The Doctor Is In
Hallo there, sweethearts. If you feel like I may have ghosted you for a bit, I place the blame solely on Dave. He’s getting out of hand. You know how it goes. But I’m back now, and I have a special guest. No, Dave, it isn’t you. I swear. Right! Before we dive in—I don’t want you to get any ideas, I know how you are—here’s a friendly disclaimer:
The below represents the opinions of psychologist Jerry Vanzant Walker, III, Ph.D., and not the opinions or beliefs of the United States Air Force or the entire field of professional psychology.
As you might have guessed by now, the special guest is Dr. Jerry Walker! You might remember months ago when I released a two-part series on mood and anxiety disorders (part I—part II). Well, this is a bit of a follow-up to that. We’ve focused on the science and on the individuals suffering these types of disorders, so now we’re getting another POV.
Now, if you’ve dealt with any chronic or recurring disease/disorder, I’d be willing to bet that going through the gauntlet of finding a doctor has been a fucking nightmare. That’s just the way it is, sadly. Trying to find medical help—whether mental or physical—can be extremely frustrating. There’s a disconnect somewhere. Whether we like doctors or not, we subconsciously place them on a pedestal. We expect them to know everything about anything that could be wrong with us because, I mean, doctor. You know? Well, surprise! That’s not how it works. Something we need to remember when seeking medical help is that medical professionals are people too. Calm your tits, Dave, I know it’s a revelation.
Meet the Psychologist
Dr. Walker is a licensed psychologist who’s been working (both active duty and as a contractor) for the USAF for the past six years. He earned his BA in Psychology and BS in Communication Studies from the University of Texas—where he was also a male cheerleader—and earned his Ph.D. in Counseling Psychology & Human Systems from Florida State University. Dr. Walker always had a desire to serve the military. He started talking to recruiters while in high school, but his parents were adamant that he go to college first. The study of psychology always fascinated him, but in undergrad it became his passion. In grad school, his program’s Director of Clinical Training (a former Navy psychologist) asked if Dr. Walker had ever considered working for the VA or military.
After entering the Air Force for his psychology residency in San Antonio, Dr. Walker spent the remainder of his career at Langley Air Force Base in southeast Virginia. He works as an embedded psychologist and behavioral/human factors consultant for a large intelligence organization on the Langley Air Force Base. As if that weren’t enough, he also has a local part-time private practice. The work ethic is strong with this one.
Throughout his military career, Dr. Walker has run an outpatient substance abuse program, a 25-person multidisciplinary outpatient mental health clinic, a suicide prevention program for 11,000 personnel at a military installation, and a disaster mental health team which responded to eight crises. He has also served as the sole psychologist for 9,000+ American, British, Canadian, and Australian military personnel in a deployed location. Dr. Walker’s graduate research and personal proclivity toward resilience and performance enhancement—vs treatment or remediation of deficits—led him to pursue opportunities within the military to work with special operations forces and other communities which might benefit from having an in-house psychological consultant.
When he isn’t working, Dr. Walker spends time with his wife and son. He’s a bit of an outdoorsy guy who enjoys kickboxing, playing racquetball and guitar, and reading fantasy. I mean, he’s legit a real person. Not a cyborg or robot or Pleadian. Damn Pleadians.
Diagnosis from a new POV
I’ve heard a good deal of horror stories when it comes to getting a diagnosis and finding the right treatment. I’d make a joke about one of the side effects of trying to get a correct diagnosis being a sharp pain in the ass, but I’m realizing it’s becoming my own personal cliché. Which you’d know if you read Rise and Run. So never mind. Joke aborted, shameless plug ended. In any case, I wanted to provide a new POV on the diagnosis process so that we can get a better understanding of, you know, the whole process.
According to Dr. Walker, diagnostics is a continual process that involves listening to what the patient says—or doesn’t say—and knowing the right questions to ask and how to ask them. “Most mental health professionals use the Diagnostic and Statistical Manual, 5th Edition (DSM-5) as a guide when making a diagnosis,” says Dr. Walker. “Mental health disorders are described generally in terms of clusters of symptoms, so in order for a patient to meet diagnostic criteria, they generally have to endorse a sufficient number of symptoms from various clusters or categories.”
Dr. Walker usually utilizes the first session to try to get a general sense of what the patient is experiencing and the timeline/progression of symptoms. “It may be several sessions before we are able to trace [an individual’s] presenting concerns to their etiology,” says Dr. Walker. When this happens, he will sometimes provide a general (e.g. Unspecified Anxiety Disorder) or tentative diagnosis until there is enough information to either rule in or rule out a diagnosis with more certainty. “Sometimes a patient won’t reveal certain symptoms or experiences they’ve had or are having until much later on in treatment, because they didn’t believe them to be relevant to their presenting concern,” Dr. Walker explains. “Additionally, we have to determine the extent and severity of functional impact of these symptoms, as this is a core component of mental health diagnoses.”
Dr. Walker notes that empathic listening is critical to both fostering a collaborative, working relationship with a patient and determining accurate diagnoses. “It also helps to have general working knowledge of the DSM-5, though I do keep a pocket reference book nearby in case I need to refer to the diagnostic criteria for some of the rarer disorders.”
Trick or Treatment
So, we’ve gone through the diagnosis process and now we get to the fun part. Treatment! Or, rather, a whole host of attempted treatments that are less than stellar, followed by a winner. At least, that’s generally the patient’s experience. I asked Dr. Walker about the path to treatment and whether the original diagnosis could change depending on what worked and what didn’t. “Contemporary psychological practice emphasizes the use of evidence-based practices (i.e. psychological treatment procedures that are widely supported by a series of sound research studies) for the treatment of specific mental health conditions,” Dr. Walker says. “Depending on the complexity, acuity, coping resources, insight, etc. of the patient and their mental health condition(s), treatment can vary widely in terms of scope and longevity. I’ve helped folks ameliorate chronic PTSD in as little as four one-hour sessions. I’ve also worked with an individual with childhood-related PTSD and Borderline Personality Disorder on a weekly basis for nearly two years (with relatively minor ultimate progress).” There’s also an aspect of patient commitment and patient-therapist relationship impacting the efficacy of treatment: “The stronger these are, generally the better the outcome.”
I want you to pay close attention to this next bit. There’s an important message there. “Psychologists do not prescribe medication [usually] but they do advocate for their patients and refer them to prescribing mental health providers when appropriate,” Dr. Walker says. Advocate. That’s fantastic. It’s great if you can find a healthcare pro who will advocate for you, but I want to stress that it is even more important for you to advocate for yourself. The more proactive you are when dealing with health problems and the more you advocate for yourself, the more likely you’ll be able to find a healthcare pro or team that will be willing to advocate for you. What’s that, Dave? Oh, yes. Got distracted. Back to the path … of treatment! “Typically, a general class of medication will be selected for treatment of specific mental health conditions. There does seem to be some evidence that specific drugs within a class are more indicated for a specific condition than others,” Dr. Walker says. “They also may have different effects/side effects (e.g., Zoloft, an SSRI, has been deemed safe for use to treat depression during pregnancy, though Prozac, also an SSRI, is not).”
And, as it turns out, the original diagnoses can change based on medication responses/non-response. “There are some cases I’ve seen where a prescriber gives a medication that reveals the diagnosis was entirely different. An SSRI prescribed for depression set off a manic episode, wherein it was discovered the patient did not have unilateral depression but actually a bipolar disorder.”
Mental Health and Violence
One mental health conversation that pops up periodically (mostly sensationalized in the media) is mental health in relation to extreme acts of violence—after mass shootings or spree killings, for instance. “Believe it or not, acts of violence are rarely related to mental health disorders such as depression, PTSD, or schizophrenia as the popular media might have you believe,” says Dr. Walker. “In actuality, substance abuse has a far higher contribution to self-harm, domestic violence, child abuse, and sexual assault.” I can’t say that’s surprising. The way the media presents most mental health discussions is a detriment to both the understanding and perception of mental health issues. Come, plebes, let us take a journey in the Way Way Back machine because I want to reference a particular mass shooting. If we look at the case of Charles Whitman, he obviously knew something was wrong. He sought help. It was only after his death that an autopsy (requested in his suicide note) revealed a tumor that “conceivably could have contributed to his inability to control his emotions and actions,” according to the Connally Commission. So, I guess my question is: At what point during the diagnosis/treatment phase is it determined that a patient’s symptoms are from, say, chemical imbalance issues vs something like a tumor or brain injury? Well good news, kids, because that’s a question Dr. Walker and his ilk are trained to consider.
“In most of the diagnostic criteria in the DSM-5, there is a line that asks whether the presenting symptoms could be better explained by a medical condition or the effects of a medication,” explains Dr. Walker. “This requires the psychologist to have a basic working knowledge of neuroanatomy, psychopharmacology, and neuropsychology, which allows us to ask appropriate questions to rule out the possible influence of these variables on the [individual’s] presenting condition.” If the psychologist deems it appropriate, they will refer the individual to another provider for additional assessment/testing to clarify the root cause of the presenting symptoms. “This has happened several times in my career. I once referred a patient to his primary care physician to request an MRI based on the patient’s reported onset of severe headaches and display of pseudobulbar affect—random, uncontrollable laughing and crying. A patient with a mild traumatic brain injury from an automobile accident six years prior developed OCD. One time I had a patient present with hypomanic symptoms (super happy, talkative, goal-directed, restless, etc.) who, it turned out, was abusing Adderall he got from his roommate.” Dr. Walker doesn’t have admitting privileges or the ability to refer patients for certain medical tests, so in cases like those mentioned above, he consults with other medical providers and encourages them to investigate further.
Things, they are A-Changin’
Over the past few years, more people have joined the campaign to be open about mental health. “I get the feeling that there are a lot of misconceptions about mental health disorders, though I’ve seen mental health stigma gradually decrease in the general population over the last decade,” Dr. Walker says. “Mental health disorders are, by definition, abnormal. This has a negative connotation, but in truth all this means is that mental health disorders are not the predominant function of our brains or behavior. As with any minority condition or trait, this makes understanding the experiences of someone with a mental health condition difficult for the majority who do not have this personal experience or exposure.”
As we talk about mental health issues more frequently and in a more open-minded and educated manner, we gradually begin to lessen the stigma. “The millennial generation seems to be more prone to talking about mental health issues and advocating for disenfranchised/minority members, including those who suffer from relatively rare mental health conditions like OCD, schizophrenia, and Bipolar Disorder,” says Dr. Walker.
If you or someone you know is struggling with any type of mental health issues, reach out, talk about it, and seek help. You are not alone.