Having Trouble Getting a Clear Diagnosis
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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 lights soon!


Dear Doc' -- 
Glad you found the
dark therapy; 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 the 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.  

Dr. Phelps 

Published January, 2003


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