Question:
Hello,
I am a 22 year old female, with no family mental issues I know about (not a very talkative family). I’ve seen many doctors regarding my mental health issues as well as therapists (one for appx 3 years, one for appx. 5 months up til now), and the only thing I have really learned about myself is that I am really very bad at analysing my own motivations and behaviours. I’m not very comfortable in the therapy situations, especially regarding expressing my feelings, but I do try. Due to issues, such as insomnia (with very sporadic and short lived hypersomnia), extreme conflict avoidance, inability to concentrate, indifference towards things that I used to enjoy, bitterness/resentful feelings towards loved ones, self-mutilation, abysmal self esteem, self-sabotage in career and school, and suicide attempts, I have seen a variety of psychiatrists. The first psychiatrist I went to see was when I was 18, nearing the end of my second year of college, as my issues were interfering with my schoolwork. He diagnosed me as chronically depressed and put me on medications, telling me to refer to my family doctor for any prescription changes. I did so. After many many months, and many types of medications that had no effect on my mood, and another suicide attempt, I was referred to a different psychiatrist. This doctor suggested that I was not in fact depressed, and that I should go on lithium, but did not tell me why he felt that would be a good medication for me. I responded that I wasn’t interested in a prescription, especially not a long-term one, unless I had a diagnosis, and he told me that I should not go to a psychiatrist unless I was looking for medications. Not impressed, I went back to my doctor and asked him to refer me to another psychiatrist. I did go see the new psychiatrist, who was much more personable than the ones I had seen before. His obeservations were that I seemed to have traits of borderline personality disorder and cyclothymidia, but as the anti-depressents did not work, he did not think I had depression. He then told me that if I felt I needed to be back on anti-depressents (even though I explained to him that they did not work), I could get another referral to go see him, otherwise I should just continue seeing my family doctor and therapist. I left his office feeling rather upset, having no more answers than when I entered.
That’s where I am today. Is it strange to want a diagnosis so badly? The only thing I can think of in this situation that is worse than having a mental illness is the idea that I don’t have one, and my behaviour and feelings are invalid. I also understand that diagnosing a mental illness or personality disorder is not that simple. Should I continue on as I am now, without seeing any more psychiatrists, or should I try and find one who will speak to me (without being rude) for longer than a half an hour? I am not sure if it is worth my or the doctor’s time. Thank you for your time and advice!
-A. Leigh
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Answer:
You pose some interesting questions that need to be answered. Two of the main categories of diagnosis in psychiatry are Axis One and Axis Two categories. It is the Axis one diagnostic areas that call for medication. They include things such as Dysthymia (Depression), Major Depression, Bipolar Disorder and others. It is the symptoms of these behavioral disorders that respond to medicine. The second area, or the Axis Two category, is the various personality disorders. These are behaviors that are learned over many years, going back to early childhood. Various types of psychotherapy are used to help people learn new and more adaptive or healthier behavior with which to cope with life. If you have a Borderline Personality Disorder (and I do not know whether you do or not), you would go for intensive psychotherapy. Cognitive Behavioral Therapy (CBT) is used with this personality disorder with success. However, personality disorders usually have Axis I diagnoses along with them and medication is often used to treat the associated symptoms.
You certainly have a right to ask any Medical Doctor, psychiatrist or otherwise, what he or she believes your diagnosis to be prior to starting medications. The psychiatrist who recommended Lithium may believe that you have a Bipolar Disorder. However, medications are sometimes used for purposes other than their original intent.
An example of medication used for other than its intended purpose is Lithium. I have seen cases where a psychiatrist will add Lithium to an anti depressant when the anti depressant did not seem to work very well when taken alone. In one case, adding a small dose of Lithium made a dramatic difference in the life of the patient. There are examples of anti seizure medications being used to treat some types of depression and with very great success.
Having said this, I have no idea why the one psychiatrist refused to tell you your diagnosis or why he thought Lithium was a good idea. I am also somewhat surprised that one or more of these psychiatrists referred you back to you medical doctor, unless it has something to do with your health insurance and that could be the reason. Usually, a psychiatrist who prescribes medication to a patient continues to see that patient until they are stable on medication. Stability means that the patient is free of symptoms. Thereafter, the treating psychiatrist will ask to see the patient once a month or less, just to follow up and be sure that there are no side effects or other problems.
The next issue is to understand that mediation, by itself, is never the complete answer to mental health issues. It is recommended that patients see a therapist while taking prescriptions because it is important to learn how to cope with the illness, life’s problems and other life issues. Human nature is such that there is an enormous amount of learning and relearning that goes on throughout life and that is why psychotherapy is so necessary whether medications are taken or not.
Because medications and psychotherapy work together it is recommended that you see a therapist and psychiatrist who work together and consult with one another. This team approach to treatment is what works best in the types of circumstances that you are in. You can start with a psychiatrist who, besides medication, can also refer you to a therapist or start with a therapist (psychologist or clinical and experienced social worker) who can refer you to a psychiatrist. It is this team approach that provides the most comprehensive and complete type of mental health treatment that is available. Psychiatrists can do the psychotherapy but they tend to be the most expensive of the mental health professionals to see. That is why people who have less in the way of insurance or cash go to psychologists and social workers. If you wanted to see the psychiatrist for both medication and psychotherapy you would need to ask if they do therapy and ask about the fees in order to decide if it is affordable. Otherwise, ask the psychiatrist to refer you to one of the therapists they commonly use.
Finally, there is no question that you should see a psychiatrist who will talk to you. In fact, this is true of any MD you ever see, regardless of speciality. The comfort level that you feel with your Doctors is enormously important. One cannot feel a sense of trust in an MD that they are not comfortable speaking with.
