Thursday, August 21, 2008

Does Diagnosis matter?

This post is partially inspired by Sara at "My Sad Alter Ego". Her post "How I cured my Personality Disorder Without Even Trying" started out tongue in cheek (although I sense she also feels she is misdiagnosed)...She Starts, "Quit going to a psychiatrist! And voila: Borderline-be-gone!(Yuk yuk)"

(please Sara correct me if I'm wrong about your feeling you have been misdiagnosed). I have known a few people who have been misdiagnosed as having Borderline Personality Disorder, only to be told years later...whoops, you actually have Bipolar Disorder.

I guess my BIG question for this post is, "Does a diagnosis really matter? Or is it sufficient to treat the symptoms people are experiencing, regardless of what it is called?

My appointment with Dr. X. was difficult to begin with, but by the end I wanted to stay and talk longer. I hate the 50 minute hour. I would give anything to go for a walk for a few hours with my pdoc. To really have an extended appointment in a different setting.

I hadn't written about this this week, because I made such a bold statement about my life suddenly taking a new direction, that I was reborn and had become a new person. I felt embarrassed when two days later I found myself in another state of depressive hell. My entire new personal "constitution" disappearing before my eyes.

I told Dr. X. about my revelation. I explained that I believed my dream was LITERALLY sending me a message, telling me to let my old me die and to become a new me. He looked a bit concerned, until I said I understood it was ME passing me the message, that it was my subconscious. It wasn't like I was getting third party messages. I do however, believe I get sent important messages especially from from my dreams, but also from nature; when I see coyotes in the field, or a bald eagle flies directly above me, or a plant passes me a message from my Mom. I feel some sort of mystical connection to the natural universe.

Anyways...Mysticism aside...Dr. X asked me if I was the wolf in my dream if perhaps the dream was telling me I have much more power and that I am much more calm and sure of myself than I give myself credit for. I definitely see that aspect of myself when I am well, and I especially see that when my mood goes extremely high.

This led to my asking him about both my medications and my diagnosis...the diagnostic labels are something he really does not like to place on patients. He seems to believe in treating symptoms, avoiding labels ("labels are for insurance companies", he once told me), and ensuring that a patient's subjectively positive experiences are never pathologized. I like his approach, but I sometimes also feel extremely confused by his avoidance of a diagnosis.

So yesterday I asked him straight out. "Do I have bipolar disorder? I know you have told me you have never seen me manic, but have you seen me hypomanic?"

(Inside my head I am thinking: "If I do have Bipolar Disorder just tell me and then I understand the importance of being on all this medication, also, I am provide me with medication and lifestyle advice all of which is in keeping with what I understand helps people with bipolar disorder. You also talk about managing my cycling mood. Sometimes I just need to KNOW the truth about what is happening inside me. I feel sometimes I am being kept from the truth. I need to know what I am up against. Does this type of cycling lead to a higher potential of mania if I don't take medication? Are you worried about my switching into mania? If not...why the hell am I putting my body through all these medication trials? Why don't I just let my high moods happen?)

Instead of all those questions, feelings and statements all I ask is "Do I have Bipolar Disorder?"

He hummed and hawed, looked at me and said, "I don't want to patholigize your good moods. I have seen your mood so high that I believe it, in conjunction with the lessened sleep that accompanies those mood states, makes me believe the extremely high mood is unsustainable. Some could argue that you become hypomanic".

Me: "Are you afraid to tell me I have Bipolar Disorder? If I don't have bipolar disorder why am I on all these medications? Especially, why am I on a mood stabilizer? Maybe I don't need that medication."

Dr. X.: (paraphrase) No I am not afraid to say you have bipolar disorder. I don't want you to see your good moods as a bad thing.

Me: Well, how do we know if I should be on all this medication?

Dr. X.: Unfortunately there is no "test" to say you should be, or not. We need to determine that based on how you are feeling...I see with the Prozac you have had many more better times, or days than you have on any other medication.

Me: Well, maybe I should try going off the other medications, because maybe it is the Prozac that is making all the difference. I'd especially like to get off the Valium.

Dr. X.: I agree going of the Valium at some point might be a good idea, but I would rather it be when you are sleeping better than you are now, and when you are less anxious.

Me: I understand, but what if I switch my Valium for that new medication you were telling me about (Pregabilin)...I note that at this point our session is up.

Dr. X: This is a really important conversation. Let's talk about this next week.

Oyy. I really think I do have bipolar disorder. My highs are way too high...I know that. They feel like I have become some kind of god. Like I am better than well, am perfect, am adorable and fascinating, charismatic and completely free. It is as if I have somehow melded perfectly with the cosmos. The world changes and I see far more intensely and deeper than I ever see when I am depressed, or even when I feel well. Problem is...It feels soooo amazing to feel that way, and it is an intense departure and relief from my depression. I wonder if a mood stabilizer is holding me down. I have not felt any highs since I began mood stabilizers. I miss the relief. What if I could be that way all the time. Life would be amazing.


sara said...

This is interesting...I think you have a very good doctor. I'm not a psychiatrist, but I also don't believe a whole lot in dx in psychiatry.

I know that the idea that I am borderline is ridiculous - I have none of the isn't like you could say I have just less than you need for the DSM...I really have none. But this term reflects more what the psychiatrist thinks about you than any reality, and means something different when psychiatrists use it than the original, technical meaning.

In short, they say, your diagnosis mostly reflects what your psychiatrist thinks about you: Bipolar means you're interesting/they like you, depression means you're boring. Borderline means they hate you, and schizophrenia means they feel sorry for you.

In short, I am a young, attractive woman with a lot of anger. In psychiatrist shorthand, that is "borderline" whether or not that has anything to do with the actual technical definition of borderline.
Basically, what it means is that my shrink is both sometimes turned on by me and sometimes frustrated...
but it has nothing to do with me.

And really, the minute he insisted, and also wouldn't explain or discuss why he thought that, I should have fired him, as it indicates that the countertransference is not under control.

And the differnce is, he thinks that therapy is the answer more than meds, even though any therapy has never ever helped me and with meds, my life goes back to normal and functional and completely ok.
The question of whether therapy even does any good in borderline is a whole other issue as well.

Here is a good article on that particular diagnosis.

Aqua said...

Hi Sara,
Some of what you are saying has been what I have heard from many others. Often the diagnosis of Borderline Personality Disorder (BPD) seems to have a lot of negative, condescending and (dare I say) sexist conotations attached to it.

Personally, if I was a psychiatrist I would find everyone fascinating. I believe a good psychiatrist can maintain enough objectivity to accept that people are who they are, they are no less exciting, or boring given their diagnosis.

I hope so...because my "oficial" diagnosis is Major Depressive Disorder"...I hope I'm not boring Dr. X to death (although I often wonder how he sits there and listens to me go over and over the same bloody prblems, week in and week out).

If I really disagreed with my diagnosis I would seek a second opinion...I definately recognize, as does Dr. X, that there is a bipolarity" to my depression. Why I am concerned is I want to be on the least amount of meds that work...and if I do not need a mood stabilizer, because Iam not in danger of going manic, then I want to stop taking it. It will be a discussion Dr. X. and I have, and probably something I will try.

Unfortunately I worry that people get labelled BPD and then the people in the healthcare system treat them like pariahs. That makes me very angry. No matter what our Mental Illness, all we really want is to feel well and to be treated like other human beings who have illnesses...with dignity and respect.

sara said...

As far as I know, BPII is a highly consistent diagnosis. It does not slide into full on mania. (Unlike, say, cyclothymia, which about half eventually slide into BP2.)