bipolar disorder drives me crazy

[Suedehead]

This is a rant.

I've been a resident for almost 3 years (moonlighting for almost a year), and I have a nemesis, and it is bipolar disorder.

I spend so much time undoing this diagnosis, weening people (cautiously and collaboratively, of course) from an over-simplified understanding of their lives and symptoms. They come to me on amazing amounts of medicine that they've been on for years with a diagnosis of bipolar disorder that I can tear apart after a 30 minute interview (and I am a very careful diagnostician; avoiding assumptions, knowing criteria, obtaining collateral, open to surprise, wanting to make sense of these peoples lives). In fact, I wish they DID have bipolar disorder because then things would be so much simpler (from a treatment perspective, at least). These people are super sick, have terrible mood troubles, but are almost invariably better described as personality disordered or as having anger or substance or relational problems. most probably have good old major depression. but not bipolar disorder.

Now, I have great respect for bipolar type I disorder. It's a nasty disease. It's also terribly EASY to diagnose. I've seen it countless times on inpt units. These patients are truly maniacal for WEEKS (not days) and typically are chronically depressed (though not always).

And after 3 years of residency, I have no idea what bipolar type II disorder is. I've been trained to screen for maniacal tendencies and patterns that meet dsm criteria. And I do, for every patient. I screen for it. And I suppose some people could meet criteria, but again.... they are almost invariably described better by something else. Seems the idea that someone can be a 'little bit' bipolar has translated to diagnoses en masse.

This is not simply a pet peeve. I see this diagnosis everywhere. This is like an epidemic. Drives me nuts. For me it symbolizes lazy thinking on our part, or worse, that we are a field at odds with itself, unable to make sense of the human condition and using well-meaning but poorly constructed disease models to sooth ourselves. I only very rarely find a clinician who is conscientious of these issues. we are not be trained to think with nuance. Very frustrating.

I'm even thinking of doing child/adol training not because I LOVE working with kids but because at least there I might get some explicit experience with attachment issues, family/relational issues, behavioral issues.... adult training hints at these but has largely succumbed to a biological approach... and bipolar disorder.

And I feel lonely when I bring the issue up with other residents or attendings because I'm either anti-psychiatry or I haven't screened carefully enough or I don't understand the criteria or I don't have enough experience, etc. I'm sure some of you will agree with them. ....I hope they're right. I hope as things go on that it will all coalesce, that these hordes actually do have bipolar disorder and psychiatry is not nuts. But I doubt it.

Sigh. Makes me worry about my future in this field that seems so very unaware of itself.

Rant done, folks. Sorry if I've ruined anyone's dinner.

---

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[OldPsychDoc]

This is a rant.
....
And I feel lonely when I bring the issue up with other residents or attendings because I'm either anti-psychiatry or I haven't screened carefully enough or I don't understand the criteria or I don't have enough experience, etc. I'm sure some of you will agree with them. ....I hope they're right. I hope as things go on that it will all coalesce, that these hordes actually do have bipolar disorder and psychiatry is not nuts. But I doubt it.

Sigh. Makes me worry about my future in this field that seems so very unaware of itself.

Rant done, folks. Sorry if I've ruined anyone's dinner.

Entirely justified rant.

I spend a lot of time reciting my "It's not 'bipolar', it's 'borderline'" script with patients. Lately, I've also been talking a lot with patients about intermittent explosive disorder, as well. "Bipolar" has gone the direction of "schizo-" in the popular parlance--meaning something entirely different than the actual diagnoses.

 

[loveoforganic]

Entirely justified rant.

I spend a lot of time reciting my "It's not 'bipolar', it's 'borderline'" script with patients. Lately, I've also been talking a lot with patients about intermittent explosive disorder, as well. "Bipolar" has gone the direction of "schizo-" in the popular parlance--meaning something entirely different than the actual diagnoses.

This is completely true. Layman bipolar seems to pretty much exclusively mean "temperamental."

 

[Cody1MD]

Are you saying that bipolar type 2 is underdiagnosed?

 

[Cody1MD]

http://www.psycheducation.org/depression/frameset.html

 

[billypilgrim37]

Are you saying that bipolar type 2 is underdiagnosed?

No, it's simply misdiagnosed. The under and over are rarely systematically true in any meaningful way.

 

[whopper]

The problem here IMHO is laziness and cutting corners on the part of the mental healthcare provider. I've complained about this in other threads. Just because someone is irritable (or for that matter having just 1 of the symptoms of bipolard such as poor sleep) does not make them bipolar disordered. Other doctors, however, operate on this notion.

Then they add the cascade of meds. Seroquel, Klonopin, Topamax, and Neurontin. Some docs I know add 4-5 meds on the first visit.

 

[nitemagi]

I'm a little bit of a dissenter. Partially because I've heard directly from Akiskal here about his philosophy and why he thinks basically everything is a bipolar variant. Not that I believe that. But I recognize that there is more to a bipolar diathesis than just I and II. Bipolar III and hyperthymic temperament I most definitely believe.

Akiskal's argument (again which I listen to but don't endorse) is that if borderline isn't a bipolar variant, why do some borderlines feel better on mood stabalizers. And my answer is the same I give to all the "ADHD" people that roll into my office/clinic/hospital. Everyone focuses better on stimulants, everyone's mood variants decrease on a mood stabalizer.

My main point is that I don't take the DSM as the bible, and research supports viewing bipolar as a spectrum not a yes/no. Our patients lock onto a bipolar diagnosis as an excuse for their behavior and often even their families let them use the excuse. What I teach to my patients, even those with legitimate bipolar I is that you can do things to change your mood besides pills, and in fact it's your responsibility to do so.

 

[atsai3]

On the inpatient ward, an Axis I diagnosis is often the only route to obtaining insurance reimbursement. So often the patients with borderline as the 'primary' source of their misery will just get bipolar or 'mood disorder NOS' tacked on. In addition, starting a new medication is often a route to getting insurance to continue paying for a hospitalization. So if a borderline ends up in the hospital due to acute breakdown in problem solving ability, and his/her current medication regimen has been doing fine, the meds will get swapped or tweaked somehow just to justify the hospitalization.

-AT.

 

[strangeglove]

The problem relates to "If you are a hammer, everything looks like a nail." Psychiatrists are trained more and more to be psychopharmacologists only. This is due, in part, to increasingly poor reimbursement for psychotherapy. So, when patient with borderline personality disorder presents to a psychiatrist, he/she will be given a diagnosis that will 1) allow for reimbursement; 2) justify prescribing medications and not psychotherapy. Thus, another patient with Bipolar II is born.

 

[kugel]

On the inpatient ward, an Axis I diagnosis is often the only route to obtaining insurance reimbursement.

I work primarily with the Medicaid reimbursement regs for my state, so I certainly don't know the other insurance reimbursement procedures well. Please explain which insurances won't pay for an Axis II dx when the pt meet criteria for imminent danger to self/others.

My own experience has been that the initial admit is paid based on the documented acuity and need for a locked door, e.g. Suicide attempt with continued intent, assault (or intended homicide) due to psychotic beliefs, eating non-food items due to psychosis, refusing food for days b/c of belief it is all poisoned, etc.

 

[OldPsychDoc]

Agree with Kugel--I think that it's largely myth that "insurance only reimburses for meds and Axis I". I frequently have patients admitted for whom I indicate that Borderline PD is the primary diagnosis, and I've never added meds just to justify an inpatient stay. Would I use a mood stabilizer in these patients? Sure--they need help settling down sometimes, and I'm trying to avoid getting them addicted to ativan and klonopin--but that doesn't mean they're "bipolar".

 

[nitemagi]

Nice letter to the editor this month in Archives, by Dr. Mattes from Princeton on this topic.

http://archpsyc.ama-assn.org/cgi/content/full/67/11/1198

 

[kugel]

Nice letter to the editor this month in Archives, by Dr. Mattes from Princeton on this topic.

http://archpsyc.ama-assn.org/cgi/content/full/67/11/1198

Unless it's worth $30 for one-time access to read it, I'm gonna' need a little help knowing what's in it.

 

[whopper]

My main point is that I don't take the DSM as the bible, and research supports viewing bipolar as a spectrum not a yes/no. Our patients lock onto a bipolar diagnosis as an excuse for their behavior and often even their families let them use the excuse. What I teach to my patients, even those with legitimate bipolar I is that you can do things to change your mood besides pills, and in fact it's your responsibility to do so.

Agree but be careful of seeing things in greys when they may be more black and white.

Is it true that several people without ADHD will concentrate and focus better on a stimulant? Yes. Does that justify giving out a stimulant to everyone? No. If someone gave out stimulants to everyone, IMHO they'd likely do more harm than good and in effect would be a drug-dealer. There is also the philosophical divide that several doctors believe we should only treat pathology, not give medications for enhancement. (E.g. steroids, stimulants, testosterone for body building competitions).

People also need to exercise and develop their own coping skills. The less medications we can put someone on, almost always the better.

Someone diagnosed with borderline PD improving on a mood stabilizer may have really had cyclothymia or bipolar II. Given that mood stabilizers are not the first-line treatment, it should not be used instead of psychotherapy, but at most an adjunct.

I stabilized someone on Abilify 30 mq QAM with schizoaffective disorder. She came to me on 5 meds. After Abilify, she lost weight, maintained stability and felt better. Then she was transferred back to the previous unit. The previous psychiatrist put her back on 5 meds (Zyprexa, Prozac, Depakote, Klonopin, and Topamax). The patient didn't like the regimen but continued to take it thinking the doctor somehow knew what she was doing.

I asked the doctor why so many meds? "Well James, I can just tell she's depressed. I know she doesn't show any signs. I know she doesn't complain of depression. I can just feel it. That's why I added Prozac. I put her on Depakote because one day she was upset because she found out her daughter was arrested. She was upset and I decided she needed something to stabilize her mood. I started the Topamax becuase the Zyprexa and Depakote induced weight gain. I started her on Klonopin because she told me she likes it. It gives her some euphoria."

A psychiatrist is not trained in the Force. That psychiatrist apparently disagrees with me.

 

[Cruzinman]

A psychiatrist friend of mine tells me that he can see 3-4 patients/hour for a brief medication management visit and make twice as much reimbursement than if he saw one patient for psychotherapy in the same time frame.

 

[whopper]

People also need to exercise and develop their own coping skills. The less medications we can put someone on, almost always the better.

I just wanted to clarify, this does not mean we don't medicate at all, but try to reduce polypharmacy as much as we can while doing as much good as we can for the patient.

This definitely means don't start patients on five meds on their first visit unless there is very strong reason to support this.

 

[masterofmonkeys]

akiskal's work on temperament is really interesting. I am currently reading The Temperamental Thread by Jerome Kagan and find the whole thing fascinating. I definitely think we don't think enough about personality styles and temperament and that the DSM-IV is no help there. Some interesting changes in the DSM-V might change that and I'm pretty excited about that stuff.

That said, I think there is a clear difference between mood reactivity and mood instability. Poor choice of words perhaps, but for me bipolar tends to fall in the latter category. Whereas mood reactivity for me seems more of a temperament/personality issue. Which is not to say that mood reactivity in the extreme might not qualify as an Axis I disorder in and of itself, but that I see it as on a totally different spectrum separate from bipolar illness.

 

[nitemagi]

Overall I agree. I do think we overprescribe, for many of the reasons cited above. I also think we overdiagnose. And while stimulants make everyone focus better, that's exactly the reason I question the overdiagnosis of ADHD as well. Not that it doesn't exist, but that it's overdiagnosed. I had a patient who told me a psychologist told them that since they have racing thoughts they have ADHD. It's just as possible that that was what the patient took out of the conversation, but that that isn't what the psychologist actually said. My point is we need to encourage our patients to take responsibility for their emotions and behaviors, to work to change them via therapy, meds, and positive lifestyle choices.

I may buy that gray is a shade of black, or that white is a lighter shade of gray, but you won't convince me white is a shade of black.

 

[billypilgrim37]

One of my supervisor says at least twice a session, "The ones that need the meds don't want to take them, and the ones that don't need them want more and more and more." While that's not exactly revolutionary, I think we should at least acknowledge our frustration is with the latter patient population (and our colleagues who deal with them poorly).

Time from onset of symptoms of bipolar disorder, especially BP depression, to proper treatment is still many years, and given the terribly high rates of substance abuse, legal problems, and suicide in bipolar disorder, well, that's kinda bad. MoM hits it on the head with that distinction between being a temperamentally reactive person versus someone who has discrete periods of expansive or irritable mood that are distinct changes from baseline. And that's a pretty difficult thing to parse on a cross-sectional interview.

So I think it makes total sense to fret about our pts whose greatest need is to learn better coping skills and frustration tolerance, and the poor care we see many of them receive. But let's not totally throw out the bipolar II baby with the borderline bathwater.

 

[TheWowEffect]

I asked the doctor why so many meds? "Well James, I can just tell she's depressed. I know she doesn't show any signs. I know she doesn't complain of depression. I can just feel it. That's why I added Prozac. I put her on Depakote because one day she was upset because she found out her daughter was arrested. She was upset and I decided she needed something to stabilize her mood. I started the Topamax becuase the Zyprexa and Depakote induced weight gain. I started her on Klonopin because she told me she likes it. It gives her some euphoria."

Somehow, this does not sound like a real converation to me..

 

[whopper]

Somehow, this does not sound like a real converation to me..

Paraphrasing. This other doctor works in the same hospital as I. She and another doctor in the hospital went to the same residency program in KY and they both medicate patient using the same polypharmacy style. I don't know if it's coincidence or by their training.

e.g. I just had a guy that one of those two discharged on Haldol Decanoate 100 Q 4 weeks and Haldol 15 mg QBID among the typical 5 other meds they usually put someone on. I dont' get why he needed all 6 of those meds but putting someone on Dec and oral....why? It's not like that Haldol Dec 100 mg was the first dosage (in which case that'd make sense). He was hospitalized for 9 months.

The polypharmacy is a problem but also the ability for these patients to pay for their meds...but that's another can of worms.

 

[erg923]

Can I ask why being upset about ones daughter being arrested is viewed as a "symptom" that needs "treatment"? I think this overaching assumption/implication is much more frightening than this individual case of unnecessary polypharm.

 

[firedoor]

These people are super sick, have terrible mood troubles, but are almost invariably better described as personality disordered or as having anger or substance or relational problems. most probably have good old major depression. but not bipolar disorder.

Amen. On a somewhat similar note, I suspect that agitated depression may often be misdiagnosed as some form of a mixed state these days.

 

[surftheiop]

Can I ask why being upset about ones daughter being arrested is viewed as a "symptom" that needs "treatment"? I think this overaching assumption/implication is much more frightening than this individual case of unnecessary polypharm.

I think that was his point.

(Or thats how I read it)

 

[erg923]

I know he realized that. I was just saying how scary it is that the doctor he was talking about pathologizes normal reactions to life events- no telling how many other patients of hers are being treated/conceptualized in the same way.

 

[SpiritiualDuck]

Depression is not depression, I think that we need to look at the cyclicality of affective disorders and not poles. Many patients with highly recurrent depressive disorders will likely benefit from a mood stabilizer. People often don't remember, and surely never show up telling us that I feel better, more energized, creative, etc and a mood stabilizer for hypomania. And, arguably, some folks that fall on this bipolar spectrum have had predominantly, like most will, depressive episodes.

 

[firedoor]

Depression is not depression, I think that we need to look at the cyclicality of affective disorders and not poles. Many patients with highly recurrent depressive disorders will likely benefit from a mood stabilizer. People often don't remember, and surely never show up telling us that I feel better, more energized, creative, etc and a mood stabilizer for hypomania. And, arguably, some folks that fall on this bipolar spectrum have had predominantly, like most will, depressive episodes.

This notion that cyclicity should supercede polarity as an organizing principle for mood disorders, strongly advocated by Dr. Frederick Goodwin, is a controversial one and I think an excellent topic for discussion in a separate thread as it is an issue separate from (though related to) that of the original post.

I don't believe that most of the type of patients referred to in this thread would fit into the broader conceptualization of the bipolar spectrum to which you are referring. At least I think not.

As masterofmonkeys stated, It's important to distinguish here between mood reactivity vs. mood instability.

 

[LM02]

Agree with most everything posted above!

This is a really relevant article, that I site in my research quite often.

http://www.ncbi.nlm.nih.gov/pubmed/18466044

What I will also add is that BPII is extremely difficult to diagnose in inpatient settings because, by definition, patients are not being admitted for hypomania - they are almost always being admitted for acute depression. So there is no opportunity to witness hypomania, and clinicians have to rely on retrospective report from a person who has a negative lens clouding their self-report. There is also evidence that BPII is more likely associated with chronic depression (Collaborative Depression Study has shown that patients with BPII spend 50% of their lives with some level of depressive symptomatology), so it carries over into the outpatient setting as well.

In my experience, BPII can be diagnosed, but it really requires experience working with a patient long enough to get a clearer picture. A brief clinical interview is not terribly reliable or valid in this regard. Not surprisingly, I feel this is also true for proper diagnosis of personality disorder (the structured clinical interviews for personality disorders have notoriously poor reliability).

There are some published data showing that, from time to initial clinical presentation, it takes approximately 12 years to get an accurate BPII diagnosis. It's a total mess.

 

[9point75]

I'm bipolar and I need my Seroquel/Zyprexa/Abilfy/Risperdal/Depakote/etc. "How come you say you're bipolar?" Because I'm just so angry, I can go from being happy one second to completely berzerk the next second. Everything little thing sets me off. "How long have you felt this way?" Pretty much always. "When was the last time you felt happy?" Never. "How would you feel if I said you look and sound like a depressed person?" It's true, I am depressed... How come nobody has ever told me that before? "Everybody else is probably scared of you and your completely irrational grown up temper tantrums. You break things, you throw things, you fight people and society would rather you get fat and sleep 16 hours a day on your discmelt/m-tab/zydis. If I had more time I could probably help you with an anti-depressant and some real in-depth, empathic, insight-oriented therapy, but for now I have to rely on a social worker who has written bipolar all over your chart and documenting everywhere that you are impulsive/violent/unpredictable/etc. and I'm supposed to shoulder the responsibilty of lifting the dopamine blockade that has been in your brain since age 16 and replace it with Prozac? Great"

 

[OldPsychDoc]

I'm bipolar and I need my Seroquel/Zyprexa/Abilfy/Risperdal/Depakote/etc. "How come you say you're bipolar?" Because I'm just so angry, I can go from being happy one second to completely berzerk the next second. Everything little thing sets me off. "How long have you felt this way?" Pretty much always. "When was the last time you felt happy?" Never. "How would you feel if I said you look and sound like a depressed person?" It's true, I am depressed... How come nobody has ever told me that before? "Everybody else is probably scared of you and your completely irrational grown up temper tantrums. You break things, you throw things, you fight people and society would rather you get fat and sleep 16 hours a day on your discmelt/m-tab/zydis. If I had more time I could probably help you with an anti-depressant and some real in-depth, empathic, insight-oriented therapy, but for now I have to rely on a social worker who has written bipolar all over your chart and documenting everywhere that you are impulsive/violent/unpredictable/etc. and I'm supposed to shoulder the responsibilty of lifting the dopamine blockade that has been in your brain since age 16 and replace it with Prozac? Great"

I am totally visualizing this as one of those text-to-cartoon vids.

Except that you left out the request for Xanax and Adderall...

 

[nitemagi]

I'm bipolar and I need my Seroquel/Zyprexa/Abilfy/Risperdal/Depakote/etc. "How come you say you're bipolar?" Because I'm just so angry, I can go from being happy one second to completely berzerk the next second. Everything little thing sets me off. "How long have you felt this way?" Pretty much always. "When was the last time you felt happy?" Never. "How would you feel if I said you look and sound like a depressed person?" It's true, I am depressed... How come nobody has ever told me that before? "Everybody else is probably scared of you and your completely irrational grown up temper tantrums. You break things, you throw things, you fight people and society would rather you get fat and sleep 16 hours a day on your discmelt/m-tab/zydis. If I had more time I could probably help you with an anti-depressant and some real in-depth, empathic, insight-oriented therapy, but for now I have to rely on a social worker who has written bipolar all over your chart and documenting everywhere that you are impulsive/violent/unpredictable/etc. and I'm supposed to shoulder the responsibilty of lifting the dopamine blockade that has been in your brain since age 16 and replace it with Prozac? Great"

Stop it. You're giving me flashbacks.

 

[whopper]

Can I ask why being upset about ones daughter being arrested is viewed as a "symptom" that needs "treatment"? I think this overaching assumption/implication is much more frightening than this individual case of unnecessary polypharm.

As some noticed above, that was my point. Some doctors pathologize normal reactions.

Other doctors I've seen give the argument that one medication only treats patients in a specific modality and that several problems are often of a type of multifactorial receptor involvement to justify polypharmacy.

e.g. one patient I saw was on....

Risperdal 2 mg QBID
Seroquel 200 mg QHS
Topamax 100 mg Qdaily
Neurontin 300 mg QBID
Lexapro 20 mg Qdaily
Depakote 1000 mg QHS
Klonopin 1 mg QBID
Vistaril 50 mg Q QID

What this patient had, I'm not so sure because the medication polypharmacy covered up everything on his clinical appearance. The patient claimed to have anxiety that fit the category of generalized anxiety disorder before treatment. The patient also told me he felt like a zombie on his medications and didn't want to be on them but only continued to take them because he was told by his doctor to do so.

I found that doctor's argument bogus. 1-Pretty much all the psychiatric medications work on several receptors. Having a scattershot pharm strategy like the type I've seen from some doctors completely ignores that fact. E.g. in Seroquel, histamine receptors are maximally blocked before the dopamine receptors are blocked. So what's the point in giving an antihistamine with the Seroquel?
2-Several of the psychiatric medications designated to treat a specific disorder only work at specific dosages and may have not have the intended effect if taken in a manner not directed by the manufacturer. Again, Seroquel, given at 50 mg a day is unlikely to have any antipsychotic benefit. Having a logic that Risperdal 1 mg QBID and Seroquel 50 mg QHS is somehow superior treatment goes against several standards we are supposed to utilize.
3- this type of polypharmacy is horrendously expensive and very likely unnecessary.
4-For the patient, polypharmacy is harder to maintain. It's not easy having to keep track of several pills a day.

That is not to underplay that polypharmacy is sometimes needed and justified. If a case gets to that point, however, the proper algorithm needs to have been tried. E.g. the doctor should have tried at least a conventional treatment before polypharmacy is started.

 

[billypilgrim37]

E.g. in Seroquel, histamine receptors are maximally blocked before the dopamine receptors are blocked. So what's the point in giving an antihistamine with the Seroquel?

Really. Bad. Allergies.

Like when one of my patients was depressed because she was getting the sniffles from her "panic attack therapy" dog.

 

[nitemagi]

Really. Bad. Allergies.

Like when one of my patients was depressed because she was getting the sniffles from her "panic attack therapy" dog.

Only logic for another antihistamine on top of seroquel is the acclimation to antihistamine effects for sleep. But once I see someone getting tolerant, I try to avoid going down the seroquel route for sleep. Particularly for anyone on seroquel over 300mg without an underlying psychotic disorder. Usually I'm inheriting these patients.

 

[kugel]

True story of ~27 yr old man (as best I can remember it)

"I know I have Bipolar Disorder. I've been off my Seroquel for 4 months because it was just too much hassle to come in for appointments every 2 months. And I couldn't afford the time off work. But now I realize I have to get back on it. I have these anger outbursts, "explosive disorder" I think they call it, and I can get really violent. I'm not joking with you, Doc. You would not want to be around when I get pissed off. People get hurt. I put the last guy in the hospital. I've lost my job because of my illness, so I can't pay rent. My mom will let me stay with her, but only if I'm on my medication. So, if I can't get my Seroquel, I have no place to stay and I'll just have to beat the crap out of somebody in order to go to jail 'cause I can do that again - but I refuse to be homeless. I know my chart says I was on 600mg of Seroquel at night, but I was taking twice that amount 'cause I have a really high tolerance to medications. The last doc knew that, but refused to prescribe the right amount, so I had to buy the rest off the street. But now I have no income, so I can't buy it off the street anymore. If you don't prescribe 1200mg a night, I'll just end up hurting someone - maybe my own mother. So it's all up to you, Doc. What's it gonna' be? Now I promise I'll come in for appointments, since I'm not working now, but every 4 months would be a lot better than every 2 months since my Mom has to drive me. Oh, and I might as well tell you that my urine will be dirty for weed, 'cause that's all I've had to control my mood swings. I mean, I had to do something, didn't I? But I can cut down if I'm on the Seroquel. Then I only have to smoke when I get really pissed off."

Well, Seroquel isn't an appropriate medication for your situation and the idea that you needed 1200mg is just one proof of that. So I'm not going to prescribe you Seroquel. And since you've been off it for 4 months, we have a chance to start fresh. Now that you're not working, you have time to go to weekly therapy and substance abuse meetings. If you attend all the recommended groups and appointments for the next month, I can be gathering all your old records and prescription history, and it will give me time to talk with your family about their perceptions of the problem and what seems to trigger your outbursts. Then we can discuss what medicines you've tried at what doses and try to figure out if any of them ever helped you. But I need you to understand clearly that it won't be Seroquel and any reasonable treatment plan is going to include intensive therapy and substance abuse treatment, and we will be running frequent drug screens so that I know what chemicals are in your body.

"Well, then F--- You, Doc. You just don't give a s--- if I end up committing murder, do you? I don't have time to do all that and I don't need to when we know what works for me. I know me better than you do, and the last doc certainly knew me better than you do, so just get down off your high horse and get in the real world where the rest of us live. I just need to know if you're going to prescribe what's already proven to work for me, of if I need to report you for refusing to treat me properly."

I think our appointment for today is over. I don't see what's to be accomplished any further today. We've both had our say. You're welcome to make an appointment whenever you want to proceed with developing an actual treatment plan. You can even make an appointment for tomorrow if you like, but this appointment is over.

 

[Existenz]

This is a rant.

I've been a resident for almost 3 years (moonlighting for almost a year), and I have a nemesis, and it is bipolar disorder.

I spend so much time undoing this diagnosis, weening people (cautiously and collaboratively, of course) from an over-simplified understanding of their lives and symptoms. They come to me on amazing amounts of medicine that they've been on for years with a diagnosis of bipolar disorder that I can tear apart after a 30 minute interview (and I am a very careful diagnostician; avoiding assumptions, knowing criteria, obtaining collateral, open to surprise, wanting to make sense of these peoples lives). In fact, I wish they DID have bipolar disorder because then things would be so much simpler (from a treatment perspective, at least). These people are super sick, have terrible mood troubles, but are almost invariably better described as personality disordered or as having anger or substance or relational problems. most probably have good old major depression. but not bipolar disorder.

Now, I have great respect for bipolar type I disorder. It's a nasty disease. It's also terribly EASY to diagnose. I've seen it countless times on inpt units. These patients are truly maniacal for WEEKS (not days) and typically are chronically depressed (though not always).

And after 3 years of residency, I have no idea what bipolar type II disorder is. I've been trained to screen for maniacal tendencies and patterns that meet dsm criteria. And I do, for every patient. I screen for it. And I suppose some people could meet criteria, but again.... they are almost invariably described better by something else. Seems the idea that someone can be a 'little bit' bipolar has translated to diagnoses en masse.

This is not simply a pet peeve. I see this diagnosis everywhere. This is like an epidemic. Drives me nuts. For me it symbolizes lazy thinking on our part, or worse, that we are a field at odds with itself, unable to make sense of the human condition and using well-meaning but poorly constructed disease models to sooth ourselves. I only very rarely find a clinician who is conscientious of these issues. we are not be trained to think with nuance. Very frustrating.

I'm even thinking of doing child/adol training not because I LOVE working with kids but because at least there I might get some explicit experience with attachment issues, family/relational issues, behavioral issues.... adult training hints at these but has largely succumbed to a biological approach... and bipolar disorder.

And I feel lonely when I bring the issue up with other residents or attendings because I'm either anti-psychiatry or I haven't screened carefully enough or I don't understand the criteria or I don't have enough experience, etc. I'm sure some of you will agree with them. ....I hope they're right. I hope as things go on that it will all coalesce, that these hordes actually do have bipolar disorder and psychiatry is not nuts. But I doubt it.

Sigh. Makes me worry about my future in this field that seems so very unaware of itself.

Rant done, folks. Sorry if I've ruined anyone's dinner.

this is kinda like when you study borderline pd and then you think everyone has it lol

 

[Suedehead]

this is kinda like when you study borderline pd and then you think everyone has it lol

it's more like having studied bipolar and realizing nobody has it.