I sat across from her and in my most official yet trusting psychiatrist’s tone gave the spiel I delivered many times.
“Amanda, I’d like to start you on a medication that might help your depression. Like every medication it can cause side effects, however, many people have no side effects or only have minor ones. This drug can cause weight gain, increased risk of diabetes, and increased risk of heart disease.”
A year ago I — a psychiatry resident — was on the receiving end of a similar speech. I had just started taking an antipsychotic, the same medication I prescribed to my sickest patients. Patients like Amanda who were so depressed they contemplated suicide, patients with psychosis who heard voices, or patients who were manic and went days without sleeping.
“I think we need to start exploring the possibility that something else is going on, that perhaps you’re on the bipolar spectrum,” my psychiatrist had stated.
I shifted forward onto the edge of the mahogany leather armchair. “How long have you been thinking this?”
“Not long, but in the past month you’ve described more impulsive behavior, you’ve called your thoughts obsessive, and you’ve been more activated since starting Zoloft.”
Impulsive? Obsessive? Activated? Do I need to be in the hospital? Will I lose my job? I need to get out of here. I still have five minutes. She keeps staring. Klonopin.
I left her office and entered the hospital. This can’t be true. What if she’s wrong? I scurried into the residents’ office, a tiny room with artificially colored windowpanes. The conversation around me faded into white noise, drowned out by the sound of the booming air conditioner. I sat down, reached for the pocket DSM-V on my desk, and thumbed to page 71.
Hypomanic Episode: During the period of mood disturbance and increased energy and activity three of the following are present:
Inflated self-esteem or grandiosity
Nothing is wrong with feeling confident about myself, right?
Decreased need for sleep
Did waking up at 6 am with tons of energy count?
More talkative than usual
I’m always chatty.
Flight of ideas or subjective experience that thoughts are racing
Well, I normally journal when my thoughts are overwhelming, and I have been journaling almost every day.
I’m usually easily distracted, there’s just so much to get done, and I have to do things when I remember.
Increase in goal-directed activity
I finished that grant, started a music listening group amongst colleagues, and created a new blog this week.
Excessive involvement in activities
Unfair, I’m always busy.
None of the answers were no. What did that mean?
I knew, of course. I wanted to cry. What if other people found out? I would have to tell my program director. I’ll never make chief, I remember thinking. I’ll never get a job.
Sometimes my colleagues and I would jokingly diagnose ourselves with caffeine withdrawal disorder or some other obscure illness using the DSM. I had sat in front of a specialist, who was diagnosing me, a psychiatrist, with bipolar disorder. I knew I was anxious, but bipolar disorder seemed like a stretch. What was the proof? I thought back to high school, when I was so anxious over grades I began to have stomachaches. During college, adolescent crushes became incessant thoughts about women who had no idea I existed. There was graduate school, when I irresponsibly partied during finals. Then I deferred my first year of medical school, depleted my savings, and moved to Rio de Janeiro without a job. During my first year of medical school, I was so fixated on finances I could barely sleep, eat, or read and needed to see a psychiatrist. Now, I was ruining my relationship by obsessing about another woman. There were the failed trials of Prozac, Celexa, Lexapro, Cymbalta, Wellbutrin, Viibryd, and Zoloft. This diagnosis suddenly seemed like a real possibility.
Two weeks later I started the antipsychotic.
A year later, I have no sex drive, I fall asleep interviewing patients, and my pants don’t fit. However, I am no longer plagued by the intrusive thoughts that previously permeated my inner world. I work, live, and daydream without chaos.
Recently, I told my psychiatrist I was writing a story about my diagnosis.
“And what diagnosis is that?” she asked.
“Being on the bipolar spectrum.”
“You know I never diagnosed you with bipolar disorder.” She explained that the antipsychotic was targeting complex symptoms of anxiety.
I’m not on the bipolar spectrum? This is anxiety? But the antipsychotic is working… Is she wrong? I can’t believe I told people.
We sat silently. I was angry at being misled, confused by what my diagnosis actually was, yet at the same time relieved that I might just be suffering from anxiety.
Mostly, I questioned the integrity of my progress over the past year.
I remembered feeling embarrassed in psychopharmacology class, where my classmates theorized medication regimens for hypothetical “bipolar” patients, talking about them like scientific projects. I remembered telling my best friends about my diagnosis, worrying that they would think of me as the “crazy friend.” I imagined the time I fell asleep in a one on one conference with my supervisor. I thought about the nerve-wracking phone conversation when I told my new girlfriend about my diagnosis. I relived that dreadful morning meeting with my program director when I disclosed my diagnosis and asked for his support.
I envision sitting across from Amanda at our next visit. I will tell her how hard it will be to tell friends and family about her diagnosis. I will warn her that she may fall asleep in the front row of her art history lecture. I will prepare her for the weight gain that may cause her clothes not to fit. I will inform her that a diagnosis is not set in stone, and could be wrong. I will tell her these things as a doctor, who has had both the misfortune and the privilege of being a patient.
Kali Cyrus is a psychiatry resident.
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