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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.

8 Responses

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  1. She also 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.

    It is very well worded… and it’s how I’ve felt about the world of psychiatry for a while and even more so after my stay on the ward last summer and after reading my notes saying I didn’t look actively depressed! So not looking actively depressed means I cannot possibly be suicidal… what utter bullshit, I know to become a psychiatrist takes some time in medical school but they don’t teach them to mind read! I know in my own head and heart if I had not been admitted into the ward last year when I was i.e. if the CHRT had refused to give me a bed when I’d requested it I would have carried out the plan… thankfully they admitted me and I’m still here to tell the story and it seems things are going okay, but I still get suicidal – a lot it doesn’t go away… I would like to write more about it on the blog but I’m wary because of who is reading, I’ve had a lot of suicidal thoughts recently with it being mum’s first anniversary and the stress and anxiety of college, particularly last week on mum’s first anniversary, that was quite bad…

    Psychiatrist’s need to look beyond seeing depressed people as people who don’t get dressed and stay in bed all day… gone are those days…

    Maybe for you over time things with Dr M may change and given time and some regular appointments things may improve and the therapeutic relationship will get better for both of you.

    In the mean time take care x

    Alison

    Tuesday, 16th March 2010 at 6:57 pm

  2. You’ve been referred for therapy? I would suggest that’s much more important than any diagnosis, and more important than getting on well with Dr M. Actually, a suspicion of PD makes it more likely you’ll be referred to a competent therapist (who will see through the diagnosis straight away).

    cbtish

    Tuesday, 16th March 2010 at 9:38 pm

  3. CBTish – I was referred for therapy 6 months ago, long before any of this debacle happened. Waiting for the assessment appointments to know what form it will take. Told it will be a while yet though before it comes through.

    I do hope future people can see through any diagnoses but I still worry what people will think about me when they read my notes.

    intothesystem

    Wednesday, 17th March 2010 at 12:13 am

  4. I’ve been labeled with Borderline exclusively by professionals who seemed to particularly dislike me. Some of those who I have got on with have told me that no, I have nothing of the sort, I don’t exhibit borderline at all. I’ve had friends read the diagnostic criteria (admittedly, very unscientific) and say it doesn’t sound like me at all. With PDs in particular, as you sort of mention, I think you could probably take anyone and write a story where you frame select behaviors into the diagnosis.

    PDs just generally seem like such a hurtful diagnostic category. They seem handed out too liberally by professionals whose own handbooks say that it has to be a pervasive and longstanding pattern, even that it should not be diagnosed before age 18 at the earliest. PDs seem to say that everything about a person is wrong and that they are unpleasant to be around. With depression they often say, “but you have all of these other strengths to build on.” With PDs… that doesn’t seem to happen. With all of those general connotations attached to a PD diagnosis, how do they expect someone to react?

    jessa

    Thursday, 18th March 2010 at 8:22 pm

  5. 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

    I had that problem with a therapist. I quit therapy soon after. “Invalidating” was the word I ended up using. I told her that when I started to articulate something and she jumped immediately to “this thought process is wrong, let’s fix it”, I felt like she wasn’t taking my feelings seriously, but she said that was how CBT worked and that was all she could offer.

    I find positivity very difficult to deal with. For me, the chronic nature of my illness is something that I’m trying to come to terms with, and not always succeeding. So when they get all perky when actually, I know the relapse rates and I know my real prognosis, I just feel like they’re trivialising it and that they don’t know what they’re doing. Sometimes I just want to say, “Look, if you can think positively about this, then you haven’t read enough.”

    And it scares me, because I specifically want help preparing myself for the worst without it becoming a self-fulfilling prophecy. I need expert support in that area, and instead it’s the area where they’re most willing to leave me dangling on my own.

    Lorna

    Sunday, 21st March 2010 at 8:36 am

  6. She is always very positive and encouraging. […] I find that she can ignore the negative, which means I don’t feel like I am being listened to or taken seriously.

    Sounds a bit like my shrink, who’s developing a reputation of assuming all of her patients have already recovered…

    I find taking an advocate helps, I felt I was listened to more, and also it gave me the confidence to ask the difficult questions. I don’t know if there are any organisations in your area that could provide one, but if there is I’d really recommend it.

    As far as asking for a referral, you could spin it not so much as saying you wanted a ‘second’ opinion, just as a suggestion of somewhere which might have fresh ideas on treatment. I’ve only asked for a second opinion once (non-mh) and will never do it again, having said that, if it’s out of trust, then it’s less likely to be her ‘golfing buddy’ (or equivalent)…

    At the end of the day, though, if the trust has gone from the relationship then really you need a new psych (it’s just asking for that without it looking like a reaction to the Dx…)

    I hope you find a workable solution.

    Take care,
    Differently

    differentlysane

    Sunday, 21st March 2010 at 1:47 pm

  7. Look, if your doctor can’t twig that sick people can be functional, then she doesn’t deserve to practice. And if she immediately assumes there must be PD when the magic pills don’t work, doubly so.

    Stop making excuses for her, get an advocate and do something about this.

    DeeDee Ramona

    Thursday, 25th March 2010 at 10:04 pm


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