Friday, April 18, 2008

Bipolar Diagnosis (Part 2)

When I reread what I'd written about bipolar diagnosis yesterday, I realized that what I recommended only should be considered a small part of the larger diagnostic process. In fact, what I wrote was short-sighted, and I apologize.

What I should have said (and this is my personal opinion) is that while the process of mental illness diagnosis has degenerated into matching symptoms to the Diagnostic and Statical Manual of Mental Disorders (DMV IV) criteria, that's a huge disservice.

In traditional medicine, the best doctors have always known that diagnosis is an art. In The Lost Art of Healing: Practicing Compassion in Medicine, Bernard Lown, M.D., writes: "Practicing the art of medicine requires not only expert knowledge of disease, but an appreciation of the intimate details of a patient's emotional life usually presumed to be within the province of the psychiatrist."

And yet, how many psychiatrists really do effective diagnoses? No matter how many psychiatrists (and psychologists) I talked to, none of them really listened, and thought outside the box. If they had, things might have turned out differently, because I unknowingly had provided them with critical information, which they ignored.

At every first visit, I said: "My first depressive episode occurred when I was at Cal, and I think that while I was there something broke inside me that could never be fixed." Yet, none of the psychiatrists ever considered that to be an important piece of information, although I am one of the few people who believes that the initial trigger is extremely important.

I also said, "For 25 years I had these semiannual six-week periods of unhappiness (undiagnosed depressions) in April and October." Yet, no psychiatrist ever asked: "Is there anything significant about those months?"

If they had asked, I would have said, "April is my birthday and for years I used my birthday as a period of reflection. Every year I would ask myself over and over again, "What happened at Cal that caused such an enormous shift in my orientation to life, and these periods of such unhappiness?"

If my doctors had followed this line of inquiry, they would have understood that what I actually was doing was "rumination," which is thinking over and over about a negative experience. In my case, I didn't realize this was a bad thing to do. I thought I was using my critical thinking skills to try and heal myself.

The other significance of April is that it is the anniversary of the month I started college. A few years ago, I read that many people suffer depressions on the anniversary of a traumatic life experience. Thus, both the rumination and anniversary of starting college were viable reasons to experience the April depressions. And had a doctor uncovered them during the diagnosis, I might have been able to end the cycle.

The causal factors for the October depressions are less clear. There may have been a seasonal element to them. Yet, only one psychiatrist suggested the possibility that the fall depressions might be related to Seasonal Affective Disorder. Also, I returned to Cal in October of 1968--my second quarter--which was the very worst part of my experience there. Again, this is an anniversary of sorts.

My point is that these questions aren't rocket science. Each of us may have incidents in our lives that trigger depression episodes. The problem is that psychiatrists believe that while the first depressive episode may be triggered by a life event, subsequent ones are not. They are caused by brain kindling, which means that after a few depressive episodes, our brains become rewired and automatically switch into a depressive mode.

However, like much else related to bipolar disorder, this theory is conjecture. The fact is that our brains have elasticity. And if we know that a specific event is causing a depressive episode, it may well be that if we meditate, do guided visualization, or learn self-hypnosis, we can prevent this recurrence.

But the key to taking charge of our illness is to have a doctor ask questions during the diagnosis--or in subsequent meetings--which will uncover information to help heal us. Instead, once I was diagnosed as bipolar II, in every subsequent consultation with a new psychiatrist (and I've seen 5 different psychiatrists in the last 15 years), all they did was confirm the original diagnosis.

I believe this is medicine at its worst. As Dr. Lown says, "Doctors focus on the chief complaint (which in my case was always depression) mainly because medical schools do not train students in the art of listening. Obtaining a careful history, while emphasized, is not actually taught... Furthermore, the history provides soft data while a doctor craves solid facts... Limiting history-taking to the chief complaint often initiates fruitless pursuit of irrelevant matters that are quite tangential to the main problems.

(to be continued)


bart said...

thanks for this well thought out and insightful post... you've made a major statement here but one i find intuitively right, in assuming that there are no hard and fast categories really, that most conditions are spread over multiple categories of the DSM criteria... if that is the case, then you are justifiably right in saying that it takes more than books and a lot of schooling to pronounce a diagnosis, it also takes a knowledge of the individual involved and a considerable deal of empathy and intuition to find an effective treatment...

hope this helps, it's not an easy subject...

keep well...

Bipolar Wellness Writer said...

Dear Bart,
You're welcome. Thank you for the thoughtfulness of your comment.

The problem with the current method of diagnosis is that it's not geared for problem-solving with the goal of wellness. It's more of a "one size fits all" proposition. And, of couse, everything would be quite different if the medication worked for most people.

Also, once people get their diagnosis--it's a life sentence--which is even more depressing.


Annie said...

I agree with you about the idea of triggers. Triggers have brought on my depressive episodes. There may be a seasonal component to depression but it is another trigger to consider not a diagnosis of SAD. Your posts are so helpful for me, thanks. Annie

bart said...

Your page attracts alot of barts.'My name is Bart as well.
Thanks for the article. As a future psychologist it's always very informative to read articles like this.It's important for my own development as a psychologist.
Thanks for the energy and effort you put into the site and this article

JayPeeFreely said...

I read the last couple of posts. I can understand why you might be at a crossroads with the blog. You do likely need to move on to something else, and that's good.

You've done a world of good writing this. With the book you just wrote, and maybe, possibly, compiling some of these posts (and reader responses) into a second one, you might have something of market on the concepts, diagnoses, tactics to fight aspects of bipolar and the care.

Editing what you got would be task - but a fun one, I think.

Have a good weekend! Go Cubs! (oh, that's my charge...;) )

Nancie said...

Dear Susan,

This is another great post.

You made a very good point that "the key to taking charge of our illness is to have a doctor ask questions during the diagnosis--or in subsequent meetings--which will uncover information to help heal us."

That will be really helpful in our recovery process. One of my counselors did that for me during my 9 sessions with her and that really helped me in a most wonderful way.

Hope you have a wonderful weekends!


Bipolar Wellness Writer said...

Dear Annie,
I'm glad the posts are helping you. Thanks for letting me know. This entire notion of triggers is something I read about a few years ago--and not in a book on bipolar disorder. When I did further research online,I figured out all the rest.


Bipolar Wellness Writer said...

Dear Bart (II),
I'm glad my article and my site is helping you. Actually, I think that a lot of people who are bipolar (and perhaps those with other illnesses as well) might help "future" psychologists and doctors.

Since there is such a poor prognosis for our illness, if we don't help ourselves, no one else will. But thanks for letting me know. Your willingness to learn from a "patient" says a lot about you!


Bipolar Wellness Writer said...

Dear JayPeeFreely,
Thanks again! You've been a major source of support and I so appreciate it. Thanks for your advice for a new book idea. I've been playing with some ideas as well. In response to you; Go Cubs! I'll check out your newest baseball posts over the weekend.


Merelyme said...

This is a very good post. I think doctors are very fallible and mostly pay attention to depressive episodes. I have only been diagnosed with clinical depression in the past but I always knew there was something a little more than this.

Bipolar Wellness Writer said...

Dear Merelyme,
Thanks for your comment. Unfortunately, we all have to check our own symptoms to determine whether we feel the diagnosis is valid or not. And sometimes, we have to "help our doctors help us."


Duane Sherry said...

I think much of the healing has to come from within - deep down.

When we are talking about ourdeepest emotions, we are talking about our 'souls' (in secular terms).

These souls need to be handled with the upmost care, and few are gifted enough to know how to do so as doctors or therapists.

I am certainly not against all therapy, and feel it can be very helpful - as long as the person on the other side has the realization that it is truly another soul they are working with.

This requires compassion, and empathy beyond what many people are capable of, and an ability to really listen - sincerely, and out of concern.

And once the source of the pain is found - knowing what to do with it - especially past traumas.

I think it takes a belief in the whole person inside each and every broken one.

I think it comes down to having a belief that this wholeness can be drawn back out.

How do we find it? How do we bring it back out?

I think we have to go inside....deep-down for these answers - which are unique for each of us.


Bipolar Wellness Writer said...

Dear Duane,
This is one of the best pieces I've ever read on the subject. You're absolutely right. I couldn't agree more, but I have never been able to articulate it in this way. What a wonderfully sensitive and thoughtful analysis of this topic. I can't thank you enough for writing it!