Which of These Diagnoses?
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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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