Q: Having Trouble Getting a Clear Diagnosis|
Dear Dr. Phelps,
I am one of those patients who is having trouble getting a clear diagnosis. I
am myself a family practice doctor, and wonder if this makes physicians
reluctant to dx me with bipolar disorder.
I have had severe treatment resistant depression for most of my life, with
sudden severe suicidal crashes. But at times, especially in the summer, I
overspend, take on projects, feel happy and lively, and need less sleep. Often I
feel a mixture of symptoms. The worst is when I am feeling guilty and depressed,
but I become agitated and restless; at those times I have sobbed and sobbed,
whipped myself with a belt, and come close to suicide. I have been working
with a psychologist for about 10 years and with various psychiatrists for 4
years. Antidepressants work initially, very rapidly, but then stop. For two
years I've been on Depakote. I've gained about 15 lbs. on it and lost hair, but
on the ER form that got better and stabilized. I've been on sleeping meds for
four years--I was on Ambien and now Temazepam. Without them I can't fall asleep.
For six months I've been on risperdal 0.25 in the evening, and it seems to help
me wind down and get to bed earlier. It also has helped when I've been in an
acute mood crisis. One of my physicians tried Zyprexa, but I felt so slowed down
I couldn't manage. I am currently (in winter) having hypersomnia, decreased
energy and increased appetite. I've missed work and feel flat and dull.
I've seen 3 psychiatrists and 1 psychologist and they all say I have a mood
disorder of some type, but they won't say I'm bipolar. No one has ever suggested
trying me off antidepressants. I think I'm bipolar I rapid cycling and need to
be treated in a more serious way. My functioning has definitely deteriorated--I
have left medical practice. I got a degree in English and teach writing, but I
still teach residents. However, I am barely making it because of my sleep and
energy problems and my difficulty concentrating.
I apologize for this long email. I'm probably in a bit of a mixed state at
present. I would just like your recommendations for how to approach my
psychiatrist in order to get the best diagnosis and treatment. I have a HMO
(Kaiser) and am seeing a new psychiatrist 12/31.
Thank you for your extremely informative web pages. The information on
medications and dark therapy was especially interesting. I'd better turn off my
Dear Doc' --
Glad you found the
that's could be pretty relevant for you in the summer, at least as something to
try for rapid cycling without having to wait for a diagnosis. With the fact
that you have difficulty falling asleep, despite Ambien or temazepam, it might
even have direct impact now (i.e. in the winter); there's something funny, i.e.
mixed state-like perhaps, about having trouble falling asleep despite having
hypersomnia. I also have some hunches about this pattern marking some cortisol-stress
problem, or mid-forties reproductive hormone change problem, but I've yet to be
certain about that (my preliminary thinking, perhaps relevant given the Depakote,
can be viewed under the "metabolic
syndrome" heading on my site, in case you
haven't found that yet -- if it makes any sense in your situation).
As far as the diagnosis part goes, you may already have
tried taking the
Mood Disorders Questionnaire.
There's a newer test for "bipolar spectrum" versions of bipolar disorder, called
Bipolar Spectrum Diagnostic Scale.
Try that one too and take the results of each to the next psychiatrist. As you
know from your experience as a doctor, you'll have some trouble if you walk in
and announce your diagnostic impression, but a half-apologetic statement of
"I've done some research but I have an open mind" might go all right.
Light therapy also
sounds relevant; I imagine you've already tried a light box, and a dawn
simulator, preferably together if neither alone was sufficient? Finally, I
believe very strongly in exercise programs as a regular daily event for
those who are trying to maximize symptom control without medications -- relevant
for you here in that this is another "treatment" you can experiment with while
waiting to see what diagnostic conclusions will be reached next. Good luck to
you with all this.
Published January, 2003