Talking to Your Psychiatrist – How To Guide

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I get really bad doctor anxiety and have trouble saying what I want to say at appointments. I find writing things down as I think of them days in advance helps. Here are some pointers on making appointments with your psychiatrist effective for both of you.

Be honest. This is important. Don’t lie to your psychiatrist. Don’t exaggerate. Don’t hide symptoms. Don’t be embarrassed. He’s probably heard it all before.

If you think a medication is or isn’t working, tell you psychiatrist this and why. It’s important to be informed on your medications. It’s important not to control your medications, because the psychiatrist is the one with the MD and training, but if something isn’t working, you have the right to say so.

Psychiatrists don’t often offer therapy much anymore*, but they do need to know about your life and general health. A psychiatrist is trained in diagnosing mental illness and treating it with psychotropic drugs, or a referral for therapy or other care, like a medical doctor would diagnose a physical illness and treat it with the appropriate care or medication.

Don’t focus so much on your diagnosis, focus on your symptoms(1). The diagnosis is generally used in communication with insurance companies and too many people get caught up in the diagnosis hype. Treating symptoms is most important. Right now, the DSM has just changed over to the DSM 5(2), and things are confusing. It can take a while to reach a diagnosis, so focus on eliminating the symptoms and getting better.

Be reasonable with your psychiatrist. There is no magic pill (I’ve been told this by so many doctors) and you have to work at it, too. Mood trackers, therapy, keep track of medications, go to all appointments. Don’t stop a medication unless you’re having a side effect that could kill you. Some medications require blood tests – get them done. Work with your psychiatrist.

A psychiatrist is a doctor and is going to have good and bad days. There are good and bad psychiatrists out there, trust me, I’ve had a couple of bad ones. Fortunately, right now, I like my psychiatrist. It’s not always easy to change doctors, especially if you’re in a country like Canada (where I am) and there’s a doctor shortage. A psychiatrist should always remain professional and never be rude to you.

*A psychiatrist is a doctor trained in psychiatry with an M.D. A psychologist is more often referred to as a therapist and you spend more time working on issues with them. Very few psychiatrists offer 50 minute appointments with a couch, a notepad and psychotherapy anymore, unfortunately.

 

Signs of a good psychiatrist:

  •  They listen to your concerns and don’t ask the same questions over and over.  They will ask relevant questions, about your mood, your current situation, and current meds.

I had a psychiatrist that asked me, every appointment, if I had quit smoking “dope” yet. I had never smoked “dope” in the entire time I saw him.

  •  They respect your concerns, needs and what you say.
  •  They stop medications if they don’t work, or if the side effects get bad.  I had a psychiatrist bitch at me when I had to stop lithium due to diabetes insipidus. He said I “complained too much”. Same one that accused me of smoking dope. I had two doctors telling me I couldn’t take lithium, and that psychiatrist was being a jackass, he had never heard of the condition. Fortunately, he retired. (Note: I only stayed with him because of how hard it is to find a doctor in this area)
  • A good psychiatrist respects your wishes with medications and doesn’t intimidate you about them. You should be able to be open about medications – you live with the side effects of them and you also pay for them one way or another.
  •  No psychiatrist should tell you you’re going to fail or never get better. If they feel that way, they should refer you.
  •  They should schedule appointments appropriately. Some people need to be seen every few months, some need to be seen more often.
  •  They should have open time to see a patient in crisis. Sometimes they can’t get you in that afternoon, but they should be able to get you in fast.
  • Keeping you waiting for hours in the waiting room is not good. They should also return phone calls in good time. It’s disrespectful and unprofessional not to.
  • You should feel comfortable and not threatened with the doctor.(3)

(1) Talking to a Psychiatrist
(2) DSM5 HomePage
(3) Makings of a Good Psychiatrist on Shrink Wrap

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Self Diag-nonsense

We’re all guilty of this. With the internet, it’s even easier to diagnose yourself. Everybody has taken the personality disorders test, probably multiple times. (How many times have you scored the exact same? I don’t keep track, so I don’t know)

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Wake up call. Those aren’t diagnostic tests. The same way as an online IQ test can’t tell you you have an IQ of 180: only a few people in the world ever have scored that high in real life, they don’t come around often, based on the Stanford-Binet test. A psychological test has to be carried out by a psychologist or psychiatrist in person (with the new teleconferencing stuff, maybe, I’m not sure) and can take a few weeks or months. I was assessed over 6 months after multiple hospitalizations and treatments. An IQ test is similar, it cannot be biased, and the person has to be assessed by the tester for their reatctions. A lot comes into play.

Basically, an online IQ test is just a test with different scoring. Instead of 0-100% it assigns a number. An online psychological test is the same thing, but they have disclaimers: not a diagnostic tool. (Don’t ever pay for either one!)

I can say I hit a lot of DSM criteria, but it’s easy to say that about myself. Other people can say I hit different criteria. To get 3 psychologists and 5 psychiatrists to agree on my diagnoses was kind of amusing, but they did agree. (For the record, I was diagnosed with bipolar disorder type 1, rapid cycling with psychosis, schizotypal personality disorder, later on ADHD inattentive type and at that time, EDNOS, which is currently in remission). I did have to do that damn 500 question test. Apparently I exaggerated (that was what everyone who took the test got accused of: they exaggerated!) so the results weren’t clear. The psychologist had to use her head instead of the computer. Poor thing. Okay, enough about me.

Insight is good. Being a know-it-all and changing your treatment plan, double doctoring, doctor shopping and more are not good. In socialized health countries (pretty much everywhere but the US) most of that is harder to do. I work with my psychiatrist with medications, that is, if I really hate his medication decision, I’ll let him know, he’ll reconsider. When I was discharged from inpatient care, it was a mutual decision. If I’ve heard of a new medication, I’ll ask about it, and he’ll fill me in, about how he thinks it would work me me, and then it usually ends in, “and your insurance doesn’t cover it yet”. (It generally takes a year from the med coming out for my insurance to cover it!)

I have never told a doctor, “I think I have..”, partly because I think it’s rude and I’m shy, and partly because I’m not a doctor. Well, except for when I broke my jaw and ribs. “I think I have a broken jaw” fit. If you recognize symptoms earlier because you have heard of them and are able to seek help earlier, that’s even better.

Doctors are often guilty of self diagnosis, especially during medical school. They think they have every disease in the book. Medical studentitis is the name it’s given, as a joke.

“When you self-diagnose, you are essentially assuming that you know the subtleties that diagnosis constitutes.”

Not all mood swings mean bipolar disorder(1) for example. Self diagnosis can get in the way of proper diagnosis. Everybody has mood swings, but certain criteria has to be met. Bipolar disorder is actually not that common, despite hearing about it all the time. A GP should be seen before a psychiatrist so physical illness can be ruled out first. Sometimes physical illness feins psychiatric illness.

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Even if you do not want conventional treatment for depression, you may want conventional treatment for a brain tumor.
Self diagnosis is underminig the doctor, too, not good for the relationship, and the doctor could just end it. The diagnosis isn’t what is being treated. That is used for insurance information, symptoms are being treated.

Here are a few problems with self diagnosis:

  • – You can be missing something you can’t see, for example, focusing too much on one thing and forgetting the rest.
  • – Thinking too much is wrong, or thinking not enough is wrong.
  • – It can interfere with the doctor/patient relationship and agitate the doctor (they do get agitated)
  • – It can get in the way of proper treatment
  • – It can be hard to accept a correct diagnosis, and you could be disappointed that you’re wrong if the doctor disagrees.

Let your doctor do the work, that’s his or her job.

Even a doctor cannot diagnose or treat him or herself. For a lack of a better phrase, it’s a conflict of interest!

“Be honest and upfront with your doctor and make sure to let him know all of your symptoms, even if you do not feel that they are important. Also disclose any and all medications you are currently taking as well as supplements to make sure that your doctor has all the information necessary to treat your illness.”(2)

  1.  The Dangers of Self Diagnosis
  2. The Internet and Self Diagnosis

I suck. And I’ll start updating more, too.

August 1 2008 I had been discharged from my longest hospitalization.

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October 7th, 2013 I was hospitalized until October 24th because the stress of life, the universe and everything kicked in and I broke down. Of course, no beds on my Dr’s unit, so he loopholed me through PERT – Psychiatric Emergency Resource Team. They had an emergency room physician come in and put me on a Form 1. 72 hour involuntary hold. Dr N, my pdoc, was not impressed. He took me off it when I was transferred to Unit B, the ward he works on. I was a danger to myself. What crap.

I had a panic attack when they handed me the Form 42 (copy of the Form 1). PERT is just seclusion rooms. Luckily, I wasn’t locked in. They nurse gave me some Ativan and a heated blanket. I slept. BF showed up. He brought McDonalds. My friends took my car back to the apartment. The next day I was transferred to Unit B, where my pdoc works. I had a private room. It was BF’s birthday. He saw me anyways. I owed him big for that!  They tried to give me Ritalin at 10pm, night meds. I refused it. They charted I was “refusing meds”.  My pdoc laughed the next day, thankfully, saying it was good I knew to refuse Ritalin at 10pm! He then told them to NEVER give it to me after 4pm.

Pdoc was good to me. Saw me daily. I had a pass for Canadian Thanksgiving. It sucked, my dad was drunk and being an ass. It was a short pass, thankfully, I had BF with me. “Oh, back so soon.” Oh, yes. BF went for his MRI results: No change in the tumor since his diagnosis a year ago!! MRI’s are yearly, now. At the best cancer centre in Canada, only 45 min away from us. He had a seizure last night. His neurologist is still working on the meds. Less bad, shorter seizures, but still minor seizures. No unconsciousness, no disorientation, but still.

So, we had a lot of groups. I met a couple cool people. I had a day pass, I went to the barn, went riding.

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That’s me on Sparkle. She’s a five year old, gigantic Thoroughbred filly. Her registered name is “Sparkle Tangerine”. I did some walk, trot, canter and a small jump. She was very good. Look how tiny I am on her!  I was exhausted when I got back.

I did all the groups. I got so sick of the religious crap from a lot of patients. There wasn’t a lot of super craziness like I’ve seen. No restraints used, no chemical restraints used. A few “code whites” (unmanageable or violent patient) called. I was going to go long term, but the beds weren’t available. Dr N saw staying on the ward was getting hard on me, and we agreed on discharge for the 24th. I start outpatient therapy next Tuesday for anxiety, stress. CBT, that sort of thing. One on one. The only cost is parking.

I now take Geodon (aka Zedox), Lexapro (Cipralex), Ritalin, Topamax, Clonazepam, mostly at lower doses, managing. and my normal meds for my health. I was diagnosed with endometriosis yesterday. BLAH. I start birth control (I’ve had a tubal ligation!!) after my period to try to ease the pain. If not, we do more drastic things. It’s not the worst thing in the world. The ultrasound could have shown a million WORSE things. (Endo is not detected on most ultrasounds) I’ve decided on rotator cuff surgery. Dr N was great to me in the hospital. I thanked him before I left, for his patients. The rec therapists were great. One I’ve known since 2002. We even had a ball pit!

That’s my life for now.

Fun Facts About Bipolar Disorder

I hate being bipolar. It’s awesome!

Well, we know that people with bipolar disorder are definitely mentally interesting (I much prefer that to mentally ill) but here are some fun facts I’ve pulled together. I’m writing this for a bit of a laugh, why so serious?

Lithium can make concrete harder and can power small batteries. (Also, when I broke my jaw at age 18, I poured my lithium capsules into cranberry juice as that was the only way to take it, my jaw was wired shut, and it turned the cranberry juice green!) Also, lithium is extremely toxic to humans in it’s normal form. When it is converted to a salt (lithium carbonate) it is safer. (Same with table salt!) Nobody knows exactly why lithium carbonate stabilizes the mood.

Bipolar disorder is often misdiagnosed. In women, they are more likely to be diagnosed with depression (unipolar) and men are more likely to be diagnosed with schizophrenia. I’ve actually been diagnosed with both at different times, but eventually, they just said, “you have bipolar disorder type 1 and schizotypal personality disorder”.

Nobody knows what the hell schizotypal personality disorder is. I went to a walk-in clinic because I had a UTI and the doctor asked why I was taking all these psychiatric medications. I told him my diagnosis and he said “oh, schizo-TYPICAL personality disorder” and I then argued with him for a good ten minutes, because schizo-TYPICAL personality disorder doesn’t exist. It’s schizo-TYPAL. I eventually got my damn antibiotics and he wrote down on my file that I’m schizo-TYPICAL. Is that a good thing or a bad thing?

Us bipolar folks are said to be the hardest to treat. Why, thanks! I guess it’s because we’re all over the goddamn map. Over half of those with a bipolar diagnosis have attempted suicide, and 1/5 do so successfully.

Manic episodes can be brought on by irregular sleeping patterns. Too much sleep? You can end up manic. Not enough? Same thing. I once worked at a restaurant, doing 8-12 hour shifts during a manic episode. I didn’t sleep for 3 days, got some sleep on my day off, and then resumed. I was full blown manic and I don’t remember the details, as with most of my episodes, but I ended up on lots more medication.

Rapid-cycle bipolar disorder means that you have more than 4 episodes a year. Only one manic episode is needed to diagnose somebody as having bipolar disorder. Ultradian (episodes lasting hours to a couple of days; may be phased out in the DSM-5) cycling is extremely controversial and is often mistaken for a mixed episode. (And mixed episodes can also been mistaken for ultradian cycling)

The higher you swing, the harder you fall. (True!)

The hippocampus, which means “sea horse monster” is bigger on the left side of a bipolar brain.

Mania is not always fun. It can be downright devastating. A lot of people with bipolar stop taking their meds when they get hypomanic, thinking that they’re normal and don’t need them, and WHAM, get him with mania. Some things manic people like to do: Spend every cent in the bank, have sex with anyone that has proper ‘equipment’, abuse substances (self medicate), drive recklessly and don’t think of consequences.

Many people with bipolar disorder are more creative than the rest of the population, in such things as art, writing, and more. Some people refuse treatment because they don’t want to give up their gift.

Bipolar disorder doesn’t discriminate on race, religion, sex, gender or age.

 And finally:

We are dazzling, passionate, and adventurous lovers.

Scary Side Effects Part 3 – Antidepressant Induced Mania?

In the 1980’s, bipolar disorder was called manic depression and was a feared word. It was changed to bipolar (two poles) later in the 1980’s and diagnosed more and more. But often, the patient will present with depression symptoms, and get prescribed an antidepressant, which can cause horrible hypomanic, mixed, and even full blown manic episodes. This can be because we go to the doctor when we feel down, not up. After years and years of being bipolar, I know when to see a doctor for mania. (Also called “insight”)

 Mania can feel great, but it can also be dangerous. Impulsivity, people giving away all their money. Then comes the inevitable crash. Many bipolar suicides are accidental during a mixed or manic state. Some may say that antidepressant induced mania is just a side effect, it isn’t indicative of bipolar disorder. There are a lot of controversies about it.

 Some people put on antidepressants are bipolar, but it can have the same effect on somebody who isn’t bipolar. Their moods start cycling(1) and they start showing clinical features and meeting the diagnostic criteria of bipolar disorder. Is this a lasting effect? It can be. The criteria for bipolar disorder is one manic episode, although most have several.

 The findings of this study confirm that treatment-induced mania is a clinical phenomenon that belongs within the bipolar spectrum rather than a coincidental treatment complication, and that it should be placed under ‘bipolar disorders’ in future classification systems.” (1)

Statistics

Thirty-five percent of the patients had a manic episode rated as likely to have been antidepressant-induced. No variable was a predictor of vulnerability to antidepressant-induced mania. Cycle acceleration was likely to be associated with antidepressant treatment in 26% of the patients assessed. Younger age at first treatment was a predictor of vulnerability to antidepressant-induced cycle acceleration. Forty-six percent of patients with antidepressant-induced mania, but only 14% of those without, also showed antidepressant-induced cycle acceleration at some point in their illness. (2)

 Antidepressants can be devastating to someone with bipolar disorder. It can send the patient into a mixed or manic state. Some people are able to tolerate antidepressants such as tricyclics, MAOI’s, or Wellbutrin, but SSRI’s and SNRI’s have a tendency to push you over the edge. However, this may not be true at all!

 

Myth or Mania? Controversy

Sometimes the myth is just an incorrect use of language. Many people have detected a temporal association between the use of tricyclic antidepressants and mania in patients with bipolar disorder, but no mechanism is indicated. There is an assumption the association could extend to all antidepressants despite chemical and pharmacological transformations.(3) 

This association between mania and SSRI’s hasn’t been found. Studies find that the switch rate is no different than that of normal bipolar disorder when the patient is on an SSRI or SNRI.

 Revisiting the Controversy

Mania is likely to be antidepressant-induced and not attributable to the expected course of illness in one-third of treatment-refractory bipolar patients, and rapid cycling is induced in one-fourth. Antidepressant-induced mania may be a marker for increased vulnerability to antidepressant-induced cycle acceleration. Antidepressant-induced cycle acceleration (but not antidepressant- induced mania) is associated with younger age at first treatment and may be more likely to occur in women and in bipolar II patients.”(4)

 

Conclusion

Antidepessants can make a bipolar patient exhibit signs of mania. When the antidepressant is stopped, the mania generally goes away. Antidepressants are often prescribed for those that are bipolar, for the symptoms during depression. (I take Luvox for Pure-O OCD). However, a mood stabilizer with an antidepressant effect such as Lamictal or Lithium would be more effective than adding on antidepressants.

 

There are controversies, so keep that in mind. Also, with any medication and diagnosis: YMMV (your mileage may vary)

 

 

  1. http://psychcentral.com/news/2011/10/13/antidepressant-induced-mania-similar-to-bipolar-disorder/30300.html

  2. http://www.ncbi.nlm.nih.gov/pubmed/7625459

  3. http://thelastpsychiatrist.com/2005/07/do_antidepressants_induce_mani.html

  4. http://ajp.psychiatryonline.org/article.aspx?articleID=171161

CAT & PET Scans for Diagnosis Bipolar Disorder

CAT (sometimes referred to as CT, computer axial tomography) scans are a diagnostic tool for problems in the brain. It’s a painless procedure, takes less time than an MRI, and doesn’t have the risks from the magnetic fields. It is used mainly to rule out other disorders before a diagnosis of bipolar disorder can be made.(1) Generally if there is something found abnormal on the CT scan, an MRI is ordered.

 “Information gathered from a CT scan isn’t useful in making a bipolar diagnosis”

 PET (Positron Emission Technology) Scans work differently. It uses radiation (eek!) or nuclear medicine imaging to produce a 3-D picture of the human body.(2) The machine detects pairs of gamma rays emitted indirectly by a positron(3) emitting radionuclide, which is in the body on an active molecule. The images are constructed on a computer, and many machines take a CT scan and X-ray during the procedure. Again, this is a painless procedure, just boring.

 PET scans are used to diagnose health conditions, or find out how an existing condition is developing, to see how the treatment is working.

 And now onto the mental illness part.

Pharma companies have been saying mental disorders are chemically based for years, but actually, there isn’t really any proof.(4) A PET scan is changing that, they are finding interesting results comparing PET scans from the mentally interesting to the normals.

 Research:

  • Depressed brains are more active

  • PTSD sufferer’s brains are less active

 The other side of the fence(5)

What Brain Scans Can Do

  • Show damage to brain tissue, the skull, or blood vessels in the brain

  • Be used with other medical tests to help doctors find the right diagnosis for mood and behavioral problems

  • Help researchers study healthy brain development, effects of mental illnesses or effects of mental health treatments on the brain.

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What Brain Scans Cannot Do

  • Diagnose mental illness when used by themselves

  • Predict risk of getting a mental illness.

 There is a lot of controversy surrounding brain scans and mental illness. Some say yes, some say no. Specific scans can show the damage done by drug use, however. They are mostly used to rule out neurological disorders. Perhaps in future years, technology will allow us to see into the brain more carefully.

 

 

 

 

 

  1. http://www.answerbag.com/q_view/1928160

  2. http://www.medicalnewstoday.com/articles/154877.php

  3. Positively charged particles

  4. http://gaia-health.com/gaia-blog/2011-11-27/pet-scans-proof-that-depression-is-a-chemical-imbalance-or-a-psychiatric-delusion/

  5. http://www.nimh.nih.gov/health/publications/neuroimaging-and-mental-illness-a-window-into-the-brain/neuroimaging-and-mental-illness-a-window-into-the-brain.shtml

 

The Fisher Wallace Unit: Worth it?

ImageThe Fisher Wallace Unit.

 

I personally haven’t tried this thing out, because I can’t afford it, and I haven’t done the research. It almost seems too good to be true, so I’ve gone investigating on if this device helps or not. It is said to be used for anxiety, insomnia, and depression.

It is supposed to work relatively fast, they claim it will “relieve your symptoms within 60 days of receipt” or you get a refund(1).

 

How does it work?

It is portable and is considered “cranial electrotherapy stimulation” (CES). The name does sound kind of scary. It is delivers pulses to stimulate the brains production of serotonin and GABA(3) and beta-endorphins, three things that basically make you feel better. (2) It is FDA cleared and appears to have no side effects and has been in use for over 20 years. It is mainly used in depression, anxiety and insomnia but there are reports that it works well for alcohol withdrawal as well. No placebo effect was found(4).

 

It is used twice a day for 20 minutes. It delivers a mild current that is 1/1000th of the jolt given for ECT, so you’re sort of performing ECT on yourself. Let’s go on.. there is no memory loss. One in 500 people said they had a headache after using the CES. If the electrodes aren’t wet enough before being used, there can be irritation because of this. Some people say they feel nothing at all, others say they feel a slight tingling where the electrodes are placed.

 

Cranial Electrotherapy StatisticsImage(5)

 “It is concluded tht CES is a clinically significant addition to the treatment regimen for this patient population.”

 Is this too good to be true?

  1. The purchase price of the device will be refunded, minus a $69.95 processing fee to cover the costs of used disposables (sponges, headband, carry case) and device testing and processing. Shipping charges and the purchase of extra accessories (such as extra sponges) will not be reimbursed.” http://www.fisherwallace.com/cranial-stimulator-refund-policy

  2. http://www.fisherwallace.com/how-cranial-electrotherapy-stimulation-works

  3. GABA: A neurotransmitter that slows down the activity of nerve cells in the brain.

  4. http://www.ncbi.nlm.nih.gov/pubmed/3521373

  5. http://www.fisherwallace.com/uploads/Ray_Smith_CES_Monograph.pdf