bipolar...

[randomdoc1]

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Curious to know what other people's experiences/thoughts are. That is, with people who insist on the bipolar diagnosis and go out pursuing mood stabilizers and antipsychotics. I've had a recent case who I was not convinced was bipolar but pt has undergone various mood stabilizers and antipsychotics from another provider. No surprise, still depressed, feeling sedated and totally flat after thousands of dollars spent on outpatient visits (not with me) and medication that wasn't a fit to begin with. I've educated pts about jumping the gun on saying someone is bipolar due to the side effect profile of the medications as well as just as big a danger of not treating the underlying disorder, but some people seem to keep pursuing it. It is rewarding when pts come to terms with what their diagnosis actually is though, but it can take some serious trial and error on their part. I wonder if it is more the allure of something that can be "fixed"... or maybe bipolar is just a sexier label to have?

Not to say I don't diagnose bipolar spectrum disorders. I certainly have and certainly treat it!

 

[st2205]

Depression and anxiety sounds too routine, too normal. To tell someone they “just” have depression is insulting to their suffering, and not appreciating the severity of their condition. Never mind that bipolar is inaccurate, the bipolar label is sufficient for society to say “oh, that’s serious,” much as the difference between Jimmy’s strep throat and Sally’s breast cancer.

So when you tell someone they don’t have bipolar disorder, what they hear is that their psychiatrist is abandoning them, that you can’t bother to take the time to recognize what’s really wrong, and that you think this is just “all in their head,” and believe they aren’t suffering.

/countertransference

 

[randomdoc1]

lol, never mind the parkinsonism, EPS, metabolic syndrome and oh, the progression of the depression to the point where other psychiatrists start recommending ECT...

 

[st2205]

lol, never mind the parkinsonism, EPS, metabolic syndrome and oh, the progression of the depression to the point where other psychiatrists start recommending ECT...

I picked up a patient recently on 800 mg of Seroquel, 300 Effexor, 40 Prozac, BuSpar 30 BID, trazodone, then a combination of every prn you could think of (taken schedule, naturally)... hydroxyzine, propranolol, Gabapentin, and there were a couple others I can’t think of. “Can’t change any of them” because they all help, yet they’re telling me how miserable they are. Also, they’d have to go to the hospital if I changed meds. But they want to get back on Ativan. Said no and they went to the hospital and were admitted.

 

[randomdoc1]

I bet the patient's really fat. That's one beastly dose of seroquel. Maybe they could use some prn olanzapine.

 

[birchswing]

I bet the patient's really fat. That's one beastly dose of seroquel. Maybe they could use some prn olanzapine.

Some evidence that weight-gain for Seroquel and Zyprexa is not dose-dependent:

https://www.omh.ny.gov/omhweb/psyckes_medicaid/scientific_summaries/quetiapine.pdf

Management of Antipsychotic-Related Weight Gain

Given that Seroquel is handed out like candy for anxiety disorders (and pretty much anything and everything) and that mood stabilizers from completely different categories (anti-epileptics) are used in bipolar as well, I'm not sure if this problem of these particular metabolic side effects necessarily tracks with a penchant for a bipolar diagnosis. The drugs are problematic regardless of the diagnosis or patient's self-diagnosis.

It might be worth exploring what the patient means when they say they are bipolar. For example, how do you distinguish a dysphoric hypomania from an intense GAD state? They might be communicating something using the wrong words, but it might still be valuable information.

 

[randomdoc1]

Some evidence that weight-gain for Seroquel and Zyprexa is not dose-dependent:

https://www.omh.ny.gov/omhweb/psyckes_medicaid/scientific_summaries/quetiapine.pdf

Management of Antipsychotic-Related Weight Gain

Given that Seroquel is handed out like candy for anxiety disorders (and pretty much anything and everything) and that mood stabilizers from completely different categories (anti-epileptics) are used in bipolar as well, I'm not sure if this problem of these particular metabolic side effects necessarily tracks with a penchant for a bipolar diagnosis. The drugs are problematic regardless of the diagnosis or patient's self-diagnosis.

It might be worth exploring what the patient means when they say they are bipolar. For example, how do you distinguish a dysphoric hypomania from an intense GAD state? They might be communicating something using the wrong words, but it might still be valuable information.

I do get what you are saying. Yes, it is true regardless of diagnosis, the side effects are the side effects. I guess what I was trying to say is that I educate patients that going down the bipolar route is very serious. The disorder is managed with antipsychotics (a good portion of them come laden with weight gain) and mood stabilizers, some with a very narrow therapeutic index and can also have end organ damage in the long term. I have explored what people mean when they say they are bipolar and had discussion about what bipolar actually is. Fortunately most are receptive to the working diagnosis I have for them and most of my people have "just" depression and anxiety. Although as we all know, those disorders can be very serious and debilitating as well. The patients I'm left talking about are the ones that still insist they are bipolar, they convince themselves they have had mania (albeit history shows only in context of abusing amphetamines and alcohol) and they try every bipolar med under the sun they can find a psychiatrist to prescribe for them (such as when they are inpatient or in a residential program setting). Not surprising, to no relief because (surprise!) they actually don't have bipolar disorder. I've seen cases where patients have done this, found a psychiatrist willing to prescribe for them and eventually their depression just gets so bad psychiatrists start to recommend SSRI but pt is still worried about the "bipolar". Eventually the depression got so bad that ECT was recommended. In cases like these, I transfer care (when they are not in crisis of course) when pts keep insisting bipolar because 1) their depression will just get worse and it's not liability I want on my hands and 2) we're disagreeing on the plan anyways.

 

[Attending1985]

I find those averse to not having bipolar disorder have an externalizing personality disorder. This is their main defense against accountability and shame and taking that away is unacceptable. I do let these people know I don’t agree with the diagnosis and will not be prescribing high risk medications and recommend therapy.
On the flip side there are also those who are dysregulated and are ok with hearing something else is going on.

 

[NickNaylor]

I have this discussion not infrequently - many of my clinic patients come from the community mental health system (which, by the way, only treats patients with diagnoses of MDD, bipolar disorder, schizophrenia, and schizoaffective disorder - I'll let you imagine what that means with respect to diagnoses) with all kinds of crazy diagnoses that are totally inaccurate. I will sometimes get some resistance about the diagnosis, but I haven't had the experience of people "pursuing" mood stabilizers/antipsychotics. Most people are happy to get off the medications when I tell them that they're not necessary.

 

[Attending1985]

I think the bipolar spectrum diagnosis should be done away with. I think it’s caused much more harm than good.

 

[randomdoc1]

I think the bipolar spectrum diagnosis should be done away with. I think it’s caused much more harm than good.

On the flip side, I've used that theory to help patients accept that they probably are not "that bipolar" (although far as I'm concerned, that's my personal code for not bipolar period). I've at times said that there's a theory it is more of a spectrum, but that also means the entity of bipolar is not homogenous and it is not one size fits all. Then I tell the patient they seem to sit further towards the unipolar side, and patients with their symptoms tend to respond more to the antidepressants and LOW DOSE antipsychotic augmentation. People seem to feel that their argument that they have bipolar is not completely disregarded and their defenses tend not to get as high.

On the other hand, I see how it can be a slippery slope and turn into a polypharm nightmare from an rx happy psychiatric provider.

 

[birchswing]

In popular media (going on that since I don't know anyone who is identified as having bipolar), you hear about people with bipolar who do OK with treatment but in their manic phases feel like they're doing well and don't want medication.

But it seems like you all are saying there are some people who are the opposite--they don't have bipolar, but they want to take bipolar medications. What is the secondary gain? I don't usually think of mood stabilizers or atypical antipsychotics as joyride pills. Unless they just want to sleep a lot?

 

[st2205]

What is the secondary gain? I don't usually think of mood stabilizers or atypical antipsychotics as joyride pills. Unless they just want to sleep a lot?

1. It provides a fantastic medium for facilitation of avoidance and helps superficially dissipate psychological distress when not confronting the more unpleasant reasons for their suffering.
2. Medications, especially “heavy” or “dangerous” medications, gives further validation to their conditions.
3. Medications provide an external anchor to which they can tether, having no confidence, or usually awareness, of their own internal anchors.
4. Medications may have a numbing effect, which plays in to avoidance.
5. As most humans have a drive to find meaning and purpose in their lives, some find that meaning through their suffering and assuming the identity of one who is sick or suffering.
6. Being on more medications helps bolster applications for things like disability or letters for emotional support animals.
7. Being on sedating, mind-dulling medications boosts the argument for why you need an Adderall pick-me-up.

 

[randomdoc1]

1. It provides a fantastic medium for facilitation of avoidance and helps superficially dissipate psychological distress when not confronting the more unpleasant reasons for their suffering.
2. Medications, especially “heavy” or “dangerous” medications, gives further validation to their conditions.
3. Medications provide an external anchor to which they can tether, having no confidence, or usually awareness, of their own internal anchors.
4. Medications may have a numbing effect, which plays in to avoidance.
5. As most humans have a drive to find meaning and purpose in their lives, some find that meaning through their suffering and assuming the identity of one who is sick or suffering.
6. Being on more medications helps bolster applications for things like disability or letters for emotional support animals.
7. Being on sedating, mind-dulling medications boosts the argument for why you need an Adderall pick-me-up.

I am thinking of a case I recently discharged. The patient who presented with his mother. Dozens of weeks later of intensive therapy and mood stabilizers and antipsychotics later by the quack who labeled him as bipolar he's now severely depressed, numb, and sleeping a lot. Mother now asking for Provigil. I said, let's first check TFTs and make sure his OSA is well controlled. Also make sure he's not actually over medicated and this already obese patient is not gaining more weight from these meds before adding on yet another medication. He's been followed closely by multiple psychiatrists and one said he really should just be started on an SSRI. As a matter of fact, sounds like multiple psychiatrists challenged this whole "bipolar" bull but mom is still clinging to the diagnosis and says if you put multiple psychiatrists in a room, they'll all have a different opinion so it's still possible he's bipolar and that means he must be bipolar. Mom says no to SSRIs because of the "bipolar". I told them I am in the process of starting my own practice anyways and won't be able to provide the level of care he needs, but I encouraged him to keep following with me until his appointment with his new psychiatrist. They cancelled their appointments. I was frank with patient and the mother, I said I'm really not convinced he's bipolar to the point that the mood stabilizer and antipsychotic he is on is a good match for him. If anything, he's now severely depressed. Not to mention he still has very primitive and maladaptive coping with pronounced borderline traits...I think my initial hunch was right after all. Sheesh.

 

[Attending1985]

1. It provides a fantastic medium for facilitation of avoidance and helps superficially dissipate psychological distress when not confronting the more unpleasant reasons for their suffering.
2. Medications, especially “heavy” or “dangerous” medications, gives further validation to their conditions.
3. Medications provide an external anchor to which they can tether, having no confidence, or usually awareness, of their own internal anchors.
4. Medications may have a numbing effect, which plays in to avoidance.
5. As most humans have a drive to find meaning and purpose in their lives, some find that meaning through their suffering and assuming the identity of one who is sick or suffering.
6. Being on more medications helps bolster applications for things like disability or letters for emotional support animals.
7. Being on sedating, mind-dulling medications boosts the argument for why you need an Adderall pick-me-up.

Very well put. Number 4 is huge. The medications make me just numb enough to go on living like I am squashing motivation for change.

 

[Attending1985]

On the flip side, I've used that theory to help patients accept that they probably are not "that bipolar" (although far as I'm concerned, that's my personal code for not bipolar period). I've at times said that there's a theory it is more of a spectrum, but that also means the entity of bipolar is not homogenous and it is not one size fits all. Then I tell the patient they seem to sit further towards the unipolar side, and patients with their symptoms tend to respond more to the antidepressants and LOW DOSE antipsychotic augmentation. People seem to feel that their argument that they have bipolar is not completely disregarded and their defenses tend not to get as high.

On the other hand, I see how it can be a slippery slope and turn into a polypharm nightmare from an rx happy psychiatric provider.

I don’t see it as producing very good results medication wise. How many of those diagnosed with bipolar spectrum receive huge benefits of medications? In my experience very few. On the other hand as many have posted on this thread the label has caused huge harm.

 

[randomdoc1]

I don’t see it as producing very good results medication wise. How many of those diagnosed with bipolar spectrum receive huge benefits of medications? In my experience very few. On the other hand as many have posted on this thread the label has caused huge harm.

The only time I've pulled out the spectrum theory is to get people off mood stabilizers and antipsychotics (or at least decrease their dose) and get people treated for their actual depression and anxiety. I can't speak for anyone else though.

 

[tr]

I've never met a patient who *wanted* to have bipolar disorder and didn't. I have met a lot who had it and didn't want to believe/accept it. It seems to be a much more heavily stigmatized diagnosis than unipolar.

I absolutely think of bipolar disorder as a spectrum. This is after a couple of experiences with depressed individuals who reported a mild degree of cyclothymia but were generally high functioning and didn't meet criteria for bipolar II. In both cases I decided to go ahead and put them on unopposed antidepressants. One ended up in the hospital with psychotic urges to kill his dog and the other had a full manic episode while conveniently out of the country. Never again. If I get a whiff of bipolarity I won't do antidepressant alone, even if full criteria are not met. The risks are just too high.

 

[hallowmann]

I have this discussion not infrequently - many of my clinic patients come from the community mental health system (which, by the way, only treats patients with diagnoses of MDD, bipolar disorder, schizophrenia, and schizoaffective disorder - I'll let you imagine what that means with respect to diagnoses) with all kinds of crazy diagnoses that are totally inaccurate. I will sometimes get some resistance about the diagnosis, but I haven't had the experience of people "pursuing" mood stabilizers/antipsychotics. Most people are happy to get off the medications when I tell them that they're not necessary.

Had a borderline patient recently pitch a fit when I questioned her bipolar diagnosis and her current antipsychotic regimen. In complete seriousness, she started yelling and saying that she "felt a manic episode coming on" because I wouldn't give her her atypical. She is not the first. I'm actually amazed at the number of borderline patients that come in with a "bipolar" diagnosis.

1. It provides a fantastic medium for facilitation of avoidance and helps superficially dissipate psychological distress when not confronting the more unpleasant reasons for their suffering.
2. Medications, especially “heavy” or “dangerous” medications, gives further validation to their conditions.
3. Medications provide an external anchor to which they can tether, having no confidence, or usually awareness, of their own internal anchors.
4. Medications may have a numbing effect, which plays in to avoidance.
5. As most humans have a drive to find meaning and purpose in their lives, some find that meaning through their suffering and assuming the identity of one who is sick or suffering.
6. Being on more medications helps bolster applications for things like disability or letters for emotional support animals.
7. Being on sedating, mind-dulling medications boosts the argument for why you need an Adderall pick-me-up.

#6 The patient described above, I later discovered was on disability for her bipolar diagnosis, so she had a pretty big incentive to keep that diagnosis and associated scripts on board.

 

[st2205]

So you missed one. The patient described above, I later discovered was on disability for her bipolar diagnosis, so she had a pretty big incentive to keep that diagnosis and associated scripts on board.

See #6.

 

[hallowmann]

See #6.

Haha, thanks, obviously reading comprehension went downhill for me at midnight

 

[Attending1985]

I've never met a patient who *wanted* to have bipolar disorder and didn't. I have met a lot who had it and didn't want to believe/accept it. It seems to be a much more heavily stigmatized diagnosis than unipolar.

I absolutely think of bipolar disorder as a spectrum. This is after a couple of experiences with depressed individuals who reported a mild degree of cyclothymia but were generally high functioning and didn't meet criteria for bipolar II. In both cases I decided to go ahead and put them on unopposed antidepressants. One ended up in the hospital with psychotic urges to kill his dog and the other had a full manic episode while conveniently out of the country. Never again. If I get a whiff of bipolarity I won't do antidepressant alone, even if full criteria are not met. The risks are just too high.

I agree there is a certain biology who should not be put on antidepressants but does this mean they’re bipolar? Would they ever have become manic if antidepressant treatment was not utilized?

 

[tr]

I agree there is a certain biology who should not be put on antidepressants but does this mean they’re bipolar? Would they ever have become manic if antidepressant treatment was not utilized?

Presumably not, which is why I think the spectrum theory makes sense. There seem to be these people who have a very mild bipolar diathesis that wouldn't ever have become frankly hypo/manic without a specific precipitant. They don't fully meet criteria for bipolar I or II, but they certainly aren't unipolar. Hence, spectrum.

This is true for other psychiatric disorders as well (broader autism phenotype, etc.), I don't know why bipolar disorder would be an exception.

 

[Shikima]

"It's my bipolar acting up." "I'm manic because I'm up one minute and down the next." "Nothing works for except for (x)."
10 Billion inpt discharges with F31.xx diagnoses.

 

[randomdoc1]

Presumably not, which is why I think the spectrum theory makes sense. There seem to be these people who have a very mild bipolar diathesis that wouldn't ever have become frankly hypo/manic without a specific precipitant. They don't fully meet criteria for bipolar I or II, but they certainly aren't unipolar. Hence, spectrum.

This is true for other psychiatric disorders as well (broader autism phenotype, etc.), I don't know why bipolar disorder would be an exception.

I have seen this before too, more with SNRIs but some have had most therapeutic response on an SSRI after trials of mood stabilizer and atypicals. Fortunately I don’t encounter these less straightforward cases very often. So there really isn’t a one size fits all. Stahl illustrates the spectrum model in one of his books as well.

 

[Attending1985]

Presumably not, which is why I think the spectrum theory makes sense. There seem to be these people who have a very mild bipolar diathesis that wouldn't ever have become frankly hypo/manic without a specific precipitant. They don't fully meet criteria for bipolar I or II, but they certainly aren't unipolar. Hence, spectrum.

This is true for other psychiatric disorders as well (broader autism phenotype, etc.), I don't know why bipolar disorder would be an exception.

The issue I take with it is taking a phenomenon that could simply be an adverse medication reaction and assign a chronic illness label. Chronic illness leads to chronic treatment which may be unnecessary and harmful.

 

[randomdoc1]

1. It provides a fantastic medium for facilitation of avoidance and helps superficially dissipate psychological distress when not confronting the more unpleasant reasons for their suffering.
2. Medications, especially “heavy” or “dangerous” medications, gives further validation to their conditions.
3. Medications provide an external anchor to which they can tether, having no confidence, or usually awareness, of their own internal anchors.
4. Medications may have a numbing effect, which plays in to avoidance.
5. As most humans have a drive to find meaning and purpose in their lives, some find that meaning through their suffering and assuming the identity of one who is sick or suffering.
6. Being on more medications helps bolster applications for things like disability or letters for emotional support animals.
7. Being on sedating, mind-dulling medications boosts the argument for why you need an Adderall pick-me-up.

This may already be part of number 3...but some patients seem to just want a pill to "fix" things. I see it in borderline patients who are resistant to appropriate therapies because yes, it does take some work versus being fixed with a pill. Many times when I see patients who don't want to adopt lifestyle changes including therapy and work on their part, they start looking for alternative diagnoses to throw more pills at. So many end up on that uppers, with downers, polypharm nightmare and then you just can't tell dipsquat until all the polypharm is cleared out first. Often times a full washout is what is needed to clear the air and start from scratch but most times patients don't want to do that. Of course, the cases where I was able to clear it up for patients, those are tremendously satisfying.

 

[Attending1985]

This may already be part of number 3...but some patients seem to just want a pill to "fix" things. I see it in borderline patients who are resistant to appropriate therapies because yes, it does take some work versus being fixed with a pill. Many times when I see patients who don't want to adopt lifestyle changes including therapy and work on their part, they start looking for alternative diagnoses to throw more pills at. So many end up on that uppers, with downers, polypharm nightmare and then you just can't tell dipsquat until all the polypharm is cleared out first. Often times a full washout is what is needed to clear the air and start from scratch but most times patients don't want to do that. Of course, the cases where I was able to clear it up for patients, those are tremendously satisfying.

quote from patient last week “my husband has borderline personality disorder but no doctor has been able to fix him.” She also has BPD her therapist and I are working together on this but unfortunately has been diagnosed with bipolar spectrum in the past and is stuck on this.

 

[randomdoc1]

quote from patient last week “my husband has borderline personality disorder but no doctor has been able to fix him.” She also has BPD her therapist and I are working together on this but unfortunately has been diagnosed with bipolar spectrum in the past and is stuck on this.

That's when I pull out the lecture about how many psychiatric cases can have comorbidities but there is usually a primary disorder. Standard is to especially address the primary disorder. Even if she had some bipolarity in her, there are plenty of patients with legit mood disorders that benefit from DBT and other therapy modalities. Still not a free pass to look to meds to fix things in my book, no siree...

I also explore with them that, this med only route (maybe with passive investment in therapy) does not seem to be working we need to try other modalities. I often make an analogy with diabetes. For example, let's say you are on insulin, tried different insulin regimens and that darn blood glucose is still too high. Well...time to get more strict about those diet changes. Or would they still want to keep eating burgers and fries and slowly fry off their entire vascular system and all the end organs? You can still try to rely on insulin alone, but the facts are the facts and it ain't gettin' you nowheres...

 

[clausewitz2]

That's when I pull out the lecture about how many psychiatric cases can have comorbidities but there is usually a primary disorder. Standard is to especially address the primary disorder. Even if she had some bipolarity in her, there are plenty of patients with legit mood disorders that benefit from DBT and other therapy modalities. Still not a free pass to look to meds to fix things in my book, no siree...

I also explore with them that, this med only route (maybe with passive investment in therapy) does not seem to be working we need to try other modalities. I often make an analogy with diabetes. For example, let's say you are on insulin, tried different insulin regimens and that darn blood glucose is still too high. Well...time to get more strict about those diet changes. Or would they still want to keep eating burgers and fries and slowly fry off their entire vascular system and all the end organs? You can still try to rely on insulin alone, but the facts are the facts and it ain't gettin' you nowheres...

Where on Earth do you practice that your patients have reliable access to an adherent DBT team, an MBT team, or Transference-Focused therapists? A workbook and a DBT skills group is helpful but is in no sense of the word a specific or hugely effective treatment for true BPD.

Yeah, actual therapy would be best, but it requires specialized practitioners with a very high risk tolerance. It is highly likely that your BPD patients have had the experience of therapists finding out about their history in an intake and running screaming in the other direction. Polypharmacy with limited utility is not a good thing, but I get the temptation if it's not clear what else they ought to be doing.

Maybe your neck of the woods has plenty of the appropriate resources, but I struggle to identify good referrals for these folks. We had a former resident who went so far as taking the course Kernberg and Yeomans offer in TFT with plans to open a private practice focusing on just these people, but no luck yet.

 

[randomdoc1]

Where on Earth do you practice that your patients have reliable access to an adherent DBT team, an MBT team, or Transference-Focused therapists? A workbook and a DBT skills group is helpful but is in no sense of the word a specific or hugely effective treatment for true BPD.

Yeah, actual therapy would be best, but it requires specialized practitioners with a very high risk tolerance. It is highly likely that your BPD patients have had the experience of therapists finding out about their history in an intake and running screaming in the other direction. Polypharmacy with limited utility is not a good thing, but I get the temptation if it's not clear what else they ought to be doing.

Maybe your neck of the woods has plenty of the appropriate resources, but I struggle to identify good referrals for these folks. We had a former resident who went so far as taking the course Kernberg and Yeomans offer in TFT with plans to open a private practice focusing on just these people, but no luck yet.

I'm fortunate enough that there's 3 DBT adherent programs in my city 😀. My favorite one though, does have a 3-6 month waiting list and there is also one provided by the county but they do accept commercial insurance. The latter is very time intensive, like a PHP basically but for up to several weeks, so that can be a barrier for some. They have a good track record though for helping some of the most challenging cases in the city. There is also a residential DBT adherent program in the next city over, but it's women only.

 

[Stagg737]

I've never met a patient who *wanted* to have bipolar disorder and didn't. I have met a lot who had it and didn't want to believe/accept it. It seems to be a much more heavily stigmatized diagnosis than unipolar.

I absolutely think of bipolar disorder as a spectrum. This is after a couple of experiences with depressed individuals who reported a mild degree of cyclothymia but were generally high functioning and didn't meet criteria for bipolar II. In both cases I decided to go ahead and put them on unopposed antidepressants. One ended up in the hospital with psychotic urges to kill his dog and the other had a full manic episode while conveniently out of the country. Never again. If I get a whiff of bipolarity I won't do antidepressant alone, even if full criteria are not met. The risks are just too high.

I've been taught not to place individuals with bipolar on unopposed SSRI's do to the potential for throwing them into a manic/psychotic state, but I thought the actual research on whether this phenomenon was actually due to antidepressants was mixed. Are there any decent papers or articles showing that antidepressants have a higher risk of precipitating mania than other medications?

I'm actually amazed at the number of borderline patients that come in with a "bipolar" diagnosis.

It's dat rapid cycling bipolar all the FMs keep telling me about! /sarcasm

Presumably not, which is why I think the spectrum theory makes sense. There seem to be these people who have a very mild bipolar diathesis that wouldn't ever have become frankly hypo/manic without a specific precipitant. They don't fully meet criteria for bipolar I or II, but they certainly aren't unipolar. Hence, spectrum.

This is true for other psychiatric disorders as well (broader autism phenotype, etc.), I don't know why bipolar disorder would be an exception.

If a precipitant causes them to become hypo/manic though, wouldn't that automatically qualify them as bipolar assuming that precipitant wasn't a drug with that potential effect? And if they can't become manic without that precipitant, wouldn't that fail to meet the criteria for "not otherwise caused by another medical condition or medication/substance"?

I guess I'm asking is how would you then differentiate between being on the bipolar spectrum from MDD/another depressive disorder with concomitant substance-induced mania? It seems like a pretty blurred line that you can't define without multiple treatment rounds and trial and error.

 

[st2205]

Last I reviewed, data seems fairly split on whether or not the switch thing is as big as assumed. In any case, I’m highly skeptical of bipolar disorder (at least the way it’s diagnosed), even in research, and I’d have to presume not having real, true bipolar 1 cases would add a lot of noise about that.

That being said, I’ve only seen a legit switch to mania (that I’ve been aware of) 3 times, each being an SNRI, and each resulting in psychosis. The third one came in to clinic last week. Each time it’s been someone diagnosed with anxiety, started on an SNRI by someone, they get worse and thebdise is increased, and by the time they see me they’re psychotic.

I remember seeing some data about Wellbutrin not being associated with switching, which makes little sense theoretically, but I’ve gotten more comfortable using it with people that have a history of mania.

 

[randomdoc1]

Last I reviewed, data seems fairly split on whether or not the switch thing is as big as assumed. In any case, I’m highly skeptical of bipolar disorder (at least the way it’s diagnosed), even in research, and I’d have to presume not having real, true bipolar 1 cases would add a lot of noise about that.

That being said, I’ve only seen a legit switch to mania (that I’ve been aware of) 3 times, each being an SNRI, and each resulting in psychosis. The third one came in to clinic last week. Each time it’s been someone diagnosed with anxiety, started on an SNRI by someone, they get worse and thebdise is increased, and by the time they see me they’re psychotic.

I remember seeing some data about Wellbutrin not being associated with switching, which makes little sense theoretically, but I’ve gotten more comfortable using it with people that have a history of mania.

Likewise. I rarely see true antidepressant induced mania and all the ones I did see were SNRI. I have seen SNRI induced very suggestive manic symptoms on people with no prior known history of mania or hypomania but fortunately that's been very rare. Uptodate mentions it happens more with SNRI, TCA. I think it also mentions that SSRI and bupropion are just as likely to do it as a placebo? Every SSRI induced "mania" were pretty much anxious folks or very personality disordered or SUDs. The studies on bipolar period have a lot of noise in them, it's such a hard diagnosis to make reliably unless it's frank obvious raging mania. I thought I read somewhere that it is highly comorbid with borderline personality disorder which makes me wonder, how the heck can you tell which is the bipolar and which is the borderline personality disorder?! Then you lump people who may have comorbid personality disorder in the studies and bleh.....

 

[st2205]

Likewise. I rarely see true antidepressant induced mania and all the ones I did see were SNRI. I have seen SNRI induced very suggestive manic symptoms on people with no prior known history of mania or hypomania but fortunately that's been very rare. Uptodate mentions it happens more with SNRI, TCA. I think it also mentions that SSRI and bupropion are just as likely to do it as a placebo? Every SSRI induced "mania" were pretty much anxious folks or very personality disordered or SUDs. The studies on bipolar period have a lot of noise in them, it's such a hard diagnosis to make reliably unless it's frank obvious raging mania. I thought I read somewhere that it is highly comorbid with borderline personality disorder which makes me wonder, how the heck can you tell which is the bipolar and which is the borderline personality disorder?! Then you lump people who may have comorbid personality disorder in the studies and bleh.....

Saying bipolar is comorbid with borderline PD is about as valuable as simply saying they’re just borderline PD. I couldn’t think of a better pairing where one diagnosis would almost be a rule out of the other without being mutually exclusive. I’ve really only seen a couple true cases of both.

 

[FlowRate]

I've been taught not to place individuals with bipolar on unopposed SSRI's do to the potential for throwing them into a manic/psychotic state, but I thought the actual research on whether this phenomenon was actually due to antidepressants was mixed. Are there any decent papers or articles showing that antidepressants have a higher risk of precipitating mania than other medications?



It's dat rapid cycling bipolar all the FMs keep telling me about! /sarcasm



If a precipitant causes them to become hypo/manic though, wouldn't that automatically qualify them as bipolar assuming that precipitant wasn't a drug with that potential effect? And if they can't become manic without that precipitant, wouldn't that fail to meet the criteria for "not otherwise caused by another medical condition or medication/substance"?

I guess I'm asking is how would you then differentiate between being on the bipolar spectrum from MDD/another depressive disorder with concomitant substance-induced mania? It seems like a pretty blurred line that you can't define without multiple treatment rounds and trial and error.

The best evidence is that TCA's can induce rapid switching.

The rest of the evidence is poor, especially for SSRI's "inducing" mania.

(This is not from a completely exhaustive personal search, but I have looked into it to some degree.)

 

[Ceke2002]

I thought I read somewhere that it is highly comorbid with borderline personality disorder which makes me wonder, how the heck can you tell which is the bipolar and which is the borderline personality disorder?! Then you lump people who may have comorbid personality disorder in the studies and bleh.....

Anecdotal, I know, but a late friend of mine did have a bonafide comorbid diagnosis of bipolar and borderline PD, and the difference between the two presentations was both stark and obvious. Mind you I've also known several other people who have claimed a comorbid diagnosis of bipolar and BPD, when that hasn't really been the case. In this instance though, yeah let's just say I don't know too many borderlines who end up being placed on repeated sections, of longer than 6 months, on a locked psych ward.

 

[tr]

If a precipitant causes them to become hypo/manic though, wouldn't that automatically qualify them as bipolar assuming that precipitant wasn't a drug with that potential effect? And if they can't become manic without that precipitant, wouldn't that fail to meet the criteria for "not otherwise caused by another medical condition or medication/substance"?

I guess I'm asking is how would you then differentiate between being on the bipolar spectrum from MDD/another depressive disorder with concomitant substance-induced mania? It seems like a pretty blurred line that you can't define without multiple treatment rounds and trial and error.

These are good questions. I don't have data--based answers for them.

My gut feeling is that if you are talking about a short-term mania-like episode induced by acute intoxication with a stimulant like cocaine or amphetamine that resolves when the period of intoxication is over, then yeah, anyone can have that. But if you are talking about an extended period of mania induced by an antidepressant that lasts 4+ days after the drug is washed out then I think that's a strong suggestion that the person is on the bipolar spectrum.

The two cases I mentioned were both SSRI induced (monotherapy). One was previously medication naive, but had a clear cyclothymic pattern that had been managed by keeping regular hours and living a low stress life with regular exercise in a pleasant climate. The problems arose when this situation was disrupted by initiation of overnight shift work, resulting first in depression and then switching to psychotic mania after initiation of SSRI.

The other had recurring depression and previous exposure to SSRIs without manic results (but also without particularly much benefit) plus one previous episode of steroid-induced mania. I think the mania in this case resulted from a combo of pushing the SSRI dose combined with circadian disruption (air travel across multiple time zones).

Both were high functioning and neither was personality disordered. I really don't often see bipolar and BPD confused. It may help that we have excellent DBT resources here and BPD is not too terribly stigmatized. But really, personality disorders are by definition chronic, not cyclic. That doesn't seem like such a tough call to make?

 

[FlowRate]

In this instance though, yeah let's just say I don't know too many borderlines who end up being placed on repeated sections, of longer than 6 months, on a locked psych ward.

This definitely happens for both good and bad reasons. Some of my most debilitated patients were borderline (frequent, severe self-injury.)

 

[Ceke2002]

This definitely happens for both good and bad reasons. Some of my most debilitated patients were borderline (frequent, severe self-injury.)

I should probably further clarify then that the hospitalisations were never for the borderline part of her diagnosis. I thought best practice was to not offer or allow repeated hospital admissions for BPD, although yes I do also know some cases where involuntary treatment on a temporary basis has become necessary. Hmm, interesting. 🙂

But yeah it was kinda fascinating, in an incredibly morbid way because of the final outcome, to observe the difference in her when comparing her typical borderline type symptoms, with what she was like when she was in a manic state - sudden bursts of confidence, talk about being on top of the world, she's worked out a way to fix everything, increasingly rapid speech, and then it would progress from that to her becoming increasingly manic/hyperactive, not sleeping for days on end, jumping from one topic to the next so that you could barely follow her pattern of thought, lots of grandiose type ideations, religiosity that was way outside her normal state of beliefs...and that was usually around the point where sometime after we'd get a notification from a friend or family member along the lines of 'Sorry to have to tell you, but E was found wandering the streets half naked and yelling incoherently last night so she was taken to psychiatric hospital XYZ under police escort'.

 

[FlowRate]

repeated hospital admissions for BPD

Right, if they can generally keep themselves relatively safe/alive outside of the hospital.

But when they're "addicted to death" in a way that's not just provocative, it's a little tough to justify not putting them in a hospital.

 

[Georgit]

There is too much inside the category of BD

I rarely see true antidepressant induced mania and all the ones I did see were SNRI. I have seen SNRI induced very suggestive manic symptoms on people with no prior known history of mania or hypomania

With abuse substances, NET/DAT inibitors ( MDPV is infamous for this) are more prone to give psychosis and raging mania than SERT/DAT inibitors like methamphetamine.

 

[Georgit]

increasingly rapid speech, and then it would progress from that to her becoming increasingly manic/hyperactive, not sleeping for days on end, jumping from one topic to the next so that you could barely follow her pattern of thought

Very hort attention span and be reckless, that is what strikes me more in a case of medicated BD I
In a way childsh, free of troubles living the moment. But childs needs someone taking care of them and sometimes forcing them to attend to their duties.... this could take the patients to an involuntary treatmen, the word "bipolar" is a fad but the real diaseas can be severe.

 

[Stagg737]

These are good questions. I don't have data--based answers for them.

My gut feeling is that if you are talking about a short-term mania-like episode induced by acute intoxication with a stimulant like cocaine or amphetamine that resolves when the period of intoxication is over, then yeah, anyone can have that. But if you are talking about an extended period of mania induced by an antidepressant that lasts 4+ days after the drug is washed out then I think that's a strong suggestion that the person is on the bipolar spectrum.

The two cases I mentioned were both SSRI induced (monotherapy). One was previously medication naive, but had a clear cyclothymic pattern that had been managed by keeping regular hours and living a low stress life with regular exercise in a pleasant climate. The problems arose when this situation was disrupted by initiation of overnight shift work, resulting first in depression and then switching to psychotic mania after initiation of SSRI.

The other had recurring depression and previous exposure to SSRIs without manic results (but also without particularly much benefit) plus one previous episode of steroid-induced mania. I think the mania in this case resulted from a combo of pushing the SSRI dose combined with circadian disruption (air travel across multiple time zones).

Both were high functioning and neither was personality disordered. I really don't often see bipolar and BPD confused. It may help that we have excellent DBT resources here and BPD is not too terribly stigmatized. But really, personality disorders are by definition chronic, not cyclic. That doesn't seem like such a tough call to make?

Interesting, those cases make me curious as to whether the sleep disturbances would have precipitated true mania or psychosis on their own even without an SSRI had they been allowed to go on long enough though. It makes me wonder how common it may be for patients to have such mild bipolar disorder than they need to be put under very significant stress to precipitate mania even once. I'm also hesitant about that though because I don't want to lend credence the the idea of patients who say they have "a touch of bipolar disorder" as I don't want to unnecessarily give people such labels when they may not be correct.

 

[Ceke2002]

Very hort attention span and be reckless, that is what strikes me more in a case of medicated BD I
In a way childsh, free of troubles living the moment. But childs needs someone taking care of them and sometimes forcing them to attend to their duties.... this could take the patients to an involuntary treatmen, the word "bipolar" is a fad but the real diaseas can be severe.

Childish, or childlike is a good way to describe it actually; like a kid standing on top of a fort shouting 'I'm the king of the castle', before jumping off and not realising they're about to break something. It was kind of like watching the brakes come off of someone's brain. Not that I have any actual training in either medicine or therapy either, but I always found I had a very different internal response to someone who was simply emotionally dysregulated vs someone who was in a state of mania - being around someone who was emotionally dysregulated would induce feelings of stress, anxiety, and finally just sheer frustration, but being around or witnessing someone in a manic state was more like this sense of having a Mack truck barrelling towards me.

And yes, the real disease can be very severe, and having seen it first hand with a couple of people I will never understand the desire for someone to have the illness when they don't actually have it. The friend I spoke about above took her own life back in the early 2000s, and the other person (male) that I knew spent his life going back and forth between the streets, halfway houses, and hospital. Hmm yeah, gimme some of that, that's totally the sort of life I want to be leading. 🙄

 

[nancysinatra]

1. It provides a fantastic medium for facilitation of avoidance and helps superficially dissipate psychological distress when not confronting the more unpleasant reasons for their suffering.
2. Medications, especially “heavy” or “dangerous” medications, gives further validation to their conditions.
3. Medications provide an external anchor to which they can tether, having no confidence, or usually awareness, of their own internal anchors.
4. Medications may have a numbing effect, which plays in to avoidance.
5. As most humans have a drive to find meaning and purpose in their lives, some find that meaning through their suffering and assuming the identity of one who is sick or suffering.
6. Being on more medications helps bolster applications for things like disability or letters for emotional support animals.
7. Being on sedating, mind-dulling medications boosts the argument for why you need an Adderall pick-me-up.

And this is not Munchausens disorder... because???

 

[nancysinatra]

I am thinking of a case I recently discharged. The patient who presented with his mother. Dozens of weeks later of intensive therapy and mood stabilizers and antipsychotics later by the quack who labeled him as bipolar he's now severely depressed, numb, and sleeping a lot. Mother now asking for Provigil. I said, let's first check TFTs and make sure his OSA is well controlled. Also make sure he's not actually over medicated and this already obese patient is not gaining more weight from these meds before adding on yet another medication. He's been followed closely by multiple psychiatrists and one said he really should just be started on an SSRI. As a matter of fact, sounds like multiple psychiatrists challenged this whole "bipolar" bull but mom is still clinging to the diagnosis and says if you put multiple psychiatrists in a room, they'll all have a different opinion so it's still possible he's bipolar and that means he must be bipolar. Mom says no to SSRIs because of the "bipolar". I told them I am in the process of starting my own practice anyways and won't be able to provide the level of care he needs, but I encouraged him to keep following with me until his appointment with his new psychiatrist. They cancelled their appointments. I was frank with patient and the mother, I said I'm really not convinced he's bipolar to the point that the mood stabilizer and antipsychotic he is on is a good match for him. If anything, he's now severely depressed. Not to mention he still has very primitive and maladaptive coping with pronounced borderline traits...I think my initial hunch was right after all. Sheesh.

Munchausens by proxy

 

[nancysinatra]

I find those averse to not having bipolar disorder have an externalizing personality disorder. This is their main defense against accountability and shame and taking that away is unacceptable. I do let these people know I don’t agree with the diagnosis and will not be prescribing high risk medications and recommend therapy.
On the flip side there are also those who are dysregulated and are ok with hearing something else is going on.

That's what I find too. But I would go farther and question why we don't diagnose factitious disorders among individuals who seek out psychiatric diagnoses that don't fit them and treatments(!) that they don't need.

It's also interesting that people here are saying that the see all these people who claim to be bipolar but REALLY, they're just depressed. Because I think you can say the same thing about depression, a lot of the time! A lot of patients come in talking about their "depression" - saying how bad and how untreatable it is - when 9 times out of 10 there's a substance abuse situation going on, or a personality disorder, or a secondary gain issue, or there's been poor medication adherence. I find the true cases of pure MDD to be pretty uncommon, and treatment resistant MDD even rarer, yet people talk about them like they're so common.

 

[nancysinatra]

lol, never mind the parkinsonism, EPS, metabolic syndrome and oh, the progression of the depression to the point where other psychiatrists start recommending ECT...

But it's wrong to misdiagnose for a more basic reason. We are doctors and we should care about always making correct diagnoses! We care about beside manner and empathy in psychiatry, right? But we get a pass on diagnostic accuracy! I have never understood this...

Even if the treatment for two conditions is identical, does that make it ok to misdiagnose one for the other? For example, prednisone is used to treat both asthma and psoriatic arthritis. If you went to the doctor with exercise induced wheezing and they told you you had psoriatic arthritis, BUT just by luck they prescribed prednisone, would that doctor be doing a good job? No of course not.

Similarly a fracture of the radius and the ulna may result in the same treatment - a cast. But what radiologist would keep their job if they consistently confused these conditions?

Granted we don't have x-rays and the DSM doesn't help us out much, and patient histories are often very poor. But still. Bipolar has specific criteria...

 

[clausewitz2]

And this is not Munchausens disorder... because???

Because the psychological distress motivating the quest for this diagnosis is real and not actually simulated/fabricated?