Into the system…

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Archive for March 2010

Busy, Busy, Busy…

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For someone that doesn’t work I seem to be awfully busy at the moment.

And it seems I won’t be going back to work for a while.

My consultant had been pretty keen for me to contact my employer to try and look for a strategy that would see me getting back to work, or at least to get me back in contact with them a little more. It was suggested that perhaps I could help out with some corporate citizenship work or at least have a contact in the area I could meet up with to discuss work. All of my contact has been with the HR team who are based in London. As I am not allocated to a project I don’t have a manager at the moment, let alone one in the North West. I don’t even have a “Career Counsellor” right now as mine is on maternity leave. So I’ve had very little contact with work and I’ve only been into the office once in the last 18 months (to get my laptop upgraded). The place has become completely alien and the thought of trying to go back is pretty scary. I don’t think Dr M realistically thought I’d be ready to go back in the immediate future, but she wanted me to consider doing something to give me hope of going back.

So I contacted my HR rep to see what she thought. She needed to look into this and wanted me to go see Occupational Health before she made any decisions. She didn’t want to allocate a new Career Counsellor unless I was actually going back, so that wasn’t an option, but she did say she’d look at finding a Manchester contact for me. She wouldn’t agree to the idea of me going into the office or helping out unless there was an OH report which supported this. I suspect their liability insurance wouldn’t be too happy if I was on sick leave, went into the office and then I hurt myself or something.

So I was referred back to Occy Health. An appointment was arranged and I saw Dr R on the 18th. I’d seen him before, 18 months ago. He had been nice last time and had a lot of experience in psychiatry, so I was glad it was him again. He remembered me and I tried to update him on what had happened. I have a document saved on my computer which covers all the main events of my “Mental Health History”, so I took this with me to refer to. I think he was pretty shocked at what had happened since I’d last seen him. At the end of the appointment he said that when he saw me last he’d expected me to have a pretty rough time over the coming year or so, but he’d never expected it to be as bad as it was.

He mentioned a lot of the usual occupational health stuff. Things about how work is generally good for people and that I should be encouraged to go back as soon as possible. He quoted the statistic that 50% of people who are off work for more than 6 months never return (Scarily, 75% of people off for over a year and virtually none of those off for two years or more ever return) and he commented on how long I’d been off. He said he was concerned about my chances, but he was hopeful that at least I have youth on my side.

He seemed genuinely worried that I may be dismissed due to incapacity if I was off much longer. I am worried about this because my Permanent Health Insurance payments would cease if that happens. He said he’d hate to think I’d have a life of benefits ahead of me. Not exactly what someone needs when they are struggling to handle the thought of being alive. He warned that with such a long absence and dismissal for ill health, I would be nigh on unemployable, which is a pretty depressing thought. I should have a great career ahead of me and instead I am dealing with the possibility that is over. I hope not.

We discussed whether or not I could go back to work. I don’t really think I am ready. I’ve only been out of hospital for about a month. My medication is still being adjusted and I am struggling with side effects and anxiety. Things are so unpredictable that I just don’t know how I can plan to go back so soon. I was pretty surprised when Dr M brought up a return to work in the first place, but I understand that I do need to go back as soon as possible and was willing to at least see what could be done.

He agreed with me though. He wants me to be fairly stable for a couple of months before he considers approving a return. He seemed a little surprised that I had even been referred to him so soon after coming out of hospital. He was uncomfortable with pushing me back too soon because there is too much at stake.

If I went back to work for a little while and struggled, ending back on sick leave, then I would not only lose my ESA for 6 months, but I’d probably end up losing my job. They’d be more likely to dismiss me if I failed to complete a phased return. Of course there’s also the very real risk that it would tip me back over the edge and I’d try and kill myself. Not exactly something anyone would want to risk encouraging.

We also discussed the fact I am waiting for therapy and I’m likely to find that pretty hard going. It would not be good for me to go back and then to start therapy. There is good chance that it will make me worse, before it makes me better and we wouldn’t want that to risk my return to work. He’d rather that I knew at least what was happening with my therapy referral before I go back.

He did agree though that we should be doing something to normalise work and the office a bit more. I need to be in contact with HR and I need to go into the office occasionally before I try to go back. At the moment I feel like I don’t belong there and I hardly know anyone. It would be good if I could get used to going in before I try and do any work there. He agreed that helping out with the occasional task might also be helpful and a good way of keeping me in touch with work. The more we can do to convince my company that I do still want to work for them and that there is a good chance that I will again, the better.

So that’s the plan. Try and get more in touch with work, keep myself busy and doing enough work related tasks as possible and lots of hoping that I will get better and stay well long enough for us to consider a return. I will probably see him again in a few months, all being well.

I left fairly pleased with the outcome. Dr R seemed to understand my predicament and agreed that I wasn’t ready to return. I am a lot more worried about my future though. He was genuinely concerned that I will end up jobless and moneyless. At the moment financially we can cope with being on sick leave, but if I lost my PHI payment or ESA then we’d really struggle. I am comfortable with the fact I have a job to go back to with a company that has treated me well. I’m pretty scared that this might change. I don’t know how I’d find a new job and try and get back to work all at the same time.

The report arrived last week and was pretty much as I’d expected. My HR rep seemed fairly happy with the report, although perhaps a little disappointed that I am not ready to return. She called me today to find out if there was anything else she could do to support me. I have been given a contact in the Manchester office now and I’m meant to be talking to her tomorrow. It was suggested that I talk to her about things I can do in the Manchester office to give me something to do and to give me a taste of work. I need to build up my confidence and remind myself that I can actually do that job. I worry that I’ve lost my ability to work. I am not as sharp any more. I’m so slow and unproductive. I struggle to concentrate and think. I worry I will just not be up to the job.

We will see. If I am to get through all of this I need to go back. I loved that job and I want to go back. I just hope that I can. I am very scared that I won’t.

A Little Clarification…

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My last post, Distressing Diagnosis… was a little on the rushed side and basically unfinished when I posted it. I knew if I didn’t publish it when I did, I wouldn’t get the chance for a while, but I kinda wish I’d held back. I’ve been back and edited it a little, but it still doesn’t say everything.

Edit: (17/03/2010) – I’ve actually ended up reworking this post quite a lot too. I didn’t read it back yesterday and since then I’ve realised it was all over the place and made little sense. It is a little better, but I just find this so hard to write about objectively. I am struggling with it all.

Lets get one thing straight. Dr M isn’t a horrible person or a bully. In many ways she’s actually quite nice and well meaning. She is trying hard to help. I can see that and I appreciate it.

She said she doesn’t want to do anything that will make me worse, and she did agree to remove the diagnosis in my notes when I said it wasn’t helping. I guess I can’t really argue with that. I asked her to change her diagnosis and she agreed to do so. I don’t think she’s changed it in her mind, even if she has on paper, but that is at least something.

She genuinely thinks she is helping and that she is doing the right thing. She keeps saying that she will make me better and that the future is hopeful. She is always very positive and encouraging. Many patients probably really appreciate this approach, but I find it a little too much. I don’t see enough evidence to support her positivity and that can actually be damaging. It makes me lose faith and trust. I find that she can ignore the negative, which means I don’t feel like I am being listened to or taken seriously. Unfortunately she doesn’t seem able to recognise this or she is unwilling to adjust her approach.

She also gives me her time – lots of it. She tries not to rush her appointments and lets them take as long as they need to, even if that means she runs behind fairly often. One of my ward rounds was over 90 minutes long, which when I realised seems pretty incredible. She saw me regularly on the ward in addition to the weekly ward rounds. She is now seeing me fortnightly as an outpatient, as opposed to the huge expanses of time between each CMHT appointment (4 months!). This is a good thing. It is closer to what I was used to in The Priory and a vast improvement on my other NHS experiences. Usually they sit you down and before you know it the appointment is over and nothing seems to have happened.

There are certainly good points to her care so far. I think it probably is an improvement on my other experiences with the NHS, but there are issues and I am finding those hard to deal with. Overall though I don’t think she’s a bad psychiatrist. I am just not sure she is the right doctor for me and I am not sure I am the right patient for her. Things just don’t seem to be working.

I don’t think it helps that we just don’t seem to get on. She was not impressed with my initial request to not be patronised and I think that clouded her opinion of me right from the start. She doesn’t seem to understand my job and why I like it. She doesn’t seem to know how to deal with me questioning her. I have a real sense that she just doesn’t like me for some reason. There was one point that she pretty much said that she couldn’t get on with me in “real life”, although I can’t remember the context now. My bloke tells me that is paranoia, but I remember it because I was shocked at the lack of professionalism and was upset that she didn’t like me.

I know I can’t hold this against her though. People don’t get on with each other and that’s a fact of life. If she doesn’t like me then fair enough. I’m not sure I’d get on with her in “real life” either. It wouldn’t matter though if it didn’t affect our therapeutic relationship. I worry that part of the reason she has diagnosed NPD purely stems from a sense that she doesn’t like me. Is it because she thinks I’m arrogant because I didn’t want to be patronised? Is it because I don’t agree with her opinion? I fear that in many ways it probably is.

It’s always going to be easier to trust and work with someone you get on with and I am finding this hard. It was one of the things I found great about working with Dr G. We got on well and could talk about anything, not just my treatment. It felt a lot more therapeutic and less clinical, which I think is important when dealing with mental illness, which is so entwined with emotion. I miss the way things were with Dr G and I am not used to the change. I don’t see the relationship with Dr M ever being like that. I find it hard to talk to her and hard to trust her. I am meant to tell her how I feel, yet I don’t feel comfortable doing so.

I also struggle with the fact that she doesn’t seem used to dealing with patients who are capable of getting dressed, eating and general functioning. Even if you had just tried to kill yourself, said you felt absolutely terrible and were threatening to do yourself in, if you could get up and about, communicate, eat and drink etc. then you are not really depressed and should be discharged. There seemed to be little acknowledgement of the fact that patients hide how they are feeling and put on a mask. There was a lot of focus on the functional side of depression and little acknowledgement of the emotional side and how patients felt. I wasn’t the only person who noticed this. A few of the more functioning patients felt that they were always being pushed to go home, treated as if they weren’t really ill and made to feel like they were a fraud. One patient was discharged too early a couple of times because she always hid how she felt and seemed “well” but she ended up back in hospital within days. You would have thought they would realise this was a problem. I don’t think this is purely down to Dr M. There were unbelievable bed pressures and the nurses weren’t exactly great at observation, but at the end of the day she makes the decision to discharge.

I wondered if this was because she is used to treating patients who aren’t functioning – those who are catatonic, staying in bed, barely speaking etc. In many ways these patients probably are more severely depressed, but that doesn’t mean they are more “worthy” of being in hospital. Non-functioning patients are a lower risk because they aren’t even capable of hurting themselves, where as a functional patient who is dealing with distressing thoughts needs to be kept safe. There didn’t seem to be much acknowledgement of this. I always felt like I was being told my problems weren’t important and that it didn’t matter how I felt.

Maybe Dr M has a problem working with me and other patients in a similar situation because she just finds it easier to deal with patients that do as they are told and don’t answer back. I guess anyone would find it easier to deal with people that follow blindly and don’t question things, but it is wrong to judge those that aren’t like that. Maybe it is as simple as a power trip. She likes to be in control and feels threatened when that power balance is upset? I don’t know.

It was also a common complaint on the ward that she thinks she’s really in touch and that she knows what you are thinking, but the reality is she’s often a long way off. Sometimes you get this hint that she might actually understand and then she says something else to contradict that five minutes later. It can be quite frustrating because you get this feeling of hope that she is listening and understands and then you get disappointed. You often feel like she is jumping to conclusions or judging you and I find it hard to talk to her. I don’t have this problem with Dr N and I never had it with Dr G. They listen to you and seem to understand what you are trying to say.

I think my feelings towards the NPD diagnosis have made it hard for me to work with her. I am offended and upset by it and I associate her with this distress. It feels like a personal attack and I find that hard to deal with. I don’t want to be considered as narcissistic, arrogant, self-serving etc. I want to be a “nice” person, someone that people can trust and get on with. I read the descriptions of people with NPD and I am scared that anyone could think I was like that. I am disgusted with myself that someone can think I am the horrible person that the NPD diagnosis describes. I can’t handle my thoughts and emotions around this and I need someone to direct those frustrations at. I guess naturally I will direct them at her. As much as her views of me may be misguided, my feelings towards her are skewed because of my feelings around this.

I still don’t think the NPD diagnosis is very accurate (although I do understand to some degree why she may have diagnosed it). I certainly don’t think I meet the criteria and I think she was wrong to diagnose it in the way she did. I really question her judgement and it is going to be hard to work with that in mind.

Personality disorders seem to be her diagnosis of choice and that worries me. She seems to be giving anyone that doesn’t respond well to medication, functions “too” well or who doesn’t fit in the usual boxes, a personality disorder. There was someone on the ward who was diagnosed with Bipolar Disorder many years ago and she had seen multiple psychiatrists who agreed with that diagnosis. Dr M began treating her, quickly questioning depression and suggesting her personality was to blame for her thoughts. There seemed to be no logical reason for this, only the fact that she functioned fairly well and medication had stopped working.

I guess in many ways a PD diagnosis means the emphasis is on the patient to get better and not the doctor. If the patient doesn’t improve the psychiatrist doesn’t need to justify herself in any way. The patient is also fairly powerless because any questioning of the diagnosis could be considered a symptom of the disorder. “I’m the doctor, you’re the mental, now do as you’re told”. It probably helps that there is enough of an overlap between symptoms of a personality disorder, general life experience and other conditions that there will probably always be some evidence you can use to back up your opinion.

A little off topic perhaps, but I do still want a second opinion on the diagnosis, but I don’t know how I go about getting it. With the diagnosis lifted from my notes, I don’t know where I stand. My personality is now “under investigation”, but does that mean she is going to change the way she thinks about me? I doubt it. Do I just wait and see what happens when the therapy referral comes through or do I try and get things clarified now? Presumably there are still mentions of the narcissism on my notes, so will that influence things in future?

I wonder if I should ask about the Affective Disorders clinic in Manchester. A couple of people have suggested it to me and they have someone who focusses on “complex needs”, who may be able to comment more on the relationship between my mood disorder and any personality problems. There’s also the CUPS service in Cardiff, who has a similar service offering second opinions to anyone in the UK with complex mental health issues. The problem with these services is they require referrals from your consultant and I don’t know how to ask her, without sounding like I don’t trust her opinion.

I don’t know.

I still don’t really know what to do or think about it all. In some ways I know I should just try and forget about it now that the problem label has been rewritten, but the therapeutic relationship thing is a problem. I still have to see her every couple of weeks after all and I don’t know how things are going to work.

I guess my conclusion is though that Dr M isn’t all that evil. It’s the NPD diagnosis that’s the problem and it is going to be an elephant in the room for a while I think.

Distressing Diagnosis…

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I am still finding the whole story of my diagnosis pretty distressing. Every time I think about it I feel like shit. More often than not I start crying. I am so ashamed, offended, frustrated, insulted, embarassed, disgusted, shocked; all of those and more. By diagnosing me with NPD, Dr M has labelled me as a horrible person, someone that no one would want to know. It hurts. I can’t stop hating myself for it.

I went and saw my GP, Dr N last week. I had written some notes for him outlining my thoughts on the diagnonsense issue, but when I went to pass him the notes, he said Dr M had written to him. For some reason I took that to mean she had actually told him my diagnosis and I withdrew my notes, but I realised later that she probably hadn’t given the detail. I wish I’d got him to read my letter anyway, but it’s a little late for that. Initially he tried to defend the suggestion that I had a personality disorder, mentioning that he had considered it in his differential dx when he first treated me back in 2008. He said that I shouldn’t worry about the diagnosis, diagnoses change and that it isn’t a personal attack. It was at this point that I managed to tell him, in between my tears, that it wasn’t the PD element I found particularly distressing but the narcissistic bit. I don’t think he knew which PD I had been diagnosed with until then. There was a look of surprise on his face and his attitude shifted. He was more receptive to my suggestions that the diagnosis was inaccurate, although he did defend Dr M. He suggested that she must have had reasoning for the diagnosis and that generally he trusted her, but he also agreed that she hadn’t known me very long. I said that I was scared of objecting and he finished my sentence for me, saying “because you’re afraid of it coming across as narcissistic”. I felt a little comforted that he understood this as it gave me hope that others would too. I do feel like I am trapped by this diagnosis, unable to complain for risk of compounding the issue. In the end, Dr N suggested that I sent Dr M a letter, ahead of my appointment this Monday as he didn’t really know what else to suggest. I agreed to do this and we sorted out the medication thing and that was it really.

I was generally a mess during the appointment. I couldn’t stop crying, which I think surprised Dr N a little. Despite the fact that I’ve seen him many times when I’ve been really low, anxious and generally at my worst, I very rarely cry. I can only actually remember one other occasion.

Usually I leave his appointments feeling a little better, but I went into this one with hope and left feeling pretty dejected. I do think he understood and was concerned, but I didn’t feel supported as such. I had hoped he would be able to help me in some way, although how, I do not know. I had hoped he would tell me he didn’t agree with the diagnosis, but I am not sure he would admit that, even if he wanted to. I guess that it’s probably not professional or wise to criticise a consultant’s opinion. I found myself losing all hope that this was something I could fight. I feel like I am fighting it alone and don’t know what to do. I had wanted to know there was someone on my side and I was disappointed that he chose to stay on the fence. I pretty much felt like giving up and resigned myself to the fact I am a horrible narcissistic person.

I got home and wrote the letter though. I found it hard to find the words and to keep it professional. I needed to stick to the facts and didn’t want it to become emotional. I wanted to be careful and not write anything that could be used against me, but even still I know that it doesn’t matter what I say, it could always be twisted into something else. I emailed it off to Dr M’s secretary and tried to forget about it, but no matter how hard I would try, it was haunting me. I felt physically sick with anxiety all weekend. I couldn’t face the thought of seeing Dr M again.

On Monday I saw Dr M. I didn’t get much sleep on Sunday, which is unsurprising really. I never get much sleep the night before appointments. My bloke came with me. In many ways I was uncomfortable with this, but I needed someone there. I was too scared to go alone.

She wouldn’t start the appointment with my email. She wanted to ask what I’d been doing and how my mood was and the usual. I found this hard when all I wanted was to get the diagnosis thing over and done with. I guess she did this to maintain control over the appointment.

We conceded that there had been a tiny bit of improvement in my mood. I have had the odd better day in the past couple of weeks, which I’d not had for some time before, but then the bad days are just as bad as ever. At times they are actually worse because anxiety has joined the depression. I have never really had a major anxiety problem before, but at the moment I am completely on edge. There is a churning anxiety there all the time and it flares up, leaving me feeling sick, shaky and tense. I think about things and suddenly my heart skips a beat, my chest gets tight and I feel this wave of unease washing over me. The diagnosis issue is the biggest trigger for this, but not the only one it seems. Sometimes it even happens for no conscious reason and this unnerves me even more.

We eventually got onto my letter and diagnosis. This part of the appointment is actually a bit of a blur now. I was too anxious and too upset to really take things in and I don’t actually think much was said. I was crying within moments of approaching the topic and at times the sobbing got the better of me. I couldn’t think. I couldn’t speak.

She said she was expecting my objections. It felt like she was saying “Look! I know what you’re like. Of course you’re going to write to me and object to the diagnosis. It just shows you’re narcissistic”. She may has well have. That’s how it felt.

I remember her trying to justify the diagnosis, saying that she hadn’t made it just on a few isolated examples, but that Dr S agreed that there was plenty of evidence. I tried to argue that she has barely had chance to know me and that considering I’ve not been well it would be hard to get a representative idea of my personality, but I don’t think it helped.

She pretty much counteracted everything I could say and I was losing the will to debate. It was a little like trying to swim upstream, with big sticks floating down the river towards you. You can see them coming and you know they are going to hurt when they hit you, but you can’t do anything to stop it. In the end, you just keep floating down river.

I tried to get my bloke to back me up and say it was ridiculous, but although he conceded he didn’t think I met the diagnostic criteria, he didn’t exactly add much weight to my argument. I almost felt that his near-silence only served to strengthen her opinion. I just felt helpless without anyone on my side.

At one point I asked her how she could diagnose any personality disorder so quickly and I suggested that she shouldn’t give the diagnosis until she was absolutely sure. She replied with “ohhh, I’m sure!”, said in that annoying way that implies you are ridiculous for even suggesting otherwise. This pretty much finished me off. The way she said it has echoed in my brain since and it doesn’t matter what happens to the diagnosis in the future, I’m always going to have those words telling me I’m a narcissistic cow running in the background.

She did however keep saying that she doesn’t think diagnoses are that important. I found this frustrating, because if that was the case I don’t see why she gave a diagnosis in the first place. There was no need to write it in my notes in big letters if it doesn’t matter. There was a lot of  discussion about how the diagnosis does or doesn’t matter and how it is or isn’t helpful, but I am not sure I was even following at the time.

I was asked what diagnosis I thought was accurate. What personality traits I felt were a problem. I didn’t really know what to say. At the time I could think of a few obvious ones, but I wasn’t thinking clearly. It’s something I have considered before, yet when called upon I went blank. I was also worried about saying anything too incriminating.

She asked if the diagnosis was really a problem or if it wasn’t helping. I agreed that it was making things worse, because I am so frustrated and upset by it. She said that she didn’t want to do anything that will make things worse and I know she does genuinely mean that. She told me that if it would make me feel better she wouldn’t specify the NPD. So now my diagnosis is going to say something like “moderate depressive episode” and “personality under investigation”.

On paper, I guess things are a little better. The horrible word is gone. I am back to a potential PD, but a non-committal one.  The problem is, it doesn’t change the way I feel or the way Dr M feels about me. The damage is done. I’ve been labelled as narcissistic and I am hurt and upset by it. I am still thinking about it far too much. I hate myself for it. I find myself thinking about what I’ve said and done and trying to work out if I’ve been narcissistic and if I have been in any way, then I beat myself up over it. I obsess over it and just use it as more and more evidence of why I am a crap, evil person and that I would be better off not being here.

I could go on. There is more I want to say, but I am pushed for time. Sorry all for cutting an entry short, yet again. Just too much going on, both in life and my head.

Hope everyone is well. xx

Edit: I tidied this entry up a bit. It was written when I was pushed for time and I didn’t exactly express myself too well in places. The strain of things is taking its toll in many ways.

Written by intothesystem

Wednesday, 10th March 2010 at 9:49 pm

Diagnonsense…

with 34 comments

This post is inevitably going to be very long. I have been thinking about what to say for days now and I just haven’t been able to force myself to do it. I need to write though as I must get this straight in my head.

I seem to have writers block. I sit down here with the intention of writing and making sense of everything and I can’t do it. I try to put all of these thoughts down onto the screen and I can’t. There are too many conflicting worries. Too many fears. I know what I have to say, but I am scared. I am scared of writing for making it real.

As you may have read, there was talk about changing my diagnosis when I was first admitted. I was a little surprised and worried about this to say the least. It was hard enough getting a firm diagnosis the first time, let alone having to go through it again. I had accepted the Bipolar II diagnosis and was felt it was accurate. I’ve not found any other diagnosis that describes my experience as well, although I do accept there are so many overlaps between psychiatric diagnoses that it is possible to get things wrong or mixed up.

I am uncomfortable with the idea that Dr M seemed to decide I didn’t have Bipolar Disorder in about 10 minutes. She referred me to Dr S, who is a consultant psychiatrist specialising in psychotherapy. She’s involved with the EDT team that I have been waiting on since last year.

Dr S assessed me over two, hour long appointments. Dr M wanted someone with a therapeutic background to assess me and provide input on my diagnosis. Dr M was obviously considering a personality disorder, although amazingly it seems not the one I thought she was (BPD). I am starting to wonder though how much Dr M influenced Dr S’s assessment.

Dr S asked me about all sorts of stuff. We did the usual history thing and she dug deeper on some things. She asked me a lot about my mood. One thing I was uncomfortable with was the constant assertion that my experience of high moods, could just me not recognising normal moods because I spend so much time depressed. I don’t agree with this. It is not normal to be working 16 hours a day, hardly sleeping yet not tired at all, running around your office doing a million and one things, laughing and talking constantly and generally not being able to concentrate on anything.

At the end of our second session, she told me what she thought. She agreed that I had “some form of mood disorder” but wouldn’t commit to anything. She told me that she was leaning towards recurrent or chronic depression rather than Bipolar II disorder, but wouldn’t dismiss that completely. She also mentioned “personality traits” (mainly perfectionism and high standards) that she said perhaps made me more susceptible to mood episodes, but she also said she didn’t think there was enough to suggest a full personality disorder diagnosis.

So what did Dr M think? I tried to find out, but she kept avoiding the subject. With regards to mood, she did mention dysthymia at one point, but surely by definition dysthymia would never be severe enough for hospitalisation? There were times when she even questioned whether or not I was, or had ever been depressed, which seemed bizarre.

When asked about the personality side of things she said she  “didn’t want to open any boxes that can’t be closed”, implying that it could be dangerous to give a diagnosis without being certain. She said there were personality traits which she was concerned about, particularly focussing on “high standards”, but she didn’t feel any were severe enough to consider a full PD diagnosis. She would also tell me that labels weren’t important and that we should focus on trying to “change the way I see the world”.

I saw Dr N a couple of weeks ago and he said my diagnosis had been changed on the system. This sparked my curiosity because I couldn’t get Dr M to commit to anything. I asked him what it said and he looked it up. It just said “moderate depression” and “personality disorder”. Nothing more specific than that. I think we were both curious as to what PD, although I think he suspected borderline too. After all, he had even suggested it back when he first met me, but it hadn’t been mentioned again since.

I saw Dr M again last week. We got through pretty much the whole appointment before I eventually found an opportunity and the courage to ask about my diagnosis. She had to look back through my notes to find it, which is a little scary. You would have thought she’d know what diagnosis she had given me.

It states clearly:

  1. Moderate Depressive Episode
  2. F 60.8 Other Specific Personality Disorder.

I have issues with the first diagnosis, but didn’t express them because I was so surprised and concerned about the second point. I didn’t know what F60.8 actually said, so I asked her what PD she referred to and she mentioned Narcissistic, which I was surprised about. Of all the PDs I had considered she might give, it was not that one. I told her this and she just said that she “felt the signs were there” and that Dr S agreed with her. I told her what Dr S had said to me; that there were some unhelpful personality traits and that I accepted those, but also that either of us didn’t think any constituted a full personality disorder diagnosis. Dr M then tried to justify her decision by saying it was not the primary diagnosis, but that if she thought it was there it should be documented. Somehow she seems to have decided to open the box after all.

I wanted to question how helpful any personality disorder diagnosis would be, let alone an inaccurate one, considering there aren’t any specialist services or extra treatment available here, but we had already gone well over my time and I didn’t have the fight or words to argue.

I want to argue though. I want to fight. The more I have read and the more I think about it, the more unhappy I am about this diagnosis. It doesn’t seem accurate and really doesn’t seem helpful.

I am less concerned about the depressive episode diagnosis, although that has its problems, but the personality disorder diagnosis is really concerning me. I find myself offended and ashamed by it. No one wants to be considered self-serving, unempathetic and arrogant. I think the shame has actually been one of the barriers to posting about it. I don’t even want to put my name near the diagnosis I’m so unhappy about it. The fact it is written in my notes for posterity is disconcerting to say the least.

So what is wrong with this diagnosis?

Firstly “Moderate Depressive Episode”.

If you consider the ICD-10 explanation of this diagnosis, F32.1, you have to note that by referring to a depressive episode you are implying that it is the first episode of depression. For me this is far from the case and I don’t like that my diagnosis neglects to consider any past mood episodes. It is almost as if she doesn’t believe I have been depressed before.

I also question the severity, but I understand that this can be subjective. Many people would go off my BDI score, which is still above 40 (severe depression is considered 30+). I do have more than four of the ICD-10 listed symptoms, but I would also suggest that some of these symptoms are marked and distressing, making it severe. Actually attempting suicide would surely put the suicidal ideation into distressing territory? Worthlessness, guilt etc are all pretty marked too. The thing is I still function reasonably well so people can be forgiven for thinking I am better than I am. It also doesn’t matter. The treatment for a moderate episode varies little from a severe one and it doesn’t make much difference whether it is my first episode or 10th.

What about the lack of acknowledgement of hypomania or high mood? The treatment for Bipolar II Disorder is different to that of Major Depression. I have responded much better to the introduction of Lamotrigine as a mood stabiliser than I did to any antidepressant to date. What if they try to take me off this? Would I respond better to a different one and will they ever try it? Usually antidepressants make me agitated and unstable. I have been okay with the Reboxetine so far, but it doesn’t seem to have lifted my mood at all, so what will happen if they change it? What if I am given an antidepressant that sends me skyward? It worries me.

At the end of the day though I am depressed at the moment and that’s the important thing. It’s the other diagnosis I’m most concerned about.

So – F60.8 “Other Specific Personality Disorder” (Narcissistic).

The ICD-10 does not give individual diagnostic criteria for the disorders listed in this category, so I will assume that the DSM-IV criteria is what Dr M is referring to, after all she had a copy of the DSM on her desk when I saw her.

The criteria for Narcissistic Personality Disorder is as follows:

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
  2. is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  3. believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)
  4. requires excessive admiration
  5. has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations
  6. is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends
  7. lacks empathy: is unwilling to recognize or identify with the feelings and needs of others
  8. is often envious of others or believes others are envious of him or her
  9. shows arrogant, haughty behaviors or attitudes

It is also a requirement in the ICD-10 that any specific personality disorder diagnosis meets the general diagnostic criteria for personality disorders.

According to ICD-10, the diagnosis of a personality disorder must satisfy the following general criteria, in addition to the specific criteria listed under the specific personality disorder under consideration:

  1. There is evidence that the individual’s characteristic and enduring patterns of inner experience and behaviour as a whole deviate markedly from the culturally expected and accepted range (or “norm”). Such deviation must be manifest in more than one of the following areas:
    1. cognition (i.e., ways of perceiving and interpreting things, people, and events; forming attitudes and images of self and others);
    2. affectivity (range, intensity, and appropriateness of emotional arousal and response);
    3. control over impulses and gratification of needs;
    4. manner of relating to others and of handling interpersonal situations.
  2. The deviation must manifest itself pervasively as behaviour that is inflexible, maladaptive, or otherwise dysfunctional across a broad range of personal and social situations (i.e., not being limited to one specific “triggering” stimulus or situation).
  3. There is personal distress, or adverse impact on the social environment, or both, clearly attributable to the behaviour referred to in criterion 2.
  4. There must be evidence that the deviation is stable and of long duration, having its onset in late childhood or adolescence.
  5. The deviation cannot be explained as a manifestation or consequence of other adult mental disorders, although episodic or chronic conditions from sections F00-F59 or F70-F79 of this classification may coexist with, or be superimposed upon, the deviation.
  6. Organic brain disease, injury, or dysfunction must be excluded as the possible cause of the deviation. (If an organic causation is demonstrable, category F07.- should be used.)

I guess you can draw your own conclusions from reading the criteria and what you know of me from reading here. I guess others may have a different opinion of me, but I hope they can see that this is not what I am like.

I have decided to go through each point of the NPD criteria myself to see if I can work out what does and doesn’t fit.

1. Self Importance

has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

I really don’t think this is the case. I often downplay my achievements, because I can actually find it hard to admit them, even recognise them. I was bullied at school for being clever and a “swot”, so I am not really comfortable with admitting my successes to people. Yet when I’m assessed by mental health professionals I do of course have to talk about my achievements and talents, so I guess they can be forgiven for not realising this. It’s hard not to talk about these things when you are asked to give your life story. I have a good job, which I have been successful in, I got a 2.1 at university, I got 3 As at A Level, I got 11 GCSEs including 4A*s and 4As. These are facts though, not exaggerations.

I don’t believe I am superior, certainly not to anyone with equivalent achievements. Most of my colleagues at work have a similar background to me and I certainly don’t consider myself superior to them. Yes, my academic record is superior to someone who left school with 3 Cs at GCSE, but that doesn’t make me superior; just better at school.

I think this is hard when you have been generally successful. You can seem like you are bragging when you are not, it’s just the truth. I remember during the assessment with Dr S there was a lot of focus on my achievements and suggestions that considering my age I had done well. I generally agreed with her, but now I almost wonder if she was fishing for this.

2. Grandiose Fantasies

is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

I don’t even believe in unlimited success or ideal love so how I can be preoccupied by fantasies of these things, I don’t know. When Dr M and Dr S had been talking about high standards, they actually seem to mean in this sense, rather than the perfectionist sense, which I didn’t realise until this diagnosis was made. So I’ve been agreeing with them when I actually disagree. They seem to think I expect to be highly successful and powerful. I don’t. In the past I had been fairly ambitious, expecting to do well at school and going on to get a good job, but I don’t expect “unlimited success”. Anyone with a good academic record starting out on a career similar to mine has similar expectations. This is usually something to be considered positive and not out of the ordinary. Now of course I’m depressed and even the most simple tasks seem ambitious, which would suggest that these thoughts aren’t pervasive either, therefore not meeting the diagnostic criteria.

There was a short period fairly recently where I had thoughts of going into politics as I wanted to make a difference and there was a lot of focus on diversity in politics and increasing the number of women in parliament. I can be passionate about issues and want to do something about them. I guess I may have been fantasising a little at the time, but even still this is not an unrealistic ambition. I have been interested in politics for years and often considered it as a future career option, but not because I want to be all powerful.

I have had the odd grandiose moment when my mood has been high though and I have admitted this. Of course they question whether or not I’ve ever experienced hypomania, so will put this down to personality rather than symptoms of a mood disorder.

3. Special Status

believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

This is one that I guess I can identify with, although I am not sure it is correct. I do not believe I am special as such, but I guess I do feel more comfortable with people that have a similar background or interests to me. I think everyone does though to some degree and it is not like I will not associate myself with other people. I try to judge people on their merits and will talk to anyone.

I can see why they may think this is true though. During my assessment with Dr S she asked me about my regrets regarding me degree choice. She asked about how I chose my course and one of my considerations was choosing a respected university. This consideration was mainly to keep my career options open as opposed to anything else. There are plenty of graduate employers that only recruit from top universities. I guess this could be seen as wanting to be associated with “high-status institutions” though, so they may well use this as an example when diagnosing me.

4. Admiration

requires excessive admiration

Erm. I don’t know how to reply to this. I cannot deny I can have difficulty responding to criticism and that I like praise, which I guess may come under this category, but I don’t require or seek excessive admiration. If someone likes me that’s a bonus, but if they don’t then fine.

5. Entitlement

has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

A sense of entitlement? I expect fair and reasonable treatment, but I don’t expect favourable treatment over others. I am a strong believer in equality and a sense of entitlement would go directly against this.

I can at times be stubborn and this could be misconstrued as expecting compliance with my expectations. I will compromise, but I try to be assertive as well. I don’t see this as entitlement though. We are usually encouraged to be assertive when in therapy, so it would be wrong to judge this as being narcissistic.

6. Exploitative

is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

It is criteria like this that makes me so uncomfortable about this diagnosis. I don’t want to be considered self-serving. I don’t take advantage of others in order to get ahead and I find it horrible when people do. Some of examples given are things such as dressing provocatively to get your own way. Ignoring the fact that if I dressed provocatively people would run to the hills, I would never do this. I hate the idea on too many levels.

7. Lacking Empathy

lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

There are two sides to this for me. In many ways I am often considered too empathetic. I consider other people’s needs often to the detriment of my own. I was told off repeatedly by the therapists at The Priory for considering everyone else first, for listening to the others and offering them advice and support, but for not giving myself the opportunity to speak and receive that support back. I would like to think that I understand how others feel and that I am sensitive to their needs. I certainly try to be, so I am not unwilling.

Yet, I know occasionally my bloke finds I have a lack empathy towards him. He says I don’t realise how much the things I say and do hurt him or recognise how he is feeling. I think our relationship is an isolated case though, because there are many ways in which I act different with him than I do with others – lack of assertion is another.  I also don’t think depression helps matters much. I guess a suicide attempt could be seen as not taking other’s feelings into consideration, but if you knew how much I worried and obsessed over this beforehand you would realise it is not.

8. Envy

is often envious of others or believes others are envious of him or her

I think everyone gets jealous now and again. I can be envious of others that have recovered from illness, because I wonder why I have not. I can be envious when someone gets better grades than me at school. I can be envious when I see people having a great time when I am depressed. I wouldn’t say it is often though and certainly no worse than most.

I really don’t believe anyone is envious of me. There would be no reason to be. I’m depressed. My life sucks!

9. Arrogance

shows arrogant, haughty behaviors or attitudes

I hope I don’t, but I guess at times I can be a bit of a snob and I’m guilty of generalisations. I am not exactly appreciative of chavs and I can sometimes be a bit rude towards people that watch rubbish on TV, but I’m not alone on this. I don’t think I’d go as far to say that this is a major problem or that I was particularly bad at it. I certainly know people who are worse than me!

_______________________

Anyway.  I’m going to post this now. It’s not really complete. There is plenty more I could say on the matter, but I’ve been at it for hours and if I don’t post it now it may be days before I do finish it. Maybe I will edit this post, or maybe I’ll add another. We shall see. This is well over 3500 words long now and I have spent quite a few hours on it.

Does anyone have any ideas of what to do next? I just feel a bit lost and trapped. I’m worried that if I question the diagnosis, it will come across as narcissistic! That is the biggest problem with personality disorders. Questioning it is just further evidence of the disorder and can all be seen as part of the problem.