Why "Physical" or "Psychiatric" Distinction
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Q:  Why 'Physical' or 'Psychiatric' Distinction for Me

Dr. Phelps,
I have not been diagnosed yet, but I have symptoms of Bipolar II, i.e., rapid cycling (became ultra-rapid in July-August of 2001. I had not been on antidepressants for some time before that time.)  My question concerns DSM criteria for bipolar.  It states symptoms cannot be attributed to any medical condition or reaction to drugs. 

I was diagnosed with major depression but exhibited manic symptoms after being on Trazadone for several months.  The med was so effective for my depression that I did not know I had a problem until I got into serious trouble (risky behavior, spending, eventually a suicide attempt).  That was six years ago. 

Also, I have fibromyalgia-like symptoms and chronic fatigue to the point where I am disabled most days.  My doctor told me I probably cannot be officially diagnosed with these disorders since I have a lengthy history of depressive illness.  All of this is confusing to me.  One doctor tells me my problems are physical and another tells me my problems are psychiatric.  Why does it have to boil down to one or the other?  Why is it so difficult for some to accept that a person can suffer from more than one illness?  I am having a very difficult time with moods/mixed episodes and chronic fatigue and pain.  It doesn't matter to me who treats me; I just want to feel better!

I believe DSM is supposed to be only a guideline, but some doctors go strictly by the book, and that leaves people like me out in the cold.

Dear Barbara -- 
Your frustration is entirely understandable, one that I've had too although from the other side of things, i.e. the treatment side.  You ask "why does it have to come down to one or the other", physical or "psychiatric"?  Right -- as though there is really some distinction to be made between the two.  As you can probably see, the distinction arises in part because of the training and mindset doctors get in medical school (not to mention Rene Descartes and years of tradition following his "mind-body dualism").  With symptoms like yours, which are difficult to treat from any perspective, you become a "hot potato" -- no, she's your patient; no, she's your patient, etc.  It wouldn't be so tough if there was a great treatment for your symptoms -- then it would be more obvious who was supposed to do what. 

However, in my experience I've seen fibromyalgia and fatigue and mood symptoms show up in the same patient, often not together, but almost as though there were independent "cycles" for each set of symptoms.  And, I've seen a few of those folks do better when I set out to treat at least their severe insomnia and their mood instability, using mood stabilizers.  Often there's a history of childhood or sexual trauma that needs to be addressed through psychotherapy.  But I have seen some clear improvement in symptoms, even just from the medications alone.  Unfortunately it's often not the dramatic complete improvement that would allow us all to say "see?" to the doubters, i.e. those who were saying "no, this is not a problem I'm supposed to treat".  

So on the basis of the your story here, I'd have some hope that by treating you for "bipolar disorder", as though that were the main problem (which means using mood stabilizers and no antidepressants, basically), you might see some impact on sleep and pain and maybe even energy as well.  I hope that's what happens. 

Dr. Phelps

Published November, 2002



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