Treating the Diagnosis, Treating the Patient
"All medical specialties," asserted psychiatrist Robert L. Spitzer, M.D., "overemphasize diagnoses and sometimes lose sight of the patient." (Science News, 1998). According to the DSM-IV, Sammy is classified as a 309.24, 307.21, 314.01 with moderate psychosocial stressors and a GAF (Global Assessment of Functioning Scale) of 70. But my mind paints a hundred faces of children with those descriptors. Do we not need a richer view of Sammy, one that ties his symptoms to his inner world, one that puts a unique face on the child? In the biologic arena, Sammy was burdened by neurocognitive vulnerabilities?tics, probable attention-deficit/hyperactivity disorder and possible verbal learning disability?that might have made him feel out of control and overwhelmed by incoming stimuli. His prematurity and early exposure to phenobarbital(Drug information on phenobarbital) might have contributed to his biological issues.
The psychological component of the assessment revealed that Sammy had accomplished many age-appropriate developmental tasks: separating from his parents in most situations, forming relationships, being curious about his situation, and identifying problems and proposing theories about them. He was able to bear some intense feelings, but intermittently became overwhelmed, as evidenced by his tantrums, separation anxiety and somatic symptoms. Clearly, he had work to do in the arenas of self-soothing and affect tolerance. Sammy knew right from wrong. He was empathic and gentle in his judgment of himself and others. He had, for the most part, achieved age-appropriate ego and superego capacities. In short, Sammy was well into the stage of development referred to as latency.
In my sessions with him, Sammy had difficulty choosing activities, and there was an impulsive quality to his initial choices. The fact that Sammy, himself, had been chosen by his adoptive parents might have burdened his own ideas about choosing and setting aside the unchosen. He was reluctant to discuss the adoption. Sammy was concerned about his brother's orthopedic problems. He said the facial tics occurred because his own body sometimes felt uneven. Perhaps the "uneven" feeling had as much to do with an underlying biologic disorder as with unresolved feelings about his brother's problems, which included facial asymmetry.
Sammy's home environment seemed stable. His parents agreed to try to expand their own capacity to tolerate feelings and to help Sammy do the same with his own feelings. To Sammy's parents I communicated my psychodynamic hypotheses about particular symptoms so that they gained a sense of how I think about their child. I introduced the notion that Sammy's biology and dynamic issues can intertwine to create his symptoms. For example, his stealing might have both an impulsive root, due to the attention-deficit/hyperactivity disorder, and a psychodynamic root, in which the stolen items served as a metaphor for the parental attention he had lost to infertility and his brother's medical problems.
I recommended that Sammy begin a child psychotherapy plus psychopharmacologic evaluation, neuropsychological testing and possible medication trials. Clearly, Sammy was amenable to psychotherapy, since he was thoughtful about his problems, used metaphor and symbolic play, and tolerated to some degree the painful affects touched upon during the assessment. The treatment goals: to allow Sammy some relief from neuroco-gnitively driven symptoms; to help him understand his biologic self; to help him understand his life experiences and how he may have made sense of them in ways that frightened and worried him; to increase toleration of strong affects; to promote self-soothing capacity and strategies. I also recommended ongoing parent guidance sessions.
When I was a second-year medical student starting my clinical rotations, I was anxious about determining diagnosis. A senior physician told me the following story. An attending psychiatrist brought a group of medical students to assess a patient. "Always listen to the patient," he said, "for therein lies the path to diagnosis." Then he left the room. Upon his return a few minutes later, the students confidently announced the correct diagnosis: porphyria! Stunned, the psychiatrist asked them how they had figured out the diagnosis so quickly. The students had really listened to the patient; they had asked why he was in the hospital, and he had named his illness. Were all diagnostic assessments only that simple!