Oct 3, 2023·edited Oct 3, 2023Liked by Dr. Samantha Boardman
This is an interesting take and I understand the cause for concern about overpathologizing and over-diagnosis of patients. At the same time, as a now medical student who, for years, thought that the anxiety I experienced with dating, test-taking, the voice shaking when I was called on in class, and other areas of my life was completely normal. Some of it was normal nerves, but some of it was disproportionate to the situation and I definitely compensated in ways where it may have not been obvious that I was dealing with anxiety that needed treatment. But it was only until I began going to therapy for unrelated reasons, having a practitioner recognize that I had GAD, and then starting an SSRI that my brain finally quieted down and I realized that the mental Olympics my brain had been going through was NOT neurotypical. I wish I had been given the space to explore a GAD diagnosis and see if it fit my experience earlier in my life.
I want to ask: how do we navigate the fine line between overdiagnosis and underdiagnosis especially in high functioning individuals who may be good at masking their symptoms?
You pinpoint the challenge-trying to better understand the line between what is pathological and what is normal requires nuance, education, and communication. Under treatment remains as much a problem as over treatment. Thank you for your comment.
Love this. Thank you. I have a lot of 'normal' anxiety and it appears with every new day there are new challenges that challenge me and my ability to 'handle' what has come my way. It sometimes feels like out of a movie life is so unpredictable. I guess that's my dilemma is looking for some predictability in life and the fact is we can't 'predict' people and their actions. Sometimes I feel like I need more of a 'shield' then a 'feather'.
Clinically how would you categorise anxiety that is appropriate, say in the context of Ukraine like you mention, but interfering in someone’s ability to function, you could imaging someone struggling to sleep or engage socially in this context. That seems like neither a disease or a normal part of life.
I understand the point…but in behavioral health, medical necessity requires a diagnosis to treat. In this case, upon presentation, this person would most likely be diagnosed with a trauma related disorder, and hopefully given an accurate diagnosis.
Though there is a fine line between what is a normal response to stress and dysfunction, I have found behavioral health professionals tend to pathologize normal responses more than not…and part of it may be due to the medical necessity requirement so they can get paid. The medical model seems to promote diagnosis even when the response is “normal.”
That’s what I was wondering about in relation to the original post. If you were trying to avoid that pitfall how would you then ideally treat a scenario that falls in between a proportional response but one that is still difficult to cope with. The presumption is that the difference between anxiety and trauma is simply quantity and I’ve heard it been described as more complicated than that, more to do with lasting effects.
Dr Boardman has also previously raised some interesting points about how psychological coping isn’t always appropriate ie in the context of someone having just suffered a horrific accident and I was curious if there are conceptual gaps in how we think of mental disorders or illnesses.
I think there are definite gaps. I worked in a community mental health center during my career. In our model, a client would see a medical provider for medication, see a therapist for therapy or both. My frustration was and continues to be medical staff failing to refer clients for therapy when their circumstances clearly indicated the need.
Ideally, we determine the need for treatment by conducting an assessment of symptoms and the functional impact of those symptoms (another part of medical necessity). Then we have to render a diagnosis. This diagnosis is to guide treatment. Often, the best treatment is therapy.
This is an interesting take and I understand the cause for concern about overpathologizing and over-diagnosis of patients. At the same time, as a now medical student who, for years, thought that the anxiety I experienced with dating, test-taking, the voice shaking when I was called on in class, and other areas of my life was completely normal. Some of it was normal nerves, but some of it was disproportionate to the situation and I definitely compensated in ways where it may have not been obvious that I was dealing with anxiety that needed treatment. But it was only until I began going to therapy for unrelated reasons, having a practitioner recognize that I had GAD, and then starting an SSRI that my brain finally quieted down and I realized that the mental Olympics my brain had been going through was NOT neurotypical. I wish I had been given the space to explore a GAD diagnosis and see if it fit my experience earlier in my life.
I want to ask: how do we navigate the fine line between overdiagnosis and underdiagnosis especially in high functioning individuals who may be good at masking their symptoms?
You pinpoint the challenge-trying to better understand the line between what is pathological and what is normal requires nuance, education, and communication. Under treatment remains as much a problem as over treatment. Thank you for your comment.
Thanks for this, starting a new project today and trying to manage my anxious energy in a productive fashion!
I hope this helps!
Love this. Thank you. I have a lot of 'normal' anxiety and it appears with every new day there are new challenges that challenge me and my ability to 'handle' what has come my way. It sometimes feels like out of a movie life is so unpredictable. I guess that's my dilemma is looking for some predictability in life and the fact is we can't 'predict' people and their actions. Sometimes I feel like I need more of a 'shield' then a 'feather'.
Being a retired mental health therapist, I have seen many instances where clients were misdiagnosed, only to over-identify with that diagnosis.
Clinically how would you categorise anxiety that is appropriate, say in the context of Ukraine like you mention, but interfering in someone’s ability to function, you could imaging someone struggling to sleep or engage socially in this context. That seems like neither a disease or a normal part of life.
Perhaps an Acute Stress Disorder. A lot of anxiety has roots in trauma.
The point is it doesn’t sound that disordered
I understand the point…but in behavioral health, medical necessity requires a diagnosis to treat. In this case, upon presentation, this person would most likely be diagnosed with a trauma related disorder, and hopefully given an accurate diagnosis.
Though there is a fine line between what is a normal response to stress and dysfunction, I have found behavioral health professionals tend to pathologize normal responses more than not…and part of it may be due to the medical necessity requirement so they can get paid. The medical model seems to promote diagnosis even when the response is “normal.”
That’s what I was wondering about in relation to the original post. If you were trying to avoid that pitfall how would you then ideally treat a scenario that falls in between a proportional response but one that is still difficult to cope with. The presumption is that the difference between anxiety and trauma is simply quantity and I’ve heard it been described as more complicated than that, more to do with lasting effects.
Dr Boardman has also previously raised some interesting points about how psychological coping isn’t always appropriate ie in the context of someone having just suffered a horrific accident and I was curious if there are conceptual gaps in how we think of mental disorders or illnesses.
I think there are definite gaps. I worked in a community mental health center during my career. In our model, a client would see a medical provider for medication, see a therapist for therapy or both. My frustration was and continues to be medical staff failing to refer clients for therapy when their circumstances clearly indicated the need.
Ideally, we determine the need for treatment by conducting an assessment of symptoms and the functional impact of those symptoms (another part of medical necessity). Then we have to render a diagnosis. This diagnosis is to guide treatment. Often, the best treatment is therapy.