Abstract
To the Editor
The editorial in a recent edition of ANZJP invites contributions to assist in diagnosis and treatment of bipolar disorder (Malhi and Berk, 2011). The editor notes the clinical reality of patients’ mood experiences may not always be easily accommodated by existing diagnostic frameworks. Psychiatrists are treating people in distress with all the complexities that task entails, not disorders per se.
The editor says removing an incorrect diagnosis of the disorder is colloquially described as ‘depolarising’. ‘Depolarising’ could be regarded as part of the broader challenge of identifying what is actually going on for the patient who presents.
The clinical art of psychiatry involves needing to prioritise what a patient needs at a particular time. Integral to treating patients with bipolar is thoughtful pharmacotherapy treatment informed by guidelines but tailored to the individual patient. In periods of relative wellness there is a potential for us, with our patients, to understand what previously has been either not known or relegated under the catch-all ‘that’s my bipolar not me’. While we can appreciate what is often being described by a comment like this, namely the significant gulf between a patient’s experience during a period of illness and their current relatively well state, it can also be used in a defensive way to protect one from knowing something that one would prefer not to be aware of. To what degree a patient is interested in this, to what degree we are interested in thinking about this, is an arm to the editorial invitation for contributions to ‘depolarising bipolar’ for our patients. This is not a pejorative process. My experience is that this work needs a trusting therapeutic relationship in which a patient and psychiatrist are interested and open about this area, and time. It can lead to some real discoveries: a behavioural response, previously perhaps considered as ‘bipolar’, might also or for some patients more accurately, come to be understood as a more longstanding way of coping with some painful emotional vulnerability. This recognition allows the patient more responsive options when the issue arises again in relation to the identified problematic behaviour. What form this work takes is linked to the psychiatrist’s thinking about the patient’s needs. It might be an aspect of supportive therapy in the context of good clinical care, or it might be part of some focused psychotherapeutic work.
Our discipline’s focus on trying to understand and help the person with the disorder (Ellis and Hickie, 2001), rather than treating disorders in isolation, can assist in the challenge outlined by the editors (Malhi and Berk, 2011). This focus assists both psychiatrist and patient to avoid getting overly ‘polarised’ in their outlook.