Part Two: Insidious Onset
Receiving a diagnosis…being a diagnosis
Although I don’t usually think of myself in these terms, I am in fact a diagnostician by training. As a psychotherapist, it’s an integral part of my work 
which serves two basic functions. The first is mundane and uncomfortable: in order to be reimbursed for my services by insurers I need to provide those insurers with a reimbursable diagnosis for my patient. The second is more complex and more poignant: I am beginning the process of putting words to human suffering. And in psychotherapy, putting words to suffering is the way in which healing happens.
A more mechanistic way of saying this is that diagnosis guides treatment. More than a label, a diagnosis gives me a framework from which I can attempt to help.
Central though the task is however, diagnosis and mental health have never meshed well. Witness the interminable wars over the definition of categories and criteria for each new version of the American Psychiatric Association’s Diagnostic and Statistical Manual (the “bible” of mental health diagnosis). You don’t usually see vicious debates breaking out between doctors (and pundits and advocacy groups and ordinary people) over the definition of Arthritis, say, or Measles. Unlike mental health diagnoses, such conditions are characterized by clear-cut and physically observable symptoms, which can be confirmed by empirical lab tests.
Although, as will become clear as my own story plays out, when medicine bumps up against the outer edges of objectively definable symptoms (as in the case of conditions like Chronic Fatigue Syndrome, say, or Fibromyalgia), the same sorts of debates begin to flare up.
In mental health the discomfort around diagnosis speaks to an underlying dilemma in how we think of ourselves as human beings. As a mental health worker I am trained to value the uniqueness of each human experience. As a result I recognize how easily a diagnostic label can conflate with and distort a person’s identity. Because we don’t say “I have Depression,” but rather “I am depressed.” We don’t say “she suffers from Borderline Personality Disorder,” but rather “she’s borderline.” That tension exists in patients as well as clinicians. Part of us wants our experience to be clearly definable; another part of us insists that mystery lies at the core of our unique human experience.
Completely correct, absolutely wrong
From time to time I teach diagnosis to graduate counseling students, and it is always an invigorating experience. Counseling students commonly approach the DSM with a high degree of wariness, even hostility. They see it as a medical model which imposes a pathology-based perspective on human experience, contrary to the strength-based compassion from they wish to operate.
I tell them that are completely correct. And I also insist that they are absolutely wrong.
I suggest that they consider a simple, specific scenario.
Say you’re a counselor and someone comes to you saying that they are feeling overwhelmed by sadness over the break-up of a romantic relationship. As a counselor, how do you help them while refraining from imposing a diagnosis on them?
The answer to that question quickly reveals the many subtle levels of diagnosis that take place within all of our human interactions.
The hardcore counselor-type will maintain, following the technique of Carl Rogers, that simply listening and compassionately reflecting back a person’s experience is all that is necessary.
But what is it, exactly, that you are reflecting?
“You’re feeling really sad because your girlfriend left you.”
You may not be assigning a diagnosis in making that statement, but you are agreeing with (and thus reinforcing) your client’s self-diagnosis.
And where are you going to go from there? How are you going to help?
I maintain that you can’t move forward in any way without holding some sort of diagnostic theory in mind. I don’t think it’s possible for a counselor to set aside your own assessment of the meaning and causes of their client’s condition. Further, I believe that it’s potentially dangerous for us to believe that we can do that.
To be clear, this is a different level of diagnosis than the DSM code you put down on the form that you submit to an insurer. Diagnosing with the DSM is a process rife with problems. But that doesn’t mean that diagnosis itself is the problem. Because a diagnostic process of some sort is essential to our ability to make sense of other people (and ourselves). We understand others by attributing meaning to their words and actions. But of course the meaning that we assign may or may not correspond to the meaning others give it. Many who are drawn to mental health professions are uneasy with the idea of claiming an authority which allows them to interpret the behavior and the experience of others. This uneasiness is a good thing. Because there’s a power in that authority that can easily be mishandled or abused. The challenge of diagnosis lies in being able to recognize that while assigning a diagnosis to a human experience helps us to make sense of that experience, it simultaneously increases the risk of our misunderstanding that experience.
Refugee
There is a certain category of medical patient whose fundamental goal in interacting with medical professionals is solely to obtain a diagnosis. For that person, the meaning of a diagnosis transcends the meaning it might have in more routine medical interactions.
Say you’ve got a bad sore throat and your doctor does a culture and identifies it as strep. That is not an event which fundamentally alters your definition of yourself. But if instead you suffer from vague and shifting symptoms, if those symptoms come to shape your day-to-day experience, if they persist for months and years, and if no one in the medical profession can identify an empirical basis for those symptoms…
Well, that’s the situation I was about to find myself in. I was joining the ranks of the medical refugees. And from the perspective of a medical refugee a diagnosis – any diagnosis – becomes the holy grail. Because without a diagnosis, no one can treat you. In this situation even a really nasty diagnosis – MS, ALS, cancer – becomes preferable to living your life knowing something is very wrong without being able to identify what it is. Just as your identity and your experience has become shaped by your symptoms, the search for a coherent diagnosis becomes a profound search for meaning and self-definition. It’s a search for truth.
As I described in my previous post, the diagnoses that I had been given (or had assigned to myself) to make sense of the changes in my sexual functioning included normal aging, endocrine imbalance, and Post-Traumatic Stress Disorder. The first was untreatable, the latter two had been treated without a resolution of the underlying symptoms, suggesting either that the treatment was inadequate or that the diagnosis was inaccurate.
And things were about to get much more complicated.
Markers
Although there are certain clear markers, the changes in my functioning didn’t happen abruptly. Rather, it was what the medical field refers to as an “insidious onset.”
Through the summer of 2008 I was continuing to see the endocrinologist, who was looking carefully at my blood levels as he tried to fine-tune the dosage of my testosterone and thyroid medication. He witnessed one of those markers – an inexplicable abdominal rash that developed that summer. It was blistery and itchy and it persisted for six weeks or so. It was odd, nothing like anything I’d ever had before, and I noticed it without knowing what to make of it. He looked at it and did more or less the same thing that I did. He said, “hmmm.” Then he went about his business.
Around the same time I developed what I first assumed was an ordinary running injury. Every morning when I went out on my run I began getting sharp shooting pains in my left leg after about a half mile in. I assumed it was a pulled muscle of the sort I’d had in the past. My first response was simply to try to power through it. When it didn’t go away on its own, I laid off of running for awhile – that had always worked before. But it didn’t help this time. And worse, I began experiencing the same pain in other situations (driving was especially bad) and I started experiencing a series of other sharp pains in my lower back and leg.
Finally I went to my doctor, who said it was Sciatica. A nice, clean diagnosis. He prescribed an anti-inflammatory and some physical therapy. The treatment helped a little, but it didn’t eliminate the pain, which I continue to experience intermittently. It was an interesting diagnosis because it seemed both accurate and insufficient. I continue to wonder what, if any role this particular symptom plays in the larger diagnostic picture.
In order to avoid activating the sciatic pain I switched to biking for exercise. But I began to experience a heavy exhaustion when I biked at my usual pace up even very moderate hills. As a (former) distance runner, I am very attuned to the responses of my body to different levels of exertion, and so I could clearly recognize this as a change in how my body was performing. This was not just the ordinary aerobic effects of a good work out. This was a feeling of internal collapse.
It was odd and it was very distinct. It’s usually the place I start when doctors take a history, because it’s the clearest early symptom related to the fatigue and weakness that I suffer from presently. It is a key marker in my subjective experience as well, one of the few things that has been consistent over these past few years: when I exert myself beyond a certain level, I experience a physical collapse which is marked by a feeling of weakness, shakiness and light-headedness. One of my key adaptations over the past few years has been modifying my exercise routine in order not to trigger this response. I no longer run. I bike regularly, but not intensely and not on hills the way I have always enjoyed. Instead, I have joined a gym where I can work out on exercise machines in a regulated way which usually keeps me from triggering this response to exertion.
I hate the gym. But it’s the only way that I can continue to get the exercise I need.
This is where diagnosis begins to cross over into the realm of self-definition. Because whatever was wrong with me was altering my ability to do the things that make me who I am. I went back to my doctor and tried to explain what I was experiencing. I told him that there seemed to be something larger wrong with me, that these changes were broader than the limited diagnosis he’d given me. He shrugged and said, once again, “welcome to middle age.”
A Million Bucks
It was clearly time to find a new doctor. I talked to a colleague who recommended an Internist she knew. She said: “this guy’s like a dog with a bone when he gets a diagnostic puzzle. He’ll keep working on it until he figures out an answer” That sounded good to me. I met with him and he took a history, gave me a physical. He ran some basic blood tests, all of which came out normal.
“I can run more tests,” he said, “but I’m not sure what they’ll show.”
I asked for a referral to an oncologist. I wanted to rule out any recurrence of the cancer.
Then I had my first real “episode.”
This was in November of 2008. An early snow had fallen – it was wet and heavy. I went out at mid-day to shovel the sidewalk. This is an activity that I ordinarily enjoy. I like the physical work-out, the exertion, and the visible result of my efforts. But this time something started happening to me. I started feeling light-headed. And weak. It was like the experience I’d had while biking, but much more intense. It was a difficult sensation to describe, but I can say that I didn’t feel well connected to my own body and even though I seemed capable of continuing to exert the effort necessary to shovel the snow it didn’t feel like a good idea to keep doing it. And all of the physical sensations seemed oddly focused on the upper half of my body.
It was really strange. It was not something that had ever happened to me before.
My wife looked at me when I came inside and she grew instantly alarmed. She said I looked like a ghost. Which was what I felt like. I recovered after an hour or so and I felt depleted but more or less normal afterwards. My wife got me an appointment with the new doctor for the next day.
“I have an idea about this,” he said. “I don’t think that this is going to be a House episode.”
He gave me an EKG and he thought he saw an abnormality in it. It seemed to be a cardiac issue. I observed his diagnostic certainty. I tried to accept it. Coming from a mental health perspective, I could not think about any diagnosis without also considering the meanings attached to it. What would it mean to me to have heart problems? On one hand, the prospect of a heart attack was frightening. On the other hand, it seemed like one of the most well-understood and treatable of conditions. That was comforting.
But it also just didn’t quite fit. I was a marathon runner. Aside from high cholesterol, which was being adequately treated with statins, I had never had anything that remotely like a heart problem.
The next day I found myself on the treadmill at the cardiologist’s office.
The guy was old-school. Paternalistic and condescending.
“No one ever beats the treadmill,” he said.
But I was a trail runner, accustomed to running straight up the side of mountains. The test required that I get my heart rate up to a certain level at which I would be adequately “stressed.” It took a long time for me to get there. And when I finally did, when I was unplugged from the machine, the doctor came in and told me what I already suspected: my heart was in better condition than 99% of the ordinary population. The abnormality that my internist had seen was actually an artifact of how unusually strong my heart was.
I have struggled throughout this experience with this particular paradox: I look really healthy. That’s one reason why nearly every doctor I have seen throughout this odyssey has suggested that the real diagnosis must be depression, or anxiety, or both. Even though I am more familiar than they are with these diagnoses and their treatments, even though I have described to them the years of therapy I have been through and have outlined the lack of correlation between my mood and my physical symptoms.
“Have you considered going back to a therapist?” one doctor asked me. “Because on paper you look like a million bucks.”
As I began inexplicably losing weight, this disparity between my outward appearance and my inward experience was about to grow even greater.
