By Rachel Rutkie, a Washington state-based psychologist.
Self-perception is a funny thing. It is common for a therapist to say to a client “You are the expert of yourself and your experience.” If that is the case, what is the problem with self-diagnosing?
Even as a licensed psychologist, I have the inability to formally diagnose myself. When we are hoping to objectively observe our personal experience we run into various barriers. All people experience themselves through their biases, existing mental frameworks, acquired knowledge, and personal experiences. Our self-understanding can easily cloud our judgment and inherently conflict with objectivity. Of course, all human perception is subjective to some degree, however, there is a spectrum. When observing the self, we will likely be less objective than someone who is observing from the outside, especially if the person on the outside is trained to catch their own biases and to lean on their objectivity and knowledge.
A Case Example
Let’s consider an example of how self-perception can get tangled and distort our ability to self-diagnose:
Jade is a multiracial woman in her mid-twenties who has experienced two traumatic events over her lifetime: she was sexually assaulted in her teenage years and was in a car crash as a child. Throughout childhood, her parents would criticize her persistently and would spend little time with her. Though Jade was developing within normal limits as a child, her parents would tell her she talks too much, is out of control, is overly sensitive, and they implied she was a burden. Throughout her school years, Jade had difficulty making friends and felt confused about social cues; she perceived that she was always doing something wrong. She has had persistent difficulty sleeping, persistent anxiety symptoms, and is uncomfortable when there are loud noises in the environment. Her self-worth and life satisfaction are low.
When Jade attends her first session with a therapist, she reports that she talks too much and that she has difficulty with self-control (though this is objectively inaccurate). She describes her low self-concept and downplays the impacts of experiencing traumatic events because she believes it is burdensome to have needs and to express authentic emotions. She also describes herself as developmentally delayed because she internalized her parent’s criticisms.
If Jade had gathered fragmented information about mental health conditions from the internet and social media, her self-perception may inform her that she has Major Depressive Disorder, Attention Deficit and Hyperactivity Disorder (ADHD), and Post-Traumatic Stress Disorder (PTSD). And, she may also believe she has Autism Spectrum Disorder.
From a clinician’s standpoint, Jade is indeed a contender for various diagnoses. If she were my client, I would be considering Social Anxiety Disorder, ADHD, Major Depressive Disorder, PTSD, Generalized Anxiety Disorder, and potentially Autism. While it is theoretically possible for Jade to meet the criteria for all the diagnoses above, it is unlikely. A rule of thumb for many clinicians is to use the nuances of a person’s experience to conceptualize their symptoms with as few diagnoses as possible. The question becomes: When considering psychological, biological, and social factors, which diagnoses conceptualize a person’s experience best?
It could take multiple sessions of clinical observation/client collaboration, professional consultation, administering evidence-based measures, and/or completing a formal psychological evaluation to determine with certainty which diagnoses capture Jade’s experience best.
When I consider the information above, I would guess that ADHD-like symptoms would be better attributed to her depression symptoms, her misperception of self which was passed down by her parents, and her anxious distress. Upon further evaluation, I would learn that Jade was likely developmentally typical and would rule out Autism. Because PTSD entails extensive criteria for a formal diagnosis, it is possible that even with Jade’s trauma background and reaction to loud noises that she would not meet the criteria for PTSD. However, I would need more time and more information to feel confident in my conceptualization. In addition, I would have a lot of work to do to pull apart which pieces are Jade’s internalization of external criticism and which pieces are at the core of her experience and of her mental health difficulties. This is a process that Jade would be unlikely to complete accurately on her own.
Pros and Cons
The lens we look through, which is informed by our experiences and self-concept, distorts our self-understanding. People with and without clinical training have self-biases that can lead to misunderstandings of symptoms and cloud our objectivity when attempting to form the big picture.
Researching diagnoses and learning more about psychological processes can be fascinating. For many of us, we can find incredible relief by understanding that we are not alone. Once a struggle is named, we can experience a release of tension and an increase in peace of mind. There is an art to striking a balance between connecting with others through our overlapping human experiences while also striving to disrupt over-identification with a diagnosis before working with a professional.
The over-identification with a specific diagnosis can lead to people attributing their difficulties to the wrong sources. For example, if I believe I have Social Anxiety Disorder, I will likely attribute my lacking social skills to a preoccupation with rejection, when perhaps my lacking social skills are due to lacking social experience. Though the interventions to address my lacking social skills will overlap regardless of diagnosis, it is more efficient to work with a professional to help me catch my over-identification with rejection sensitivity, so I can better address the root of my problem.
Factors That Complicate Diagnosing
The symptom clusters that make up a diagnosis are complex and nuanced. Even clinicians with formal training and years of experience can struggle to pinpoint which diagnoses are appropriate for a person. Below are four factors that can create complexity and confusion in the diagnosing process.
First, when a person appears to meet criteria for more than one disorder, clinicians refer to the disorders as co-morbid. When comorbidity is at play, the presentation of symptoms is often more difficult to assess. For example, if someone only meets the criteria for Autism, they will likely display rigid routines and a preference for sameness. If someone meets the criteria for both ADHD and Autism, then they may have some preferences for daily routine, but they may have little ability to follow through with
preferred daily routines. These two people would likely present quite differently in session, and thus the Autism diagnosis may be missed in the person with co-morbid conditions.
Second, rarer diagnoses are often misunderstood and more difficult to confirm, even for trained clinicians. Dissociative Identity Disorder (DID) is a great example. Oftentimes, when a DID diagnosis is expected, the person is referred to a specialist due to the complexity of the diagnosis and the nuanced training that is required to diagnose and treat DID.
Third, many diagnoses appear relatively straightforward on paper but are easily misconstrued. Obsessive Compulsive Disorder (OCD) is one commonly misunderstood diagnosis. Even as a trained clinician, I have had difficulty deciphering the difference between Generalized Anxiety Disorder (GAD) and OCD when working with a client. Someone with GAD has anxiety about many things; by definition, their anxiety has generalized. However, it can appear at times that someone with GAD is engaging in compulsive behaviors. For example, someone with GAD may become preoccupied with fears of over-withdrawing their bank account. They may check their bank account after every purchase to make sure that they have not been hacked or that they have sufficient funds. From far away, this could appear to fit into OCD, however, it is not necessarily the case. Clinical experience and consultation would be the most helpful in diagnosing this person accurately.
Fourth, it is inevitable that human beings will resonate with one or more symptoms of a variety of disorders. All symptoms have a clinical threshold that needs to be surpassed for the symptoms to be deemed a formal diagnosis. Part of what trained clinicians are skilled at is deciphering the difference between clinical and subclinical levels of a given symptom.
If all of us who have a rough day consider ourselves to have depression, the term itself loses its meaning, and people with clinical levels of depression are left feeling dismissed and misunderstood. One factor that determines whether a diagnosis is included in the Diagnostic and Statistical Manual (DSM; the manual that outlines formally recognized mental health diagnoses) is whether the cluster of symptoms is statistically deviant from the general population. In other words, formal diagnoses will not be experienced by everyone, everywhere, all at once.
One purpose a diagnosis can serve is to validate a person’s mental health struggles. An opportunity we have as a culture is to work toward validating distress in ourselves and others, regardless of whether it has been formally labeled. If we feel anxious and are treated with compassion as we learn to self-regulate and address our symptoms, perhaps there would be less urgency in obtaining a formal diagnosis and less temptation to fit ourselves into a box that may not be the right fit.