Dr. B's Blog

4 vs. 5. What's the difference?

[Part one of this series of blog posts (because it has to be a series or I'm never going to get any of is published) will be a quick orientation to the concept of psychiatric diagnosis. Future parts will be much more extensive and go into the ongoing discussion regarding categories vs. dimensions in the DSM-5.] If you answered “1” to the question posed in the title of this article, you’d be right and wrong depending on what the units were measuring. When it comes to mental health diagnoses, it’s all in what is being measured. It could be a difference this >< large or one quite a bit bigger.

The debate about the "correct" way to make a diagnosis is at least as old as the Diagnostic and Statistical Manual and its categorical definition of mental illness. A quick lit search for the terms "categorical" "dimensional" and "diagnosis" reveals a discussion going back over 25 years.(1, 2, 3, 4 ).

Why the ongoing debate? The question essentially boils down to whether psychopathology is different in kind or merely in degree from typical emotional experience. That is, do people who experience what is considered a diagnosable mental illness have a qualitatively different experience of emotion than others?

Is sadness in Major Depressive Disorder a different kind of sadness? Or is it just a difference in how intense it is?

Is the anxiety someone with Generalized Anxiety Disorder experiences a different kind of anxiety? Or is it just more intense or pervasive?

How does a psychologist make a diagnosis?

The "right" way to make a diagnosis is to ascertain the level of severity of one's symptoms through either a structured or unstructured interview or questionnaire or other form of assessment. Using the information gleaned from this assessment, symptoms are compared to what's listed in the DSM to see if enough symptoms have been endorsed to be given a particular diagnosis. A thorough psychologist/assessor would make sure that there are no rule-outs or disorders that supercede the one being considered. 5

The decision after an assessment is a binary one: does the person meet enough criteria to be given this diagnosis? Take the diagnosis of Major Depressive Disorder. There are 9 criteria that can be considered. Five of those nine criteria must be met, with one of them being the first criteria. If a person meets 5, they can be given the diagnosis. If a person meets 4 of them, they cannot. That person would be considered to have "subthreshold" depression.

What's the difference between those two people? It could be just a matter of 1 fewer day of sadness or it could be a lack of something more substantive like hopelessness. The former is much less of an actual difference than the latter, obviously, and can make a significant difference in presentation and outlook.

(More to come on this topic in a future post, probably next week.)

  1. A recent article in Wired Magazine talks about this debate.↩
  2. Some more discussion of the Wired article can be found on mindhack. These articles are just a couple of the many on the subject. ↩
  3. Thomas Widiger’s classic article on Axis II and categories back in 1993.↩
  4. Lorna Smith Benjamin’s response to Widiger.↩
  5. For example, if a person has ever had a manic episode, future diagnoses of Major Depressive Disorder are ruled-out because Bipolar Disorder would supercede the diagnosis due to the history of a manic episode. ↩

Immersion and Mindfulness

I'm a big fan of games. I think a good game can be a nice distractor (a distress tolerance skill) when we need one, can be a nice reward if we're struggling with motivation (an emotion regulation skill) and help us practice mindfulness if we're, umm, mindful while playing. I came across this article a little while back which highlights some of the reasons games have the effect they do on us.

People who experience immersion tend to only consider choices that make sense in the context of the imaginary world. Someone immersed in Red Dead Redemption, for example, might be more likely to use travel methods, like stagecoaches, that make sense within the game, instead of methods that don’t (like fast traveling from a menu screen). People immersed in media also tend to enjoy it more.

It's not "research" in the sense that there's no hard data, but there is some sound theory in the reasoning and a couple of links to relevant research articles.

Ψ What is DBT?

What is DBT?

We are often asked this question by friends and family and, while there are a number of websites devoted to DBT, it’s hard to get a clear answer on this very important question. Keep in mind that there is no one, specific answer you’ll get to this question. Ask 10 DBT therapists “what is DBT?”, though, and you’ll likely get some combination of these points:

  • Dialectical Behavior Therapy
  • An empirically supported treatment for the treatment of Borderline Personality Disorder. It is expanding its research support to include other conditions such as anxiety disorders, depression, substance use and eating disorders.
  • A skills-based treatment to help one develop a “life worth living”.
  • An acceptance-based treatment designed to help one cope with life.

All of these descriptions are accurate but they don’t really help explain what DBT means and how it might help you more than other types of treatment like Cognitive Behavioral Therapy (which, itself is an EST for a variety of conditions).

When we’re asked what DBT is, depending on the audience, we will go into talking about how DBT is a “third-wave psychological treatment which is based on CBT but adds some essential components like Mindfulness and Acceptance.” Again, this is a completely accurate description, but doesn’t give you a sense of what that actually means.

Dialectical Behavior Therapy is a treatment that works on a number of levels, including some of the same ones found in Cognitive Behavior Therapy. In CBT, there has been, historically, a great emphasis placed upon changing and challenging your thoughts to change how you feel. This is all well and good for many situations and emotions, but there is an essential piece of the puzzle missing. Emotions aren’t just the product of thoughts. As emotion researcher Paul Ekman talks about in his book, Emotional Awareness: Overcoming Obstacles to Psychological Balance, emotions are not just thought about, they are felt, physiologically. As a result, you may be able to successfully challenge your thoughts but still feel the way that you do.

This line of thinking about emotions also leads one to the somewhat judgmental conclusion that if you would just “think differently,” you would feel differently. That is, it’s your fault you feel as you do. While it may be your responsibility to address how you feel, change the situations you find yourself in, and accept your lot in life, it most certainly not your fault. Just like it’s not your fault if you get wet when you’re standing in the rain.

How does DBT address this problem?

DBT focuses on a model of emotion that takes into account not only the thoughts that precede an emotion, but also the physiological changes one experiences prior to its onset. It teaches ways to address those changes so that you can approach emotions in a multi-faceted way. In DBT, You will learn the skills required to effectively challenge your thoughts.You will learn how to change your physiology. But, most importantly, you will learn how to understand and accept your emotions to help keep them from taking over your life. This, I believe, is the key difference between DBT and CBT and the reason DBT is applicable to many conditions aside from the currently researched ones. It is surely not the only treatment that could work, but I find that it is the most useful approach to take.

DBT is a principle-driven, as opposed to protocol-driven, approach to therapy. You will not have an “agenda” per se set at the beginning of a session, for example. What are the principles that can help us understand your current situation and what technique would be helpful to address it?

A comprehensive DBT program is important to help you learn these skills and generalize them to your environment.

DBT will also help you address interpersonal problems that have arisen in your life and get through those times that are so overwhelming all you can hope to do is tread water. On top of all of this is the notion that Mindfulness is a key to your psychological well-being.

The Big Picture

When one talks about DBT as a treatment modality, it’s important to recognize that it’s not just about skills training group. These groups are an essential part of any DBT program, but it’s not the only part. A comprehensive DBT program will incorporate all of the following components:

  • Weekly individual therapy where goals are discussed, motivation is maintained and problem-solving is taught.
  • Weekly group therapy where skills are taught and practiced.
  • Telephone coaching where skills are generalized to your environment.
  • And therapist consultation team meetings where your therapist makes sure he or she is delivering the treatment effectively and not missing important details.

Further, behavior tracking using “diary cards” is important to help you monitor what is going on in your life and how you are dealing with them with your skills. These diary cards also give your therapist a chance to get a quick glance of your week and see where things need to be addressed.

If this sounds like an approach you think might be helpful, contact us.

Ψ Yerkes-Dodson Law

On multiple occasions throughout my week, I talk about the Yerkes-Dodson Law 1. It occurs to me that I should probably write up a post on this subject so that others can get a sense of what it means to have functional anxiety and when anxiety can be helpful or harmful. The “law” is not complicated, but understanding it can go a long way towards helping people who suffer from things like performance anxiety or social phobia.

Generally speaking, conventional wisdom suggests that there’s an inverse relationship between anxiety and performance. That is, the more anxiety you have, the worse your performance. That’s partly true, but only half of the story. The other half is that there is a point at which too little anxiety can affect performance as well. So, there’s a direct, as opposed to inverse, relationship between anxiety and performance. There’s a point in the middle, between the two relationships, direct and inverse, where anxiety and performance are at optimal levels.

Think of an inverted “U”, with the point in the middle being that optimal level of anxiety for peak performance. In non-psychology terms, it means that you need to feel some anxiety to do well. Think of it like this: If you are never anxious prior to taking a test, are you really going to study? Probably not. But if you’re too anxious prior to taking a test, can you study effectively? Probably not. The key is to maintain an optimal level of anxiety without going too far in one direction or another.

How does one do this? Well, there are a number of ways, but I prefer to have people practice some mindfulness meditation. In addition, working on identifying thoughts that are causing them to become more anxious than is called for by the situation (e.g., it’s perfectly understandable to worry about failing a class if you don’t do well on your final, but it’s a bit much to imagine the end of your earning potential if you fail). We call this “cognitive restructuring” in the CBT/DBT areas of psychotherapy.

Footnotes:

  1. A note about wikipedia links: I like Wikipedia.org for information on various subjects, with the caveat that Wikipedia can change from the time I link to the page. As of 01/22/09, the information on Wikipedia about Yerkes-Dodson is accurate. I can’t speak to how long it will remain so, but you can always go back through the revision history and see what it said today.↩