DX: Bipolar Disorder NOS

Not being a psychiatrist, I can only imagine how difficult it must be to diagnose a condition that’s as much of a chameleon as bipolar disorder. In fact, I was surprised when mine gave me a provisional BP diagnosis at our first appointment back in March of 2012. He’s pretty conservative in this area, as well as with medications—a position I appreciate as a clinician myself. I don’t want a shrink who passes GO and collects $200 before the couch is warm underneath my butt.

However, he wasn’t even sure I had bipolar at that time; I think the diagnosis was given mainly as a reference point, and he added “question of depression”, thinking he might change it back to MDD if I followed the pattern he saw in the office that first day. (He did start me on a bit of Lamictal though, which helped that end of things considerably.) The idea was that if this turned out to be the case, we’d have a couple more visits to do some therapy and then I’d go back to my regular doctor, since the average case of depression usually doesn’t require the care of a psychiatrist.

Well, we all know how THAT turned out. A couple of months into treatment, I waltzed into the office for an appointment on a nice, warm, sunny spring day, higher than a kite and dressed in bright, almost garish clothing; he took one look at me and asked, “Are we manic today?”

Of course I denied it, and of course he pretended to believe me, but that’s when the ‘question of depression’ diagnosis went away. Bipolar Disorder Not Otherwise Specified (NOS, for short) stayed put, and since then there have been no doubts whatsoever that the bipolar designation is 100% spot on.

Where we can’t seem to resolve matters is which actual flavor I have. My symptoms are all over the map; but as severe as they can be, they don’t always rise to the level specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is essentially the Bible for diagnosticians. For example, I’ll meet three of the criteria for a manic episode, but the fourth is dicey so it’s technically considered hypomania. Or I’ll have a depression that lasts for a week-and-a-half, but not the two full weeks required to qualify for such an episode.

There are times, however, when I meet every single criterion for a major mood episode, and that’s where the NOS diagnosis gets even fuzzier. Technically, if you’ve ever had a mixed episode (symptoms of both mania and depression at the same time) or full-blown mania, your diagnosis is Bipolar 1. I’ve had two mixed episodes just in the 15 months I’ve been in treatment, as well as several incidents of mania, two of which were very serious and nearly required hospitalization.

A few words about mixed episodes: In short, they are a brass-plated bitch. I just came through one about a month ago, and the scars still remain. If you’ve never experienced the feeling of being totally out of control, just try sitting on your bathroom floor at 2 AM, scrubbing the tiles with an ancient toothbrush and bawling like a toddler deprived of her favorite blankie.

But almost all the other symptoms I have are more consistent with Bipolar 2: severe ‘atypical’ depressions in which I sleep 10-16 hours a day, eat everything that isn’t red hot or nailed down, and feel like 300 lbs. of lead. I also experience periods of HYPOmania during which I have both great energy and enough of my wits about me to put out prodigious quantities of work, and to enjoy life con brio.

Recently I asked my pdoc about updating my diagnosis, as it was still in the NOS (translated: wastebasket) category and I really want to pin this thing down so that I don’t have to explain it to people, like the job counselor at Voc. Rehab, when they want to know if I’m Bipolar 1 or 2. Actually, I’d like even more to be able to explain it to myself; and BEING bipolar, I lack the ability to deal consistently well with life’s grey areas.

Now, my pdoc will be the first to tell you he isn’t the world’s greatest diagnostician when it comes to determining the “grade” of bipolar in a given patient, unless of course he or she is floridly psychotic and needs hospitalization at the time of diagnosis. (I’ve come close to going inpatient, but it hasn’t happened yet……and I hope it never does.) He works with a well-known bipolar specialist and consults with him on some particularly gnarly cases, but mine apparently isn’t gnarly enough, and that’s a GOOD thing!

So he hemmed and hawed around, making a case for both varieties, though he figured if I MUST pin him down on it, he’d probably call my version a 2……but he couldn’t rule out 1 either. (Confused? So was I.) In the end, he said he still had to label it NOS because he just couldn’t make that determination as yet. (This was before my latest mixed episode, in which he treated me for mania when I thought I was depressed; turned out he was correct and I settled down within a few days. That’s why HE gets the big bucks and I don’t. DUH.)

Perhaps one day he’ll figure it out and come up with a firm diagnosis so I can quit doing my little OCD-ish thing and worrying about specifics. Or not…..I’ve heard that it sometimes takes months to determine whether a person is bipolar at all, and several years more to flesh out the picture of bipolarity with which he or she presents. So as cautious as my doctor is, the fact that he saw enough on the very first visit to diagnose me as BP is rather telling. And as many different meds as I need to control it, NOS can be pretty serious, even if the books tend to dismiss it as “a mild form of the disorder”.

I just want it wrapped up all neat and tidy with a bow. Is that too much to ask? LOL