Appointment With My Pdoc: Some Thoughts On What The Hell Is Wrong With Me

I had an appointment with my pdoc  the other day.  I was hoping to get my diagnosis straightened out.  I feel like my current diagnosis of major depressive disorder doesn't quite fit.  I cycle seasonally, and when I'm unmedicated (or under-medicated), I cycle daily.  There's no diagnosis for these symptoms in the DSM, but I can say that I relate more to stories from folks with bipolar than I do to those about straight-up major depression.

My pdoc thinks the issue is hormonal.  He says that the human circadian rhythm involves changes in cortisol levels throughout the day.  Night owls, he says, have more variable cortisol levels, and we hit a low point in the late afternoon/early evening.  Maybe I'm just extremely sensitive to this shift?  He's sure that there's an issue with cortisol levels, so he's going to do a literature search and get back to me.



My whole situation is an excellent illustration of the difficulties inherent in making a mental health diagnosis.  The DSM provides collections of symptoms, but these symptoms could be caused by any number of things.  This is why anyone who feels emotionally depressed and lethargic should get their thyroid checked before taking any sort of antidepressant -- the symptoms of hypothyroidism mimic clinical depression pretty convincingly.

I still don't know what the hell is going on with me, but it seems like there's a good chance that a sensitivity to cortisol is giving me symptoms similar to bipolar III (a dx featured in the upcoming DSM, in which depressive episodes are cyclical, but there is no mania or even hypomania).  Lamictal might be treating the effects of this without getting at the underlying cause ... and unfortunately, there may be no way to treat the underlying cause.  There's a a very good chance that there are a whole host of causes that manifest as "bipolar disorder" or "major depression".

The fact is that there's still no way to look at the brain while it's working and identify exactly which hormones and neurotransmitters are doing what.  Brain imaging only tells us which parts of the brain are active doing certain tasks, and how which brain bits are more (or less) active in folks with a particular mental illness.  I look forward to the day when neuropsychiatry has more specific, effective diagnostic tools at our disposal.