Keeping a Journal Can Help Lead to an Accurate Diagnosis

Keeping a Journal Can Help Lead to an Accurate Diagnosis

For far too many years, I made an egregious mistake. I did not keep a journal.

In my October blog entry, "Admitting That You Have a Mental Illness Is Essential to Recovery," I recalled that for years I had a condition, known as anhedonia. This is a state in which individuals with a mental illness do not recognize that they have a disorder and do not, therefore, seek treatment.

The results for those persons with severe mental illness can be catastrophic. Indeed, I self-medicated with alcohol while tenaciously working to achieve success in a number of areas. In retrospect, I was considered to have a high-functioning bi-polar II disorder. I was able to be ambitious and detailed in my work, but in my private life, I often, except for periods of remission, was in a state of anhedonia, which is an inability to experience joy, happiness or pleasure.

In many respects, anhedonia overlaps with depression. My lack of understanding that my general incapability of enjoying my personal life -- and manic disruptions in my work life -- was an unnecessary burden that I carried with me for decades. I thought it was normal to be "uncomfortable in my own skin," except for rare times that the cloud of despair lifted, and I was able to be in the moment.

In looking back, I am sorry that I did not keep a journal. Frankly, I didn't have the discipline to write down the details of my private life because I was so often irritated, angry and ruminating about my fears, particularly when it came to relationships.

If I had kept a journal, I might have discovered my shifting and painful moods. In bipolar II, like many mental disorders, documenting the chronology of your behavior can lead to increased self-knowledge and recognition. Such self-probing can offer a perspective other than being entrapped in anxiety and despair. That, in turn, can lead to seeking treatment.

Another reason keeping a journal can have a significant impact on improving one's mental disorder is that it allows a therapist to understand your history without having to wait for it to be revealed in therapeutic sessions, which might take a rather long time. This is particularly true of the current increased pressure on therapists to see more patients with more limited amounts of time, either as authorized by insurance or due to a large case load. A journal can provide a road map to your shifting mental states and lead, hopefully, to more accurate diagnosis in significantly less time.

A journal, even after diagnosis, can offer more documented self-insights and behavior, which, in return, can often further assist in recovery.

For some individuals with mental health disorders, there may appear to be insurmountable obstacles to begin writing.  Obtrusive thoughts and the vicissitudes of one's disorder may prevent developing the discipline to record one's thoughts and moods. This was certainly the case with me for many years.

However, there is a solution. 

Just start writing, perhaps only a few sentences at first. Develop an ability to dive inward into recognizing your behavior and thoughts and distance yourself from your disorder as much as you are able. This may be difficult, at first, to achieve. After all, it is not easy to write about yourself when you are not in control of your thoughts and behavior. With determination and tools like meditation and yoga, you may, however, succeed in beginning a journal.

The most important step is to begin writing daily without expectations. Let your mind take you wherever it goes. In a while, you will probably be able to start honing in on recording the details of your daily life. This, in turn, can assist in the process of healing.

Mark Karlin is retired, after a long career in advocating against gun violence, as a hospital executive, an online journalist, a consultant, and founder of a progressive website. He graduated from Yale University, cum laude, with an honors degree in English and received his MA from the University of Illinois.

Admitting That You Have a Mental Illness Is Essential to Recovery

Admitting That You Have a Mental Illness Is Essential to Recovery

You can have a mental illness for years and not be fully cognizant of it.

I know that, because that was the case with me. The condition is called anosognosia (meaning lack of awareness of one's mental illness).

A website, TAC.org, states, 

Anosognosia, also called lack of insight, is a biological condition that prevents some people with severe mental illness (SMI) from knowing that they are experiencing symptoms of a brain disorder. Anosognosia is thought to be the most common reason for not seeking or maintaining treatment for people with severe mental illness.

Beginning with my freshman year at college, I was depressed and in anguish at times, but never associated my condition with needing mental healthcare. In retrospect, the first signs of depression and hypomania occurred, unrecognized by me, in my senior year of high school. Then I felt, at times, a high degree of alienation from my fellow classmates, with the exception of a handful of friendships, coupled with hypomanic high achievement.

Indeed, I felt mal dans ma peau, French for uncomfortable in my own skin. However, I thought this was the way I was and the way that I would always be. Although I briefly saw a psychiatrist when I was a student as an undergraduate at Yale, I didn't see how therapy could help me because I didn't recognize the severity of my mental and emotional disorders. Marijuana and alcohol were self-medicating, but appeared to be acceptable as daily habits in my life that eased my pain.

In retrospect, I believe that I was hampered in developing friendships by social anxiety disorder, avoidant personality disorder and dependent personality disorder. The symptoms of these disorders often overlap. They were later found to be due to my depression, and after that a final diagnosis of bipolar disorder ll.

To this day, I find it hard to understand how I could be unaware of how my personality was so off key, so ridden with anxiety, despondency and social discomfort without realizing that I was in need of therapeutic and medication help. Indeed, anosognosia is considered a neurological disorder unto itself. 

I believe that many people struggle with such symptoms while assuming that they are so much a part of their personalities that they don't think of therapeutic or medical treatment. A further problem is that many psychiatric disorders are nuanced and fluid.  As an article in Psychology Today notes "psychiatric diagnoses may be imprecise, they may change over time, and there may be mitigating factors." Bipolar disorder, for example, often exists on a spectrum that changes from time to time.

One estimate is that 50% of people with schizophrenia and 40% of people with bipolar disorder have anosognosia before being diagnosed or are never diagnosed at all. This, as in my case, can take years upon years. The lack of vitally-needed treatment may contribute to suicidal ideations and actual suicides.

I was fortunate. I never thought of committing suicide due to my despair and helplessness, even though it literally took decades before I was properly diagnosed. Only then did therapy and medications help lift me out of my despair and hypomania, which manifested itself as dysphoria at times (mixed mood states including both depression and hypomania simultaneously). Dysphoric symptoms include discontent, irritability, stress, aggression, and feelings of anger, guilt, or failure.

For me, in any case, there were only limited anti-depressant and bipolar medications in the early '70s when I was in college and in the immediate years after I graduated in 1973. Many people today are taking effective medications to help manage severe mental illness. However, before the '80s they might have received electroconvulsive therapy or have been institutionalized in the absence of all but a few medication options. Or they might have lived their lives in ceaseless helplessness. There were also more limited therapeutic options.

Fluoxitene (Prozac), the oldest SSRI, was not available on the market until 1988. Until then, only a limited number of antidepressants, most notably monoamine oxidase inhibitors and tricyclics -- which could have serious side-effects -- were available. Lithium was prescribed in research and off-label, but is was only approved by the FDA in 1970 to manage bipolar disorder. Since Prozac was approved by the FDA, there has been steady progress in the development of many medications to treat depression, bipolar l and II and other mental health disorders. 

When you self-medicate, becoming addicted to a substance, which I did, you travel even further away from seeking a means of alleviating the dread of your mental health disorder, while actually exacerbating the underlying mental illness. The self-medications further kept me from an awareness of the need for seeking help.

It is vital to get outside of "your own skin" and look at your moods and fears as if you were a third party evaluating your condition. If your symptoms match a mental disorder, you should seek a professional evaluation. If you do not do so, and you have a mental illness, you may condemn yourself to a lifetime of torment and desolation, or even suicide.

This is a life-changing lesson I learned the hard way. 

Mark Karlin is retired, after a long career in advocating against gun violence, as a hospital executive, an online journalist, a consultant, and founder of a progressive website. He graduated from Yale University, cum laude, with an honors degree in English and received his MA from the University of Illinois.

The Dreadful Toll of Alcoholism and Mental Illness

The Dreadful Toll of Alcoholism and Mental Illness

The comorbidity of alcohol use disorder and depression is well documented. For those with both, they are co-dependent with the other. It is estimated that 1/3 of people with severe depression are also addicted to alcohol at one time or another.

I was one of them. 

Although I was initially diagnosed with depression (and later bipolar ll), it was usually during the depressive periods that I depended on liquor to self-medicate, even after I started taking anti-depressant pills. In turn, the alcoholism exacerbated my depression, social discomfort, and anxiety when I wasn't drinking. I never thought about the warnings on most anti-depression medications to not drink alcohol.

However, I never drank during the day at my various jobs or at home until my family went to sleep. In fact, I was energized by my work in my remission phases. I became obsessively absorbed in the details of my day-to-day tasks, leading me to excel and become extraordinarily successful in many different areas.

There were times during my periods of hypomania and racing thoughts that the pressure of working at a Herculean breakneck pace also led me to drink excessively at night. This was a pattern that lasted off-and-on for decades, except for the short or long periods of remission.

On vacations overseas, my addiction to alcohol was incessant and unquenchable. During the days on such trips, I stayed sober, but at nights and when flying, all bets were off.

It was at Narita Airport in Tokyo in 2019 that I reached my abject nadir, as my wife and I were waiting at the gate for a plane to transfer to Hanoi to begin a three-week vacation in Southeast Asia.

My wife is an avid reader and when she is absorbed in a book, there is very little that can distract her. I told my wife that I was restless -- which given my racing thoughts was not entirely untrue --  and needed to walk around. In a duty free shop I bought some miniature Absolut bottles and guzzled down six of them in a washroom stall. My wife was still absorbed in her novel when I returned, and she didn't notice that I was inebriated.

Alcoholic debauchery was not infrequent when flying to stave off my depression, my anxiety, and my desire to avoid interacting with people, such as strangers sitting next to me in an airport waiting area or on the plane.

When we arrived back to the O'Hare international terminal, after our trip to Vietnam, Cambodia, Laos and Thailand, I had already made the decision to go cold turkey, and I did.

I have not had a drink since that day, I have never attended an Alcoholics Anonymous meeting, gone through withdrawal, or received therapy for my former alcoholism. Like many conundrums associated with mental illness, it remains a mystery that I had the willpower to stop so abruptly. 

I didn't become what is known as a dry drunk, which is someone who still craves alcohol; I became stone cold sober, losing any desire to become drunk. I no longer walked through aisles of liquor shelves at supermarkets with a compulsive craving for the gleaming bottles and the temporary relief that came with intoxication.

It was then, when I was no longer waking up after blackouts, that I was ultimately diagnosed as being bipolar II.

There is no doubt in my mind that my closet alcoholism was precipitated by my vacillating moods (most notably depression) as a bipolar.

 It has been five years since my last drink. I think with more clarity, I am more open to relationships, emotions, and social engagement. I avidly volunteer for a variety of causes in my retirement, with my mental health under control due to an effective "cocktail" of medications and therapy.

I occasionally remember when we socialized with a colleague of my wife's and her boyfriend when I was in my mid-20’s. I got blindingly drunk. I was beyond remembering what transpired, a total blackout, and only afterward, my wife thanked me for driving the couple to their hotel. 

As I look back, I feel grateful beyond words that I did not get into a catastrophic accident and kill anyone, including myself. Fortunately, I had the good sense after that not to drive after drinking.

But that horrifying, irresponsible behavior is behind me. I finally feel that I have arrived home, and the possibilities of such disasters and dissolution are no longer on the horizon.

Mark Karlin is retired, after a long career in advocating against gun violence, as a hospital executive, an online journalist, a consultant, and founder of a progressive website. He graduated from Yale University, cum laude, with an honors degree in English and received his MA from the University of Illinois.

Many Insurance Companies Are Refusing to Pay for Mental Health Care Despite Federal Law

Many Insurance Companies Are Refusing to Pay for Mental Health Care Despite Federal Law

According to the US Centers for Medicare & Medicaid website, the federal Mental Health Parity and Addiction Equity Act (passed and signed into law in 2008),"generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits."

In 2010, the Patient Protection and Affordable Care Act (Obamacare) added the mental health requirement to include individual health insurance policy holders.

However, a blockbuster ProPublica investigative article, aired by NPR on August 25, details how a large number of insurance providers are evading the requirement using a number of different subterfuges. The lengthy news story details how many patients are being denied care. Furthermore, many therapists and psychiatrists are leaving the commercial and non-profit insurer networks because of obstacles that include denial of care, delays in payments and impediments to communicating patient needs.

ProPublica found that,

It is often the insurers, not the therapists, that determine who can get treatment, what kind they can get and for how long. More than a dozen therapists said insurers urged them to reduce care when their patients were on the brink of harm, including suicide.

All the while, mental health providers struggled to stay in business as insurers withheld reimbursements that sometimes came months late. Some spent hours a week chasing down the meager payments, listening to hold music and sending faxes into the abyss.

The news site interviewed more than 500 providers across the nation and found the outlook for adequate provision of mental healthcare by insurance companies -- particularly for long-term maintenance -- to be generally difficult, with lives often at stake. The exodus of providers and insurance companies overruling recommendations by therapists means that those who seek mental health care may often have to pay for it out-of-pocket. For severe mental illnesses, this could cost thousands, even tens of thousands of dollars.

Persons seeking therapy are confronting "a system to squeeze them out" because their conditions can be "chronic and costly." In short, they are "bad for business."

ProPublica reported, "There are nowhere near enough available therapists in insurance networks to serve all of the people seeking care....The consequences can be devastating."

In a previous NoShameonU blog, I detailed the growing shortage of psychiatrists and identified other options for care. But many of these non-psychiatric mental health providers are now finding it untenable to wrestle with the insurance companies for authorization of care and reimbursement, among other issues. Many psychiatrists and alternative therapists are no longer affiliated with insurance companies and will only see clients for cash.

The federal laws don't define how the insurance companies determine mental health standards of care. ProPublica found that "They often create their own internal standards instead of relying on ones developed by nonprofit professional medical societies. These standards can then be used to challenge diagnoses or treatment plans."

There are less than nine states (Illinois is one of them) that have set minimum criteria for what is considered medically necessary care for mental health patients, and it is likely that there are still loopholes that the insurance companies will exploit. In a hopeful sign, California, which has passed minimum standards, fined the giant non-profit Kaiser Permanente system $50 million for violating state guidelines and required the 12.5 million member provider to invest $150 million in behavioral health care. The reality, however, is that 41 states still do not have any minimum required standards for insurance companies.

Given that numerous sources cite that approximately 50% of Americans with mental health needs do not receive care, let alone those who receive inadequate care, the ProPublica article should be a wake up call to Congress to rectify this gaping hole in the Mental Health Parity and Addiction Act.

Mark Karlin is retired, after a long career in advocating against gun violence, as a hospital executive and founder of a progressive website. He graduated from Yale University with an honors degree in English. 

The Misdiagnosis of Severe Mental Health Disorders

The Misdiagnosis of Severe Mental Health Disorders

It would be ideal to visit a mental health provider and receive an accurate diagnosis of your illness. That is, hopefully, most often the case.  However, several studies have shown that a wide variety of psychiatric conditions may be initially misdiagnosed.

The peer-reviewed journal "Psychiatry" published a research paper in 2006 that cited a study that found "As per the survey taken by the National Depressive and Manic-Depressive Association (DMDA), 69 percent of patients with bipolar disorder are misdiagnosed initially and more than one-third remained misdiagnosed for 10 years or more."

A 2011 study in "The Primary Care Companion for CNS Disorders" found that primary physician "misdiagnosis rates reached 65.9% for major depressive disorder, 92.7% for bipolar disorder, 85.8% for panic disorder, 71.0% for generalized anxiety disorder, and 97.8% for social anxiety disorder."

Borderline personality disorder is difficult to diagnose, as another example, and is often mistaken for bipolar disorder or even unipolar depression, or not considered a mental illness at all.

Other studies have shown appreciably lower rates of misdiagnosis, but clearly individuals with a mental health disorder are more likely to be misdiagnosed than someone who has pneumonia, for instance.

An article by Michael G. Pipich in a 2021 edition of "Psychology Today" warns: 

Some [of my patients with bipolar disorder who have been misdiagnosed] have reported to me that while their pre-existing depressive episodes may improve with antidepressants, they often experience manic episodes that are more agitating and consequential than ever before. 

Schizophrenia is not infrequently misunderstood as a diagnosis. The National Alliance on Mental Illness flatly states on their website: "Diagnosing schizophrenia is not easy." The Johns Hopkins Early Psychosis Intervention Clinic reported in 2019 that "researchers report that about half the people referred to the clinic with a schizophrenia diagnosis didn't actually have schizophrenia." That is a stunning statistic, but representative of the fact that whether people with mental health issues are underdiagnosed or overdiagnosed, the result is the same. They are likely to be receiving medications and treatment that do not address their complete underlying condition.

In 2021, "The Huffington Post" ran an article entitled, "5 Mental Health Conditions That Are Way Underdiagnosed." 

Some conditions tend to be particularly underdiagnosed (meaning more people have them than get a diagnosis) or misdiagnosed (meaning they’re told they have something else). That means too many people continue to struggle on their own rather than connecting with the treatment they need and deserve. 

"Consumers" may be perplexed as to why providers using the Diagnostic and Statistical Manual of Mental Disorders (DSM-Edition 5) sometimes can't match the criteria listed with distinct mental disorders. There are many reasons for that, far too many to list here. 

However, a key factor may be the limited time period that most people with mental health problems have with providers.  Most complicated mental diagnostic categories require long-term interaction with the client and the ability to pick up on nuances in behavior and recollections.

Unfortunately, many clients don't know the specific language to use that reflects the medical criteria in the DSM, and so medical symptoms are sometimes not communicated clearly. Furthermore, many symptoms of mental health conditions overlap.

Also many beleaguered providers likely want to quickly establish a diagnosis because of time constraints or due to a lack of knowledge in the case of primary physician "screeners."  It can be speculated that hospitalized psychiatric patients may receive more accurate diagnoses because of the intensity of time spent observing, testing and talking with them and the long-term experience of psychiatric unit staff. However, misdiagnoses can happen even in these cases.

If you think that you are being misdiagnosed, you should strongly consider getting at least one second opinion as an option.

Mark Karlin is retired, after a long career in advocating against gun violence, as a hospital executive and founder of a progressive website. He graduated from Yale University with an honors degree in English.