What Would be the Best Way to Proceed to Show the Psychiatrist the bipolar disorder that the Psychologist and My Friends and ...
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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.

Robert
 

Dear Robert –

What a 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.

You may 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.

Which leads 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?

If their 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.

Of course 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”.

You might 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.

Finally, 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.

One more 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.

Since after 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?

[You might 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, days, weeks)?

[Obviously these are very “open-ended questions”. You’re trying not to be accused later of “leading the witness”.  ]

 

In any case, good luck with your efforts to get this straightened out. At minimum I think those two links above may prove useful.

Dr. Phelps

 

 
Published November, 2009
 

 

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