Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness
The field of mental healthcare has its roots in medicine. The earliest mental health professionals were doctors—psychiatrists. Like medicine, psychiatry and clinical psychology are based on the process of assessing patients’ symptoms, performing some sort of test if needed, assigning a diagnosis, and creating a treatment plan based on that diagnosis.
This is a very sensible approach for most medical issues. If I appear at my primary care doctor’s office complaining of persistent headaches, she shouldn’t just treat the headache by prescribing a painkiller. She should refer me to someone who can figure out what’s causing the headache, and then treat that condition, whether it’s extreme stress, a head injury, a bacterial infection, a brain tumor, or some other problem.
Even though we’ve been treating mental health issues this way for at least a century, it’s not the best way to treat them. And many psychiatrists, therapists, and researchers are starting to realize that.
That’s why we’re finally starting to see approaches to assessment and treatment of mental illness that move away from the much-argued-about diagnoses in the DSM, and sometimes away from the concept of mental illness altogether. Psychologists such as David Barlow, Rochelle Frank, and Joan Davidson have been working on so-called transdiagnostic approaches[1]; the newest edition of the DSM includes a chapter about a proposed new way to diagnose personality disorders that’s based on specific personality traits rather than broad, stigmatized labels[2].
I’m looking forward to the day when the field as a whole has shifted to these types of approaches entirely. For now, I needed a tool I can use with clients to help them (and myself) understand what they’re dealing with and access helpful resources and support. So I created my own informal dimensional assessment.
This assessment is a list of 33 (and counting, I’m sure) ways in which our brains can get in our way. You could think of them as symptoms, but I prefer to think of them as painful patterns, or building blocks of mental distress. Everyone has at least some of these; many people have a lot of them and don’t necessarily suffer greatly for it. It’s all a matter of degree.
Most of these terms are actual mental illness symptoms that appear in the DSM or in other clinical psychology texts. Some of them I coined from existing words because they aren’t really being talked about very much yet. Each of them shows up commonly with at least one established diagnosis, and most relate to quite a few of them.
In creating this list, it was important to me to try to get at the ways in which people who aren’t therapists or scientists might actually think of these experiences. So each building block has a statement with it. The way I plan to use this clinically is to show clients a list of the statements and ask them to rate each one on how much they agree or disagree with it. That would give both of us a sense of what their psychological landscape looks like, regardless of which DSM diagnoses it might resemble.
The initial feedback I’ve gotten is that folks find this really helpful for communicating with their therapists and psychiatrists about what they’re dealing with. I think that’s a great way to use this tool. Therapists know specific interventions that target many of these things; coming to a session and saying that you’d like to address your amotivation, emotional disregulation, and tendency to ruminate is bound to be more helpful than just saying that you want to be less depressed.
Agitation: "I often feel so on edge that I need to be moving constantly, as if I want to crawl out of my skin."
Amotivation: "I struggle with getting myself to actually do things, even when I want or need to."
Anhedonia: “I don’t get any joy out of things I used to like.”
Attention disregulation: “I can’t seem to choose when to stop or start paying attention to something.”
Avoidance: “I find myself trying to avoid things that bring up painful thoughts or feelings.”
Cognitive inflexibility: "When things don't go the way I wanted or planned, it's very difficult for me to adjust my expectations or make a new plan."
Compulsiveness: "Sometimes I feel like I need to do an action or ritual in order to feel okay, and I feel awful if I try to force myself not to."
Depersonalization: “Sometimes I feel like I’m not really in my body, or I don't know who I am.”
Disordered eating: “I have a hard time controlling what or how much I eat; or, I need to control it so carefully that it’s hurting me.”
Dissociation: "Sometimes I experience a memory so strongly that I'm not sure who, where, or when I am."
Distress intolerance: "I don't feel like I can handle strong emotions. I need to make them go away."
Dysmorphia: “I seem to see my body differently than other people do.”
Emotional disregulation: "When I have strong emotions, it's very difficult for me to manage them and calm myself down."
Emotional lability: “My mood can change quickly between extremes.”
General anxiety: “I often think about things that could go wrong in the future.”
Guilt: "I feel guilty even when I didn't do anything wrong."
Helplessness: "I don't really believe that there's much I can do to help myself feel better or improve my life."
Hopelessness: “I feel like things won’t turn out okay.”
Hyperactivity: "Having to sit still and not move makes me extremely uncomfortable."
Hypervigilance: “I’m always on the lookout for possible danger, and often I sense danger where there isn’t any.”
Identity disturbance: "I don't have a strong sense of who I am; it depends mostly on the opinions of the people around me at the time."
Impulsivity: "Sometimes I say or do things without thinking about them first, and afterward I can't always tell you why I did them. When I have an urge to do something, it's very difficult to keep myself from doing it."
Inattention: “I can’t make myself focus on things I need to do.”
Irritability: “Little things annoy me so much I want to yell or snap at people.”
Mania: "I have periods of time during which I feel extremely energetic, irritable, or 'high,' and during these periods I tend to sleep little, talk too fast, accomplish a lot of things, or do things I later regret."
Obsessiveness: "I have intrusive thoughts that bother me and I can't make them stop."
Panic: “Sometimes, my breathing speeds up and my heart starts rushing, and I feel like I’m going to die.”
Psychosis: "I perceive or believe things that feel very true to me, but aren't true according to everyone else."
Rejection sensitivity: “I feel like I can’t deal with it if someone dislikes me, or says no to me. I'm constantly on the lookout for potential rejection, and I probably sometimes see it when it isn't really there."
Rumination: “When I start thinking about something negative, I tend to keep thinking about it over and over and feeling even worse.”
Social anxiety: “When I’m around people, I worry about how I’m coming across or what I should say or do.”
Splitting: "I tend to see people either as extremely good or extremely bad, and I can switch quickly from one to the other."
Suicidality: "I have thoughts that I want to die, or that I wish I could just not exist."
Although I’ll probably never be able to turn this into an Official Research-Verified Published Thing or anything like that, I do hope to keep refining it and making it useful to my clients—and to any other therapists who want to give it a try.
—
[1] https://www.newharbinger.com/blog/transdiagnostic-psychology-why-we-need-transdiagnostic-road-map
[2] https://www.psychologytoday.com/us/blog/fulfillment-any-age/201303/whats-new-and-old-in-the-dsm-5-personality-disorders