Response to Lithium & BP Diagnosis
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Q:  Response to Lithium & BP Diagnosis

I am  mental health professional, psychiatric R.N., Licenced MFCC, PhD. I am very familiar with the DSM-IV. I have had lifelong severe depression, tried many antipressants with only partial relief with Wellbutrin, but continued almost obessional, driven, suicidal thoughts. I was recently started on lithium. Finally, after reaching a dose of 1800mg I am completely free of suicidal thoughts which has now lasted for 4 months. My psychiatrist changed my diagnosis to BipolarII but I do not meet any of the criteria for hypomania other than some inner restlessness, no other symptoms. I have used lithium in the past as an adjunct to an antipressant, up to 900mg with no response. My question is: Does the fact that I have only responded to lithium automatically change my diagnosis to Bipolar even though I do not meet the criteria? Also, If there are any resources you might be aware of on this could you please direct me to them. I have searched tirelessly for some on the net. I'm ha!ving great difficulty accepting this diagnosis. Thank you very much for your response.

Dear Dr. M' -- 
Fair question.  The quality of thinking you describe -- "almost obsessional, driven suicidal thoughts" -- might count on the "hypomanic" side of things, as well as the inner restlessness.  Decreased need for sleep?  I.e. being able to function well on 4-6 hours for days, sometimes?  You've got a lot of letters after your name -- does that reflect being able to really crank out the work sometimes, more than most people you know?  Is it like that only sometimes?  If it's like that all the time, you might have what Dr. Akiskal (Hagop Akiskal, formerly of NIMH, now head of the Mood Disorders program at UC San Diego; and one of the most well known researchers on the outside edges of bipolar disorder, as you may have seen from your research) would call "hyperthymic temperament" .  Such people just live close to the hypomanic side of things all the time, no cycling.  But they have relatives with bipolar disorder fairly commonly.  

Those would be the kinds of things I'd look for to help support the diagnosis enough for you to find reason, satisfactory to you, to have to work on accepting the "diagnosis".  But you have probably already recognized that at this point the label is far less important than the outcome.  You'd only really need it at this point if what you were doing now wasn't enough down the road, and then the question would be whether to add a little bit of an additional mood stabilizer (i.e. the move that would generally follow from this diagnosis).  

However, I know what you're talking about (I think) from talking with my own patients.  There's something qualitatively different about the feel of the label "bipolar" versus "depression".  Obviously society doesn't know, generally, about the fine distinctions between bipolar I and bipolar II.  To most people out there, bipolar means "crazy".  So it would be difficult to accept the label on those grounds alone.  

On the other hand, to the extent this is possible (and I am acutely aware of the limits on this), the more people like you "accept" the label (or at least people sort of like you, who have more clearly defined BP II), and are willing to let it be known that they have a "bipolar variation", the more widely it will become understood that there are versions of bipolar disorder that don't include full manic episodes.  Over time it is going to become clear that this is a fairly prevalent condition that must be screened for prior to giving antidepressants, for example, and such screening would end up identifying quite a few folks who are then going to face the same problem you're facing:  minimal suggestive symptoms for hypomania, but just enough (including perhaps a relatively clear-cut family history of bipolar disorder) that they really must wonder about the safety for them of taking antidepressant medications.  

But I digress.  I hope you've looked at the "bipolar spectrum" way of thinking, including as shown on my website about bipolar II.  That's the way I'd want you to be thinking:  not "do I have it?" but rather "do I have just enough of it to warrant this approach?", i.e. "am I just a little ways over there on the bipolar spectrum, just far enough to make a difference in treatment?"

Good luck with your acceptance work.  

Dr. Phelps

Published November, 2002



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