Diagnosis

First...thanks to all who commented on my post, "Am I the Only One?" Each of your responses were full of things I think are true in many ways. Very valuable comments.

I have wondered for a long time why the DSM IV does not take a different approach to Depression and Bipolar Disorder. Based on my experience of myself, and my listening to and reading about, other's stories I really believe the way Depression and Bipolar Disorders are categorized is incorrect.

It seems really clear to me that Depression and Bipolar are on a continuum of one illness; that they are not two seperate illnesses. Here is my proposal for the next DSM:

Depression --->Bipolar Continuum

1. Mild Depressive Episode
2. Dysthymia
3. Moderate Depressive Episode
4. Major Depressive Episode (MDD if more than one episode.)
5. Major Depressive Disorder No Cycling (I'm not refering to bikes;>)
6. Major Depressive Disorder Mild Cycling
7. Major Depressive Disorder Moderate Cycling
8. Major Depressive Disorder Major Cycling
9. Cyclothymia
10. BP II
11. BP I

Then the descriptives...chronic, psychotic etc. Of course, I am a layperson and there could be things in between that I haven't thought of...but it seems like depression is connected more closely to BP Disorder than is currently described. It seems people who have had numerous episodes of depression may be more likely to begin cycling at some point. Maybe I'm wrong, but this has definitely been my experience.

When I was young I either cycled between wellness (for me hyperthymic...quite a bit higher/more irritable than the average mood...this definitely runs in my family) and depression. The depressive episodes fairly short and sometimes extremely short, changing from suicidal to extremely high in one day, or every few days.

As I became older the episodes began to get longer and longer, and more severe. They began to really affect my ability to do the things I wanted to do. Now my mood cycles are much worse going between feeling suicidal and going so high I get intense anxiety and agitation...so I begin having difficulty functioning at either end of the scale. Do mood cycles increase both in length and strength as we age, or as we have more and longer depressions? Or did the medications I have taken kick me into some kind of cycling pattern?

It seems I never had the intensity of cycling before I began trying medication. So I wonder if some of the medications initiated some of my cycling? Or did years and years of not sleeping well kick me into my mood swings? Or are they psychological (vs. biological)...do I cycle up so high because I am pushing to get well and I have so much momentum that I somehow manage to push right past the well stage? What about how the world seems to change when I am high? I feel I can see the life force pumping through everything. The colours are intense and it is as if I can see things at the cellular level..intense and more beautiful than when I just feel okay.

Does it matter why? Does it matter "what" I experience? Does it need a label? What would happen if there were only experiences and no labels? What if my cycling were a gift? What if it weren't a gift, but I accepted it as one? Would I be well?

Am I the Only One?

**Addendum added: I just went for a walk and I realized that another reason I don't understand is because of my difficulty understanding, or accepting anything that is not black and white. I get completely confused when something is in a gray area. It makes absolutely no sense to me.

I often feel annoyed, frustrated, and maybe like I am being lied to when my pdoc and I discuss my diagnosis. I was talking to a friend about this and she asked me, "Why does it matter?"

That is a good question, and at first I really couldn't think of why it mattered to me. All I knew was that it did. It really did. It really, really did. It annoyed me, frustrated me, made me question my illness, made me worry about my illness, and made me not understand my illness.

Here is a "stream of consciousness" discussion with myself about WHY this bothers me so much. (***I have not edited it, because I was feeling a bit angry as I was writing...and if I edit I will remove some of the feelings):

First my pdoc says, I have major depressive disorder with cycling that takes me almost to hypomania, but not quite. Fine...I think that is close to accurate, although I can think of many times when my own feelings were that I was way to high for this to be "normal". Not that I want to 'be" a label, or be labelled, but it is kind of like when a person is diagnosed with something, they want it to be the right diagnosis...for example, if I have liver cancer, I don't want to be told I have kidney cancer, only to find out later I have liver cancer. I just want to know.

My confusion is compounded when my pdoc and I decide to use medications that work for BP disorder, when he expresses that I have a "bipolarlike": depression...(huh?) ...and when I find my mood increasing dramatically, my not sleeping more than a few hours a night and my mood ranging from super high, to wired, to happy, to high again and back. When I see myself doing more than I have done in years, all initiated within the time I have not been sleeping, and yet felt high and energetic.

But I still haven't figured out WHY it matters to me so much...partly sometimes I feel like the truth is withheld because of the stigma many attach to bipolar disorder, partly it seems my pdoc doesn't really put much emphasis on diagnosis, rather he looks at symptoms and how to address those (which makes sense)...but what happens if something happens to him and suddenly people who do base their treatments on diagnosis, see I am on a "bipolar" medications combo, yet I do not have bipolar. What if they decide I don't need the medications I am on? what if they don't recognize that I cycle despite not having bipolar?

I still don't understand why I feel frustrated that my mood disorder doesn't fit into a simple descriptive diagnosis. I can't be the only one. Some people have Major depression with no cycling, some have cyclothymia: "The highs of cyclothymia are called hypomania, a milder form of mania. The lows consist of mild or moderate depression"...Mayo clinic), some have BPII Mayor depression and hypomania, some have BPI, major depression and mania...where are the people who have major depression and a milder form of hypomania...sort of a reverse of cyclothymia? It doesn't make sense. And if people exist along some kind of spectrum, why don't they simply have some kind of, for example, 1-10 rating for mood cycling of all different kinds?

Also, how do you explain to your family what is going on? to your spouse? your friends? if there is officially no such thing as what you have? How do they find out information that might help you if what you have does not exist in any "official" context? How do they know you are just not making it all up?, or that you struggle both with the highs and lows?

I'm not sure if any of this makes sense, or if it even matters to anyone. Am I the only person confused by a psychiatric diagnosis? I guess the big reason I feel irritated is that I just want to know. I need to attach a name to how I feel. I want to know if my mood cycling is my fault, if I am in control of changing it, if I have done something wrong to create this type of mood hell. Or do I have an illness that causes me to feel this way? Is change my responsibility completely? Or are parts of my highs an illness which I need to control with medicine/therapy/lifestyle changes? Do I really go high...or do I imagine it? For some reason right, or wrong, I need to understand more than I do.

Rethinking Wednesday's Session

I am not sure what was up with me Wednesday. I entered my session feeling despondent and down about not being able to hang onto the feelings I had a few days prior about being ABLE to change my life, being EXHORTED by my dream to change my life, feeling SURE the switch had finally flipped and I was magically better.

I recognize today, there is no "switch"...it is more like a light dimmer that I need to turn up very slowly to bring more light into my life. The switch is what I don't want or need. It represents the endless cycling mood states I need to get out of.

I was rereading some of my posts, and I recognize that I do have a lot of cycling to my moods. I also understand what Dr. X. meant on Wednesday when he said he worries my higher moods, in conjunction with less sleep, might be unsustainable. I see it, but I wish they were sustainable. Problem is the higher I go, the more likely I am to crash afterwards.

I also see that when my mood is high, it is generally not a bad thing...I don't go off and buy houses, or gamble my life savings away, or cheat on my husband, or do anything that is potentially harmful to me or anyone else.

In fact, that state is a state of freedom for me; freedom from social anxiety, depression, anger, freedom from all the symptoms that haunt me when I am depressed. I also do not lose my insight into my mood state. I can tell when my mood is high. My high mood is really high, but not pathological in any way.

I don't know what it is, but I am often afraid people are lying to me, or hiding things from, or keeping things from me, or spying on me, or have some secret agenda that they don't want me to know about. I think my concerns about my "real" diagnosis being withheld from me fall into that category.

Dr. X. has told me there is a "bipolarity" to my depression. We have also talked about the tendencies in my family, especially on my paternal side, towards hyperthymic temperaments; how my well might be higher than many people's well. It really does describe me perfectly.

I think I was being weird when I got all concerned about having bipolar disorder and not being told about it. Part of my worry stems from the fact that my cousin has Bipolar Disorder, and though undiagnosed, my Uncle had all the symptoms of it as well.

So I worry I am headed that way. The only way I can see it sometimes becomes a problem is for others in my way when I am really hyper. I know I sometimes overwhelm others. Also, I do worry that my high mood will become so high I won't be able to control myself. I think that worry stems from some of the wild, and stupid things I did when I was younger when I was high.

When high I absolutely could not say no to anything...which frightens me now. What if I go high and cheat on my husband, or cannot control my sexuality, or take off with some stranger. I did do those things when high before. I worry I am capable of that again.

Why does it really matter to me one way or the other. If my treatments are helping me, if the mood stabilizers have slowed the cycling (or at least made it less drastic), if I have a really great therapeutic alliance with Dr. X. who really cares what my diagnosis is. Plus, why would Dr. X. not tell me the truth? In my experience he has always been forthright, open and honest about everything during my treatment.

I think part of the difficulty is that I see things in black and white. Grey areas are difficult for me to understand, to conceptualize. I am the product of a very black and white upbringing. My home was very top down authoritarian. My Dad being a policemen lived by very strict rules/laws. I like to think I am open minded and able to understand life is not so simplistic, but some of my belief systems are so hard wired in me it is difficult to change, grow, and understand concepts that sit outside of strictly laid out guidelines and rules.

It is really funny though:

...what I love most about my therapy with Dr. X, and Dr. X. himself, is his refusal to see things from a dogmatic perspective. I love that he challenges the status quo. He feels like the perfect role model for me; the person who is best able to challenge my strict adherence to rules, the person most capable of helping me learn to both see, and accept that life, like a beautiful drawing, is full of many, many shades of grey.

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 thinking...you 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.