Q: What Would be the Best Way to Proceed to Show the Psychiatrist the
bipolar disorder that the Psychologist and My Friends and Family See?
Hello Dr. Phelps,
My question relates to the comorbidity of borderline personality disorder (BPD)
and bipolar II (BPII). I am a military member that has now seen a total of 7
mental health counselors, 2 psychiatrists, 3 psychologists, 1 prescribing
psychologist and 1 counselor. 3 of the doctors say that my dx should be BPD and
some form of BP and 3 say it should be BPD only, no one knows what the counselor
has to say as we still haven't been able to get his notes. I am currently on a
psychopharmacological cocktail of 200mg Seroquel, 50mg Topamax and 150mg Effexor
XR. The meds have helped tremendously and friends and family say they have not
seen me this cool and collected ever.
So, here's the rub my current psychiatrist is one of the doctors saying BPD only
and my current psychologist is one of the doctors saying BPD and BPII. If the
official dx comes down on the side of BPD only, I will be administratively
discharged from the military and have no benefits and the 9 years I have spent
in service will be all for not. If the dx comes down on the side of BPD and BPII,
I will receive a medical evaluation board that may medically retire me and I
will receive benefits equal to those of a normal retiree from the military.
According to the psychiatrist, the medications are to treat the symptoms of the
BPD. I have been on various antidepressants for 14 mos. and I have been on the
Seroquel and Topamax for almost 5 mos. According to the drug information sheets,
they are all for BP.
Therefore my question is, what would be the best way to proceed to show the
psychiatrist the bipolar disorder that the psychologist and my friends and
family see? I am thinking of stopping the meds, I have had 2 health panels where
everyone butted heads and walked away with no true resolution and this has been
going on for over a year now. I am not able to do the job I joined the military
for, military intelligence, and I spend all day fixing fitness machines instead.
Any advice would be greatly appreciated.
mess. Sorry to hear about this, a diagnostic debate with some very, very real
consequences. Here are a couple of ideas. First, see if your psychologist (or
maybe a military base librarian, if you have such a thing) can help you get hold
of an article about bipolar and borderline that presents an entirely different
way of thinking about the two, just for background information for yourself. You
may have seen my “translation” of this article on my website, about
mood symptoms as waves. The article itself, by Dean Mackinnon and Ron Pies,
is linked – abstract only – at the beginning of that webpage (Mackinnon
hyperlink). That is the information any good librarian can use to get you a copy
of the article itself.
have read my essay on
Borderline versus Bipolar; if not, do so now. You’ll see the symptoms of
each condition compared head to head. Almost an impossible distinction, in my
view, with two exceptions I’ve emphasized there.
to my second idea. Mind you, I’ve never had to try this approach, so it could be
dismissed out of hand by the powers you’re dealing with (i.e. there is no
precedent for this approach as such). Here’s the idea: it seems to me that you
could invite people who knew you prior to medication treatment to
comment on what they used to observe. You might even use the skeptical
psychiatrist to invite these comments (e.g. he sends the invitation
letter, maybe one you have prepared in draft so he won’t balk at the extra work,
to the addresses you provide (maybe have all the envelopes ready to go to
demonstrate you’re ready to do all the work) so that there is less chance
someone will later claim you prepped these people or somehow influenced their
responses. Ask them to describe what they might have seen as symptoms. Or, if
that is not clear, they could simply comment on whether they ever thought you
were having “marked shifts in mood and energy”, and if so, how long might a
given mood/energy phase last?
comments focus on symptoms and not on relationships, I think that could be
viewed as supporting a bipolar diagnosis (not that this means you don’t also
have borderline PD, although frankly I cringe as I write that sentence because
the very label is so counter-productive. Your experience is a particularly
paradoxical example). Because if a friend or relative does not talk about
certain symptoms which manifest themselves only in relationships (abandonment
fear and chronic emptiness, as emphasized in my essay linked above), then I
think one could make the case that bipolarity is the better explanation for
other symptoms they might mention, which can occur in either condition.
if the descriptions do describe chronic emptiness and abandonment fear,
this does not mean that you don’t also have bipolar disorder. So if
that’s the outcome of your invitations, it won’t help with the diagnostic
dilemma: you’ll still be stuck about where you are now. But note: in my view
this exercise cannot end up confirming the “BPD only” diagnosis; whereas it
might add weight to a case such as “bipolar is primary, and therefore the
presence/absence of borderline-ness is moot re: military discharge status”.
have to certify in some way that you’ve not corresponded or communicated with
those whom you invite to comment. Because now you know what you’re looking for.
All this cannot work as intended if you could even possibly be construed as
having tipped them off. So careful how you proceed if you want to try this.
you’d also be looking for an emphasis, in the invited descriptions, of “cycles”:
not erratic mood reactions to events, but shifts in mood independent-of-events
-- and shifts in energy as well. Energy shifts are not prominent in BPD
(can occur, but they’re not at the center of the picture). For example, in
bipolar depression, extremely low levels of energy are common. People talk about
hardly being able to walk. When they sit, they hardly move, even when speaking.
Conversely, when people are manic (or hypomanic, though it’s harder to recognize
when it’s not as dramatic), they have so much energy that it’s usually
noticeable as soon as the person walks in the room.
point to emphasize: these two diagnoses, like most in psychiatry, are made based
on history. And it’s also clear, in my field, that history from others is
even better for diagnostic questions like the one you describe than history from
the patient himself. “Collateral information”, it’s called. Not subject to the
filter of your memory, for example. So the data you’d gather by inviting
recollections of you prior to medications is not just additional history, it’s
better than your history.
writing all that I still think this might be an idea worth trying, here is how
I’d format the questions you might want to ask of those correspondents:
Thinking back on how I used to be before xx [whenever you started treatment, or
received an effective treatment], what do you remember about me regarding
anything you might have thought (then or now) was a “symptom”, something you
thought was abnormal about me?
need to reassure them that you’re fully prepared to hear about this, that you’ve
sought treatment for it and you’re better now, so they should be very frank;
maybe even explain the situation, noting that anything they regarded as a
symptom could actually be very helpful for you now.]
Did you ever think I was somehow different on some occasions than on others? If
so, how long would you estimate those different states lasted (minutes, hours,
these are very “open-ended questions”. You’re trying not to be accused later of
“leading the witness”. ]
case, good luck with your efforts to get this straightened out. At minimum I
think those two links above may prove useful.
Published November, 2009