Into the Doctor's Court WHAT TO EXPECT FROM THE DIAGNOSTIC PROCESS ou're not alone in feeling that mania and depression are very per- sonal and intense experiences. Nor are you alone if you are wary of any stranger's ability to understand what you're going through, no matter how highly qualified as a medical professional. Many people experiencing bipolar symptoms postpone seeing a doctor for as long as possible because they al- ready feel thoroughly misunderstood. Others receive a diagnosis but reject it out of hand. Still others grudgingly accept a diagnosis of bipolar disorder but then express their resistance by refusing to comply with their treatment re- gime. If you fit into any of these categories, I hope you'll reconsider the bene- fits of a professional diagnosis. No diagnostic label can completely capture your unique situation. In fact, you may feel offended by the diagnostic label because it is incomplete, imper- sonal, or simply doesn't do justice to your life experiences. But these labels do serve a purpose. First, using standardized labels allows clinicians to communi- cate with each other. If I refer a client of mine to another mental health profes- sional and say that "she has bipolar 1 disorder, mixed episode, with mood- incongruent psychotic features," there is a high likelihood that this other doctor will know what to expect. This common language serves you well should you switch doctors, as so many of us do today. Second, an accurate di- agnosis is important to selecting the right treatment. If you are misdiagnosed as having depression alone, for example, your doctor might recommend aInto the Doctor's Court: What to Expect from the Diagnostic Process 31 standard antidepressant medication (for example, Prozac, Zoloft, Paxil, or Wellbutrin) without a mood stabilizer like lithium (see Chapter 6). If you are actually bipolar, this treatment regime could make you swing into mania. Likewise, if you were diagnosed as bipolar when the real problem is attention deficit disorder, you might not benefit from the mood stabilizer regime you would be given. Notice, then, how an accurate diagnostic label helps doctors treat the whole syndrome that is affecting you rather than just the symptoms you are reporting right now. Diagnoses also help you prepare for the challenges the future might hold. Your doctor will use the diagnosis to formulate your prognosis. Will you have another episode? Will you be able to go back to work? How will you know when you're getting sick again? Knowing that you have bipolar disorder makes you and your doctor privy to all of the information that researchers and clinicians have gathered from the experiences of thousands of people like you. For example, you can expect to have another episode soon if you don't take medication, and you may need to wait for a while after an episode before go- ing back to work full time. Fortifying yourself with this information makes it easier to manage your life and minimizes the disabilities that bipolar disorder can cause. The Criteria for a Diagnosis of Bipolar Disorder Psychiatrists and psychologists rely on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders to make diagnoses (DSM-IV; American Psychiatric Association, 1994a, 2000). Note the term "manual" in the title: A clinician should be able to pick up the manual and decide whether a patient meets the criteria for a specific psychiatric illness. Applying these diagnostic criteria reliably (that is, being able to tell one disorder from another) cannot be done quickly or haphazardly: it requires considerable training, experience, and skill on the part of the mental health professional. The first edition of the DSM was published in 1952; other editions were published in 1968, 1980, 1987, and finally, 1994 (with a text revision in 2000). Each version has been informed by the research and observations of many investigators and clinicians and by experiences elicited from numerous patients with psychiatric disorders. No diagnostic manual is perfect, and not everyone agrees with the premises of the DSM-IV (e.g., Carson, 1991). In my opinion, the DSM-IV is an extremely useful manual, and no other diagnostic system exists that provides a reasonable alternative. Your doctor will first identify which symptoms you have (for example, sleep disturbance, irritability), how severe these symptoms are, and how long32 THE DIAGNOSIS AND COURSE OF BIPOLAR DISORDER they have lasted. From your particular pattern of symptoms, he or she will then determine if the diagnosis of bipolar disorder-as outlined in the DSM- IV-fits you. If it does, your doctor will then be concerned with which kind of bipolar disorder you have: is it bipolar type I or IT? Do you have rapid cycling? Bipolar I Disorder The sidebar on this page describes the major subtypes of bipolar disorder listed in the DSM-IV. For bipolar I disorder, you must have had at least one manic or mixed episode, with elated mood and three other associated symp- toms of mania (grandiose thinking, decreased need for sleep, pressured speech, increased activity or energy level, racing thoughts, flight of ideas, dis- tractibility, or impulsive behavior) that lasted a week or more andlor required that you be hospitalized. If your mood was irritable and not elated, four or more associated symptoms are required. Note how these symptoms capture the essence of the subjective experiences of mania described in Chapter 2: the roller-coaster mood states, increases in activity and drive, changes in thinking and perception, and impulsive or self-destructive behaviors. The DSM-IV Subtypes of Bipolar Disorder Bipolar I disorder At least one lifetime episode of manic or mixed disorder Although not required for the diagnosis, at least one lifetime episode of major depressive disorder Bipolar I1 disorder At least one lifetime episode of hypomanic disorder At least one lifetime episode of major depressive disorder Bipolar disorder with rapid cycling Meets criteria for bipolar I or bipolar I1 disorder Four or more episodes of major depressive disorder, manic disorder, mixed disorder, or hypomanic disorder in any oneInto the Doctor's Court: What to Expect from the Diagnostic Process 33 You may find yourself reacting negatively to how reductionistic the symp- tom labels are: what you