Psychiatrist unsure about diagnosis

[NightTerrier]

I'm just after a bit of advice really as this is bothering me far more than it should.

I recently got a new psychiatrist who is unsure of my current diagnosis of bipolar and keeps mentioning that he thinks my symptoms are more in keeping with a psychotic illness. However, when I ask him what he thinks I do actually have, he keeps saying that labels aren't important and managing the symptoms is what matters.

He took me off mood stabilisers and put me on antipsychotics. However, I was on lamotirigine and that was excellent for preventing depression. Since coming off it I have become really depressed again. So, I don't know why he is unsure of whether it's bipolar.

I just want to get a straight answer out of him. A friend suggested that maybe he's not sure, but why not? He's a consultant psychiatrist and says he's seen people with my symptoms who responded very well to the antipsychotic I'm on, which is aripiprazole.

For the record, I get about 2 episodes a year where I think the goverment are testing microwave weapons on me and I'm the victim of electronic harrassment or I think that Freemasons are telepathically communicating with me and I've been innitiated into a secret society etc. It lasts for about 1 to 3 months. These don't always coincide with hypomania or depression.

I'm having a hard time accepting that it might not be bipolar and that it may be a psychotic illness. I looked up 'psychotic illesses' and they are schizoaffective disorder, schizophrenia and delusional disorder. Undertandably, I'm now really worried. Surely my last psychiatrist would have diagnosed one of these if this was the case.

Anyway, sorry for rambling, but it's just driving me mad and I feel that he needs to be clearer with his diagnosis and reasoning, as that would help me develop a better framework for understanding what is wrong. I understand his point about labels, but he must have an idea of what he suspects the diagnosis is.

Firstly don't worry, it is very common for mental health diagnoses to change over time even with the same psychologist as more information about symptoms and the course of symptoms is revealed over time. There is a lot of overlap between symptoms. There is also research that questions the valadity and reliability of mental health diagnoses as its been found that different psychiatrists will diagnose the same person with different conditions. Due to this there is a school of though amoungst some psychologists that its more important to manage the symptoms than to label them. It is now common for people to be given the 'diagnosis' of psychosis-unspecified. Theres also a school of though that due to stigma associated with some of the psychotic illnesses it is not helpful to give someone these labels. DH has been under a psychiatrist with this approach 4 years and doesn't have a specific diagnosis. When I have asked I'm told it doesn't really make any difference so long as they manage his symptoms.

Psychosis is common in people with bipolar too though, not limited to schizophrenia and schizoaffective disorder, I believe psychosis can also be asociated with depression and borderline personality disorder. Ultimately don't let the label scare you, you are still the same person with the same symptoms no matter what diagnosis they give you. If you are feeling worse witthout the mood stabiliser feed this back to your psychiatrist and if you think it was helpful you can ask to restart it. From what I understand it psychiatry meds are very much trial and error to find the best combination for each person they need your feedback to get it right for you, don't wait for a major depressive/psychotic episode to feed back.

If you want to find out more about the diagnostic criteria for each condition the DSM V is the book the psychiatrists use to atempt to categorise mental illness into sepatate conditions. You can find the criteria online.

We use the ICD (currently on Edition 10, although 11 is out soon) rather than the DSM. Although they aim to be broadly the same, some of the names for conditions are different. They do mostly agree though.
If you find the mood stabiliser helpful ask to restart it. You can take antipsychotics and mood stabilisers together-I take both. You do need to be monitored but you're seeing the CMHT anyway.
As for 'labels" they matter less than you might think. There's a lot of overlap between different conditions and not all psychiatrists will agree on a diagnosis. Treatment is what matters. Do you feel like you're getting enough support?

Thanks to both of you.

I asked to go back on lamotrigine and he didn't want to put me on it and said that he didn't think it was working and that he didn't think bipolar was the correct diagnosis for me. So, he put me on flouxetine instead, which just made me feel drugged and completely killed my sex drive. So, I stopped taking it a few days ago and will tell him when I see him next week and ask to go back on lamotrigine again because I know that it really helped. I'm really struggling with depression at the moment, I feel so flat and demotivated and I need to get back to work.

It just seems like he has an idea of what he thinks is wrong and all he will tell me is that he thinks I have psychosis and not bipolar as my psychotic symptoms can flare up seperately from mood episodes. He also said that he isn't going to give me a stigmatising label, which really worries me as that suggests that he thinks I have a stigmatised disorder.

Obviously, BPD came to mind, so I asked him, but he said that I don't fit the diagnosis for that. So, that then left schizophrenia and I am 100% certain that I don't have that. Tbh the antipsychotic he gave me is really good and doesn't have too many side effects.

I am getting decent support, thanks. My CPN and DP both think I'm experiencing psychosis at the moment, but I honestly can't tell. I guess I'm having a very difficult time distinguishing what's real and what's paranoia, but the antipsychotic has stopped the voices. My only beef is with the med changes and feeling like a guinea pig!

That's just bizarre. If he thinks managing symptoms are more important than the diagnosis, why the fuck would he stop you taking something that helps your symptoms? I've come across "we treat the symptoms not the diagnosis" before and IME it's always a lie.

*is more important

Idk, Addley and it's doing my nut in. I've had this new psychiatrist since April and have seen him 4 times now and my DP even came with me to an appointment and asked him to put me back on lamotrigine as my mood had dipped.

Tbh, this guy seems nice enough, but I'm still unimpressed with him taking me off a drug that prevented depression. I had been on it for about 6 years.

"we treat the symptoms not the diagnosis" before and IME it's always a lie.

I agree, he has an idea of the diagnosis and won't tell me, either that or I'm being paranoid.

I guess you have to try to work with what you've got and explain again that you really feel it's worth trying again as you've felt your mood dip since stopping the lamotrigine.

I take lamotrigine and it's been fantastic for me, but even though I'd had it before, many years ago, and knew that it worked well for me, it took a year of asking and begging to get the psychiatrist to prescribe it for me again. My CMHT did the whole "we treat the symptoms not the diagnosis" thing, WHILE, in the background, they were referring me to a service that I didn't realise was tailored towards people with personality disorder diagnoses. As soon as he started to believe that I didn't have a personality disorder (because a consultant developmental psychiatrist had written a report saying I didn't have a personality disorders and that all the "PD" symptoms were caused by my previously-undiagnosed ASD), he gave me a provisional diagnosis of bipolar disorder and started me on lamotrigine. And surprise surprise, once I'd eventually got up to a therapeutic dose (which, as you know, takes ages), the drug that I already knew worked well for me, worked well, and I was well and stable again. (While we were waiting to get my lamotrigine up to a therapeutic dose, I had another very mild hypomanic episode, during which I happened to have a psych appointment, and despite the fact that other doctors had seen me hypomanic and written about it, when he saw it, suddenly he gave an official bipolar diagnosis the arrogant bastard.)

That's interesting, Addley. Maybe I'm being referred to a PD team? Oddly, the possibility of ASD has been previously discussed, but I was told that there's no point in getting a referal for an assessment as an adult because there are no local services for that.

However, if I did have a PD and they thought I did, surely it's within my right to know and not have that information withheld from me? Fwiw I don't think I have BPD, in fact, the only one that seems to fit is the paranoid one.

PS, I'm glad you got back on to lamotrigine. I think it's a miracle drug for people with mood problems.

It's possible they're thinking about a PD diagnosis but it doesn't sound like it from what you've said? And like you said, your symptoms don't fit. PD isn't episodic.

WRT ASD: under the Autism Act 2009 your area should have a clear diagnostic pathway for adults to be assessed for ASD www.autism.org.uk/about/strategy/statutory-guidance.aspx IIRC your trust is required to either provide that or pay for assessments by someone else but it depends on the area as to whether they actually do it. If ASD has been suggested by professionals it certainly seems reasonable to expect them to carry out an assessment.

My experience is that having the particular combination of ASD and bipolar disorder made both of them really hard to diagnose, as it meant that neither of them looked like a typical presentation. I'm not saying that you necessarily have both but diagnosis can be difficult if for whatever reason you don't have the textbook symptoms.

I hope you feel better soon.

A locum suggested that I had comorbid ASD and bipolar, but my new psychiatrist doesn't and he also thinks that I shouldn't worry about whether I'm on the spectrum, as he's not worried and can't prescribe any meds for that.

Psychiatrists are a funny bunch. Sometimes I wonder what it is that they do exactly. My CPN sees me far more than my psychiatrist and knows me better.

Can you switch psychiatrists?

I'm not sure, but I don't want to be seen as being difficult. Everyone really rates this psychiatrist, staff and patients.

I just want to get a straight answer out of him and to get back on lamotrigine. Tbh, there was no need for him to take me off it and I wouldn't have ended up depressed again. The lamotrigine has an antidepressant effect, but without the dodgy side effects like total loss of sex drive that comes with SSRIs.

I'm preparing questions and notes for my appointment with him next week. He actually comes across as a really nice bloke, which makes it all the more odd.

That's the problem with psychosis, by definition you generally don't recognise it at the time. It's good that the antipsychotics are helping settle things.

I would just reiterate that the diagnosis or lack of one (stigmagised or not) does not change who you are or what your symptoms are. So long as your symptoms are managed well thats the main thing.

DH ticks every diagnostic box for schizophrenia but doesn't have that as a diagnosis. I'm undecided if being given that diagnosis would be helpful or not. I asked him once and he said a diagnosis would feel like permission to be himself. I also think it would stop his family judging him so much for his behaviour. On the otherhand when applying for jobs currently he just puts depression which is far less stigmatised.

Have you requested your notes? He's likely to have recorded in there his thoughts about your diagnosis.

Whereas a family member of mine has ASD with what I would call clearly psychotic episodes, but they are put down to his asd and therefore untreatable. He wouldnt take meds anyway to be fair.
Its common for women with asd to be first misdiagnosed with a range of mental health conditions such as bipolar
The assessment might be useful just for your own knowledge if nothing else
Hope you get some answers

When I was in my last psych appointment before being discharged, I asked if there was anything we could do about my residual anxiety symptoms - the depression is well-controlled but the anxiety is sometimes still quite severe. He just said "That's probably the ASD, nothing we can do about that" wtf.

I was going to say it can take a few months but I see you've been working together since April, I think it was around six months before my psychiatrist formally diagnosed me (I still don't feel at home in the label almost two decades later but whatever). He should be able to tell you what his thoughts are. Good luck for your next meeting.

If he follows the school of thought that diagnosis specific psychotic disorders is not a helpful thing to do, then he may never give you a more specific diagnosis and may not have documented any more detail in your notes than he's told you. Theres some information about the current thinking on this in this document www.bps.org.uk/system/files/Public%20files/rep03_understanding_psychosis.pdf

I have ds with bipolar and a genetic disease. My experience has been that the "nicest" doctors that everyone loves and who have the best bedside manner are not necessarily the best doctors. The ones that I have settled on for my ds are generally (I hope they aren't reading this) a little socially awkward, but excellent doctors and very sensitive to my ds' specific needs AND very careful about medication changes when something is already working.

I would also like to add that there is an increasing amount of research and medical and scientific evidence that certain supplements can help enormously with psychosis, depression and mood disorders. Vitamin D is an important one and if you live in the UK you are probably deficient. Also there is some solid evidence that Omega 3's can be helpful. If you PM me, I'd be happy to forward some scientific papers about this.

P.S. Ds takes very low doses of aripiprazole for his bipolar, but suffers mostly from the manic side of things and not much from depression. We've recently added Sertraline for his anxiety. He used to take seroquel, but it made him super drowsy and he didn't like that feeling.

My dh has moved from a diagnosis of bipolar II to schizoaffective disorder. IMO it fits him a lot better and after a very long process he is on quite a good bunch of meds (including lamotrigine...but sulpiride and amitriptyline are key too). I'd agree with those who say if your doctor's aim is to help with the symptoms, they're not managing to achieve that yet. I also think that refusing to use some kind of diagnostic label is a cop out, actually, but I'll now read that link to understand where that school of thought is coming from.

Interesting link nolongeranxious. I disagree with large chunks of it but then dh's experience of psychological services has been largely negative or unhelpful, whereas psychiatrists have been able to build relationships with him.