[3] When a patient has made repeated suicide attempts, that patient is often labeled with the diagnosis of depression as part of a Bipolar or DID diagnosis. As we have been discussing, the correct diagnosis is critical as there are medication protocols for treating bipolar whereas there are no medication protocols for treating DID.

Bipolar Affective Disorder and DID are diagnoses based solely on their clinical presentation. Unlike malaria, they cannot be confirmed in a laboratory. In the past, before microscopes, malaria was also diagnosed by its clinical presentation, which is a specific fever pattern. But now, it is diagnosed using a microscope that enables the parasite to be seen in a blood smear.

There are no laboratory tests for these psychiatric disorders. The clinical presentation alone is used to make a diagnosis of DID or Bipolar Affective Disorder. And the evaluation of clinical presentations is subjective. It is based an interpretation of what is behind the behavior, of what is causing it. There is a risk of the clinician’s bias in that interpretation. If bias drives the decision, that can compound the risk of mistaking one diagnosis for another, perhaps correct one.

This is more common than is generally acknowledged because the same or similar clinical presentation can be seen as quite different illnesses. For example, one psychiatrist may identify something as a mood swing and decide this is a bipolar patient. Another psychiatrist might identify it instead as a dissociative event where a different alter is presenting.

Those who have difficulty in accepting the phenomenon of dissociation often choose the diagnosis of a Bipolar disorder to fit their patients into a pigeon hole with which they, the psychiatrists, are comfortable. These disorders often include depression and instability in mood states. With the identification of a behavior as a symptom, the correct diagnosis is critical because treatment is quite different for each of these disorders. A critical distinction in the diagnoses are that identifying the behavior as a symptom of bipolar legitimizes the use of drugs. This is because there are drugs approved for use in treating bipolar disorders while there is no drug approved for use in treating DID.

We do know that diagnoses having an approved drug for treatment mean short interviews with patients that are less emotionally taxing for the therapist. This means that there is a greatly diminished risk of vicarious trauma for the psychiatrist to go along with the convenience of a prescription based treatment rather than psychotherapy.

Despite the many papers published on brain amine metabolism and depression, we do not know exactly how these are truly related. Nevertheless, using drugs as the treatment means that instead of putting out the energy of empathy, and deeply listening to the patient, there is just the checklist of questions to ask. The questions are all versions of “are you feeling better?”

The answers are then coupled with trying different kinds of antidepressants, dosages and combinations. A diagnosis that has an approved drug treatment guides the psychiatrist to focus on the relatively simple task of choosing the right pill rather than on psychological and social issues. But if that diagnosis is incorrect, the resulting treatment plan will not address the problem. It will cause more suffering to the patient and often further mask the correct diagnosis.

So, the correct diagnosis is critical.

Evaluating clinical presentations means that the symptoms and signs are documented by selecting and interpreting those presentations. The problem, to give one example, is that a psychiatrist who is biased towards a bipolar diagnosis will see a behavior as hypomania. The result is that he will give a patient the latest mood stabilizer as the first line treatment. If that psychiatrist ignores indications of early childhood trauma or even remaining open to that possibility, he will simply not identify the behavior for what it most likely is – dissociation related to flashbacks of that early childhood trauma.

For that psychiatrist, a diagnosis of bipolar affective disorder and the use of a mood stabilizer will appear to be a sound clinical practice. The doctor and the drug manufacturer are protected legally from claims of negligence. It is the essential litigation insurance. It is difficult years later to prove that the doctor was wrong.

Identifying severe agitation or panic in a patient with a history of abuse as hypomania rather than recognizing it as an episode of flashback agitation is a mistake with real and difficult consequences. Flashbacks are not a feature of hypomanic behavior. But, I have seen it described as hypomanic behavior in patient files because of a clinician’s bias favoring a diagnosis of bipolar.