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Q: Which of These Diagnoses?
Dear Doctor Phelps,
I would like to start out by saying how wonderful I think your participation is
on the website. I am eighteen years old and writing to you concerning recent
events. About four years ago, after a nervous breakdown, I was “unofficially”
diagnosed with Bipolar Disorder (type 1). The diagnosis was unofficial since an
acquaintance’s mother who is a psychiatrist made the diagnosis. The doctor gave
me a bipolar screening and reviewed my family history (my aunt is Bipolar). My
parents were in denial, and being a minor at the time, I could not be officially
diagnosed without my parents involvement and an actual trip to her office. I
have not been able to “feel” emotion since the nervous breakdown as well. I know
I have had at least four (five counting now) major depression episodes and three
manic episodes since then. I have also noticed that when in normal episodes I am
actually in mixed episodes in that I am passive during the day and then about 9
o’clock at night I “wake up” and have much energy. This has been going on ever
since I can remember. In November, I had a very personal talk with a youth
leader in my church. We had this talk while on a retreat and were staying a
hotel. After the talk concluded, the other girls woke up and we decided to pull
an all-nighter (it was all ready 2 A.M.) I was immediately thrown into a manic
state (I have the video to prove it). Since then everything has gone down hill
and I have been in a major depression since. My concentration has been
completely shot and other factors contribute as well.
Now that I have given you history in a “nut shell,” I will express my questions.
Besides being depressed, other symptoms have occurred. I have engaged in the
not-so-good habit of cutting and have had black outs (I do not remember any
ofDecember or January). There have been times where I do not remember doing
things that I have done (such as dying my hair black or carving a friends name
in my leg). I have also found letters written in my handwriting which I do not
remember writing and where I refer to myself in the third person. I have always
had periods of depersonalization/disassociation and my friends have told me that
there have been times when I was “so out of it” that they just left me. One of
my friends who found out about my cutting (I do not remember telling her)
convinced me to talk with her aunt who is a school counselor. I did and a plan
was made to get help. However, after I awoke one morning with my friend’s name
carved in my leg and black hair, my friend’s aunt thought it her ethnical duty
to call children’s services. I was then sent to a psychologist who spent
seventeen minutes total with me and had me take some psychological tests. She
then referred that I go to a psychiatrist and counseling. I was never told what
was found on the tests, if anything. I am with a new psychologist now and she
has addressed no issues what so ever. I convinced her that something is wrong so
she has decided to call in a Disassociated Identity Disorder specialist just to
please me. I have not slept since November (at the most three hours a night) and
I have not cut since February. I have read that Bipolar Disorder can also exist
with other mental conditions. In youropinion, and I know it only your opinion,
do you think that DID and depersonalization disorder should be a diagnosis or
should they be diagnosed with bipolar? Should something such as Borderline
Personality or Schizophrenia be brought into the picture and the other ideas be
eliminated? It is very frustrating to me that I have been this terrible since
November and nothing has been done. Everything, especially the loss of
concentration, has so affected me so much that I received an F for the first
time in my life (never gotten below a B+ before). I will be heading to college
in the fall and I know that something needs to be done or I will not thrive as I
would hope. Thank you for your time and your reply if you choose. I also
apologize for the length of this letter, but at the present moment I am in great
need of someone who knows what they are talking about.
Dear K' --
Ouch, this sounds really rough. You're certainly paying attention to the right
kinds of things, and you've learned how to identify a probably "bipolar
component" to this (the video you mentioned, e.g.; and the sleeping so little).
You've also learned that there is a phenomenon called "dissociation", with
official names like DID. There seems to be little doubt that this is part of
your collection of symptoms, based on what you've written here.
So you ask: what should take precedence diagnostically, the DID or the
bipolar? and what about borderline, or schizophrenia?
Taking the latter question first: here's an essay about the relationship, as
I see it, between
"borderline personality" and bipolar disorder.
Schizophrenia is usually marked by prominent delusions, and/or auditory
hallucinations, or a marked change in thought process, none of which
seems to be an obvious part of your problems, certainly not compared to
dissociation, sleep disturbance, and at least one probably manic phase
associated with sleep deprivation.
Before you finish "ruling out" other diagnoses, though, ask for some help,
from a source you trust, in seeing if you might need an electroencephalogram
(EEG). It's a painless test, though a bit of a bother: electrodes placed on your
scalp record your brain waves; it takes an hour or two altogether, usually. A
few days later a report would come in from a neurologist who read the
recordings, as to whether you might have a seizure disorder that could account
for some or all of the dissociation. Sometimes brain seizures can be subtle, and
look like dissociative episodes (though usually not lasting anywhere near as
long as some of yours seem to have). They must not be missed, as they're quite
treatable usually. I doubt that's the whole explanation for your symptoms but it
just might be a part of it and might need to be checked out.
Okay, suppose you have both DID and some bipolar variation, which should be
the initial treatment focus? (ultimately both aspects, if that's what's going
on, should get treated) Although I believe that's what you're asking here, it
may be easier than that, as follows.
The primary treatments for DID usually rely on a solid treatment relationship
with a therapist, one that can go on for something like a year or two if
necessary (i.e. probably best to start when you know you're going to be in one
town for that long, e.g. during college). Medication approaches are then added
to this relationship. Even if medications were to completely stop the
dissocation, usually the relationship problems people who've been dissociating
are "raw material" for therapy.
DID is generally regarded as similar in nature to "Post-Traumatic Stress
Disorder", perhaps a relatively extreme version of PTSD. If there is a
significant trauma in your life, then PTSD might be another diagnostic
"perspective" to bring to bear -- though again, the starting place is
psychotherapy and medications are used to augment that, in most cases (i.e. the
treatment approaches are so similar, you don't have to worry too much, at least
for starters, about "getting the right diagnosis", if you're looking at DID and
PTSD).
Medication approaches for DID and PTSD usually consist of many of the same
medications used for bipolar disorder, especially "new-generation"
antipsychotics like Risperidone, Zyprexa, Seroquel (and perhaps a try of one or
two old-generation antipsychotics -- especially if you have to pay for the
med's, because the old ones are cheap and the new ones are unbelievably
expensive -- such as low-dose Trilafon); and the "mood stabilizers", focusing
especially Depakote and Tegretol/Trileptal because they are anti-seizure
medications and there is such similarity between bipolar with dissociative-like
phenomena, and one particular seizure disorder called "temporal lobe epilepsy".
The point of that long sentence is that one treats dissociation with pretty
much the same medications one uses for bipolar disorder, so in that respect you
don't have to decide which to treat first. The main medication issue is whether
to put antidepressants at the bottom of the list, which they probably should be
for someone who clearly has bipolar disorder. So you see, the issue regarding
the "bipolar diagnosis" is primarily important at this point, in my view, to
determine whether you should avoid antidepressants (which actually have one of
the best track records in PTSD and would probably be on the list of medication
to consider, in most psychiatrists' views, for DID).
Finally, thought this may be more than you were asking or asking for, I'll
give you my personal opinion as a guess that might have some relevance to your
current symptoms. I think that in some people, bipolar disorder can actually
cause symptoms that look like dissociation, but are not really in the following
ways: first, sometimes I see this kind of thing in people who don't have a
history of any obvious trauma, nor does it look to me like they are somehow
"repressing" memory of same (a very controversial area in itself, in
psychiatry). Secondly, the dissociations seem to vary in frequency and intensity
as the bipolar disorder varies, and stop when the bipolar cycling stops. The
point here is that for some people I place priority on the bipolar side of
things and see how things are going, before trying to really focus on the
dissociative episodes and their possible historical bases; maybe that might
apply for you. I mention that because after this long ramble I still realize
that might have been what you were asking about in the first place. Good luck to
you.
Dr. Phelps
Published July, 2003
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