Bipolar the catch all for everyone?

If this doctor is literally doing what you mentioned, I'd say it's inappropriate. That is said with extreme caution and again reiterating that he is doing what you said he is. I'm not there, so I can only go by what you write. I have to address that I haven't seen the guy or his work myself.

Whether or not it is true, I have found this thing too common for my tastes, which is why I'm addressing your concern and I find it believable. In fact every place I've worked, I've seen this thing happen. I've also noticed some doctors are quick to diagnose a child with bipolar disorder or ADHD when the kid does anything most kids do that is not perfect behavior such as fight with siblings, yell, not do chores...

I've seen some PCPs diagnose mental illness based on some self-report scale that I've never see empirically validated, and the questions are on the order of something everyone would have.

(I'm making the following up but I have seen some scales like this...
Have you ever not wanted to do your homework?
Have you ever been in class and just wanted to leave?
Have you ever late to work or school?

If you said yes to any of these, then you may have ADHD. Please talk to your doctor for help.)

It all ends up with several people being misdiagnosed, overmedicated, and patients (and family members) starting to believe that there's no such thing as a good psychiatrist because the patient is often put on meds that don't help but cause bad side effects.

An often comorbid problem is that when an attending doctor does this, staff members, and anyone else under the doctor such as a resident or medical student is held hostage because their ability to address this issue without their head getting cut off (in a proverbial sense) is extremely limited.

Departments, I've noticed, are often slow to react, if react at all to doctors like this. Doctors have great job security because there's not too many out there per person. So when a place has a psychiatrist, even if that psychiatrist is terrible, they often times hold onto him/her, knowing full well the doctor is terrible. Even when they let them go, they often do it in a manner far more diplomatic than the guy might've deserved.

While the DSM should not not be the end-all-be-all rulebook, it is a foundation, that I've noticed, is usually spot-on with over 90% of the disorders I've seen. When I diagnose, I specifically mention the DSM criteria in my notes as best as I can given the situation. Sometimes you just don't have enough information, but this is usually only in emergency psychiatry. Most of the time I see an NOS diagnosis, I find them BS. If I do diagnose NOSm I state why: either lack of data, or the person does have a disorder (IMHO a pattern of signs and symptoms that I or the patient could define) that is problematic and causing him/her and/or others significant problems that doesn't meet the guidelines.

All of this could be demoralizing to medstudents and residents, who often times are very eager to look up to attendings because they want to learn. Staff members such as nurses usually have seen this thing happen time and time again and build a resilience to it. All I can tell you is if this is truly going on, try not to be that type of doctor. I see doctors who practice in this manner an insult to the profession. Also be careful if you do choose to address this to higher levels. Unfortunately, the atmosphere of several places is to never question the attending, and if you complain--you're screwed.

I am so glad that I saw this post. It really hit home. I am actually another member on SDN, but for privacy purposes and because of the stigma that surrounds mental illness, I have chosen to go under a fake name (especially since I am in the process of applying to medical school).

During a very difficult pregnancy, my son and I almost died. I felt traumatized by the experience and felt some feelings of sadness afterward. Working at a hospital was challenging afterward since it reminded me of almost loosing everything.

I decided to talk a therapist (I only saw her once) about my traumatic event, and she recommended that maybe I should start on an SSRI. It was then that I saw the associated psychiatrist who promptly diagnosed me with bipolar disorder even though I had never been manic or hypomanic. He never asked about anxiety, whether I had PPD in the past, and did not want to talk about what the event that brought me into the office. I answered honestly "no" to every question such as, "Do you stay up nights? Do you multiple sexual partners Do you go on shopping sprees? Do you ever have racing thoughts? Do you halluncinate? Do you ever stay up at night because you feel like there is so much to do and you don't want to miss out on anything?......"

When I asked him why he thought that I had bipolar disorder, he did not answer me. I asked him two more times in different ways, and he didn't say anything. I had heard a rumor at work that he has a tendency to diagnose everyone as having bipolar disorder, so I asked him about it (in a calm manner). He got very angry and told me to get out. He told the office girl to, "Get her out of here right now."

I went to work at the hospital later that day, and he called the ER and disclosed to a couple ER doctors that I had been seen earlier that day in his office. He then asked the ER doctors about my work ethics. Ultimately, he was forced to resign due to noncompliance with HIPPA shortly thereafter.

When I signed to see my chart later on, I learned that he had diagnosed me with "bipolar: manic with psychotic features, histrionic personality disorder, probably long standing history of mood disorder, and a GAF of 55" He dictated 15 minutes before he had called the ER and after he had dictated that "this case is closed." I was certainly not psychotic that day (after all I went to work, was productive, and have witnesses to my behaviour), I would not describe myself as histrionic (actually more stoic), and I was still functioning rather well (all A's still, work full time, marriage was good, still take care of children well...etc). He also lied in about 75% of the H&P. For instance, he dictated a paragraph about my sleeping habits. The only thing that I said about sleep was that my son (a baby) still got up at night occasionally. In his dictation, he wrote that I stay up nights, that I had this problem even before pregnancy, and that I have difficulty falling asleep. These are things I never said or even alluded to.

I have no proof that he lied, and there is really nothing I can do about it. The hospital attorney allowed me to write an addendum to the chart without the psychiatrist's approval because of the violation of HIPPA and because of a prior incident with a nurse just months before. Although, I am not being billed for that visit, I still (along with others) reported him to Blue Cross for possible misuse or upcoding of the bipolar diagnosis. He is still under investigation, and they are getting the state involved in the case.

It's been a year now since my son was born. The feelings of sadness and any anxiety that I have revisiting my old hospital room or hearing an IV pump start beeping have long faded months ago. Talking to other mothers who had gone through similar experiences helped me not to feel alone and hleped me return to my regular, happy life.

I will forever be haunted by that bipolar diagnosis, however. Ten minutes was all that it took to be diagnosed with bipolar disorder and histrionic personality disorder. It was so easy to be labeled and with only the complaint of depression and minor anxiety after pregnancy. I can only hope that it his last experience will make me a more sympathetic physician in the future to those with mental illnesses.

You know, I too worked with a psychiatrist who had the exact same reputation of diagnosing almost everyone with bipolar disorder. It wasn't like he was making it up out of whole cloth - it was just that it appeared he was very quick to interpret it as proof of a hypomanic/manic episode if someone said they were ever irritable, had racing thoughts, or spent too much money, while I would argue those traits can occur in people who are not bipolar (just in a different degree). He said something once about how he believes that bipolar disorder often goes undiagnosed. I think he sincerely believed that he was catching bipolar patients that others had missed. Nice guy, and I didn't get the sense he was trying to be lazy or anything - just maybe not trained to appreciate the subtleties of diagnosis.

Pretty much on the order of more than half of my patients that were previously diagnosed with bipolar disorder, when asked, told me they didn't even know what it was and that the doctor that diagnosed them with it never explained to them what it was. While I haven't exactly recorded the number, I honestly think it's within +/-5% of 85%.

Then, around the same number tell me they were put on some medication for bipolar disorder, and never got any benefit for it, and were not even told the risks and benefits of the medication. Several of these people were put on meds that were IMHO very poor choices such as Lamictal starting at 200 mg Q daily without a gradual titration up, or a diabetic with poor management placed on lithium without being told of the risks of damage to the kidneys.

I've seen several of the attendings I worked during training with not doing these basic things that are supposed to be bare bones minimum treatment.

I also see several doctors getting mad when patients are curious and want to know more about their diagnosis.

So even if the above stories aren't true, I find them very believable. I mentioned once that if I do go a university route, I was thinking of doing a study where grad students are told to go to a psychiatrist, say they have a complaint and see if the psychiatrists actually do what's supposed to be considered minimum such as explain the disorder, why they were diagnosed with it, and if they followed the DSM criteria.

whopper said:

While the DSM should not not be the end-all-be-all rulebook, it is a foundation, that I've noticed, is usually spot-on with over 90% of the disorders I've seen. When I diagnose, I specifically mention the DSM criteria in my notes as best as I can given the situation. .

Click to expand...

Yeah, me too. Like when people say, "I'm bipolar because one minute I'm really happy and the next minute I'm crying. I have really bad mood swings throughout the day. My doc says I'm 'rapid cycling'."

I mean people do know that "rapid cycling" means 4 or more affective episodes per year, right? Not per hour. Not per day. Not even per week or per month. Per year. And yeah, those manic or mixed episodes need to last for at least a week or require hospitalization. Just like any other manic or mixed episode. 2 weeks for depressive. 4 days for hypomanic.

A lot of people I've seen who are very emotional (think of a stereotypical Sicilian guy who when he gets mad, puts his hand into a fist and hits the table) get diagnosed with bipolar disorder.

When I have someone who I believe is misdiagnosed, I specifically tell them something to the effect of, "Bipolar disorder doesn't mean you get mad a lot or your emotions change often." When patients tell me symptoms of possible bipolar disorder such as poor sleep, I respond to them, "well for how long was this going on for? 1 night? 2 nights? 2 weeks?" I tell them that a hypomanic or manic episode isn't the person experiencing symptoms for just a few moments. It usually has to be for at least days at at time.

sunlioness said:

Yeah, me too. Like when people say, "I'm bipolar because one minute I'm really happy and the next minute I'm crying. I have really bad mood swings throughout the day. My doc says I'm 'rapid cycling'."

I mean people do know that "rapid cycling" means 4 or more affective episodes per year, right? Not per hour. Not per day. Not even per week or per month. Per year. And yeah, those manic or mixed episodes need to last for at least a week or require hospitalization. Just like any other manic or mixed episode. 2 weeks for depressive. 4 days for hypomanic.

Click to expand...

Preaching to the choir, my feline friend...

sunlioness said:

Yeah, me too. Like when people say, "I'm bipolar because one minute I'm really happy and the next minute I'm crying. I have really bad mood swings throughout the day."

Click to expand...

When I hear a complaint like that, I typically ask, "What are the behaviors of others that set you off. What kinds of things do others say and do that send you over the edge?"

If I get clear answers about what others do that sets of the patient, then I ask, "So if others just avoid doing those stupid or rude things, then you're fine, right?"

If that's a "Yes," then I'm pretty sure I'm looking at irritability, bullying, over-dramatization, etc. Then I start asking the actual manic episode criteria, and the major depressive episode criteria. VERY often, I get clear direct answers to the irritability questions and clear, convincing, consistent "No" to the Manic and MDE questions. I then review with them that they answered "No to all the questions that would confirm a Bipolar diagnosis. They ask, "Well, then what do I have? 'Cause it's driving me and everyone around me up a wall." I explain that these are personality traits (possibly even a Personality Disorder) and that medications are likely to accomplish little/no improvement except for discrete symptoms, like maybe sleep or anxiety.

"Well then what should I do?"
"Did anyone ever suggest going to therapy?"
"Yes, but that costs money and you have to go every week or two."
"Yes, but probably a lot less money and time than what you've already lost in jobs, friends, salary, and years wasted on changing medicines every 3 months?"
"So I have to go to therapy to get better?"
"Yes! You may have to go to 5 or 6 visits with 3 or 4 different therapists before you find one that's a good fit. But I'm willing to bet that if you do that, you and those around you will be feeling a lot better in 2-3 years."
"YEARS?!"
"Yup. You've already spent 5-10 years screwing around with medicines that are unlikely to ever solve the problem. This is one of those situations of 'The sooner you get started, the sooner things will get better.'"

This conversation generally ends with either,
"Thank you. You're the first person who's ever explained it like that."
Or a much louder 2-word response, which is usually accompanied by 1 finger.

Both indicate we're done for today.

kugel said:

When I hear a complaint like that, I typically ask, "What are the behaviors of others that set you off. What kinds of things do others say and do that send you over the edge?"

If I get clear answers about what others do that sets of the patient, then I ask, "So if others just avoid doing those stupid or rude things, then you're fine, right?"

If that's a "Yes," then I'm pretty sure I'm looking at irritability, bullying, over-dramatization, etc. Then I start asking the actual manic episode criteria, and the major depressive episode criteria. VERY often, I get clear direct answers to the irritability questions and clear, convincing, consistent "No" to the Manic and MDE questions. I then review with them that they answered "No to all the questions that would confirm a Bipolar diagnosis. They ask, "Well, then what do I have? 'Cause it's driving me and everyone around me up a wall." I explain that these are personality traits (possibly even a Personality Disorder) and that medications are likely to accomplish little/no improvement except for discrete symptoms, like maybe sleep or anxiety.

"Well then what should I do?"
"Did anyone ever suggest going to therapy?"
"Yes, but that costs money and you have to go every week or two."
"Yes, but probably a lot less money and time than what you've already lost in jobs, friends, salary, and years wasted on changing medicines every 3 months?"
"So I have to go to therapy to get better?"
"Yes! You may have to go to 5 or 6 visits with 3 or 4 different therapists before you find one that's a good fit. But I'm willing to bet that if you do that, you and those around you will be feeling a lot better in 2-3 years."
"YEARS?!"
"Yup. You've already spent 5-10 years screwing around with medicines that are unlikely to ever solve the problem. This is one of those situations of 'The sooner you get started, the sooner things will get better.'"

This conversation generally ends with either,
"Thank you. You're the first person who's ever explained it like that."
Or a much louder 2-word response, which is usually accompanied by 1 finger.

Both indicate we're done for today.

Click to expand...

READ and LEARN, dear Padawans. ^^^^^^^^^^^

As beautiful as that is, I've found that most of my patients have wikipedia, have looked at bipolar disorder, and want to have the diagnosis.

"...So, based on what we've talked about for the past 30-45 minutes, it sounds like what you're going through is consistent with major depressive disorder with pretty prominent anxiety. You feel down, you're crying more, you're gaining weight because all you want to do is eat, you get out of bed at noon after lying down at midnight and not falling asleep until 3 while you worry about your daughter doing drugs, you can't concentrate on things, and sometimes you think that maybe things would be better if you just didn't wake up."
"Now, wait a second doc, you've got it all backwards. I've got the bipolar. I ain't just depressed."
"What makes you say that?"
"Doc, I have racing thoughts, I'm talking fast, I started sleepin' around, I'm distractible, and I get real irritable all the time."
"How long does that usually last"
"Exactly 4 days."
"When was the last time that happened."
"I dunno. But I got the bipolar"
"So why did your last doctor keep giving you Lexapro and Klonopin?"
"Because he didn't listen to me good like you do, Doc."
"Are the racing thoughts worrying about things that are going on, or is it like the thoughts are just zooming past your mind and you can't catch them."
"I just can't shut down doc, worrying about Betty and her crack..."
"And when do you talk fast?"
"Well doc, I drink about 3 pots of coffee every morning, so right after that..."
"Wait, when do you stop drinking coffee?"
"I usually have my last cup while watching reruns of Burn Notice on USA."
"That's like 11pm, right?"
"Yeah."
"Does the coffee keep you up?"
"Nah, it ain't the coffee. I gotta have the coffee to get to sleep, you know. Otherwise I can't settle down."
"And when did you start having more sex?"
"Well, I've always had trouble saying no to guys. They just pester you."
"And what do you mean when you say you're irritable?"
"My daughter drives me nuts! She's just ignorant. Why are you asking me all this? Are you gonna give me Seroquel or not?"

billypilgrim37 said:

As beautiful as that is, I've found that most of my patients have wikipedia....

Click to expand...

And in other news, AstraZeneca has announced that Seroquel XR has now been approved for treatment of Wikipedia...

Three "Bipolar" admissions last 24 hours--

1) 41 y/ F with hx of unstable relationships, daily abrupt mood swings, profound methamphetamine-induced paranoia.

2) 27 y/o F with hx childhood sexual abuse, unstable relationships, labile moods, cannabis use since age 13, opiate abuse. (G-d help me--this one also wanted Adderall for her ADHD that the psychiatrist diagnosed her with without knowing about her daily cannabis use.)

3) 44 y/o group home resident with mild MR, Chiari malformation, chronic head and neck pain and irritability. Shook cane at another resident of group home, is sent to ED and (rasnfrackneyouvegottabefnkiddingme!) admitted to the hospital.

How long can I keep doing this job without developing a diagnosis myself????

Ugh. In the immortal words of an ex-president, "I feel your pain."

How long can I keep doing this job without developing a diagnosis myself????

Click to expand...

I think the right treatment here is for the doctors that gave the bipolar diagnosis to be tied to a wall while the psychiatric equivalent of Torquemada questions them as to just WTF they were thinking.

Any bad answer gets a Spanish Inquisition style response.

whopper said:

I think the right treatment here is for the doctors that gave the bipolar diagnosis to be tied to a wall while the psychiatric equivalent of Torquemada...

Click to expand...

pokes them with the soft cushion!!

billypilgrim37 said:

Are you gonna give me Seroquel or not?"

Click to expand...

Oh, good. I'm glad you asked.
The answer is, "No."
So let's talk about what treatment options I am willing to consider, or are you so mad at me right now that you'd prefer to leave? I understand that the answer you got is frustrating, and if you'd rather continue the discussion about other treatment options at another time, I completely understand.
However, the possibility of Seroquel is, in fact, off the table - so that part of the discussion is done.

So let me know what we're going to do next:
A) Talk about other options or
B) let you schedule the next appt. when you feel ready to discuss the other options?

I carefully quote patient's response in the chart.

If (s)he goes on to explain why Seroquel is the only option (usually, but not always, along with talk about rights and complaints against me), I make it clear that I accept that as choice B) and that today's appt is now over and I hope the rest of the day goes better for him/her. Good bye.

kugel said:

Oh, good. I'm glad you asked.
The answer is, "No."
So let's talk about what treatment options I am willing to consider, or are you so mad at me right now that you'd prefer to leave? I understand that the answer you got is frustrating, and if you'd rather continue the discussion about other treatment options at another time, I completely understand.
However, the possibility of Seroquel is, in fact, off the table - so that part of the discussion is done.

So let me know what we're going to do next:
A) Talk about other options or
B) let you schedule the next appt. when you feel ready to discuss the other options?

I carefully quote patient's response in the chart.

If (s)he goes on to explain why Seroquel is the only option (usually, but not always, along with talk about rights and complaints against me), I make it clear that I accept that as choice B) and that today's appt is now over and I hope the rest of the day goes better for him/her. Good bye.

Click to expand...

Haha! I should have asked for Seroquel! I got kicked out of the office for asking why he thought that I had bipolar disorder. I did so in a nice and matter of a fact way. I thought for sure that he was going to call security to get us out of the clinic he was so hot. The psychiatrist was pacing back and forth behind the counter waiting for us to get out. Maybe someone told that he has bipolar disorder because he had the Sicilian thing going on?

I did not want that diagnosis. I felt a little broad sided because I had went there because the therapist said that I could benefit from an SSRI, and I walked out of there being told that I had not PTSD, not PPD, not just depression...but bipolar disorder...something that is life-long and cannot be cured just managed.

People are usually shocked when I tell them that I've been diagnosed with bipolar disorder. Even though I know that probably anyone could have walked in there and been diagnosed with the disorder from that particular psychiatrist, I know that it will always be on my chart. I don't feel good about it. I will always have to wonder if I am really nuts or just went through a traumatic event that I was able to get through by learning better coping skills. I guess time will tell.

If I ever see another psychiatrist again, I'm shooting for the dumping grounds of borderline and ADHD so that I have my bases covered.

Hmm I'm only Pre-Med but I have ADD and Aspergers so I have really stumped some docs I had a psychiatrist say I was manic bipolar once... I'm a fairly relaxed person when it comes to general life so I looked at him long and hard and said "Doctor I respect your medical education but your completely wrong" then quoted the DSM diagnostic criteria for bipolar II and he stopped reaching for his bag...I've also had PCP's throw a bunch of baseless diagnoses at me and politely said "I respect your medical education I really do but I think you should let a psyche deal with this"...There sure are allot of "bipolar" kids I see running around though .

Maybe I question people too much or play ameutur physician too much but I swear there are always times where a physician prescribes something and I'm trying to figure out the base for it or am just thinking did they loose their mind. Friend had double shattered patella with torn ACL, LCL and petallar tendon on right side and torn ACL on right side, after an MRI the ER physician gave him a script for Tylenol #3 1 tab q8h t.i.d...well that's just mean but still. Later his orthopaedic wrote a prescription for 200mg tramadol ER bid while my friend was taking a moderate dose of Cymbalta (yeah the doc knew!) my friend was telling me he had really bad headache's and was dizzy..his blood pressure was like 150/100...I told him to stop taking it and he was fine but still. Alas I'm getting off topic and I won't step on anyone's toes anymore and to anyone I've pissed off possibly I will say psychiatrists probably deal with the most **** of any other specialty (ER Physicians don't bite my head off )