Thursday, June 22, 2023

Speaking Up: Strategies for Discussing Your Symptoms with Your Psychiatrist

Over the course of the pandemic, I noticed an increase in clients seeking psychiatric consultation for the first time. Whether they'd been in therapy for years or were just starting their forays into the world of mental health, lockdown combined with increased demand made it difficult to schedule appointments and even communicate with psychiatrists. While a lucky few are able to find something that works pretty quickly, most clients end up going through multiple changes before settling on something. Even outside of work, I've noticed friends find a psychiatrist, get prescribed something, and stick with both, even if they don't work as well as they'd hope. It can take time to find the right medication and the right dosage. As tempting as it may be to take matters into your own hands, I always recommend clients be clear and honest with their providers about what has and hasn't been working.

Of course, this is more easily said than done.  It can be difficult to explain things like emotional and cognitive symptoms to anyone, much less a doctor or other healthcare provider, who may use completely different language. Often times, we're being asked about symptoms we've experienced for as long as we can remember, so the thought of rating severity on a 1 to 10 scale can feel confusing to impossible. Even if our symptoms are worse than they've ever been, it can feel disingenuous to say we're at a 10, because there's always the voice at the back of our minds telling us that someone else has it worse. Further, there can be a pressure to say the right thing, or a worry about what we’re “supposed to” report. As a result, I've noticed clients often under-report symptoms, or downplay their severity. Someone might tell their psychiatrist the new medication is "working alright" if they feel it's helping a little, but not enough, but if the psychiatrist thinks this means all is well, they may respond by saying no change is needed, even if the client is dissatisfied.

In any instance of miscommunication, my first thought is to check on what kind of language each party is using, and how they use it. In the prior example, the client is using the word "alright" to mean "some but not enough", while the psychiatrist assumed it meant "well". If this were a close personal relationship, I'd recommend discussing the use of language, or spending time clarifying what is meant. However, psychiatric appointments are often quite short. Thus, I tend to instead recommend clients change the way they talk about their symptoms. Describing their symptoms and experiences in more precise ways can help clarify the level of severity of a client's symptoms. This can also give the psychiatrist a better sense of what to expect -- a psychiatrist who knows your symptoms are moderate rather than mild will know that the lowest dosage of the first medication they start you on might not be enough.

The first piece of this is to quantify your symptoms. While using 1-to-10 scales works for some, this isn't the only way to do this. Frequency and duration are the two primary ways of keeping track of this, and are often part of the diagnostic criteria when it comes to judging severity of symptoms. It also helps to be specific about what subcategories of symptoms you experience. For example, one client may describe their insomnia by stating that it takes over an hour to fall asleep more nights than not, while another might say that they wake up 3 to 5 times each night, about 5 nights per week. Both of these reveal more information than just saying "I'm having trouble sleeping", and give useful background that can help narrow down approaches. After all, if the person who keeps waking up in the middle of the night wasn't specific, they may be given medication and advice aimed to make them sleepy at bedtime, which might not help ensure they don't wake up an hour or two later! Similarly, clients who have panic attacks often describe physical symptoms that come with them, like an increase in heart rate or sweaty palms. However, these symptoms look and feel different for everyone, and this can impact what kinds of treatment a professional would recommend.

The second piece is to measure the impact on your day to day life. Some of this includes quantifying symptoms as mentioned above, like by tracking how much time it takes you to pull yourself out of an anxiety spiral. But impact goes far beyond the time it takes to self-soothe, and often gets at the reason we decided to seek services in the first place. If a new medication makes it easier to keep up good habits and get chores done, it's worth noting, even if you're only part way to reaching your goal. If you struggle to leave the house, taking a medication that makes doing this possible once or twice a week is still better than nothing, and further, is proof of concept that it's possible to get to a point where leaving the house daily is a viable goal.

If your symptoms are hurting your productivity at work, personal relationships, or even just your ability to enjoy life, it's worth being clear with your doctor if the medication they're prescribing isn't helping, or makes things worse. This is especially the case when it comes to side-effects. If you're taking medication to alleviate symptoms of depression that come up in your romantic relationship, having those depressive symptoms replaced by anger and irritability at your partner isn't a viable solution. Even more internal, harder to quantify symptoms can get in the way of our day to day lives.  Having thoughts we can't ignore can make it harder to be present in our day to day lives, and even if we can't realistically track exactly how much time we spent thinking about something, we can still communicate whether these thoughts resulted in us missing a meeting that day or if we got less work done all week.

It’s worth noting that there are many people who experience symptoms but sufficiently manage to cope with them, such that they underreport, and may even fail to qualify for a diagnosis. The "but I have a system" answer fails to account for the fact that if you need a system to manage something like timeliness, then timeliness is still a problem, even if you already have the solution. Further, often these solutions require extra work. If you spend 15 minutes every morning double checking the locks on your doors so you’re not anxious about it later, that’s still 15 minutes of your life you won’t get back.

Even if you're theoretically able to track your symptoms, it can feel difficult to find the right words to describe what's going on for us. Mental health can be full of jargon, and many clients of mine have expressed confusion over what kinds of terminology to use. Most psychiatrists will have an intake questionnaire new clients fill out when you first begin working together, and often, these can be a good place to search for phrasings that both fit your experience and their clinical understanding. Part of the purpose of the intake is as a jumping off point to start a conversation about your symptoms, so if a question is asking about a symptom, but isn't quite phrased right, it's worth bringing this up to your provider as well. For example, many ADHD questionnaires ask if you feel as if you're "driven by a motor" as a way of checking on hyperactivity. Of course, many people with ADHD experience hyperactivity, but would describe their experience of it differently. Another useful part of looking through these questionnaires is that we may find symptoms we never realized were connected. I have had a number of clients who never realized their physical panic attack symptoms were different from general anxiety until we discussed them in session! Common questionnaires include the PHQ-9 and the Beck depression inventory.

If you have good rapport with your psychiatrist, you may find using consistent metaphors helpful, especially when it comes to examining changes in symptoms as they correlate with changes in medication. While less quantifiable language can be vague, it can also be easier than tracking and quantifying, especially for emotions and other symptoms that are less concrete. Some metaphors are generally well understood, such as those involving weather; a depressed client saying they had gone from "a downpour to a light drizzle" would effectively communicate improvements in their mood, while also clarifying that their symptoms were not entirely gone.

As mentioned above, tracking can help with measuring changes in your symptoms. Many clinicians will have clients take the same questionnaire months apart, to help monitor these changes, but you can easily do this at home, too. For more subjective descriptions, journalling can help a lot in tracking your thoughts and feelings in the moment. This is especially helpful because it can be hard to fully remember what something was like days or weeks ago by the time your appointment comes around. I have many clients who will highlight passages from their journals to read to me in our sessions, and it can really help show what a moment of panic or depressive spiral looked like, even if they're fine in session. This can also help with changing medications, as you can find excerpts from before and after a change, and look for patterns in thoughts, emotions, and behaviors. You might notice that since a change in medication, you've stayed at work for longer, had fewer intrusive thoughts about your ex, or just generally felt more positive about your life.

Lastly, I want to make it clear that communication is a two-way street, or at least it ideally should be. If you are having trouble communicating with your psychiatrist, I'd definitely recommend talking to them about it first, as they may have some ideas on how to fix things. However, that doesn't mean you have to stick with a psychiatrist who isn't working with you. Listening to you as a person is a psychiatrist's first job in treating you as a patient, so if they're not listening, they're not doing their job. Don't be afraid to look for someone else. I often say that looking for a therapist can feel like dating, in that you often have to talk to many people to find a good fit. With how many psychiatrists involve therapy in their work nowadays, this seems especially true for them as well.