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Although most patients will not have a causative underlying medical condition, the growing impact of environmental toxins, drug interactions, and degenerative diseases have increased the possibility that there is a medical origin for the condition. While psychotherapists should not live in fear of missing an unsuspected medical origin, it is important to have adequate knowledge of the medical issues that could potentially relate to their patients' conditions. This course will provide an overview and source of reference to help make a basic assessment to determine whether medical consultation might add insight to a case.
Naturally, it is not intended to provide psychotherapists with the tools needed to diagnose these medical conditions. It will, however, lay the groundwork to allow a therapist to speak in a knowledgeable way with consulting physicians and improve the likelihood of a good evaluation for the patient.
Although not every mental health problem is masking a primary medical condition, one thing is certain — when there is an underlying medical component, psychotherapists who do not consider the possibility are certain to miss the diagnosis. Consider this scenario: A family comes to a psychotherapist for help because the middle child has been defiant and difficult.
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He refuses to go to bed at night. During the day, he is hyper-reactive and non-compliant.
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This often leads to family squabbles, which frequently morph into arguments between the parents. As the therapist works with the family, it becomes clear that the fights are exacerbated by the husband's angry outbursts and bouts of rage. Although the family works hard to improve its coping skills, communication, and problem-solving abilities, the conflicts persist. It is a baffling situation. Neither the therapist nor the family members are aware that the father, who lives on a diet of fast food, has developed extremely low levels of omega 3 fatty acids.
This medical condition, not his emotional profile, is the root cause of his anger and rage. Without a physical and lab testing, this problem will likely not be detected. Although many psychotherapists are aware of the possibility that underlying physical conditions can cause or exacerbate emotional issues, the reality is that a majority of mental health practitioners spend most of their time treating uncomfortable feelings or social problems — not mental disorders, much less medical problems.
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As a result, they can easily miss the signs that might lead them to recommend a professional medical diagnosis. Even internists and physicians at hospitals often miss the underlying medical causes of mental and emotional issues. Despite advances in medical technology, there is still no test to definitively identify mental disorders.
At best, medical evaluations can provide clues and help eliminate some of the variables. When the patient's symptoms do not correspond precisely to the reference books or to similar cases they have personally encountered in the past, a physician may make a misdiagnosis as easily as a psychotherapist might. The challenge of finding potential underlying medical causes is complex. This makes failure to recognize and diagnose an underlying condition in a patient a reasonably common occurrence.
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For most psychotherapists, a good proportion of clients come for help in coping with the problems of life. Outpatient psychotherapy, couples therapy, and family therapy are some of the many techniques designed to address these woes. Family therapists routinely work with quarreling couples and troubled children amid what are often called dysfunctional families.
While psychologists and other mental health professionals in private practice also address family dynamics, they are more likely to spend time working with personal or phase-of-life difficulties, as well as treating symptoms of depression, anxiety, and panic attacks. There is no doubt that many family therapies and psychotherapies can be useful and effective in ameliorating these problems. Family therapy, couples therapy, group therapy, cognitive behavioral therapy, and other techniques have been shown to be quite effective in attenuating mood disorders, relationship problems, and social quandaries.
Although people may leave therapy feeling better, problems often recur. Even couples or families who leave your office thanking you profusely may reappear at your door six months later. People with chronic depression inevitably relapse. These events suggest that, beneath a presenting problem, may lay an undetected, chronic pathology that is the root cause of their woes. Most psychotherapists are not medical doctors, research scientists, or geneticists.
Nevertheless, all mental health professionals today must have a working knowledge of how the body works and how the world we live in affects brain function. In the last few years, incredible developments in neuroscience, genetics, epigenetics, physiology, pharmacology, the immune system, toxicology, and nutrition indicate that many mental problems can be caused, exacerbated, and treated by alterations in biological and biochemical processes. Psychotherapists are taught how to diagnose mental disorders and deliver psychotherapy. To diagnose means to observe, identify, and determine the cause of a disease or disorder.
To make a differential diagnosis means to distinguish between disorders with similar presentations by comparing their signs and symptoms. The diagnosis of a mental disorder is most often done by observing signs and symptoms which fit the diagnostic criteria in the Diagnostic and Statistical Manual DSM. Practitioners also use tests and assessments as diagnostics tools.
Although these techniques have value, they seldom address the cause of the mental disorder. DSM-5 has included a category named the neurocognitive disorder, which was formally known in DSM-IV as 'dementia, delirium, amnestic, and other cognitive disorders. We know what dementia, depression, and cognitive disorder look like, but we often do not know what causes them. We use words like reactive depression, endogenous depression, or organic mental disorders , but few professionals actually understand the implications of these terms.
The truth is that many medical disorders manifest themselves by psychological symptoms and organic mental disorders are not distinguishable on the basis of mental and emotional symptoms. When people come to us for help, they describe their problems.
As they are doing so, we listen carefully for signs and symptoms. For example, if Mr. Johnson tells us he is not sleeping well, has aches and pains all over his body, has lost his appetite, and is feeling hopeless, we begin to think he may be depressed. If he tells us that he has racing thoughts and difficulty sleeping, we begin to think he may have bipolar disorder. This strategy is useful, but often inaccurate.
Once we begin to feel confident that we have the diagnosis, we get a history of Mr.
We want to know about his childhood, his family, his hopes, and his fears. We are looking for pieces of his history that fit our theory. When he tells us that his father repeatedly abused him, we feel we know something about the cause of his problems. Oftentimes, we do not question the veracity of what we are told and have no solid data other than his subjective account to indicate that this may be the cause of his woes, but since the story does fit our belief system, it bolsters our confidence.
All mental health professionals are trained in certain theories of diagnosis and treatment.
They come to believe, for example, that depression is caused by faulty thinking, is caused by lack of serotonin, or is caused by repressed trauma or abuse. One of the pitfalls of effective psychological intervention is theoretical bias. All of us have specific training, received from professors who had their own pet theories of psychopathology.
Although being trained in a certain type of psychotherapy has value, it also can lead a clinician to overlook any signs and symptoms that do not coincide with her belief system. I was struck by this many years ago while in graduate school. One on my professors — who was trained in classic psychoanalysis — recounted the case of a woman in her mid-thirties who could not decide if she wanted children.
Although her husband was clear about wanting a child, she was ambivalent and worried that she would be an inadequate mother. He felt confident that, once these feelings came to light, the patient's indecision would disappear. He told us that, after four years of psychoanalytic therapy, she had still been unable to make the decision. Unfortunately, in this case, the problem was not well-suited for psychoanalysis. As the years rolled by and the patient became older, the problem would gradually become moot.