Does a diagnosis make a difference?

My last post – The Retreat led to an interesting discussion about depression and anti-depressants in the comments section amongst fellow bloggers. I had been to my GP as I’m off work so needed a sick note. I asked my doctor to write depression on the note which was in itself a significant step for me. I got a prescription but I hadn’t started taking them as I was going on The Retreat, and when I got back I felt so good I didn’t think I needed them. I planned to go back to work next week and ‘get on with it’. It hasn’t quite worked out that way. I continued to feel good until Wed and was functioning better – eating better and fitting in the yoga. Wed I had a riding lesson back where it all started 12 years ago; the 2nd time around horse part of my life. I was flooded with memories and I missed my old horse. I enjoyed it but I came home feeling really sad. I didn’t want to do yoga but I managed a little. By yesterday morning my thinking was dark again, I was crying and couldn’t be bothered doing anything. When I tried my brain was sluggish and I got easily frustrated. I decided to take the tablets.

What has been different is I’ve been more aware of this shift and I’ve not transformed it into something else; an irritation with C, a complaint or just a hissy fit about not much at all. I’ve also stopped myself going too far down the self critical ‘it’s all your fault you always mess up’ path too. That I credit to the retreat and yoga. It helps me keep a little bit of me in an observing role to myself so I can check what I’m doing more easily. I was resistant to it yesterday but managed a 5 minute meditation. However I’m not functioning well and I have now decided to label that ‘depression’. I am depressed or I have depression? Does it make a difference which way I say it? Does it make a difference to label it?

I don’t like diagnoses which is odd considering it’s my job to hand them out. When I first started psychiatry 30 years ago we were taught that basically people were either mad, sad or bad (I kid you not!). Psychosis, mood disorders and personality disorders. I quickly noticed that the people I met had stories to tell and usually their stories told of loss and bad things happening to them. Some people couldn’t tell you their story but their body told it for them – the young girl in a wheelchair with fixed contractures of her legs meaning it unlikely she would walk again though there was no physical reason. She had been sexually abused but she smiled and told you all was fine. She didn’t know what she was doing in a psychiatric unit. I found that the so called bad people were the most likely to go mad or be sad but because someone had labelled them ‘Personality Disorder’ no one was very sympathetic when they did. I still find this 30 years later; even though all the evidence backs up what I noticed back then. In Child Mental Health there has been a shift towards more diagnoses so that a huge proportion of referrals now are for assessments for diagnoses such as ADHD and Autism. I found that giving the child’s symptoms a label and then trying to medicate them away didn’t really work that well; especially if nothing else changed around the child; and especially if other things were not as they should be. I remember as a very green consultant seeing a child who I thought had severe ADHD. I gave the meds and at follow up asked his mum how it was going. ‘Oh I didn’t give him those she said – I stopped giving him Powerade’. A powerful lesson for me that symptoms can reflect many possible causes. I didn’t stop diagnosing completely but I tried to use it as a systemic intervention; a way of shifting parents thinking and their interactions with the child, as well as a way to get support in school. I also couldn’t help noticing that sometimes when you treated one set of symptoms a different sort popped up like an unsolvable puzzle that keeps changing shape. Quite a lot of my patients could have any number of diagnoses and none of them really helped with changing anything. I found that when people were able to put words to their secrets, their unspeakable experiences, their shame often their symptoms diminished somewhat. I was learning that symptoms have a function as well as a cause.

In 2006 I came across Pat Crittenden and the Dynamic Maturational Model (DMM) of attachment theory. (www.iasa-dmm.org). This made more sense to me than any other way of conceptualising mental health across the whole spectrum from well to really unwell had ever done so far. How you function is rooted in your early experiences and is your best adaptation to that unique context is the premise of it in a nutshell. Of course it’s a lot more complicated and I will write more about it in other posts as it has literally changed my life professionally and personally. The more I studied and trained in this the less I diagnosed, and the more I focused on trauma and adaptation.

The DMM conceptualises depression as when your strategies no longer work for you to get your needs for comfort and safety met, and you know it’s not working. Psychodynamic thinking about depression speaks of anger turned on the self; cognitive behavioural of negative thought patterns that bring you down. Women are so much more vulnerable at times of hormonal shifts – puberty, childbirth, menopause which supports a more biological understanding. I’ve used different thinking in different combinations to help patients understand what might be going on for them; a one size fits all approach isn’t that helpful. I still prescribed for patients, recognising that depression stops them from helping themselves, alienates one from loved ones and support. A barbed wire fence that keeps the pain out but the support as well. I know that meds alone can’t fix things but they can get you to a place where you can more easily help yourself. Ive not applied this to myself though. Is it arrogance that makes me think I’m different? Shame? Stigma?

Overcoming addiction is multi-faceted. We have to change our habits, find new coping strategies, new ways to manage our emotions, to have fun, to relax etc etc. We also have to deal with all the unprocessed losses and traumas that alcohol blocked out. I’ve been conceptualising my lack of energy and motivation as this – I’m processing lots of unresolved stuff as well as grieving the person I was and taking responsibility for the mistakes I’ve made. I’ve had therapy in the past so I’ve been surprised there’s still a lot of pain buried in my psyche. Also I’ve thought of it as a reorganisation process (that’s the attachment model term for significant change in how we adapt). I’m slowed up because doing things differently takes time; it’s learning a new way that isn’t yet second nature to me. I’ve also attributed it to cannabis. I’m lazy and demotivated because I’m still smoking dope. I’ve smoked dope a long time though and it’s not stopped me wanting to get out of bed in the morning before or had me crying at the thought of going to work. I’ve been reluctant to think of it as depression, an illness – until now. I’ve had enough symptoms for more than enough time to meet criteria for a diagnosis but I’ve resisted. So what difference does it make?

Firstly I think it’s given me permission to take time off work and look after myself. It is socially acceptable to stop functioning when you are unwell. Whilst I am trying to maintain as much functioning as I can, I’m not being so hard on myself for not managing all I set out to in a day. If I manage anything at all that’s ok. This is helping me keep some self compassion and stopping me from beating myself up mentally. It allows me to focus on what I can manage; walking the dogs, doing some yoga, trying to cook and eat well instead of going to work, not performing well and coming home too tired to do those things. Not doing them drags me down further. I can start from where I am at and build it back more slowly. It also allows me to separate it out from myself – one of the most helpful things a diagnosis can do. I’m struggling at work because I am depressed; rather than I’m struggling at work because I’m no good at my job. My GP said I’m self medicating with the cannabis. That’s a part of it for sure and I’m hoping that as I am able to do more I will want to smoke less. That the anti-depressants will take over some of the functions of the cannabis.

I still think the depression is related to the massive change of removing alcohol, processing unresolved issues and learning new ways of being. However I have to function as well as do this. I feel as if I’ve spent several months navel gazing and whilst necessary on one level too much of it takes you away from others and doing things that are good for you. It’s all about balance. Self awareness versus self absorption. I’m hoping the meds will help me reset that balance – reach out instead of hide away as I continue to find out who I really am without the shadow of alcohol. Help me embed the new habits that will help me stay well and connected to others and give me the energy and motivation to make the other changes I need to make; on the outside as well as on the inside.