Category: Diagnostics

Book Announcement

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So… I did a thing…

Here’s a book! I wrote it. 

ROUTLEDGE published it, and the level of fanciness I feel saying that is not measurable. 

It’s a lot like this blog, only you can get it in paper and you have to pay for it. Oh, and it has no pictures. 🙂

Actually, it’s much more comprehensive and better structured than the blog, though the writing style is a lot the same and the idea is the same – let’s BE BETTER THERAPISTS. Let’s use theory and research and our colleagues to help us do that. 

Therapists, in general, I think will really like it and get a lot out of it. So will advanced practicum students and interns. 

At any rate, I’m supposed to tell important people. So, there you go! 

It is available at Routledge and through Amazon! Oh, and if you go to the new Book page on the blog, there’s a coupon code! 

 

 

Misophonia

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Misophonia

Misophonia, or “hatred of sound,” is characterized by selective sensitivity to specific sounds accompanied by emotional distress, and even anger, as well as behavioral responses such as avoidance.

Or, as my 8 year old says, “Just thinking about the noise makes me die! Not literally. Metaphorically.” (Because yes, we do have ‘speaking accurately’ as a family value. What can I say? I’m a psychologist and a super-nerd.) Note, she says this while holding her ears and writhing. She follows up, “It’s like the sound goes inside my ears and then it gets in my body and makes all my muscles squeeze.” She squeals, like she’s something between angry and afraid. 

Yes, my darling. I hear you. For me, it’s like the sound goes inside my ears and then scrapes down all my nerves through my spinal cord. My teeth clench and my eyes close and my neck twists and my hip flexors tighten involuntarily. My autonomic system starts kicking in, but my brain has trouble turning that into a well-labeled emotional experience – something like completely irrational, slightly panicky anger disgust that’s not quite anger because I can’t quite get the cognitions to line up right.

For my daughter, it’s the sound of rubbing the seatbelt fabric. For me, the sound of a pencil writing on paper. For my husband, the sound of a rubber ball bouncing. 

If you’ve experienced this, you probably know it by now. But you can read more about misophonia here. Though it’s experienced by tons of people, it’s pretty new in terms of research and diagnostics. There is some cool brain data about the experience. It’s difficult to categorize, but if it’s significantly impairing a client’s ability to perform their basic life roles, it could probably be diagnosed at this point as Other Specified Obsessive and Compulsive Related Disorder. Though, I imagine in a decade or so, we’ll have a whole section about sensory issues and it’ll fit better there.  

Treatment is up in the air at the moment, though physicians, audiologists, and mental health folks are working on it. In our world, definitely there’s a place for distress tolerance work and maybe exposure & response prevention. But the place I’ve done the most clinical work on misophonia is couple’s therapy, believe it or not! Oh yes, most people can tolerate the discomfort on their own, but when it’s their partner making the sound, it takes on a whole new life! 

This is an experience that needs to be handled gently and cooperatively. (I mean, like we want everything handled in couples’ therapy, honestly!) The person who does not understand this probably needs to hear some of the science from us and be assured that their partner is not just making up their distress. The distressed partner probably needs to work on their distress tolerance and be sure they aren’t using their distress as a weapon. I will say that I have found that asking for a small behavior change when it’s possible is often easier, and that couples rarely want this to be the main issue. So, if the one partner could just not chew gum, that’d be great. Or throw away all the pencils with no eraser left – they’re just pencils! Consider ways to handle this issue as quickly and pragmatically as possible. Also, use it as an opportunity to talk about legitimate partner differences in experience! 

 

 

Comment below: Do you have this experience? For which sounds? Have you had clients bring it up, ever?

Post Concussion Syndrome

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Post Concussion Syndrome

Diagnostics is always more complicated then it seems – more like a DND roll than a simple symptom checklist or binary “has it” or “doesn’t have it” question. Here’s a great example:

 

Post concussion syndrome (PCS, or postconcussional syndrome) is a relatively vague set of symptoms that can continue to occur well after someone has had a head injury. The symptoms are wide and many of them are mental health symptoms, which is why it’s especially important for us to know about it. A headache is usually accompanied by symptoms like:

  • sleep problems
  • depressed mood
  • irritability
  • anxiety
  • trouble concentrating
  • difficulty with memory

Sound familiar?! YIKES! 

In fact, it’s so closely associated with other mental health conditions that 10-20% of student athletes meet criteria for it… even if they haven’t had a head injury – just because they’re stressed and somewhat sleep deprived! So, it’s important to consider all facets of this diagnostic mess!

 

 

PCS codes in ICD-10 as F07.81. Now, we probably wouldn’t want to diagnose Postconcussional Syndrome…. but we very well might want to put it in as a Rule Out or make a referral for additional testing/diagnosis with a physician or neuro specialist. 

 

We definitely want to have a question on our intakes that helps us keep this possibility in mind. For example, on my regular intake I have this question:

Have you experienced:
– chronic headache, migraine, vision changes, loss of consciousness, or dizziness?
– changes in your vision, hearing, other senses, or movement? (e.g., blurry vision, ringing in your ears, difficulty swallowing, trouble speaking, weakness or paralysis)
– difficulties with your memory, planning ability, or thinking clearly?

If so, when did you experience these symptoms and for how long?

That allows me to consider PCS, along with some other potential issues such as mild neurocognitive disorder and functional neurological symptom disorder (formerly conversion disorder). These answers can also “flesh out” other conditions, such as chronic headache associated with generalized anxiety disorder or difficulty concentrating as part of a depressive disorder. Loss of consciousness sometimes maps onto a substance use disorder. It’s a big question, but it gives lots of data and paths to follow-up on during the actual intake. 

Comment below: What are some of the diagnostically oriented questions you have on your intake? 

Psychological Factors Affecting Medical Conditions

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Psychological Factors Affecting Medical Conditions

Psychological Factors Affecting Medical Conditions

 

  1. A medical symptom or condition (other than the mental disorder) is present.
  2. Psychological or behavioral factors adversely affect the medical condition and one of the following ways:
    1. The factors have influenced the course of the medical condition shown by a close temporal association between the psychological factors in the development or exacerbation of, or delayed recovery from, the medical condition.
    2. The factors interfere with the treatment of the medical condition (e.g., poor adherence).
    3. The factors constitute additional well-established health risks for the individual.
    4. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention.
  3. Criterion B is not better explained by another mental disorder

Specify severity

Mild: Increases medical risk (e.g., inconsistency in taking meds)

Mod: Aggravates underlying medical condition (e.g., anxiety aggravating asthma)

Sev: Results in medical hospitalization or emergency room visit

Extr: Results in severe, life threatening risk (e.g., ignoring heart attack sxs)

***

This includes things like psychological distress (e.g., chronic overstress at work), patterns of interpersonal interaction (e.g., utilizing the sick role), coping styles (e.g., denial of seriousness), and maladaptive health behaviors (e.g., treatment noncompliance due to psychological reactance).

Remember – be careful making judgments about culturally sanctioned healing practices – if they don’t harm, don’t worry about it.

In concert with the medical diagnosis, this can be billed as F54: Psychological and behavioral factors associated with disorders or diseases classified elsewhere.

Some other diagnoses that you may consider in these situations, or in a differential diagnosis:

  • 3 Unavailability or Inaccessibility of Health Care Facilities
  • 1 Nonadherence to Medical Treatment
  • 0 Problems Related to Lifestyle

 

Here’s to treating the WHOLE person in the context of a team of health/wellness professionals!

Comment below: How have you seen psychological factors impacting clients’ physical symptoms? How have you convinced them to treat the psychological parts as well?

 

 

 

 

Sleep Deprivation

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Sleep Deprivation

Here’s a fun little (billable!) diagnosis I ran across recently. I’m always looking for just the right diagnoses to use that “get the job done” in terms of professional communication and clinical research that ALSO honor the individual’s experience by describing them faithfully. (See the previous post on Diagnosing Well). See if this one might add to your diagnostic repertoire!

 

Z72.820 Sleep Deprivation

Approximate Synonyms

  • Lack of adequate sleep

Clinical Information

  • Lack of the normal sleep/wake cycle
  • Prolonged periods of time without sleep (sustained natural, periodic suspension of relative consciousness)
  • State of being deprived of sleep under experimental conditions, due to life events, or from a wide variety of pathophysiologic causes such as medication effect, chronic illness, psychiatric illness, or sleep disorder.
  • The state of being deprived of sleep under experimental conditions, due to life events, or from a wide variety of pathophysiologic causes such as medication effect, chronic illness, psychiatric illness, or sleep disorder.

Comment: When is this truly useful and appropriate and when might you choose not to use it?

 

 

 

 

Diagnosing Well (Rant!)

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Diagnosing Well (rant!)

Diagnostics are tricky, right? We want to honor the human person, so we sort of hate the idea of diagnosing. And who wants to put clients in “a box”? Although, we need to get paid, right? And that means billable codes. What are we to do?

 

Rethink diagnosing. It honors the client when we can describe their conditions and situations in clear, useful, holistic ways. (Warning! Here comes the ranty part…) But that’s not an excuse to do it haphazardly, to give everyone adjustment disorder, or to get in the habit of using the same five diagnoses over and over. To really do it well, you might need to change the way you think and behave. You might start by trying some of these tips:

  • One of the lovely things about diagnostics is that it gives us clear definitions in order to do treatment-related research. So when you do diagnose, make it really count by accessing that research literature and translating it into effective treatment strategies, client handouts, and more.
  • Remember to use all of your specifiers! It’s no wonder we feel like we’re dumping clients into diagnostic categories if all we put is just “MDD” or “GAD.” (Remember that a few conditions, like “with Panic Attacks,” can be part of any diagnosis!)
  • Recall that “unspecified” diagnoses are really for ERs and quick intakes. Never leave one on a client’s chart. Go back and get the phenomenological data you need to update it.
  • When you give an “other-specified” diagnosis, remember to actually specify it in a brief narrative form!
  • Use your “Other Conditions” codes to paint as clear a picture as possible with your diagnosis, even when they aren’t billable (you may remember them as “v-codes”). Like these:
    • F50.4 Overeating associated with other psychological disturbances
    • F62.0 Enduring personality changes after catastrophic experience
    • F55.6 Abuse of herbal or folk remedies
  • There are more billable codes than you realize. You don’t need to use adjustment disorder for everything. Here are some fun examples:
    • F42.1 Obsessive-compulsive disorder, primarily compulsive acts
    • Z62.898 Birth of a sibling affecting child
    • Z70.8 Sex counseling
    • Oh, and if you hated that Asperger’s left the DSM-5, it’s available in the ICD-10 – F84.5. So is Dysthymia, and the Schizophrenia subtypes!

 

Let’s honor clients by doing excellent, thorough work. Maybe this will also be helpful to you? It’s a free PDF version of the Mental and Behavioral Health section of the ICD-10.

 

Leave a comment! How do YOU do diagnostics like a rock star?