Someone recently related to me that they had received a diagnosis but weren’t sure they accepted it. I have seen this scenario played out in the bipolar community many times: “But I am not psychotic/manic/suicidal” etc. The “problem” with diagnosis, with any kind of labeling or categorization of a person’s personality or identity or deeply ingrained mental characteristics, is that it is an incomplete way to communicate information.

Diagnosis helps doctors, patients, and families develop a common vocabulary for discussing issues that develop in perception, mood, personality, or behavior. It helps everyone proceed from the same starting line and follow the same trail. It’s an unfortunate side effect that sometimes personal reactions to diagnosis can cause rifts among these people due to the stigma and shame that a diagnosis engenders. It’s one reason I am so vocal, open, and honest about my diagnosis—the more people normalize the diagnosis, the more we can open the dialog and we can dial down the stigma. When the stigma is not a major player, more people make progress in treatment and in developing systems that support mental wellness.

Many illnesses manifest in a variety of ways, and psychiatrists are still developing the lexicon to catalog them. Even with very detailed and specific descriptions, illness is still too personal and subtle to be captured on paper in a way that perfectly describes every afflicted person. We started out as manic-depressives and when that was not descriptive enough, we branched out to differentiate between degrees of severity in presentation of symptoms of the disorder. We now have Bipolar Types I, II, and III. Within the types, there are people with mixed features, rapid cycling, ultra-rapid cycling, ultra-radian cycling, and BDNOS—Bipolar Disorder, Not Otherwise Specified. Some psychiatrists allow for additional, unofficial diagnoses.

In the end, what we are seeing is a spectrum instead of a single label to describe a variety of subtle differences in the ways that people can manifest as bipolar (for a good explanation of the bipolar spectrum, visit this site). Having experienced these subtleties, as well as experiencing the ways that symptoms can change over time, I know that it’s very difficult to rule out a diagnosis based on the premise that a particular symptom doesn’t apparently manifest.

I used to have major depressive episodes that were debilitating, with waves of despair and dramatic shifts of mood from happy to hopeless. As I aged, became more savvy, and worked through therapy to improve myself, I found that my depression began to change. As I aged, I mellowed, and the depression mellowed as well. It began to circumvent my safeguards, seeping in as fatigue, malaise. It slowly sapped me of energy and motivation. I could even see how someone would never even realize they were depressed. Whereas before the changes in mood were dramatic, bold, and wrenching, this new manifestation was insidious, subtle, and difficult to figure out.

Having seen firsthand how differently the same issue can present—in both examples, I was depressed, and yet the depression was so different in feel each time—it’s difficult for me to reject a diagnosis because my symptoms aren’t textbook perfect. However, it’s easy to see how the newly diagnosed can and do find it difficult to accept. Had I experienced my symptoms in a different way, in a different order, had I experienced the malaise first instead of the despair, and had I not had such a dramatic adverse reaction to antidepressant medication, then I, like many many other people, could have easily dismissed a diagnosis as alarmist.

You can be depressed and not want to die. You can be depressed and not consciously know why. Situational depression has a very specific trigger, bipolar depression can happen for no apparent reason at any time. Hypomania is easily mistaken for general every day happiness and normality. You don’t have to have hallucinations to be manic. You don’t need to be psychotic.

Because of the subtlety, however, you DO need to make sure you are evaluated thoroughly by a qualified mental health provider. That means going to see a psychiatrist and not a general practitioner. Choose a doctor with whom you feel comfortable, who will conduct a thorough interview and take an extensive history before making any kind of diagnosis. As much as I advocate accepting diagnosis and moving on to treatment, doctors do make mistakes and misdiagnoses do happen. For this reason it is especially important to be absolutely honest and accurate when providing your personal medical history, especially any history you have on family, as well as relating to substance abuse. It also pays to be educated about the diagnosis, and about the treatments being offered.

In 1996 I was diagnosed as Bipolar, type II with mixed features. I also am a rapid cycler. What it means for me is that I have swift changes in mood, that the changes can be very uncomfortable and cause some interpersonal issues, but are generally not “severe” in the sense that I generally have a good grasp of reality. I do not suffer from psychosis. I do lack consistent impulse control, am prone to outbursts of inappropriate behavior, and often experience symptoms of hypomania and depression simultaneously. My illness often manifests as irritability and agitation. Over time, I have also discovered that I do not tolerate intervention with medication very well, experiencing paradoxical and/or other adverse reactions to most medications used to treat bipolar disorder.

HOWEVER. I was initially diagnosed by a different doctor as unipolar, aka, “clinically depressed.” I was handed a sample of Zoloft and hurried along my merry way but within two days I was crawling up the wall of the library at university, laughing and screaming, and picking lint off of my friend’s carpet. I cartwheeled to the infirmary.

I remember sitting in a bed coloring with a concerned friend, convinced I was creating a masterpiece. The on-call nurse was only able to give me a benadryl to help me sleep and when I finally did, I stayed unconscious for 17 hours. The next day I looked at my “masterpiece” and it was very clear that there had been something seriously wrong with my perception because the picture could only be described as scary—purple and black and urgent, firm strokes, no concern for coloring within the lines and obviously the frantic output of someone not wholly under rational control.

I told the doctor I didn’t want to take anymore medication and she convinced me to just cut the dosage in half. The completely off the wall behavior stopped, however, I became completely nocturnal. Unable to sleep, jittery, shaky, I would exhaust myself by staying up all night until I could finally fall asleep as the birds began to sing outside of my window. I floated through spring break in a fog, only realizing what time of year it was when my food tray stopped appearing at my door (a friend had been quietly leaving me food when I would miss the dining hall hours). I had a massive panic attack that first night, wandering toward the student union in the hopes of purchasing a pizza, and realizing I couldn’t remember when I had last seen the sun and freaking out about the vastness of space and the size and brightness of the moon.

I was unwell.

I eventually contacted the infirmary and explained that I was broken and I would like to speak to my doctor and have her fix what I believed she had broken. They explained to me that my doctor was away because of the spring break holiday. They offered to put me through to the on-call emergency psychiatrist and I agreed. He turned out to be a fantastic doctor and in discussing my history with him and the last two hazy weeks of my life, he and I agreed that there was something wrong with the picture. He explained bipolar disorder to me and I explained to him all the ways that this diagnosis seemed to fit.

I accept my diagnosis because it seems appropriate and it gives me the tools I need in order to make progress toward sustainable wellness. I have developed a lot of insight into my mental health as I’ve pursued many different treatments, and talked with a few different doctors, some psychiatrists, some psychologists, one a social worker. I’ve done group, I’ve gone it alone. Had I known more about unipolar depression and bipolar disorder when my initial diagnosis of clinical depressed was diagnosed, I could have questioned it and rejected it. Had I known more about doctors, I could have questioned the facility and speed with which I was assessed and sent packing with a prescription. The first doctor never took a complete medical history, she never asked me about mental illness in my family. She had an incomplete picture.

While I probably have more than one comorbid issue (such as the fact that I definitely suffer from panic attacks and free-floating anxiety, a bit of agoraphobia, mild OCD and that I may have some borderline personality disorder tendencies) I believe that the bipolar disorder diagnosis describes my struggles with mental wellness very well. It provides me with a vocabulary for discussing my challenges, my needs, and my treatments with other people, in a language my entire support system can understand.

The problem with misdiagnosis is a very real one. Many people with bipolar disorder are often misdiagnosed with clinical depression. Education and familiarity with family history are key to starting any new treatment plan and if you have questions or are uncomfortable, you need to bring them up with your doctor immediately. When in doubt, get a second opinion and don’t be afraid to shop around for a doctor who fits.

Bipolar disorder does not define me, it is not my identity. It is a part of how I was shaped and how I arrived at this place in my life, but I have never been frightened of the diagnosis—I was honestly simply relieved to have an avenue for support. Does it make me different? Sure, I am all kinds of quirky. But treatment has improved me without diminishing me.

References:
Bipolar Disorder. (2009.) Retrieved on April 16, 2009 from http://www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml

Rare Bipolar Disorder Types: IV, V and VI. (2008.) Retrieved on April 16, 2009 from http://www.associatedcontent.com/article/506371/rare_bipolar_disorder_types_iv_v_and_pg2.html?cat=70

Types of Bipolar Disorder. (2008.) Retrieved on April 16, 2009 from http://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-forms

Hall-Flavin, D. K. (2008.) Bipolar disorder. Retrieved on April 16, 2009 from http://www.mayoclinic.com/health/bipolar-disorder/AN01785

Lieber, A. L. (2008.) Bipolar Spectrum Disorder. Retrieved on April 16, 2009 from http://www.psycom.net/depression.central.lieber.html