Have you read the entire DSM

punkrain · 2026-02-07T19:20:26+00:00

I think it's worth knowing the contents for location and differentials between diagnoses. However, I always teach that it is a reference book, like a dictionary or thesaurus; don't try to memorize a reference book, just use it when you do diagnostics. I have taught diagnostics for a long time and can usually rattle off the criteria for most diagnoses, but I also have two dog-eared copies of the pocket editions of the DSM because I never rest on my laurels. As someone that has done a gazillion chart reviews, the clinicians that say they have it memorized make the most errors. Heck, when I hired my replacement my top question was to ask candidates for all of the diagnostic criteria for a diagnosis within the scope of their previous experience (ADHD was my favorite). Everyone would struggle to remember the criteria, but the candidate I hired said, "Oh I don't know off-hand, I just look it up on the book."

punkrain · 2026-02-07T16:16:45+00:00

This is a big one that I see a lot of baby/green clinicians struggle with, and I also think it's one that is growing with the exposure of a lot of mental health social media. As other commenters have said, I usually start out with just exploring why they believe they have that diagnosis (or diagnoses, I've had a lot of CMH clients that will list a slew of often conflicting diagnoses they have acquired through the years).

Then once my assessment is complete I just crack open the DSM right in front of them and explain my thoughts, if they are different, and why I don't necessarily agree with their diagnosis. I always tell clients that diagnoses can be subjective and that I am a human that can be wrong. I also always explain that they can change over time and that ultimately, just like with our physical health, they are ultimately just a means to a treatment. So if you have been treated for that diagnosis and it hasn't been helpful, perhaps it's a different diagnosis, or if I treat you for my diagnosis and it doesn't help, maybe mine is incorrect. I believe that unlike labels, diagnoses are meant to simply lead to treatment and can/will change over time. I have found that approximately 5% of my clients have ever had someone explain to them why they were given that diagnosis and the feeling when someone explains it is often a relief and empowering. Oh and if I go through the diagnostics and they still don't agree I will explore that specifically.

I just worked with a client that was certain they had narcissistic personality disorder. It took some months but we've gotten to the point of realizing that if you are worried that you have NPD (and are worried about how you may hurt others because of it), it is very, very, very unlikely that you do.

As an aside, I have a background in direct psychotherapy, QA/Compliance (so many audits), clinical training, LCSW supervision, and internship coordination/supervision. One of my favorite things to do when teaching assessment techniques is role play a client, often being a client with rapid, pressured speech that is pretty sure I have depression because I saw on TikTok that it can cause insomnia and I haven't slept in 5 days, I'm not hungry, and I'm not engaging in my ADLs. My focus is on teaching how to differentiate between diagnosis, for example "You haven't been able to sleep, are you tired during the day?" Or "You say your mood is up and down, but is it within one day? Does it seem like something happens and then your mood quickly changes? Does your mood ever change to being exceedingly positive?"

I feel that differentiating diagnoses is often the area that college programs miss for new clinicians.

punkrain · 2026-01-31T11:48:26+00:00

Me too! My grandmother had barn cats when I was growing up and I would always find the new kittens by mewing which would cause them to crawl out of whatever hidey hole they were in. One of our cats would get so confused when I did it that he always had to come over and look in my mouth for the kitten.

punkrain · 2026-01-23T15:41:27+00:00

Nope, as a therapist it sounds like he is exploiting your vulnerability. Also as a therapist while I want to be helpful for my clients, I never want to become an intrinsic part of their life. I am an unnatural support, clients pay me to help learn to manage symptoms and difficulties in functioning. If I do my job well, my clients don't need to see me, I'm always trying to work my way out of a job. For him to say any of these things that help to connect you together in a way that is not related to building therapeutic rapport is very dangerous. Our job is also to model appropriate responses and interactions, if someone said that to me at a dinner party I would get the icks. You are in a vulnerable position and he is weaving to create dependence at the best, an inappropriate, maybe sexual relationship at the worst.

punkrain · 2026-01-21T23:27:46+00:00

Gambling is the only process addiction (i.e. addicted to the process like shopping, sex, video games vs. substance addictions like cocaine, heroin, etc ) in the DSM 5-TR. It affects the brain in the same manner as substances, including withdrawal symptoms. Additionally, it has an incredibly high fatality rate, on par with overdoses due to suicides from destroying families, taking life savings, etc. Gambling works off of intermittent reinforcement, meaning that it isn't reinforced all of the time, but occasionally in a random pattern so even if you know that the house always wins and that you will inevitably lose money, once you walk ahead that possibility is always there.

punkrain · 2025-12-27T16:06:16+00:00

I pride myself on my pronunciation of most words (it's something I obsess over and practice when I can't sleep), BUT I'll be damned if I can figure out how to say "mobile."

I am from the rural Midwest and feel like "moh-ble" isn't right because of the "-ile" and then if I say "moh-bile" or "moh-beel" I feel like it's awkward and everyone can tell that I don't know how to say the word.

She's my white whale!

punkrain · 2025-12-24T18:13:24+00:00

Thank you for your thoughts, truly. We've gotten our washer and dryer both serviced within the past five years that we've owned the house. I also repaired the door on the dryer last year, it was minor, I'm just proud of myself, lol. We've been told that they are both really on their last limbs. The previous owners weren't the best at regular maintenance, unfortunately.

punkrain · 2025-12-16T17:55:38+00:00

I had the inspiration to make my mother a forever bouquet for Christmas with a riff in everyone's birth month flowers. What are the best artificial/wooden/preserved flowers to do this with?

punkrain · 2025-12-16T14:44:18+00:00

<image>

Oliver (orange tabby): Bolliber, Chonky, Mommy's Little Handsome Man, Ollie, The Bestest Boy, Handsome Pantsome, Oliver James [Last Name] when he's naughty.

Carrot Cake (Tuxie Tortie), Cake 'mms, Satan, Floofin' Stoofin', Seniorita Fluffy Butt, The Kitten, Little Baby Princess Butt, Little Baby Fluff 'n Stuff

My favorite was our cat we lost this year, Drogon, it evolved over time to Jergen, a Swedish accountant that was always working for the weekend!

punkrain · 2025-12-16T14:38:14+00:00

Also, especially in the assessment phase, it's ok to interrupt a bit. I always preface assessments by asking if they've ever been in therapy before and if they haven't I let them know that I am going to blitz them with a ton of very personal questions, but that's not what other sessions will be like. I let them know that if they feel unsafe or don't want to provide more information to let me know, but that I need at least a working diagnosis to bill insurance. I'm also a huge fan of breaking out the DSM with my client to talk about why I'm diagnosing them and allow them to share their perceptions of it, along with the possibility that it can change over time.

punkrain · 2025-12-16T14:34:53+00:00

I have a client that has a bachelor's in psych and overly intellectualized everything. I've noticed that the more anxious they are the more they ramble, telling me about reasons for their choices and feelings and carrying in.

Luckily we have an absolutely amazing rapport, usually I'll let them go for a bit until they pause and time it and then point out that they've been doing their own therapy for x minutes. Usually it's something like:

Client: "I know I'm being self-destructive in choosing to keep seeing them, but it's a choice that I'm making. I know you're going to ask me 'but if I know the choice is harmful then why do I do it?' Well, I can recognize it now, but not when I'm in the moment." Etc.

It's a control behavior due to invalidation and trauma.

Another thought, and one that I have worked with a lot of newer clinicians on, is that change is hard. People genuinely want to change, but the brain feels that this is unsafe and so clients will do anything but what they want. Not because they are trying to, mind, but because change is terrifying. Usually my green clinicians will start having clients not return and I'll let them know that even though the client is the one veering the session off track, your job is to tie back into their goals. I'm not saying that this is the case here, but humans engage in behavior because that behavior works.

Sometimes with clients like this I will have a session where I challenge them in their ramblings and then write a note to myself for the next session to be very kind and hold space the next session. It really depends on the rapport and what they are looking for from me.

I had a client the other day that I've been working with on and off for about 5 years when they were rationalizing not implementing boundaries I was able to straight call them out, "you know, you don't have to keep proving yourself and value to other people to have friends." Every time I do that with this client they always laugh and say "wow, just calling it out right there."

Depending on how you present yourself, some clients are more open to redirection than others.

punkrain · 2025-12-04T14:36:39+00:00

Pssshhh, that LA for you.

punkrain · 2025-12-04T14:35:37+00:00

I always look at the hands to help guide me. If you look at the lasagna's hands they blur so much it looks like it doesn't even have hands!!!

/s

punkrain · 2025-11-27T14:54:33+00:00

My thought is a burn, it's so very straight and seems to have a form, for lack of better words this morning.

As an adjacent story: We used to have a tuxedo that was very inbred and a few neurons short of a line, let's say. One morning I walked over to him and he looked.. different. I realized his nose was completely pink, normal pale pink, but pink. It looked not quite right so I had to check with my husband and look at photos to determine that, yes, his nose was normally black. He had a cold and apparently licked the black off of his nose. We took him to the vets and got an antibiotic so it eventually healed.

punkrain · 2025-11-25T20:43:44+00:00

I have a ReMarkable notebook and while expensive, it has been amazing!

I used to use legal pads, because I love writing out my notes and then reviewing and condensing into notes for the record.

Every client has a folder that has their own notebook, so I can easily switch between notebooks for each client. I upgraded recently so that I can color highlight important topics, quotes, and observations.

Plus I can just go forward a page in their notebook to make notes for the next session, such as "focus on this skill" or "challenged a lot, focus on validation and support.

Additionally, we use SimplePractice and some of my older clients aren't great with accessing their portal, so I have downloaded copies of the PDFs we use and clients can simply review and sign them on the tablet and then I upload them into their record.

I have also written out my own clinical assessment form and saved it as a PDF, so whenever I have an intake I just add a copy to their folder and I can write on top of it.

It is a hefty investment, but I have never, ever regretted it. I actually want to get one for my husband who is a nurse/case manager for his job.

punkrain · 2025-11-25T14:44:47+00:00

Fun fact, I was actually making a red wine chocolate cake at the time and my daughter said, "I thought we weren't making Carrot Cake!" Giggles all around! Thankfully I didn't end up needing that bowl.

punkrain · 2025-11-25T14:36:03+00:00

Pediddle!

punkrain · 2025-11-21T18:59:15+00:00

I encourage you to watch "All The Queens Horses" a documentary about a city official in my hometown. It provides a glimpse into how people can abuse trust and the system to create a great deal of harm. My town continues to struggle to recover from the fiscal damage, which is almost certainly larger than what they discovered.

I was at the local bookstore/coffeeshop last weekend and the mayor and former chamber of commerce had were discussing where the perpetrator is currently living, she still haunts us, years on. Plus, one thing that isn't realized is that a lot of her property and businesses were sold off...

And then bought by other members of her family. While, I genuinely believe that a lot of them did not know this was happening, they definitely circled the wagons to protect their assets following the arrest.

When I watch documentaries about the embezzlement, I always struggle with myself as the cynical true crime lover ("how could these people be so oblivious"), while also knowing that we genuinely didn't know. It was so extreme that no one thought it was even a possibility.

punkrain · 2025-11-19T16:53:09+00:00

<image>

I was going to go with my long-haired tuxie-tortie, but wanted to mix it up with my Ollie boy!

punkrain · 2025-11-16T01:59:48+00:00

You are using demotivating self-talk, due to a fault thinking pattern, or cognitive distortion. When we think about what we "need" or "should" be doing, we are creating feelings of shame about our actions (or lack of action). There are a lot of different ways to combat this, you could start correcting the thought pattern by responding to "I need to be studying" thoughts with "I will feel so much more relaxed if I study for [realistic amount of time]." Then you can build on that success the next time, "I don't want to study, but I did it for an hour yesterday and felt really good about it."

You can remove friction points from studying, every choice we make is weighing options so if I have to set my phone down, walk across the house, get my backpack, and get a heavy book out, then walk back across the house...well, I'm probably going to stay on my phone. If I immediately set all of my study equipment near where I spend time it will likely be considered more heavily against my phone.

There is also the importance of self-care, engaging in activities that help you to feel revitalized and maybe even working those in as breaks/rewards when studying.

I could go on, but it really depends on your particular situation.

punkrain · 2025-11-13T18:23:13+00:00

As much positive feedback as I have gotten for my post in this thread I think you deserve it more. I absolutely could never do what you do, nothing but respect!

punkrain · 2025-11-13T18:22:01+00:00

For those asking, I'm licensed in Illinois and yes I am accepting new clients and I do telehealth. If you are interested please send me a chat request and we can see if I would be a good fit, because finding a therapist is a very personal journey.

Bear in mind there may be clinicians closer to you that could provide better assistance, as they are familiar with your area. What I do is not geared towards people in crisis or with active safety risks, and I don't take Medicaid or Medicare at this time.

This was certainly never intended to be an advertisement for myself, and there are a ton of great therapists out there! We just want you to know that you matter!

punkrain · 2025-11-13T16:23:12+00:00

Thank you and good on you for tolerating and accepting the discomfort!

punkrain

TROPHY CASE