want for my life and my world. And them I’m making a list of all my roles. Each role where I am not living my truest life gets a higher level of scrutiny so I can see where I’ve sold myself out. With insight and awareness comes the need to change something. Either my expectations or my actions. I’m pretty confident it will be my actions and that all of my roles will firmly reflect who I am as a whole and healthy person and I can stop wearing masks. I invite you to try this exercise as well. Let me know what you discover about yourself when you stop hiding behind the masks.