How many of us can relate to awakening from a dream that felt so real the residual emotions remained with us for hours afterwards? Or eagerly recounted the unusual plot of a recent dream to friends or coworkers in an attempt to interpret what it might mean? The phenomenon of dreaming has been romanticized by poets, studied by scientists and even analyzed by the father of psychoanalysis himself. Many have proposed theories of how to interpret dreams, and scientists have even mapped the biological underpinnings of the dream-state, yet much of our understanding of why we dream remains elusive.

Dreams are a curious thing: We often don’t recall the content of our dreams, and many people are completely unaware of even dreaming. Yet studies have found that people over the age of 10 dream, on average, four to six times per night, most frequently during the stage of sleep known as rapid-eye movement (REM).¹ During the REM stage, our minds are active, as they are during waking hours, but the rest of the body remains, for the most part, immobilized.

Purpose

Many people believe that dreams communicate to our conscious minds the emotional state and wellbeing of our unconscious mind through symbolic imagery. Others believe that dreams are the mind’s attempt to consolidate knowledge or solve problems encountered during waking hours. There is no universally agreed upon theory as to why we dream, and some reason that because so few dreams are even remembered, they serve no purpose whatsoever.

When dreams aren’t so sweet

Many people experience recurring dreams – identical or thematically similar dreams that can occur with regularity over several weeks or even a lifetime. For those suffering from recurring distressing dreams (nightmares), these experiences can be extremely upsetting and cause disruption in waking hours (residual emotional turmoil, fatigue from sleep interference and frequent distressing thoughts about dream).  

Recurring nightmares can result from stressful or traumatic experiences in life; in fact, it is not uncommon for people suffering from posttraumatic stress disorder to experience recurring nightmares about the trauma they experienced. In many cases, recurring dreams last only a short period of time and disappear on their own. However, when nightmares persist for long periods of time or become impairing, intervention may be necessary.

In a new research undertaking soon to be implemented at The Menninger Clinic, clinicians will help patients with recurring nightmares “re-script” their dreams using image rehearsal therapy (IRT).² Unlike the psychoanalytic approach through which one seeks to understand the underlying meaning behind dreams, IRT seeks to help patients cope with distressing nightmares by disrupting a negative behavior cycle, akin to the way cognitive behavioral therapy (CBT) works.

How it will work

The procedure will be similar to that introduced by Dr. Barry Krakow in 2001, in which patients are asked to keep a nightmare log, write a brief summary of the distressing dream and create an alternate “script” of a dream that is a pleasant alternative to the nightmare. The re-scripted dream ideally has a therapeutically relevant theme (such as a theme of power and control for a victim of a sexual assault). Studies have shown that when a patient sets aside time once or twice a day to visualize the new dream, nightmares tend to diminish in frequency and intensity, and sometimes disappear altogether. The typical course of treatment requires three sessions with the therapist over a period of two weeks.

Dreams can evoke a number of emotions that can carry over into waking hours. With pleasant dreams, this can be an enjoyable experience, but with recurring nightmares, such residual emotions can lead to impaired functioning during waking hours. For those suffering from recurring nightmares, developing a “new script” might help to alleviate the symptoms experienced during waking hours.

Editor’s note: If you enjoyed this post of Heather’s, check out some of her other recent posts:

• Losing faith in times of suffering
• Pseudologia fantastica: the truth about pathological liars
• Calling in depressed: a look at the limitations of mental illness in the workplace

References

¹ Schneider, A., & Domhoff, G. W. The Quantitative Study of Dreams. (2009). Retrieved from http://www.dreamresearch.net/.

² Krakow, B. et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. Journal of the American Medical Association. 2011; 286, 537-545.

Grief, loss and suffering are unavoidable components of life; in fact, they’re such common experiences that numerous books, treatment programs and theories have been developed to help people cope during these tough times. When misfortune affects others, we express condolences, offer encouragement, perhaps even quote from sacred texts.

However, when the tragedy is our own, we are sometimes left asking, “Why did this happen to me?” Regardless of what faith or spirituality you might identify with, for those who believe in a higher power, questioning how such a powerful force could allow incredible suffering is a shared experience.

Interestingly, it is often in times of trial that many people make decisive judgments about their commitment to faith or spirituality. Some grow in their devotion to a higher power, while others angrily discount or even renounce their faith – wondering why a benevolent and powerful being could allow such pain and misery.

SCIDs and suffering

In my work conducting the Structured Clinical Interview for the DSM (SCID), I frequently encounter patients who are questioning their faith – they may mention offhandedly that they no longer believe in a god, or that they lost their faith after experiencing incredible tragedy. For these patients, Menninger’s chaplain, Rev. Salvador Delmundo, Jr., can prove to be a vital resource, offering guidance and support while they struggle with questions about their spiritual beliefs and experiences and wonder how it all fits together with their mental health and overall wellbeing.

In an effort to answer some of the more common questions, I spoke with Rev. Delmundo, who shared some of the initial questions he asks patients struggling to answer “How could God allow this to happen to me?” He stated that he asks patients about their god images – thoughts, assumptions and feelings evoked when they include God or the thought of a higher power in their conversations. Learning about a patient’s feelings toward their faith helps him create a picture of how the patient defines his or her faith connection.

The importance of challenging assumptions

For some, a higher power is a benevolent force – a being that offers strength and comfort in times of need. For others, their god is defined by strength and power – a being that is all powerful and thus has the ability to prevent suffering. Rev. Delmundo references Harold Kushner, author of When Bad Things Happen to Good People, as he discusses the benefits of seeing God as a “benevolent being,” one that is comforting and loving in times of suffering. Seeing one’s higher power in this manner takes the focus off of “why did this happen” and refocuses on “how can I get through this.”

Rev. Delmundo stated that one way he engages patients in conversations is by helping them identify and dispel the assumptions about God that don’t work for them. He explained that we don’t question our assumptions about faith until they stop working. For example, the assumption that because one is faithful/spiritual/religious their God will/should protect them from pain and suffering is questioned when suffering occurs.

Asking oneself “how is this assumption working for you?” when thinking about your own spiritual beliefs can shed light on how spirituality shapes your experiences. One way we can “unfreeze” assumptions is by simply rephrasing them into questions. This requires one to switch into a curious frame of mind in order to see if recent experiences support the belief or if one is mistaken in the belief.

Helping yourself

Rev. Delmundo suggests the following for those struggling with spiritual questions in the context of recent tragedy or loss:

1. Locate a support network, which can be family, friends or a faith community.
2. Resist the temptation to immediately assign meaning to what has happened (in the context of grief, one’s judgment is often clouded and assigning meaning can cause one to be resentful in the long run).
3. Listen to other people’s perspectives on what has happened to you and don’t limit yourself to clichés.

For patients struggling to make sense of their experiences, the counseling and guidance from the chaplain can be very beneficial. If you don’t have access to such resources, asking yourself “Who is my God?” and “How is this working for me?” may reveal more about the way in which you experience your faith and provide more guidance into how you can better utilize your beliefs as a strength in times of suffering.

Editor’s note: If you enjoyed this post, check out Heather’s other recent blog posts:

• Pseudologia fantastica: the truth about pathological liars
• Narcissism works for me
• Experiences with the paranormal: differentiating between spirituality and psychopathology

Some of us are experts at picking up on it, others find themselves victims of it, but we are all guilty of it: It’s the common experience known as lying.

White lies, big lies or simple exaggerations are common to the human experience; they may be temporarily problematic but typically do not have lasting repercussions on our lives.

Sometimes, however, lying can become excessive, with lies becoming so intricate, so extreme and interwoven that they almost blur the line between one’s concept of reality and fantasy. Individuals who engage in extensive lying are known as pathological liars.

Pseudologia fantastica

There is no consensus on the definition of pathological lying, referred to diagnostically as pseudologia fantastica. Furthermore, the condition is not recognized as a diagnosable disorder in the Diagnostic Statistical Manual for Mental Disorders (DSM).

Healy and Healy argued that the condition of pathological lying should stand independently as a diagnosis, believing that pathological lying patterns develop over time in the absence of a medical condition such as epilepsy or a mental disorder such as schizophrenia.¹ Others argue that pathological lying is a result of a “psychopathic personality.”² There are also conflicting ideas about whether pathological lying is a willful act or more of an automatic (and thus unintentional) behavior.

Diagnostic interference

Suspected lying can present a formidable challenge in conducting the Structured Clinical Interview for the DSM-IV (SCID). Since the interview relies almost entirely on self-report, suspected lying can interfere with the interpretation of symptoms. Complicating matters is the brevity of interaction with the patient and the inability to check the veracity of a patient’s accounts with family members or friends (many of whom also struggle to gauge the accuracy of a patient’s statements).

An accurate history is critical to diagnoses. For example, according to the DSM, a diagnosis of posttraumatic stress disorder (PTSD) requires a history of exposure to traumatic events, with the following criteria being met: the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others AND the person’s response involved intense fear, helplessness or horror. One can see the diagnostic difficulties that may present when the legitimacy of a patient’s traumatic experience is called into question.

However, many patients do experience extreme adversities, some of which seem so outlandish that they are difficult to accept as truth but, in fact, are real. At other times a patient’s exaggeration of symptoms, or intentional flight from the truth, can be a deliberate attempt to garner sympathy or attention, or to externalize blame.

Research results

What sets pathological liars apart from the rest of us?  Well, biologically speaking, studies suggest that pathological liars suffer from structural brain abnormalities, specifically, an increase in prefrontal white matter and a reduction in prefrontal grey/white ratios, compared with normal and antisocial controls.³ These findings suggest that prefrontal impairment might play an important role in the phenomenon of pathological lying.

Still other research studies suggest that people suffering from compulsive lying have the possibility of impaired reality testing – similar to those experiencing psychosis. Some authors propose that the impulse to lie is connected to a type of “wishful psychosis,”⁴ a desire to live in a fantasy life that can be gratifying to the person, blurring the line between desired fantasy and reality to the point that the person can no longer distinguish between the two.

This concept is challenged, however, by the fact that many pathological liars express sound judgment in all other areas of life and do not typically experience the same functional limitations someone with a psychotic disorder might show. Furthermore, when confronted about their lies, pathological liars are able to acknowledge the falseness of their stories, which suggests they are consciously aware of their lying and therefore not delusional (i.e. not psychotic).

There remain many unanswered questions about pathological lying, including:

• Does it warrant a diagnosis?
• Is it a willful act?
• Is it associated with detectable brain abnormalities?

Limited research into this fascinating topic renders many plausible hypotheses about pathological lying.

While there is much dispute about the etiology of this condition, it can be agreed upon that individuals who experience pseudologia fantastica face many difficulties in their personal relationships and even professional careers as a direct result of their lying.

Editor’s note: If you enjoyed this post, check out some of Heather’s other blog posts:

• Calling in depressed: A look at the limitations of mental illness in the workplace
• Narcissism works for me
• Experiences with the paranormal: Differentiating between spirituality and psychopathology

References

1. Healy, W., & Healy, M. (1926). Pathological Lying, Accusation, and Swindling. Boston: Brown, Little. 
2. Selling, L. (1942). The psychiatric aspects of the pathological liar. Nerv Child, 335-350. 
3. Yang, Y., Raine, A., Lencz, T., Bihrle, S., Lacasse, L., & Colletti, P. (2005). Prefrontal white matter in pathological liars. The British Journal of Psychiatry, 320-325. 
4. Dike, C., Baranoski, M., & Griffith, E. (2005). Pathological Lying Revisted. The Journal of the American Academy of Psychiatry and the Law, 342-349.

The pro's and con's of disclosure.

In my previous job as a vocational rehabilitation counselor, I helped individuals with psychiatric disabilities transition back into the workforce and witnessed firsthand the difficulties faced by those re-entering the work place after a significant mental health setback. In my current position as a clinical interviewer, which involves conducting diagnostic assessments with hospitalized patients – many of whom are professionals – my previous experience has been reinforced.

While many disabilities are observable, and thus generally accepted by employers as requiring accommodations on the job (e.g. in the form of assistive technology, duty modifications and medical devices), mental illness is not obvious. In fact, it’s sometimes referred to as “the invisible disability.”

Economic impact

The impact of mental illness is often minimized in work settings despite statistics that demonstrate one of the greatest costs to employers is unaddressed psychiatric illness. “In the United States, the annual economic, indirect cost of mental illness is estimated to be $79 billion. Most of that amount — approximately $63 billion — reflects the loss of productivity as a result of illnesses.”¹ According to the Harvard Mental Health Letter, “The indirect costs of mental health disorders — particularly lost productivity — exceed companies’ spending on direct costs, such as health insurance contributions and pharmacy expenses.”²

Mental illness might not seem to qualify as a “true disability” because of the colloquial use of the terms “depression” and “anxiety” and the sometimes flippant conversations about “taking a mental health day,” which detract from the significance they hold for those with diagnosable mental disorders. For those suffering from anxiety or mood disorders, to be depressed or anxious might mean struggling to get out of bed every morning due to paralyzing anxiety or debilitating depression; striving to focus at work while trying to hold the panic at bay; or exhausting efforts to maintain the façade that everything is OK in order to evade questions or comments from coworkers or supervisors.

Additionally, coworkers and employers who are unfamiliar with psychiatric disabilities can have difficulty tolerating the limitations such disorders can present on the job, in part because the person looks otherwise “normal.” The assumption that a healthy physical appearance equates to a healthy mind is problematic for individuals with significant psychiatric illnesses. The result can be limited patience on the part of the employer when problematic symptoms begin to cause concerns or interfere with work. When individuals start coming in late or struggle with productivity, their managers may believe the person is lazy or irresponsible. As a vocational rehabilitation counselor, I also educated employers on the potential limitations of mental illness in the workplace, suggested reasonable accommodations and provided data suggesting that people with disabilities are more likely to stay with a job longer than individuals without disabilities.³

Disclosure: how and when?

Hello, I'm the new guy here.

Another component of my previous position was counseling individuals with disabilities on how and when to disclose their disability. Everyone has the right to keep their psychiatric conditions confidential; however, it is important to consider how they may interfere with work performance. In such cases it may be in the individual’s best interest to disclose to their employer so that the appropriate  accommodations may be provided. These can go a long way toward minimizing disruptions due to poor job performance, excessive absences and possible termination.

There are potential downsides to disclosing disabilities to one’s employer: the fear of termination, lessened workload leading to delay in advancement or the possibility of a breach in confidentiality. The upside to open and honest communication with an employer is the possibility for accommodations which can help employees feel more confidant and secure, while potentially  minimizing absences and possible job turnover due to symptom exacerbation. If employers do not have prior knowledge of a person’s need for accommodations, they may have grounds for termination if that person cannot adequately perform the job duties of their position.

Despite many employers’ best efforts to act ethically and professionally when managing employees with mental health issues, uninformed employers may reveal a stigmatized view on mental illness. The concept of “pulling oneself up by the bootstraps” is frequently associated with mental illness in the workplace: It is seen as something within the person’s control, a matter of will power. Yet extensive research documents the biological basis of mental illness such that, like hypertension or diabetes, the illness is not entirely within the individual’s control.

Acknowledging limitations

However, it is also important to acknowledge the employee’s role in understanding, and at times accepting, the limitations their mental illness may present in a work setting. It is the employee’s responsibility to acknowledge if and when positions or responsibilities are beyond their ability. Good self-care involves knowing limits as well as strengths.       

Mental illness can create significant problems in a work setting beyond the typical “mental health day” that some people might need in order to recalibrate. If mental illness is not properly addressed and accommodated by both the employer and employee ahead of time, then potentially avoidable stressors might not only impair job performance but also exacerbate the psychiatric illness.

1. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, Md., U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services,1999, pp. 408409, 411. 
2. Harvard Mental Health Letter. “Mental health problems in the workplace.” February 2010.
3. Benefits of Employing People with Disabilities. October 15, 2009.

In my work conducting the structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID) at The Menninger Clinic, I have the distinct privilege of discussing with patients, among others things, personality traits. This aspect of my job is particularly enthralling not only because I enjoy listening to and learning about our patients, but also because patients, for the most part, equally enjoy discussing their life experiences.

Patients help guide the interview by completing a brief personality questionnaire, which is concluded prior to the interview. They are then invited to expand on their answers, provide examples and generally talk about the kind of person they believe themselves to be. The SCID has been instrumental in uncovering problematic personality traits that can significantly impact a patient’s clinical treatment.

Personality traits

Problematic personality traits may seem readily recognizable; yet interestingly, personality disorders are some of the most under-diagnosed disorders in mental health treatment. Patients typically seek treatment for more acute problems, such as mood disturbance, anxiety and substance abuse, and often they experience relatively rapid relief of acute symptoms with the aid of medication and therapy.

By contrast, personality disorders require long-term treatment, typically including extensive psychotherapy, which, while effective, is by no means quick. Treatment for personality disorders, however, is especially critical as problematic personality traits can lead to conflict and stress in interpersonal relationships, which in turn play a role in mood disturbance, anxiety and substance abuse.

Failure to diagnosis

So why the failure to diagnose personality disorders? First, psychiatric treatment, as mentioned above, is often focused on the most acute concerns (typically mood, anxiety and substance-related). Second, labeling someone with a personality disorder diagnosis can be stigmatizing. Indeed, patients are likely to be opposed to a personality disorder diagnosis, feeling it might brand them as “a bad person” or, worse yet, beyond help. While avoiding stigma, we also must be judicious in diagnosing these disorders and acknowledge that it is hard to draw a firm line between adaptive and maladaptive traits.

Proud to be a narcissist

One of the most recognizable, if not inadvertently glorified, personality disorders is narcissistic personality disorder. Patients who endorse narcissistic traits are, perhaps not surprisingly, quite proud of them. They report:

“I would not be the person I am today if had not taken a hardnosed approach to business. You do whatever it takes, even if that’s at the cost of friendship.”

“If there is a problem I am going straight to the top; they need to know who they are dealing with.”

“The ends justify the means. I couldn’t let anything stand in the way of my success, and it paid off.”

Narcissistic individuals might acknowledge their inflated views of themselves, or they might skirt around how they truly feel, not wanting to reveal any type of perceived weakness. Those who acknowledge these aspects of their personality outright tend to have a well-defended reason for such traits: It helped them be successful. What might not be obvious to them, however, is the personal cost associated with such achievements.

Paying the price

 Extreme personality traits also can contribute to vulnerability to clinical syndromes, including depression, anxiety or substance abuse, in part by creating stress in significant relationships, such as with a spouse or partner, co-workers or bosses. Persons who exhibit extreme personality traits may find themselves at odds with others who do not “buy into” their views, expectations or standards. Extreme personality traits contribute to rigidity and insensitivity to others’ viewpoints. In addition, they can lead to social isolation, reduced opportunities for relationships, limited support networks and less satisfaction in life.

Yet, as obvious as these problematic behaviors may to be others, the person exhibiting such traits may be oblivious to them or their social cost. The individual may be the last to see that the root of their troubles is potentially within their control.

Adaptive vs. maladaptive

 So where is the line between adaptive and maladaptive? Sometimes exploration and reflection can help make patients aware of their maladaptive behavior patterns. Questions I ask in the SCID interview include: “How has this (trait) affected your relationships with coworkers, family members and friends?” “How do you think others would describe you as a person?” “Has this (trait) caused any problems at work or home?” A chance to be introspective and “mentalize” about another’s viewpoint can help an individual learn how their behaviors may be contributing to strained relationships and additional stress in their lives.

Personality traits define us; they make us who we are. They are the instigating factors behind relationships, career choices and life experiences. In moderation, such traits are valuable; in the extreme, they become detrimental to our relationships and wellbeing. So, the next time you happen across an individual justifying their narcissism through their copious achievements—remember the high price they might be paying in their relationships.

Have you ever made a wish that came true? Or considered Fate or Providence to be at play when someone or something entered your life at an opportune time? What about dreaming about an event that intriguingly played out in real life? Have you ever mourned the passing of a loved one, only to inexplicably feel their presence?

Most people probably identify with such experiences, and many would assign value or meaning to them—perhaps identifying them as divine intervention, believing in the gift of clairvoyance or feeling a special connection with the spiritual realm. Such experiences can impact an individual’s life by providing reassurance, guidance or a stronger sense of spirituality.

Is it possible that people’s stories about miracles or spiritual encounters are merely symptomatic expressions of something more ominous—a psychiatric illness perhaps? From a diagnostic viewpoint, such experiences may be labeled “magical thinking,” “delusional” or “psychotic.” Could they be chalked up to a diagnostic label? And how do clinicians have the authority to make this determination—especially as they interpret such experiences through their own spiritual (or agnostic) lens?

A matter of perspective

The issue of spirituality versus psychopathology seems to be a matter of perspective. Overvalued ideas about one’s spiritual belief system can be interpreted by others as symptoms of a personality disorder or psychosis. How do we differentiate between healthy spirituality and psychopathology? The Diagnostic and Statistical Manual of Mental Disorders (DSM) offers some guidance, defining delusional beliefs as beliefs “not ordinarily accepted by other members of the person’s culture or subculture.” However, with ever-increasing spiritual sects, it can be difficult for the clinician to know what beliefs might be shared. Additionally, the DSM references the level of impairment, context of behavior or belief and symptoms that may be substance-induced. Thus, isolated experiences that are not part of a broad pattern of disturbance should not be diagnosed.

At times a patient’s spiritual beliefs can interfere (from the clinician’s perspective) with their ability to function in a social, occupational or academic setting. These cases can be challenging to filter through the diagnostic decision tree, especially when it seems as though no one can know for sure the extent of truth to any unusual experience.

For example, I met with a patient who had a strong sense that he was “different” from others; he believed he had lived many past lives and had a special connection with the world that most people he encountered could never understand. He described countless “messages from the universe” directing him in his everyday activities. 

From a diagnostic perspective his descriptions bordered on quirky if not impairing. He became quite concerned with physical symptoms, such as feeling like his body was being taken over by an unexplained force, which doctors could not explain. He continually found hidden meanings in TV commercials or friends’ comments that most would consider ordinary experiences. Although he was able to function for the most part independently, he maintained an outlook on the world that made it difficult for him to relate to others and ultimately caused rifts in his relationships.    

SCID platform

The topic of unusual events, or what some define as paranormal or supernatural phenomena, is not typically at the forefront of most clinical discussions between patients and clinicians, in part because they are not of primary concern for patients seeking treatment. However, in my role conducting the Structured Clinical Interview for the DSM Disorders (SCID), I have a platform for discussing them.

In the psychotic symptoms module is a question about unusual religious experiences. Inevitably, patients pause before asking, “What do you mean by unusual?” At this point a dialogue ensues regarding a patient’s personal experience with the supernatural (however they choose to define it) and their interpretation of this experience. The question “Have you ever had visions or seen things others couldn’t see?” sometimes elicits responses about encounters with apparitions of deceased loved ones or patients hearing their name being called or seeing menacing, dark entities. 

In the schizotypal personality disorder module are questions about experiences with the supernatural, unseen forces and unusual perceptional experiences. Interestingly, many patients will disclose personal experiences, such as encountering an animal they believe is the spirit of a deceased relative or describing an ability to predict events that others cannot. Some patients report being guided by entities not of this world—or being protected from near fatal situations by inexplicable forces. Such experiences, while unexplainable, may have a profound impact on their outlook for the future or their belief in forces that transcend our worldly knowledge. 

I am always struck by patients’ initial hesitancy in sharing these extraordinary events; however, I understand discussing them during a diagnostic interview can seem more stigmatizing than normalizing. I find interesting patients’ insistence on presenting their story with the disclaimer,

“This probably means I’m crazy, but….”

It seems as though there is a tendency in the mental health field to dismiss such occurrences as not only strange but indicative of psychiatric illness, implied, in part, by the fact that such questions even exist in the SCID. At times patients decline further elaboration because their experience is deeply personal and meaningful and fear a diagnostic label or quizzical reaction would be demeaning. 

James vs. Freud

The topic of supernatural experiences is nothing new in psychology. In fact, psychologist and philosopher William James wrote about an enormous range of spiritual experiences in The Varieties of Religious Experience: A Study in Human Nature. James believed in an unseen reality and that mystical experiences contributed to a more fulfilling life. Rather than categorizing them as pathological, James sought to include spirituality as a healthy component of psychological functioning. James recounts examples of patients’ mystical encounters in which they felt connected to a higher power through events that ranged from auditory experiences of God talking to them to inexplicable physical energies. 

In contrast to James, Sigmund Freud tended to pathologize religion and religious experiences. In The Future of an Illusion, he depicted religion as a manmade illusion created in an attempt to control human instincts (cannibalism, incest and desire to hurt or kill one another). Freud, an outspoken atheist, likened religious practices to neurosis, claiming that humankind had an obsessive need for protection which could only be achieved through a relationship with a father figure (God). Unlike James, Freud viewed spiritual beliefs and experiences as illusions, in part because they lacked scientific explanation. The opposing viewpoints of James and Freud reflect the significant divergence in clinical perception regarding spiritual experiences that persists to this day. 

So is it psychotic or on the fringe of psychosis to believe in a spiritual connection with a deceased loved one? Should you be diagnosed with schizotypal personality disorder if you believe that ordinary things in your life are meant to give you a special message? The answer is a resounding…it depends. Schizotypal personality disorder is diagnosed not on the basis of isolated experiences or quirky beliefs, but rather on a cluster of problematic traits. Psychotic disorders are diagnosed on the basis of a major break with reality and significant impairment in functioning. It is unlikely that science will ever be able to make an absolute distinction between what is symptomatic of psychopathology and what is merely an aspect of diverse human experience. This illustrates the significant influence of cultural considerations on diagnoses and demonstrates that diagnoses cannot be reduced to a science. Ultimately, we must rely on human judgment, which makes my work all the more intriguing.

I am immersed in my new position as a clinical interviewer at The Menninger Clinic. Leaving behind my previous career as a vocational rehabilitation counselor, I never imagined finding a job that would provide the ideal platform for furthering my interest in psychiatric diagnoses. As a clinical interviewer, I administer the Structured Clinical Interview for DSM-IV disorders (SCID) to adult patients at The Clinic. The SCID covers a variety of symptoms and behaviors culminating in clinical diagnoses for a wide range of psychiatric disorders. The purpose of using the SCID at Menninger is to document diagnoses for research purposes, as well as to provide diagnostic information to treatment providers.

My position provides a unique experience with patients in that I enter the interview unbiased by previous interactions and with minimal history. Thus I am in a good position to assess patients’ symptoms from their point of view. The work is fascinating as it challenges me to decipher symptoms, using my previous clinical experience and knowledge of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to help determine appropriate diagnoses. My curiosity about diagnostic criteria is piqued as I learn how to fit patients’ unstructured experiences into a structured set of diagnoses.

Patient feedback

Since starting these interviews, I have received considerable feedback from patients regarding their DSM diagnoses. Their reactions fall into two opposing views:

1. those who accept and appreciate their diagnosis as well founded and informative and
2. those who object to their diagnosis, feeling as though it strips them of their personal experience and lumps them into a stigmatizing category.

My interest in these viewpoints was sparked by a patient who expressed loathing for the DSM. She asked why I was using the manual, explaining that in her opinion the idea of a diagnosis was too subjective, stigmatizing and counter to a therapeutic experience. The patient even asked if I could pass this information on to the people who created the DSM as a means to discontinue its use. I explained I had no direct contact with the writers of the DSM; however, I could appreciate her concern regarding diagnoses. I shared my opinion that diagnoses actually can be helpful in presenting clinicians with an understanding, on a quantifiable level, of a patient’s symptoms and behaviors. In essence, diagnoses provide a mental image that can help clinicians focus their efforts in a particular direction, leading to a more efficient approach to treatment. This was the first of many conversations that I would have with various patients who were concerned for their wellbeing, the focus of their treatment and the potentially stigmatizing effects of their diagnoses.

Not all patients express disdain for their DSM diagnoses. Some patients take the opposite extreme, that is, they  over-identify with their diagnosis. Some can get so caught up in the diagnostic label that they even adjust their own behaviors to better match those of the diagnosis-specific symptoms. For example, I met with a patient who remarked that her entire identity surrounded her diagnosis of borderline personality disorder. “I’m a borderline,” she reported, describing how she has been told this and believes it to be true to the extent that it defines who she is as a person. During our interview, she frequently referred to the diagnosis, often letting me know that her behavior “is typical of borderlines.” Subsequently, the patient seemed to match each of her examples of poor decision making with behaviors found in other people with the same diagnosis. After our meeting, I couldn’t help but wonder: Were her behaviors truly a “by-the-book” coincidence or, having learned more about the diagnosis, was she unwittingly aligning her behavior to be more like what was described in the DSM?

Another patient reported she had been depressed her entire life, noting the many experiences that resulted in her current dismal state. She had become so accustomed to discussing her depression as something that was outside of herself, yet so much a part of her life, that when asked about who she was apart from the depression, she could not recall. It occurred to me that this chronic depression may no longer be distinguishable from her personality.

Such excessive identifications with diagnoses can rob the patient of agency, externalizing responsibility onto a diagnosis as if it were an impersonal force in control of the person’s behavior. No doubt, patients can feel that their illness has control over their behavior. However, the goal of treatment is to help patients develop a greater responsibility for their illness, and the goal of diagnostic understanding is to help patients feel more knowledgeable and empowered.

Impact of a changed diagnosis

Yet another problem with over-identification: When a diagnosis becomes assimilated into one’s self-image, it can cause marked confusion if the diagnosis is ever changed. For example, one patient reported he had been told he was depressed his entire life and had therefore adopted the idea of depression as part of who he was. He had extensive knowledge about depression and the various anti-depressant medications available. He identified so much with his diagnosis that when it was recently changed to bipolar disorder, he became upset, feeling that his personal schema had been turned upside down. He now struggled with an image of being “disturbed,” having a diagnosis that in his opinion brought to mind an agitated, “crazy” person. He reported, with dismay, “They’re saying I’m bipolar now.”  In a similar example, another patient, formerly diagnosed with depression, reported going to great lengths to keep her newly diagnosed bipolar disorder a secret, driving many miles to a remote pharmacy to pick up her prescriptions. She reported discontent, fear and shame over her new diagnosis. For both patients, the cost of identifying with a diagnosis was internalized stigma.

Both of these perspectives – for and against diagnoses – have validity. On the one hand, the collection of symptoms is helpful in categorizing behaviors into an objective DSM diagnosis, which can facilitate understanding and inform treatment. On the other hand, there is a limit to objectivity. The symptoms are subjective and must be interpreted twice: once by the patient and again by the clinician. Sometimes symptoms are vague and apply to a number of different diagnoses, while at other times patients lack awareness into subtle symptoms that can make a significant difference in a diagnosis. Moreover, clinicians filter their patients’ descriptions of symptoms through their own subjective understanding of a diagnosis.

Each patient’s initial diagnosis is tentative at best and is refined over the course of treatment and through the collaborative effort of the treatment team. Most important, a diagnosis is only one facet of the understanding that goes into an individual’s treatment.

So how much weight does a diagnosis hold? You be the judge.

When you think of the word “rehabilitation” what often comes to mind is a disheveled derelict sobering up after a lifetime of bad choices or a burned-out meth addict who was a high school dropout and indulged in a life of crime and prostitution.

Rehab is for real people

What may not come to mind is the man who graduated from medical school at the top of his class and had a successful private practice for many years before an unexpected surgery led him to become addicted to pain medications, or the devoted mother who juggles three jobs to support her family and found her occasional glass of wine adding up to a bottle or two a night.

We might not consider the hard-working, decorated military veteran who is paralyzed by anxiety or the magnetic motivational speaker whose incapacitating depression prevents her from getting out of bed for months on end.

These aren’t the type of people we typically think of as seeking treatment – whether psychiatric or substance-based – in part because the media exposes us to a very narrow segment of the population making headlines in this area: celebrities. Unfortunately, this small population has a disproportionate effect on our image of a person in treatment, despite the fact that the treatment seen on TV is not representative of rehabilitation as a whole.

Media attention helps and hurts

The recent media attention celebrities have brought to treatment through shows like Dr. Drew Pinsky’s “Celebrity Rehab” can be seen as both a step forward as well as a step back. On one hand, the shows have increased awareness of the prevalence of mental illness and addiction, helping to ameliorate the strong stigma that still exists.

Charlie Sheen

On the other hand, such shows and media coverage may lead viewers to question the sincerity of patients in treatment. When popular celebs such as Lindsay Lohan and Charlie Sheen briefly enter treatment in the most comfortable of settings, sometimes only after the threat of prison time, their actions can be seen as an insincere act designed to avoid legal consequences or generate publicity.

Adding to the question of sincerity is how much of the focus is truly on treatment. The fact is most participants on shows like “Celebrity Rehab” are immaculately made up, and often seem to be purposefully acting in ways likely to garner more screen time.

While we can’t doubt the sincerity of every celebrity seeking treatment, it is important to note the feelings we come away with after watching these shows: Are we merely entertained by the antics, or are we more empathetic to the plight of these individuals?

Indeed, it’s an important question to consider, as more celebrities than ever are checking themselves in for treatment of all kinds.

The power of treatment

Despite the hype that celebrities bring to the area of rehabilitation, it is important not to lose sight of the significance of treatment. Rehabilitation, whether psychiatric or substance-based, can be life altering. Whether one enters treatment to satisfy a legal obligation, or because there is a true desire to change, most people can look back on their time in treatment with appreciation.

For me, working at The Menninger Clinic has brought to light just how grateful patients are for the treatment experience. I have witnessed patients gain a brighter outlook and better quality of life as a result of the combined efforts of the treatment team and staff. I can recall being moved by some of my first experiences here, especially listening to the stories patients told upon discharge; their heartfelt gratitude and newfound hope was inspiring.

I recall a particular patient, a self-described “hell on wheels,” who entered The Clinic in a somewhat hostile and impatient manner. Over the next eight weeks I noticed a softening of her demeanor and witnessed her engaging in meaningful and supportive conversation with fellow patients. At the community meeting where she said goodbye to her fellow patients and the program staff, she reflected on her experiences at Menninger and offered words of encouragement, as well as this thoughtful statement:

“Some of the finest people I have ever known currently live in mental institutions, or work in them.”

Touching examples such as this one help give a face and a story to a patient, who may otherwise fall into the stereotypical image of a person in treatment.

She was just one example. In fact, one does not need to look far to see the impact this Clinic and its staff have had on patients; countless letters decorate break rooms and unit walls, bearing witness to the many lives that are touched in the experience of treatment.

Keeping things in perspective

Lindsay Lohan

So the next time you hear about another celebrity agreeing to be filmed while engaging in treatment with the promise of a “spin-off show,” or you see a glossy magazine cover proclaiming that Lindsay Lohan is using her time in treatment to prepare for a new role, keep in mind that this is merely a snapshot of a very select population, and that there exists a much larger group of people who are seeking treatment to get back on track with their lives, no strings attached.