Adam Blatner

Words and Images from the Mind of Adam Blatner

Ask the Psychiatrist

Originally posted on May 6, 2015

People expect experts to know answers. But then they ask questions that only open the door, and I as the expert think, “Well, it could be due to any number of things.” For example, I was asked about a mother with “a flying phobia. I make a differential diagnosis: (1) The mom is how far away and might this “fear” be really that it’s way too much trouble and expense for the mother to visit. (2) Or, one might ask where is the mom, how far away from an airport; what would be involved in packing and getting to and from the daughter’s home; (3) how much does the mom really want to fly? How long is the trip? A few hours, almost a day, a day and a night?

I don’t assume that the “given” diagnosis is at all accurate. It may be just an excuse. And it may be that the mother takes on the burden of having a named disease as it’s far less embarrassing than admitting to the daughter—or perhaps even to herself, honestly—that it’s just not “worth it.” In other words, I am dubious of fancy diagnoses. What is said to be a phobia of flying (a disease) may be just the wariness of a tech-naive conservative old person? How long has this so-called “phobia” been going on?

Here’s another reported symptom that illustrates the hunger of people in the presence of teachers or others imagined to be wiser. They want answers. They think and hope that there are simple answers. But it is the questions that are crucial. For example, another woman reports that her six-year-old son afraid to make mistakes. I think to myself: “Well, there’s temperament: Some kids are overtly obsessive-compulsive and show other signs and symptoms of a full disorder. Others have a few signs and symptoms, not enough to qualify for an official diagnosis, but enough to make trouble.” (These are called “sub-clinical” conditions.)

Some kinds are hyper-conscientious, shy, overly preoccupied by image. For some it’s an excess of this temperament, but for many there are family inputs, if not from parents, then from grandparents or teachers. Often at least one significant adult figure pushes for perfection and consciously or unconsciously refuses to allow for silliness or play. Some cultures reinforce this ethos by believing they need to push!

Other differential diagnoses include the way some kids develop perfectionism as a neurotic defense against a variety of stresses, to compensate for various other inferior functions, things about which one is guilty or ashamed. Often symptoms are a combination of the aforementioned. (I don’t assume that I’ve made anywhere near a complete differential diagnosis, but rather I hope to remind the reader that some seemingly clear-cut complaints are in fact annoyingly general.

Often the truth will come out months or years later, sometimes never. So effective diagnosis is far from cut and dried.

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