Inquiring about bipolar d/o...

[medstudent234]

I'm an intern who has seen quite a few patients in the ED who report having bipolar d/o. If they are acutely manic it's very clear, but if not, often when I ask them about it, the say that "yeah, my doctor thinks I have that because I'm really moody."

Anyway, I was wondering how you address the validity of the diagnosis? What phrases do you use to screen for true mania?

I often say something like "have you ever felt like opposite of depressed, like you were on top of the world?" A TON of people will say yes to that though. And then I ask "what you were doing during that time?" and then the DIGFAST acronym questions asking about specific symptoms. Just curious how others do it, because I'm not as confident screening for mania as I am for other diagnoses. Thanks!!

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[nexus73]

Screening for bipolar is tricky business. For one, many patients who have been truly manic don't remember it as such, but if you ask family or friends they can rattle of a DSM5 list of manic symptoms the patient had that last for 2 weeks, and seems to cycle once or twice a year. For example, I had a patient who described being depressed in college and getting admitted to a psych unit, but once I got the records turns out he was manic/psychotic at the time, hospitalized 3 weeks. Second, many patients with emotion regulation issues (mood swings) get called bipolar, or self identify as bipolar, when in reality they're dealing with personality disorder traits/disorders.

If anyone endorses a manic episode, the first followup question is "were you on drugs". Then usually ask how their energy was while manic, people without bipolar often say they were dog tired because they couldn't sleep, which is not what you expect in bipolar mania. Basically ask questions about time course, duration of manic episodes, and frequency of manic episodes, if it's not fitting the bipolar picture, it's unlikely to truly be bipolar. The most important thing to remember, and this is what really makes it tricky, is the history from the patient isn't really as useful as collateral from reliable family or friends (or previous hospital records), which you're often unlikely to have in the emergency department. Often family will call the patient bipolar because they're emotionally difficult, but then when you ask followup questions the family describes mood swings occurring over minutes to hours, as opposed to sustained elevations of mood and energy lasting days to weeks.

 

[splik]

I often say something like "have you ever felt like opposite of depressed, like you were on top of the world?"

do not ask do this. mania is not the opposite of depression, manic patients often score very highly on measures of depression, and hypomanic patients have similar profiles on neuropsychological testing to depressed patients.

Another rookie mistake is people ask about "thoughts racing". This is again a useless question. Phenomenologically racing thoughts doesn't mean one's thoughts are sped up, but that they jump from one topic to the next, hence why the objective correlate of racing thoughts is flight of ideas. So asking about thoughts jumping around is a more sensitive indicator.

The CIDI screening tool for bipolar disorder actually gives the PPVs for each question. It's not a bad tool actually and vastly superior to the MDQ which is the most commonly used bipolar screen in the US and has a high sensitivity but low specificity. For hypomania screening I use the HCL-32 which is reasonable and can then use pointed follow up questions for diagnostic clarification.

My initial question will be "have you have a had period in your life when you weren't using drugs that for days or weeks at a time you feel unusually good, 'better than well' or extremely irritable, with lots of energy, not needing to sleep, not being able to stop talking, being more interested in sex, spending lots of money... etc?" I will also clarify that this is different from normal.

DIGFAST is good for med students, but now you are a resident psychiatrist you need to have a more nuanced picture. Many useful features of mania are not part of the criteria - for instance illusions, hyperacusis, synaesthesia, eutonia (a sense of inordinate physical fitness), hypersexuality (including same-sex experience in individuals who otherwise identify as heterosexual, sex with multiple partners, compulsive masturbation, pornography; in women especially ask about unwanted sexual experiences during these episodes), hyperreligiosity. also remember that microdepressions, mood lability, suicidal ideation, very powerful negative imagery frequently occur. Violence is extremely common in manic episodes, particularly the first episode. Common delusions include grandiose, persecutory, and erotomanic delusions. Delusions of thought interference and passivity phenomena are more common in non-white manic patients. Auditory hallucinations are common, and visual hallucinations also frequently occur.

 

[splik]

the simplest way to figure out if someone has bipolar disorder is to ask them. If they say yes they likely don't have it, and if they say no, they probably do. This is only somewhat tongue and cheek. As one resident here noted, the most remarkable thing about the bipolar clinic is none of the patients have bipolar disorder.

 

[Crayola227]

If anyone endorses a manic episode, the first followup question is "were you on drugs". Then usually ask how their energy was while manic, people without bipolar often say they were dog tired because they couldn't sleep

This is not strictly true. They can "miss" the sleep. They can feel extraordinarily tired. The way I think of it, is that they become physiologically *incapable* of sleep. This is distinct from depressive sleep disturbance in my mind in that the trouble isn't falling asleep, staying asleep, or early morning wakings.

This being physiologically incapable of sleep bit, that can range from being fully awake to a sort of sleep where you are never unconscious, meaning you are aware of every passing minute as you "sleep," to feeling refreshed after a number of hours that is just not normal, like 4-5 hours for a week and not due to life circumstances (anyone can pull multiple 6 hour nights, or a couple 4-5 hour ones, so my definition is outside of that). 4-5 hours of sleep for a week or two, some bipolar people will feel "happy" about it, and others won't.

Even saying physiologically incapable of sleep seems too narrow. Increased goal directed activities, indiscretion, activities pursued with the potential for painful consequences, can lead someone to stay up 72 hours for "fun" (which normal people would not even be physiologically capable of for the most part) whereas at some point in that stretch they might have felt tired enough to fall sleep for a few hours, but just didn't. So I see the decreased sleep you see in bipolar as multifactorial.

I would second about dysphoric mania. Some things I've seen have suggested it's more common than euphoria.
Agitation, anxiety, inner restlessness, I would add to the list.

I agree that thoughts racing is a sorta dumb question. Often the manic person feels like they're following their own train of thought quite fine. So the objective assessment is more useful than the subjective on this one.
And yes, especially mid-episode insight into their own "DIGFAST" symptoms can be pretty severely impaired.
Also, many patients will not think that they are grandiose or have inflated self esteem. There's limits to what the very manic person can self identify as symptoms.

Part of indiscretion can be staying up all night. It can be too much time on SDN. It can be telling too many stories about your personal life to the wrong people.
Hypersexuality is not just ****ing everything that moves and the above poster did a good job with a list. I think it helps if you can pin down sexual behaviors that are ego dystonic - eg someone who values monogamy hitting on married guys, just as the poster suggested.

 

[HarryMTieboutMD]

To the original poster- are you an off service intern doing a regular ED rotation? If so don't waste your time trying to figure out if the patient is actually manic or not (especially since you don't know much psychiatry yet). Just figure out if they are safe to go home or need to be seen by psych urgently. If, however, you are doing an ED psych rotation, now is a good time to refine your mental status exam and diagnostic skills. Simply asking DIGFAST (just like SIGECAPS) is for med students and won't get you very far. However, you have to have the criteria in your mind as you are interviewing the patient.

Agreed with most of what's been said. This is what makes sense to me- Kraepelin conceptualized the Manic Depressive Insanity as underactivation/overactivation in three spheres of psychic functioning- emotion, volition, and cognition (which is how Joseph Ledoux and other cognitive neuroscientists conceptualize "the mind" today). So depression is not really "sadness" (though it can be), but truly depressed patients describe a feeling of emptiness, complete anhedonia, the weight of the world on their shoulders, etc (I like the DSM criteria for melancholic features)- really an underactivation or absence of emotional activity (some can have affective flattening so severe that it looks like negative symptom schizophrenia). Mania, on the other hand is an overactivation of emotional functioning- yes, sometimes hyperthymia or irritability per the DSM but really the most striking feature for me is EXTREME lability (ie, way more than would be expected for a personality disorder), representing an overactivation/loss of control of the emotional sphere. Volition in mania (or pressure of activity) translates to both impulsive behavior and increased goal directed activity (which can often overlap). And most severely manic patients do not write long novels or complete arduous work; they attempt to start a lot of projects but are too DISTRACTIBLE to complete them (Kraepelin also described this). I tend to see successful overactivation more in hypomania (which in DSM parlance is more in line with Kraepelin's hypomanic temperament- not a true affective state). And cognition in mania is represented by pressure of speech and ultimately flight of ideas. Really, as Splik hinted at, you start to look for disordering of formal thought (overactivation and loss of control of cognition). This can be kind of tricky in certin cases where patients circumstantial/overinclusive speech (especially in people with ADHD, many of whom get misdiagnosed as bipolar) might appear somewhat "manic" but to the trained clinician they aren't. Often, speech may not but pressured but is completely derailed and on cross section look like a schizophrenia spectrum illness, but the longitudinal history shows clear bipolar, for which these patients satisfy criteria. Identifying these distinctions takes lots of clinical experience because these ADHD patients can ostensibly meet manic criteria, but in reality they are not (a lot of non psychiatrists make this mistake). Also, often time people who don't understand the Kraepelinian Dichotomy and the need for longitudinal history will call these patients schizophrenic (esp if they are African American bc a lot of older doctors have unconscious/conscious proclivity towards racism and don't think that AA people can have such an illness of "geniuses" like bipolar).

As Splik said, Mania and Depression are not "opposites", but the illness, as Kraepelin described is a spectrum of changes in emotion, volition, and cognition. The skilled psychiatrist will also look for mixed states, which can occur during transition times between mania and depression and also exist as independent states. Kraepelin has very nice graphs documenting these changes. This is one of the few areas in which DSM V improved from IV- the criteria are more flexible for mixed states. Complicating this is the tendency to catatonia, especially in mixed states, when the illness progresses to psychosis and is untreated (which is more common in affective illness than SCZ in 2016- and as likewise as Kahlbaum described in Die Katatonie oder das Spannungsirresein). One mistake a lot of people make is saying "this patient became so psychomotor ******ed depressed that he/she is now catatonic", which doesn't happen unless you see psychosis (as catatonia really signifies end stage psychosis, as Kraepelin described, but in both bipolar and schizophrenia). This is where knowing the criteria for catatonia and how to elicit exam findings (including things like catalepsy vs flexibilitas cerea and things not in the DSM like mitgehen, mitmachen, and gegenhalten) becomes important because long term bipolar patients can present with inhibited mania (almost complete catatonic stupor except for flight of ideas) and then manic stupor- (complete catatonic stupor from psychotic mania- I have seen this several times when manic patients refuse to take their meds) among other presentations.

The psychiatric interview has to be undertaken with a diagnostic purpose. The experienced and skilled diagnostician will know what mania is and isn't and tailor the interview (while using concurrent mental status exam- arguably the most powerful tool a psychiatrist has in the ED) to have a good working diagnosis. If I see a patient with the bipolar diagnosis, I start with open ended questions. First, I ask them why they carry the diagnosis. Some personality/drug addict patients/malingerers will give me a perfect checklist of manic symptoms lasting one week (avg untreated manic episode is 4-6 months), which is a huge red flag for lying (but I can usually tell by other features of general/appearance and behaviour that they are manipulative, etc). If drugs/EtOH at all are apart of the picture (even if they don't admit cocaine/amphetamines), I still see a lot of red flags. If they say "I don't know" and there are no records in the chart, I will phrase the question in an inclusive manner (though not directly after asking why they have the diagnosis): "have you ever had a period in your life where everyone noticed you were different, meaning you went a long time with little to no sleep and still had plenty of energy, you were doing impulsive things, no one could follow you, etc) and if they say "yes" then I will ask specifics (often when they say yes initially, when I ask more detailed questions I find that they weren't actually manic). If they say no and I have a strong suspicion based on current medications, other mental status exam features, etc, I will call collateral, which again, is not always reliable. I rarely screen for hypomania unless I am suspicious that someone has a bipolar variant depression and denied florid manic symptoms because then it affects treatment. And hypomania as conceptualized in the DSM is a vague and controversial idea that is a completely different discussion.

 

[hamstergang]

"have you ever had a period in your life where everyone noticed you were different, meaning you went a long time with little to no sleep and still had plenty of energy, you were doing impulsive things, no one could follow you, etc)

I don't know if this has been looked at but I also prefer to ask the patient what other people noticed. Patients often lack insight into mania, but I feel they should be able to remember everyone telling them to slow down or people having more trouble than usual understanding them.

Also, if there seems to be a possible manic episode in the past, I ask more concrete questions about it -- what was the patient doing then?

 

[Jules A]

My initial question will be "have you have a had period in your life when you weren't using drugs that for days or weeks at a time you feel unusually good, 'better than well' or extremely irritable, with lots of energy, not needing to sleep, not being able to stop talking, being more interested in sex, spending lots of money... etc?" I will also clarify that this is different from normal.
.

This is similar to what I do but I don't give a time frame initially. If they say yes, as most all pts with BPD will, I explore specific examples and then ask how long these episodes typically last. When they describe "mood swings" and indicate the quick bursts of affective dysregulation rather than ongoing symptoms that helps with r/o.

Crayola227 also made an excellent point about considering dysphoric mania. Although in my anecdotal experience it is less common than euphoric mania it is something I tended to neglect early in my career. Those patients are more concerning to me because they often get missed and again anecdotally their impulsivity can manifest as aggression or intentional acts of self harm more often than the patients with euphoric mania.

 

[clausewitz2]

This is similar to what I do but I don't give a time frame initially. If they say yes, as most all pts with BPD will, I explore specific examples and then ask how long these episodes typically last. When they describe "mood swings" and indicate the quick bursts of affective dysregulation rather than ongoing symptoms that helps with r/o.

Crayola227 also made an excellent point about considering dysphoric mania. Although in my anecdotal experience it is less common than euphoric mania it is something I tended to neglect early in my career. Those patients are more concerning to me because they often get missed and again anecdotally their impulsivity can manifest as aggression or intentional acts of self harm more often than the patients with euphoric mania.

Had never seen dysphoric mania during medical school, then it walked into our psych ED my first week on. I do not think I will ever fail to think about it again. Incredible agitated restless energy, expansive and grandiose thoughts, but also screaming obscenities and throwing things and heartbreakingly eager to take multiple doses of Zyprexa to try and make it stop for a while.

 

[splik]

40% of manic episodes are mixed states, though true euphoric mania is rare - the everwhelming majority of manic patients have an irritable edge and when challenged quick to anger and rage. microdepressions are pretty common in mania too - patients will break down in tears one minute as their thoughts race, and then recompose as if they had never experienced those fleeting moments of despair.

 

[Salpingo]

I ask if they've ever been psychiatrically hospitalized, and under what circumstances.

Not the most sensitive or specific, but it tends to rule out the mild personality disorders trying to reify their destructive behavior. Ultimately, you need collateral for a spot diagnosis.

 

[whopper]

A big number of bipolar disorder cases are misdiagnosed. 40% per one study I've seen. If someone's manic and not on drugs then the person most definitely has bipolar I disorder. I'm talking real mania. I'm not talking someone in the ER for 8 hours and gets mad cause they're been waiting so long but had been calm during the first 8 hours.

Bipolar II disorder I find easy to diagnose but only with a substance abuse free and personality DO free person with good memory and insight cause they can correctly answer the questions such as "do you have periods of time that last at least a few days where you suffer at least a few of the following 1-poor sleep, 2-fast and excessive thoughts; 3-speaking fast, 4-being excessively irritable or giddy" etc.

Personality disorders vs bipolar II and cyclothymia become difficult though after a few sessions and talking to family members I do think I get this right in most cases within 4 sessions.

A sad thing that I know many here have seen is the psychiatrist who diagnoses everyone with bipolar disorder (and most of them don't have it) and then starts the patient on 3+ meds all at once.

 

[FlowRate]

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[HarryMTieboutMD]

To the post above (which I can't even bring myself to quote):

NO. Just no. Please never write anything like that again.

 

[birchswing]

I want to offer an experience I had first-hand so that it might provide a glimpse into a person's experience. Not looking for advice on the experience. I'm not saying the experience was mania, but I offer it to show the complexities of these situations.

I had a period two years ago that was never diagnosed but seen by several doctors. I call it the spring spiral due the season it came on during and that it ended at the beginning of summer. It came on a specific day I can point to and it left on a day I can point to. It was the most awful experience of my life. I lost 40 lbs. I had no appetite. I couldn't sleep. I felt a constant internal energy and shaking, and yet I didn't have a panic attack the entire time. I had so much energy but I was so, so sick of it. People told me to stay busy. I was sick of staying busy. I wanted to stop. I would just lie there trying to sleep. I have never done more self-guided meditations in my life, which never touched the problem. I wasn't tired in that I wasn't "sleepy" but I wanted to be so badly. I would do some task to try to "burn up" the energy and feel awful during and after and still have all that energy but an exhaustion that is different than the capability to be tired or sleepy. A good night of sleep was 3-4 hours. I felt like I was being run ragged by some horrible internal energy. I didn't feel driven to do things by some desire. And I didn't do anything like shop excessively, gamble, etc. I had no self-perception changes in terms of thinking I was great, etc. I did more things because it was like someone attached jumper cables to me and it was either try to meditate it away (which did not work) or go for more walks, do more jumping jacks to tire myself out (which didn't work).

I had to keep doing my daily activities. I barely made it through the end of my semester. I only had one final exam that I had to take in person, and I was trying to attenuate every source of stimulus and sat in the back of the class with sunglasses on, drinking hot milk, rocking in a fetal position, trying to slow the driving force in my brain down enough to finish. I felt like there was a laser coming out of my forehead that just blazed everything in front of me. Normally I need tea in the morning to wake up. The idea of having caffeine in this state I was in was anathema. I even went to the ER at one point because I couldn't take it. I was convinced that *something* was wrong. I didn't know what. I thought maybe my body wasn't absorbing my medicine due to my diarrhea (another change). I was trying to keep weight on and couldn't. It was like the adrenergic system in my body was put into overdrive. My PCP did a lot of thyroid testing, pheochromocytoma testing, but nothing came back. He said he had never seen someone tremble as much as I was. He was sure something would come back in one of the tests. He's known me for about 10 years and is familiar with my anxiety, and he assured me that what I was having wasn't anxiety. He said he could see the muscles in my legs moving differently, twitching. But he could never find the cause. I hadn't changed any medicines or doses and hadn't had any life changes.

To this day, I believe it could have been mania, even though it was never diagnosed and even though it would have been an atypical presentation. There was nothing euphoric about it, though. I would use a word stronger than dysphoric if there were one. Whatever it was, it was an extremely dramatic energy level change, that's only happened once in my life.

 

[Crayola227]

I want to offer an experience I had first-hand so that it might provide a glimpse into a person's experience. Not looking for advice on the experience. I'm not saying the experience was mania, but I offer it to show the complexities of these situations.

I had a period two years ago that was never diagnosed but seen by several doctors. I call it the spring spiral due the season it came on during and that it ended at the beginning of summer. It came on a specific day I can point to and it left on a day I can point to. It was the most awful experience of my life. I lost 40 lbs. I had no appetite. I couldn't sleep. I felt a constant internal energy and shaking, and yet I didn't have a panic attack the entire time. I had so much energy but I was so, so sick of it. People told me to stay busy. I was sick of staying busy. I wanted to stop. I would just lie there trying to sleep. I have never done more self-guided meditations in my life, which never touched the problem. I wasn't tired in that I wasn't "sleepy" but I wanted to be so badly. I would do some task to try to "burn up" the energy and feel awful during and after and still have all that energy but an exhaustion that is different than the capability to be tired or sleepy. A good night of sleep was 3-4 hours. I felt like I was being run ragged by some horrible internal energy. I didn't feel driven to do things by some desire. And I didn't do anything like shop excessively, gamble, etc. I had no self-perception changes in terms of thinking I was great, etc. I did more things because it was like someone attached jumper cables to me and it was either try to meditate it away (which did not work) or go for more walks, do more jumping jacks to tire myself out (which didn't work).

I had to keep doing my daily activities. I barely made it through the end of my semester. I only had one final exam that I had to take in person, and I was trying to attenuate every source of stimulus and sat in the back of the class with sunglasses on, drinking hot milk, rocking in a fetal position, trying to slow the driving force in my brain down enough to finish. I felt like there was a laser coming out of my forehead that just blazed everything in front of me. Normally I need tea in the morning to wake up. The idea of having caffeine in this state I was in was anathema. I even went to the ER at one point because I couldn't take it. I was convinced that *something* was wrong. I didn't know what. I thought maybe my body wasn't absorbing my medicine due to my diarrhea (another change). I was trying to keep weight on and couldn't. It was like the adrenergic system in my body was put into overdrive. My PCP did a lot of thyroid testing, pheochromocytoma testing, but nothing came back. He said he had never seen someone tremble as much as I was. He was sure something would come back in one of the tests. He's known me for about 10 years and is familiar with my anxiety, and he assured me that what I was having wasn't anxiety. He said he could see the muscles in my legs moving differently, twitching. But he could never find the cause. I hadn't changed any medicines or doses and hadn't had any life changes.

To this day, I believe it could have been mania, even though it was never diagnosed and even though it would have been an atypical presentation. There was nothing euphoric about it, though. I would use a word stronger than dysphoric if there were one. Whatever it was, it was an extremely dramatic energy level change, that's only happened once in my life.

All I can say is, I can't say what this was. I would say, that your subjective experience of energy, not being able to sleep, but "missing" the sleep sounds right on for being a good descriptor.

It peeves me what I think is a misconception that the sleep is not missed in mania. That's all.

Thank you for sharing your story. I think it valuable.

 

[Amygdarya]

A supernaive question from a medical student: so how do you distinguish between dysphoric mania, mixed states and agitated depression? It seems like, at least on the surface, all of these can present as dysphoric agitation/despair. Eg., should you look for grandiosity in mania vs. lack thereof and rather guilt, self-deprecation etc in depression? What else?

 

[splik]

A supernaive question from a medical student: so how do you distinguish between dysphoric mania, mixed states and agitated depression? It seems like, at least on the surface, all of these can present as dysphoric agitation/despair. Eg., should you look for grandiosity in mania vs. lack thereof and rather guilt, self-deprecation etc in depression? What else?

I will come back to this but dysphoric mania is a mixed state. agitated depression is not a diagnosis. kraepelin described "excited depression" as one of his mixed states. in addition to psychomotor agitation (which is quite common in melancholia, particularly in the elderly), it is characterized by pressured speech, distractibility, and irritability and thus quite distinct from "agitated depression" [sic]

but you may be interested to read kraepelin's manic-depressive insanity

 

[randomdoc1]

.

To the post above (which I can't even bring myself to quote):

NO. Just no. Please never write anything like that again.

I wish I could see what that post was.

 

[FlowRate]

I wish I could see what that post was.

I drew a similarity between two disparate ways of thinking about human cognition.

 

[splik]

I drew a similarity between two disparate ways of thinking about human cognition.

it wasn't a silly post at all Harry is no fan of Freud and he was probably thinking that Kraepelin was turning in his grave to be associated so

 

[HarryMTieboutMD]

A supernaive question from a medical student: so how do you distinguish between dysphoric mania, mixed states and agitated depression? It seems like, at least on the surface, all of these can present as dysphoric agitation/despair. Eg., should you look for grandiosity in mania vs. lack thereof and rather guilt, self-deprecation etc in depression? What else?

As a medical student you don't need to know the subtleties to this level, and you likely don't have the clinical experience to really understand the differences anyway (even if during your 4-6 week clerkship you saw every variety of Bipolar). Nor do you have the clinical maturity to appreciate Kraepelin's brilliance. But yes, as Splik said, Kraepelin described excited depression and depressive mania as mixed states. In fact, in the section on "Mixed States" from Manic-Depressive Insanity, these are the first two clinical pictures described. Please see above for my post on Kraepelin's conceptualization of the Manic Depressive Insanity as a spectrum of changes in emotion, volition, and cognition. (I'm not going to retype what I already wrote).

In depressive or anxious mania, you see flight of ideas, pressure of speech, (cognition) pressure of activity (volition) with mood that is "anxiously despairing" (emotion). In excited depression, you see pressure of activity (volition) but inhibition of thought (cognition- impaired concentration), and a mood that is "anxious, despondent, lachrymose, irritable" (emotion). Or, in the former you see excitement in volition and cognition with an inhibition in emotion, and in the latter you see excitement of volition with an inhibition of cognition and emotion.

 

[HarryMTieboutMD]

it wasn't a silly post at all Harry is no fan of Freud and he was probably thinking that Kraepelin was turning in his grave to be associated so

I guarantee you Kraepelin would be turning in his grave if he knew someone attempted to compare Freud's Structural Theory of the Mind to his conceptualizations of psychic functions. Kraepelin was diagnostically agnostic from an aetiological perspective (his work with Alzheimer and Nissil notwithstanding), and his descriptions were based on his unmatched power of observation, noticing patterns and subtleties of observable changes in emotion, volition, and cognition. Freud's theories were based on "the representation of arbitrary assumptions and conjectures as assured facts, which are used beyond hesitation for the building up of always new castles in the air ever towering higher, and the tendency to generalization beyond measure from single observations" (Dementia Praecox pp 250). Even thinking about comparing the two systems is heretical.

I do like Freud ("Mourning and Melancholia" is absolutely beautiful), and he was an absolute genius, but I do not find him clinically useful for understanding inpatient (descriptive) psychiatry. Kraepelin is and always will be the master.

 

[HarryMTieboutMD]

Freud is mostly old hat now, but Bleuler's conception of schizophrenia was heavily influenced by Freud, they really put Freudian thinking into practice in the inpatient setting at the Burghölzli and they actually got very good results with patients, back in the pre-neuroleptic era

I'd be interested to see the data from this, but 1) Bleuler's conception was much broader and less ominous than Kraepelin's (which is fine because either way it's just "carving nature at its joints" as you like to point out) so there is going to be some selection bias, 2) Kraepelin noted that ~12% of his patients had near complete recoveries for10 or more years but then relapsed. And all of his Dementia Praecox patients, by definition, had some form of end stage illness ranging from simple weak mindedness to profound dementia. Kraepelin even notes that for those who do not progress beyond simple weak mindedness, really only the physician and those close to the patient can really detect any remnant of illness.

 

[sweetlenovo88]

do not ask do this. mania is not the opposite of depression, manic patients often score very highly on measures of depression, and hypomanic patients have similar profiles on neuropsychological testing to depressed patients.

Another rookie mistake is people ask about "thoughts racing". This is again a useless question. Phenomenologically racing thoughts doesn't mean one's thoughts are sped up, but that they jump from one topic to the next, hence why the objective correlate of racing thoughts is flight of ideas. So asking about thoughts jumping around is a more sensitive indicator.

The CIDI screening tool for bipolar disorder actually gives the PPVs for each question. It's not a bad tool actually and vastly superior to the MDQ which is the most commonly used bipolar screen in the US and has a high sensitivity but low specificity. For hypomania screening I use the HCL-32 which is reasonable and can then use pointed follow up questions for diagnostic clarification.

My initial question will be "have you have a had period in your life when you weren't using drugs that for days or weeks at a time you feel unusually good, 'better than well' or extremely irritable, with lots of energy, not needing to sleep, not being able to stop talking, being more interested in sex, spending lots of money... etc?" I will also clarify that this is different from normal.

DIGFAST is good for med students, but now you are a resident psychiatrist you need to have a more nuanced picture. Many useful features of mania are not part of the criteria - for instance illusions, hyperacusis, synaesthesia, eutonia (a sense of inordinate physical fitness), hypersexuality (including same-sex experience in individuals who otherwise identify as heterosexual, sex with multiple partners, compulsive masturbation, pornography; in women especially ask about unwanted sexual experiences during these episodes), hyperreligiosity. also remember that microdepressions, mood lability, suicidal ideation, very powerful negative imagery frequently occur. Violence is extremely common in manic episodes, particularly the first episode. Common delusions include grandiose, persecutory, and erotomanic delusions. Delusions of thought interference and passivity phenomena are more common in non-white manic patients. Auditory hallucinations are common, and visual hallucinations also frequently occur.

excellent post, thanks

 

[nancysinatra]

Bipolar II disorder I find easy to diagnose but only with a substance abuse free and personality DO free person with good memory and insight cause they can correctly answer the questions such as "do you have periods of time that last at least a few days where you suffer at least a few of the following 1-poor sleep, 2-fast and excessive thoughts; 3-speaking fast, 4-being excessively irritable or giddy" etc.

I don't think I've ever met a patient who fit that description. The vast majority of patients aren't articulate enough to follow the line of questioning and respond in a way that assures me they understand what I am asking. Patients also often don't listen to my questions very carefully. I have yet to find a way to accurately diagnose Bipolar 1 or 2 without seeing the patient in a manic/hypomanic state, or getting extremely good records. Good records are as rare as patients who are good historians.

 

[nancysinatra]

To the original poster- are you an off service intern doing a regular ED rotation? If so don't waste your time trying to figure out if the patient is actually manic or not (especially since you don't know much psychiatry yet). Just figure out if they are safe to go home or need to be seen by psych urgently.

If the OP is doing an off-service ED rotation, they should be learning emergency medicine, not clearing psych patients, unless they happen to get assigned to a patient who happens to have a psych problem. In that case, you're right, their job is not to make a precise psychiatric diagnosis - but not because they're not experienced enough; rather, because, that's not the job of an emergency room doc. Emergency medicine has a lot of value in psychiatry, particularly when it comes to determining who is "medically clear" or not. Spend a few weeks in a regular ER, and you will see why the ER docs get mad when psychiatry attendings reject patients for things like "hypertensive crisis." If you spend your ER month making dispo decisions on psych patients, however, you won't learn that.

You'll get more than enough time to learn psychiatry during the ridiculously overly long 3.5 remaining years of your residency. Nothing bothered me more during my own residency than how much we were encouraged to use our off-service rotations to learn more psychiatry. We were even told which off-service rotations emphasized psychosocial issues moreso than actual internal medicine or neurology, and encouraged to choose these rotations. Sure, if the chance comes along to learn more psychiatry on an off service rotation, fine, but the purpose of those rotations is to learn internal medicine, neurology, pediatrics, etc.

It's a different story if the OP is doing a psych ED rotation.

 

[FlowRate]

If the OP is doing an off-service ED rotation, they should be learning emergency medicine, not clearing psych patients, unless they happen to get assigned to a patient who happens to have a psych problem. In that case, you're right, their job is not to make a precise psychiatric diagnosis - but not because they're not experienced enough; rather, because, that's not the job of an emergency room doc. Emergency medicine has a lot of value in psychiatry, particularly when it comes to determining who is "medically clear" or not. Spend a few weeks in a regular ER, and you will see why the ER docs get mad when psychiatry attendings reject patients for things like "hypertensive crisis." If you spend your ER month making dispo decisions on psych patients, however, you won't learn that.

You'll get more than enough time to learn psychiatry during the ridiculously overly long 3.5 remaining years of your residency. Nothing bothered me more during my own residency than how much we were encouraged to use our off-service rotations to learn more psychiatry. We were even told which off-service rotations emphasized psychosocial issues moreso than actual internal medicine or neurology, and encouraged to choose these rotations. Sure, if the chance comes along to learn more psychiatry on an off service rotation, fine, but the purpose of those rotations is to learn internal medicine, neurology, pediatrics, etc.

It's a different story if the OP is doing a psych ED rotation.

Everyone's well meaning when they offer the psych cases on off-service rotations, but I usually remind them that I'm on the rotation to learn something other than psychiatry.

 

[splik]

Everyone's well meaning when they offer the psych cases on off-service rotations, but I usually remind them that I'm on the rotation to learn something other than psychiatry.

It they were well meaning, they wouldn't give the psych interns psych cases. It is much more likely that they offer them to the psych residents because no one else wants to deal with them.

 

[nancysinatra]

It they were well meaning, they wouldn't give the psych interns psych cases. It is much more likely that they offer them to the psych residents because no one else wants to deal with them.

Yeah, and sometimes they think that an aspiring psychiatrist will have some input and spare them a consult.

 

[HarryMTieboutMD]

If the OP is doing an off-service ED rotation, they should be learning emergency medicine, not clearing psych patients, unless they happen to get assigned to a patient who happens to have a psych problem. In that case, you're right, their job is not to make a precise psychiatric diagnosis - but not because they're not experienced enough; rather, because, that's not the job of an emergency room doc. Emergency medicine has a lot of value in psychiatry, particularly when it comes to determining who is "medically clear" or not. Spend a few weeks in a regular ER, and you will see why the ER docs get mad when psychiatry attendings reject patients for things like "hypertensive crisis." If you spend your ER month making dispo decisions on psych patients, however, you won't learn that.

You'll get more than enough time to learn psychiatry during the ridiculously overly long 3.5 remaining years of your residency. Nothing bothered me more during my own residency than how much we were encouraged to use our off-service rotations to learn more psychiatry. We were even told which off-service rotations emphasized psychosocial issues moreso than actual internal medicine or neurology, and encouraged to choose these rotations. Sure, if the chance comes along to learn more psychiatry on an off service rotation, fine, but the purpose of those rotations is to learn internal medicine, neurology, pediatrics, etc.

It's a different story if the OP is doing a psych ED rotation.

Really? Completely irrelevant to my previous post (or the topic of this thread). When I was doing my ED month as an intern I outright refused to see most ED psych patients, but sometimes that section of the ED became so flooded with psych patients that I had to see them on occasion, as is true in most, large academic medical centers. Plus as an ED resident the psych cases can be cleared handled pretty quickly (hence my point about safe to go home vs call psych consult), so even when I did have to "take one for the team" I still had plenty of chest pains/syncopes/abd pains/lacs to suture/etc etc etc.

 

[HarryMTieboutMD]

well there is some debate about whether dementia praecox is even the same illness as schizophrenia. certainly schizophrenia today is not degenerative (with a few possibly interesting exceptions, and the prognosis not typically as weak). his work on manic-depressive insanity is of much more contemporary relevance

I think the general conceptualization is most closely related to Kraepelin's system. But of course some of what he attempted to classify wasn't actually primary psychiatric or fits better into a different system (eg unsystematic schizophrenias vs cycloid psychoses from the Wernicke-Kleist-Leonhard system), but I think in terms of reliability and closeness, Kraepelin's Dementia Praecox is today's Schizophrenia.

Obviously it's not degenerative, but here is a nice study Danny Weinberger's group did back in the day that really represents it as a "static encephalopathy" http://www.ncbi.nlm.nih.gov/pubmed/8038938

 

[nancysinatra]

I think the general conceptualization is most closely related to Kraepelin's system. But of course some of what he attempted to classify wasn't actually primary psychiatric or fits better into a different system (eg unsystematic schizophrenias vs cycloid psychoses from the Wernicke-Kleist-Leonhard system), but I think in terms of reliability and closeness, Kraepelin's Dementia Praecox is today's Schizophrenia.

Obviously it's not degenerative, but here is a nice study Danny Weinberger's group did back in the day that really represents it as a "static encephalopathy" http://www.ncbi.nlm.nih.gov/pubmed/8038938

And this ISN'T irrelevant to the subject?

 

[nancysinatra]

Really? Completely irrelevant to my previous post (or the topic of this thread). When I was doing my ED month as an intern I outright refused to see most ED psych patients, but sometimes that section of the ED became so flooded with psych patients that I had to see them on occasion, as is true in most, large academic medical centers. Plus as an ED resident the psych cases can be cleared handled pretty quickly (hence my point about safe to go home vs call psych consult), so even when I did have to "take one for the team" I still had plenty of chest pains/syncopes/abd pains/lacs to suture/etc etc etc.

It's not necessary to come across as hostile in replying to my post. Splik and Flowrate responded to my post and neither of them accused me of irrelevance. I had no idea what past experience you had as far as an ED rotation, so how was I supposed to know you had the experience you did? You asked if the OP was doing a psych ED rotation or an off service ED rotation, and you made a comment about dispo'ing psych patients during an off service ED rotation, and all I did was respond to that.

It's totally legit for a psych intern to dispo SOME psych patients as part of an off-service ED rotation. It's not legit for them to see more than any other interns on that rotation. This happens more than you might think. You said nothing about this balance in your post, so I was just commenting on that balance. If you want to go back to talking about Kraepelin, go ahead.

 

[masterofmonkeys]

My initial question will be "have you have a had period in your life when you weren't using drugs that for days or weeks at a time you feel unusually good, 'better than well' or extremely irritable, with lots of energy, not needing to sleep, not being able to stop talking, being more interested in sex, spending lots of money... etc?" I will also clarify that this is different from normal.

This is my initial question. I did a 12 month case series while I was still in adult training and found that a reported history of bipolar by the patient had a very high negative predictive value. A self-report of Bipolar gave an odds ratio of 5:1 that they did NOT have it.

 

[nancysinatra]

This is my initial question. I did a 12 month case series while I was still in adult training and found that a reported history of bipolar by the patient had a very high negative predictive value. A self-report of Bipolar gave an odds ratio of 5:1 that they did NOT have it.

That's almost as unreliable as self-reports of medication allergies!

An interesting follow up study would be to try to find out why these people were reporting that they had bipolar when they don't. Why do certain people "identify" with certain illnesses, even when they don't actually have them?

 

[masterofmonkeys]

Because having a labeled disease excuses your behavior and your failures.

 

[HarryMTieboutMD]

though DSM-III onwards is neokraepelinian, the schizophrenia diagnosis was based on Schneider's conceptualization, though with each new addition the importance placed on the first-rank symptom diminishes, there is no disputing that DSM schizophrenia places an overemphasis on positive symptoms. In contrast, Kraepelin emphasized the cognitive symptoms and decline in dementia praecox. DSM gives little, if any, emphasis to the cognitive symptoms in schizophrenia, though it is interesting that now the drug companies have given up on new antipsychotics and have become interested in cognition that we are seeing more attention being paid to this aspect of the illness. And of course pre-DSM-III american psychiatry had a Bleulerian concept of schizophrenia, which emphasized thought disorder as the sine qua non, and the concept was so expansive as to have American psychiatrists diagnosing patients we would today regard as borderline histrionic, manic-depressive and so on as "schizophrenic"

The main neo-kraepelinian aspect of DSM schizophrenia were the subtypes which sort of corresponded with the paranoid, hebephrenic and catatonic subtypes of DP that Kraepelin described but they've got rid of those now, and quite rightly so. The Feighner criteria for schizophrenia are even less Kraepelinian.

Strictly speaking, yes, the DSM criteria itself emphasizes positive symptoms, but in conceptualizing the disease (ie, keeping criteria in mind but really thinking about "what is schiozophrenia?") most (competent) psychiatrists definitely think about the overall course and downward drift. The criteria when used clinically are really for communication, so when I write "the patient has had a long history of psychiatric symptoms characterized by hallucinations, delusions, disordering of formal thought without significant history of mania, depression, or substance," hopefully the person reading this knows that I am communicating "schizophrenia." However, when I am seeing the patient, I am conceptualizing an illness with certain premorbid risk factors (currently how much weed were they smoking that pushed them over the edge/unmasked it earlier) with a course of downward drift and absence significant psychosocial support a prognosis that is not great.

The Feigner Criteria are definitely Kraepelinian (and as a reflection Guze/Robins/Winokur started the tradition of Wash U residents reading Kraepelin): Crtierion A says, "a chronic illness with at least six months of symptoms prior to the evaluation without return to the premorbid level of psychosocial adjustment" and an "absence of a period of depressive or manic symptoms sufficient to qualify for affective disorder or probable affective disorder." Only criterion B emphasizes positive symptoms "delusions or hallucinations without significant perplexity or disorientation" and "verbal production that makes communication difficult because of a lack of logical or understandable organization." Criterion C requires 3 of the following 1) single, 2) poor premorbid social adjustment or work history, 3) family hx schizophrenia, 4) absence of substance use 1 year prior to onset, onset prior to age 40. Again, the main point here is delimitation from bipolar disorder with emphasis (in criteria A and some of C) on downward drift.

The idea of brief psychotic disorder/schizophreniform disorder is not to identify a specific illness where a patient as a period of psychosis that looks like schizophrenia that spontaneously resolves and never recurs. Instead it describes a conceptualization that prior to 6 months in a patient with good psychosocial adjustment with positive/thought disordered symptoms (that at the time of the Feighner Criteria) 60-90% when followed longitudinally would end up having an affective illness, while 10-40% would manifest as schizophrenia.

 

[Amygdarya]

I will come back to this but dysphoric mania is a mixed state. agitated depression is not a diagnosis. kraepelin described "excited depression" as one of his mixed states. in addition to psychomotor agitation (which is quite common in melancholia, particularly in the elderly), it is characterized by pressured speech, distractibility, and irritability and thus quite distinct from "agitated depression" [sic]

but you may be interested to read kraepelin's manic-depressive insanity

As a medical student you don't need to know the subtleties to this level, and you likely don't have the clinical experience to really understand the differences anyway (even if during your 4-6 week clerkship you saw every variety of Bipolar). Nor do you have the clinical maturity to appreciate Kraepelin's brilliance. But yes, as Splik said, Kraepelin described excited depression and depressive mania as mixed states. In fact, in the section on "Mixed States" from Manic-Depressive Insanity, these are the first two clinical pictures described. Please see above for my post on Kraepelin's conceptualization of the Manic Depressive Insanity as a spectrum of changes in emotion, volition, and cognition. (I'm not going to retype what I already wrote).

In depressive or anxious mania, you see flight of ideas, pressure of speech, (cognition) pressure of activity (volition) with mood that is "anxiously despairing" (emotion). In excited depression, you see pressure of activity (volition) but inhibition of thought (cognition- impaired concentration), and a mood that is "anxious, despondent, lachrymose, irritable" (emotion). Or, in the former you see excitement in volition and cognition with an inhibition in emotion, and in the latter you see excitement of volition with an inhibition of cognition and emotion.

Thank you for your responses. I'll try reading Kraepelin though that may be above my head now. But I'm a reader, so I'll try.
@HarryMTieboutMD it was actually your post that prompted my question/request for clarification. I guess it's a feature of undergraduate medical education that different types of psychiatric disturbances are presented as discrete conditions (this is melancholic depression, that is bipolar II, and that is agitated depression*) while in reality they exists on a continuum. Thus it was my medical student level attempt to separate them.
* and @splik Not that I want to argue with you, since you're light years ahead of me in your psychiatric knowledge, I just wanted to point out that "agitated depression" was not something I made up I first heard of it in my preclinical psychiatry lectures I believe (that's right, I'm gonna blame everything on my medical education!), but then as I recently searched literature for it, I found that it had already been suggested that "agitated depression" should be reclassified as mixed state - and that was more than 10 years ago http://www.ncbi.nlm.nih.gov/pubmed/15780694

Thanks everyone for an enlightening discussion!

 

[birchswing]

Because having a labeled disease excuses your behavior and your failures.

In my experience of having mental illness, it's more socially acceptable to be a jackass and/or drunk than to have behavior that is inexplicable other than through mental pathology. Drunk people who act erratically are considered funny. People who aren't drunk but act erratically are considered scary. And once being drunk becomes pathologized, it seems the person goes from party guy to pariah.

I'm not particular fond of the excuse, but "Man I was so wasted" seems to be less scary than "I was having a manic episode."

Also, you switched the agency from the doctor to the patient. The original post was about patients who had been identified by their doctors as having bipolar disorder. The fact that so many primary care doctors diagnose bipolar probably has more to do with the fact that the last big wave of newly marketed drugs were for bipolar disorder/bipolar depression and less to do with issues of moral fortitude.

 

[splik]

* and @splik Not that I want to argue with you, since you're light years ahead of me in your psychiatric knowledge, I just wanted to point out that "agitated depression" was not something I made up I first heard of it in my preclinical psychiatry lectures I believe (that's right, I'm gonna blame everything on my medical education!), but then as I recently searched literature for it, I found that it had already been suggested that "agitated depression" should be reclassified as mixed state - and that was more than 10 years ago http://www.ncbi.nlm.nih.gov/pubmed/15780694

I didn't think you were making it up! I have heard people use the term before. All I said was, agitated depression is not a diagnosis, and it isn't. It doesn't feature in ICD-1o or DSM-5 nor in Kraepelin's conception. I quite like interesting terms that aren't in the classifications, but this one serves no purpose. Psychomotor agitation is part of the diagnostic criteria for MDD, thus depression with psychomotor agitation is simply depression. The idea that is represents a marker of bipolarity is not a valid one, as no one has compared it to ******ed depression in this regard. but we know from separate studies that people with ******ed depression are more likely to have bipolar disorder too. So whether it is hyperactivity or hypoactivity, motoric dysfunction is an indicator of recurrent mood disorder and correlates with severity. The problem with the study you linked to is they have a weird definition of "agitated depression" and by circular logic argue it is a mixed state by basically saying if we call depression with hypomanic symptoms "agitated depression" then it looks like a mixed state. well, no $hit!

 

[Amygdarya]

I didn't think you were making it up! I have heard people use the term before. All I said was, agitated depression is not a diagnosis, and it isn't. It doesn't feature in ICD-1o or DSM-5 nor in Kraepelin's conception. I quite like interesting terms that aren't in the classifications, but this one serves no purpose. Psychomotor agitation is part of the diagnostic criteria for MDD, thus depression with psychomotor agitation is simply depression. The idea that is represents a marker of bipolarity is not a valid one, as no one has compared it to ******ed depression in this regard. but we know from separate studies that people with ******ed depression are more likely to have bipolar disorder too. So whether it is hyperactivity or hypoactivity, motoric dysfunction is an indicator of recurrent mood disorder and correlates with severity. The problem with the study you linked to is they have a weird definition of "agitated depression" and by circular logic argue it is a mixed state by basically saying if we call depression with hypomanic symptoms "agitated depression" then it looks like a mixed state. well, no $hit!

Haha yes, but that was exactly what I was taught as "agitated depression", at the same time as mixed states were never mentioned. But I'm getting it now, thanks for the clarification!

 

[DoctorDa]

I'm an intern who has seen quite a few patients in the ED who report having bipolar d/o. If they are acutely manic it's very clear, but if not, often when I ask them about it, the say that "yeah, my doctor thinks I have that because I'm really moody."

Anyway, I was wondering how you address the validity of the diagnosis? What phrases do you use to screen for true mania?

I often say something like "have you ever felt like opposite of depressed, like you were on top of the world?" A TON of people will say yes to that though. And then I ask "what you were doing during that time?" and then the DIGFAST acronym questions asking about specific symptoms. Just curious how others do it, because I'm not as confident screening for mania as I am for other diagnoses. Thanks!!

LATE in the interview, after some rapport is established, I ask about drug use. If they have used cocaine or methamphetamine (and in some EDs, it's not "if" but "when"), I ask if they've ever had an experience similar to that without the drug; that will generate some positives for mania. But mania generates such a lack of insight that self report is notoriously unreliable (the preponderance of both Type 1 and Type 2 errors are well-documented in the literature); collateral must be found to make the diagnosis (unless you, or a trusted colleague, has even seen the patient manic with a clean urine). When collaterals are unavailable,you can raise your index of suspicion for Bipolar Disorder by asking about the depressive episodes (which are usually much more common): are they psychotic; did they have a post-partum onset; are they associated with increased eating and sleeping (as opposed to less); did previously effective anti-depressants poop-out; did they start early; do they come often and are relatively brief......and so forth.

 

[tr]

I'm an intern who has seen quite a few patients in the ED who report having bipolar d/o. If they are acutely manic it's very clear, but if not, often when I ask them about it, the say that "yeah, my doctor thinks I have that because I'm really moody."

Anyway, I was wondering how you address the validity of the diagnosis? What phrases do you use to screen for true mania?

I often say something like "have you ever felt like opposite of depressed, like you were on top of the world?" A TON of people will say yes to that though. And then I ask "what you were doing during that time?" and then the DIGFAST acronym questions asking about specific symptoms. Just curious how others do it, because I'm not as confident screening for mania as I am for other diagnoses. Thanks!!

I screen with two questions. The first is from the SCID mania section: "have you ever felt so good, high, hyper, or excited that others noticed your behavior was different or you felt that you were not yourself?" The other is about any periods of reduced need for sleep.

If people say yes to either of those I ask about duration (4 days min for a manic episode), which gets rid of a lot of the false positives from the first two. Then I ask the digfast questions and some questions about spree behavior with specific examples (spending, speeding, sexual indiscretions).