bipolar...

[Attending1985]

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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.

I was thinking yesterday how I rarely diagnose mdd anymore. I completely agree.

 

[Attending1985]

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...

The problem is in bipolar spectrum apparently anything goes. Had trouble sleeping for a few night three years ago? There you go.

 

[Georgit]

What do you think about the cartegory " schizoaffective " ?
I think is another way to say " the nosograpy of this patient is too mixed and I do not really know, we'll see"
I see that Kraeplian dichotomy sometimes fails and some psycosis is possible with mania, but at this point I get confused.
Psychosis in itself is just something observable a phenomena that can result from many things ( sleep deprivation, substanze abuse, elderly delirium, etc), what it means diagnostically is another matter.

 

[smalltownpsych]

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'.

Decreased need for clothing seems to be a fairly specific indicator of mania. The best indicator for Borderline is how all of the same gendered staff can't stand him or her.

 

[tr]

Bipolar has specific criteria...

Yes but because we have limited/no pathophysiology for most of the disorders we treat, our diagnoses are based on symptom clusters, and there will always be an element of arbitrariness to that. Why four days and not three, or five?

A lot of what we are doing is 'carving nature at the joints,' i.e. creating arbitrary boundaries within spectra of symptoms in order to be able to assign a diagnosis.

 

[clausewitz2]

What do you think about the cartegory " schizoaffective " ?
I think is another way to say " the nosograpy of this patient is too mixed and I do not really know, we'll see"
I see that Kraeplian dichotomy sometimes fails and some psycosis is possible with mania, but at this point I get confused.
Psychosis in itself is just something observable a phenomena that can result from many things ( sleep deprivation, substanze abuse, elderly delirium, etc), what it means diagnostically is another matter.

What I mean by schizoaffective is "most of the time this person looks typically schizophrenic except the discrete episodes during which they are clearly manic/crushingly depressed"

 

[Ceke2002]

Decreased need for clothing seems to be a fairly specific indicator of mania. The best indicator for Borderline is how all of the same gendered staff can't stand him or her.

By all reports most of the hospital staff who treated her long term came to develop quite a close bond, she was one of the only borderlines I've known (including myself) who I didn't want to cheerfully strangle at least once. And yeah she got found wandering about in all manner of states of dress, or undress: she'd get these urges to go spread some sort of message (that I think made sense to noone but her), which often meant walking out of her house in whatever she had on at the time.

But yeah, I have heard that saying about indicators for Borderline being how much the same gendered staff dislike a patient - seen it a few times visiting friends inpatient as well (the loud huffing and groaning and obvious eye rolling annoyance at the patient throwing yet another manipulative fit was usually a dead give away). 😉

 

[splik]

What I mean by schizoaffective is "most of the time this person looks typically schizophrenic except the discrete episodes during which they are clearly manic/crushingly depressed"

but that is expressedly not schizoaffective disorder as defined in the DSM. depression is part of schizophrenia (post-schizophrenia depression) and mania and hypomania can occur in the course of schizophrenia or be antipsychotic-induced. sometimes the tardive dysmentia syndrome is mistaken for hypomania. more common that all of that is the significant minority of patients who have, at different points in times with complete discontinuity episodes of both affective and non-affective psychoses who do not meet narrow criteria for schizoaffective disorder so defined. you wont find this stuff in the textbooks but there is literature on all of this and the psychosis experts will tell you this. of course, much of this is mental masturbation because it is largely irrelevant whether we call something "schizophrenia" or "schizoaffective disorder", neither of which are anything more than bogus constructs with little utility.

 

[clausewitz2]

of course, much of this is mental masturbation because it is largely irrelevant whether we call something "schizophrenia" or "schizoaffective disorder", neither of which are anything more than bogus constructs with little utility.

This is the most compelling point.

EDIT: Should also clarify that when I said "crushingly depressed" I did not mean something like low mood or a touch of anhedonia, but something much more severe with prominent neurovegetative component of some kind or perhaps psychotic guilt/nihilistic delusions. Struggling to put it into a precise (and concise) description, but my mental model of "may have a dramatic response to antidepressants" v. "I guess if you look at 10,000 people like this antidepressants have an effect that clears p = .05".

 

[randomdoc1]

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

Isn't that the same for those who do have Munchausens though? I mean, people with the disorder generally do have some psychological distress...
nancysinatra does make a very interesting point

 

[clausewitz2]

Isn't that the same for those who do have Munchausens though? I mean, people with the disorder generally do have some psychological distress...
nancysinatra does make a very interesting point

People with factitious disorder generally are simulating or deliberately manufacturing a physical symptom that they would not otherwise have without clearly identifiable external reward, possibly due to psychological distress. People who probably actually are better conceptualized as BPD who want a bipolar diagnosis have significant psychological distress and are simply making a mistake in their identification of what the problem is.

There are certainly cases of factitious disorder where psychological symptoms are being simulated but unless you feel that everyone with BPD is faking their mood instability, it's not at all the same thing.

 

[randomdoc1]

People with factitious disorder generally are simulating or deliberately manufacturing a physical symptom that they would not otherwise have without clearly identifiable external reward, possibly due to psychological distress. People who probably actually are better conceptualized as BPD who want a bipolar diagnosis have significant psychological distress and are simply making a mistake in their identification of what the problem is.

There are certainly cases of factitious disorder where psychological symptoms are being simulated but unless you feel that everyone with BPD is faking their mood instability, it's not at all the same thing.

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

Especially in my residency where there was a lot of bpd and also in this case, I’ve seen docs explain why their disorder is bpd and not bipolar. After they are told what bipolar disorder is, their history magically changes. When they are challenged and it is discussed, they still insist bipolar and to be treated as such or even doctor shop until they find one who will play along. It sounds factitious to me, and falsification of sx does include exaggeration or downright changing the story which I have seen. Of course it is a fine call to make and depends on the individual case. Either way, goal is to educate the patient and avoid causing harm. I suppose you can have both bpd and factitious disorder.

I also thought the factitious family tends to be associated with personality pathology? Especially borderline. In the DSM V it mentions to consider that in the ddx.

Mood instability is a cardinal feature of bpd, I never question their reports of mood dysregulation.

 

[clausewitz2]

Especially in my residency where there was a lot of bpd and also in this case, I’ve seen docs explain why their disorder is bpd and not bipolar. After they are told what bipolar disorder is, their history magically changes. When they are challenged and it is discussed, they still insist bipolar and to be treated as such or even doctor shop until they find one who will play along. It sounds factitious to me, and falsification of sx does include exaggeration or downright changing the story which I have seen. Of course it is a fine call to make and depends on the individual case. Either way, goal is to educate the patient and avoid causing harm. I suppose you can have both bpd and factitious disorder.

I also thought the factitious family tends to be associated with personality pathology? Especially borderline. In the DSM V it mentions to consider that in the ddx.

Mood instability is a cardinal feature of bpd, I never question their reports of mood dysregulation.

I see your point, but another cardinal feature of bpd is instability or diffusion of identity. I've also encountered what you're describing, and I am not sure if I conceptualize it more as the person in question reacting to a profound threat to the shred of identity that they have managed to cling on to, or whether it is possibly a psychotic regression/micro-psychotic episode. This distorted perception of reality, history, and the environment when under stress is exactly why it was called "borderline" in the first place, after all.

 

[nancysinatra]

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

How can you tell?

 

[nancysinatra]

People with factitious disorder generally are simulating or deliberately manufacturing a physical symptom that they would not otherwise have without clearly identifiable external reward, possibly due to psychological distress. People who probably actually are better conceptualized as BPD who want a bipolar diagnosis have significant psychological distress and are simply making a mistake in their identification of what the problem is.

There are certainly cases of factitious disorder where psychological symptoms are being simulated but unless you feel that everyone with BPD is faking their mood instability, it's not at all the same thing.

I have never seen a case of Munchausens where the person didn’t also have an Axis II disorder. There is a lot of overlap. I personally feel that when a borderline or narcissistic patient is demanding to be diagnosed as bipolar, and demanding to get the treatment, and “endorsing” the symptoms despite lack of objective examples, that’s Munchausen’s (unless it’s blatant malingering.) But it’s sure not normal human behavior.

 

[nancysinatra]

People with factitious disorder generally are simulating or deliberately manufacturing a physical symptom that they would not otherwise have without clearly identifiable external reward, possibly due to psychological distress. People who probably actually are better conceptualized as BPD who want a bipolar diagnosis have significant psychological distress and are simply making a mistake in their identification of what the problem is.

There are certainly cases of factitious disorder where psychological symptoms are being simulated but unless you feel that everyone with BPD is faking their mood instability, it's not at all the same thing.

Would you parse things so finely if your borderline patient came in and surreptitiously injected themselves with E. coli infected peanut butter via a catheter they hid in their purse (based on a real example by the way)? No, in that case you would easily dx them with both borderline pd and factitious d/o. So why can’t the person who tries to trick you into dx’ing bipolar also be borderline and factitious?

I almost never put psychological factitious d/o in the chart, but I think it’s there, whenever someone wants a dx they would be better off without, assuming their motive is not pure ignorance or misinformation.

 

[clausewitz2]

Would you parse things so finely if your borderline patient came in and surreptitiously injected themselves with E. coli infected peanut butter via a catheter they hid in their purse (based on a real example by the way)? No, in that case you would easily dx them with both borderline pd and factitious d/o. So why can’t the person who tries to trick you into dx’ing bipolar also be borderline and factitious?

I almost never put psychological factitious d/o in the chart, but I think it’s there, whenever someone wants a dx they would be better off without, assuming their motive is not pure ignorance or misinformation.

I mean, a huge difference is that the person suffering from borderline personality disorder is seeking an explanation for very real psychological distress. It is much less like your peanut butter example and much more like someone with gait instability who insists they have, say, multiple sclerosis despite good neurological evidence that they have progressive supranuclear palsy. The attribution is incorrect, but they did not create or manufacture the symptoms. Factitious d/o as I said can certainly exist in the psychological realm, but it gets very tricky when you are dealing with a borderline personality organization that does have these psychotic regressions and so you can get these pan-endorsements of psychological symptoms. I do not think you should be diagnosing factitious d/o if it is otherwise fully accounted for by another diagnosis, such as BPD.

Now, someone who has otherwise been high-functioning who insists that they are suicidally depressed to gain admission but who on the unit is very cheerful, sociable, laughing and joking and playing video games without a clear external reward, there I am much more comfortable saying it is factitious. Also possibly someone who wants to be seen at the kind of community mental health agency where only certain diagnoses are permitted who starts insisting that they are hearing voices all the time but do not appear to be responding to internal stimuli at all or be in the least distracted.

You may not mean it, but the sense I am getting underpinning a lot of your posts on this topic is a suspicion or belief that people with borderline personality disorder are manufacturing their symptoms or simply lying about their psychological distress. Is that where you're coming from on this?

EDIT: I am also somewhat puzzled by the point about fine parsing - isn't that what psychiatrists ought to be doing? If we don't, go ahead and replace us with NPs who can just churn sequentially through a list of antidepressants and neuroleptics, I don't see that much would be lost.

 

[Crayola227]

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?

Hard to say. I think there's something to either the kindling theory, or just that it can take time for some people to develop into a BPAD dx. It's not like people are sx free before they have that episode where they meet criteria.

For example, I can think of a couple of patients that started with episodes of depression, had medication-induced hypomania from antidepressant treatment, discontinued, yet further down the line started developing hypomanic episodes precipitated seemingly by nothing but Spring sunshine, and eventually full blown manic episodes.

So yes, some will become manic in the absence of antidepressant treatment. And since often this is happening to people in their 20s and early 30s, they may have moved on and you never personally see the transformation from medication induced to true BPAD.