Dx late in life

[MSc44]

How can one Develope a mental illness later in life, like bipolor or other illnesses, im not sure this is possible but i see people write how people in their 40" etc are Dx with stuff like this. I thought this type of stuff shows up in late teens early 20's. I asked a psychiatrist this question and he kind of laughed, told me thats not how it works, said 95 % or those cases are just un diagnosed

he also told me that one can not all of a sudden become bipolor, or worse, if they have had mild forms of dysthymia of OCD for example

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[OldPsychDoc]

How can one Develope a mental illness later in life, like bipolor or other illnesses, im not sure this is possible but i see people write how people in their 40" etc are Dx with stuff like this. I thought this type of stuff shows up in late teens early 20's. I asked a psychiatrist this question and he kind of laughed, told me thats not how it works, said 95 % or those cases are just un diagnosed

he also told me that one can not all of a sudden become bipolor, or worse, if they have had mild forms of dysthymia of OCD for example

Several things happen in our imperfect world:
1) Some people find ways to "tough it out" and cope before it finally becomes too much to handle and they seek help.
2) People may go undiagnosed until late in life--usually when something really bad happens.
3) People find a friendly doctor to diagnose them with "bipolar" or something to justify that their mid-life crisis is really a medical disorder, even if their mood swings and impulsivity don't even remotely approach true diagnostic criteria.
4) People mask their mental illness with use of freely available drugs and alcohol.
5) Occasionally someone develops a late onset disorder, but you'd better damn well rule out brain lesions or metabolic causes first!
6) Etc...

 

[Anasazi23]

I was pretty surprised at the amount of late-onset first break cases that I admitted and cared for in the inpatient unit. A lot more 30's and 40's, even 50's aged first breaks. Of course as is mentioned by OldPsych, I feel at least a good portion of these are folks that "slipped through the psychiatry cracks."

I remember going home one day as a new resident, genuinelly worried that I was missing something serious in a woman in her late 40's who had a manic episode with akithesia-like leg movements. We did a million dollar workup, but came up empty. She got better with a small dose of Seroquel, incidentally. I still think about that case sometimes...wondering if she has a zebra we missed.

 

[psychgeek]

Just make sure you rule EVERYTHING out first. A friend of mine had a patient who was diagnosed with schizophrenia at age 58 after a history of only mild depression. He thought it was BS and wanted to investigate further. The psychiatrist declined. After 6 months of huge doses of antipsychotics a neurologist finally figured out that the patient had Parkinson’s disease and his apparent psychosis was an atypical presentation of dementia. Weird to have the dementia present first in Parkinson’s (esp. at that age), but not as weird as a 58-year-old developing Sz Sx for the first time.

 

[Anasazi23]

Just make sure you rule EVERYTHING out first.

I wish it was just that easy.

 

[psychgeek]

I wish it was just that easy.

I should rephrase. Just make sure you rule out EVERYTHING else when your psych testing is inconsistent with you diagnosis.

 

[Anasazi23]

I should rephrase. Just make sure you rule out EVERYTHING else when your psych testing is inconsistent with you diagnosis.

One of my pet peeves in medicine are lists of differentials. In the medical model, we are trained to always have a long and relevant list of differential diagnoses while we are interviewing the patient and examining them, be they psychiatric or medical. This differential, as test results come back and the exam becomes more focues, narrows. Even after this, you are often left with an alarmingly large differential, which would cost tens of thousands to rule out all concomitantly.

This is not feasible on a large scale. An expression we have in medicine is, "Common things are common." Meaning, don't assume zebra diagnoses first (another medical moniker). It's always the sad misdiagnosis story that gets the press, and understandibly yet unfortunately so.

I don't perform a somatostatin receptor scintigraphy or 24-hour urinary 5-hydroxyindolacetic acid test to rule out carcinoid syndrome on every young woman with anxiety disorder. Should I? The family members of a misdiagnosed patient would think so, I suppose.

 

[50960]

I saw a supposed bipolar woman yesterday, who is clearly schizophrenic. The pathogenesis is right on, and her sx are classic, but somehow this Dx has been missed based on a little quirk in her pathology/delusions in which she always appears manic when hospitalized. It happens..

 

[psychgeek]

One of my pet peeves in medicine are lists of differentials. In the medical model, we are trained to always have a long and relevant list of differential diagnoses while we are interviewing the patient and examining them, be they psychiatric or medical. This differential, as test results come back and the exam becomes more focues, narrows. Even after this, you are often left with an alarmingly large differential, which would cost tens of thousands to rule out all concomitantly.

This is not feasible on a large scale. An expression we have in medicine is, "Common things are common." Meaning, don't assume zebra diagnoses first (another medical moniker). It's always the sad misdiagnosis story that gets the press, and understandibly yet unfortunately so.

I don't perform a somatostatin receptor scintigraphy or 24-hour urinary 5-hydroxyindolacetic acid test to rule out carcinoid syndrome on every young woman with anxiety disorder. Should I? The family members of a misdiagnosed patient would think so, I suppose.

This particular case manages to piss me off because it involves several of my pet peeves.

1) People! Don’t order diagnostic psych testing if you are planning to ignore results that are inconsistent with your initial diagnosis. It just wastes our time, the patient’s time, and makes you really easy to sue.
2) I can’t stand it when clinicians get married to their initial diagnostic impressions. You don’t know your client nearly as well as you think you do after a 60 minute intake.
3) Consideration of base rates in diagnosis requires that one consider multivariate base rates. Moderate mental ******ation is not terribly rare – neither is Asperger’s. The two together are unheard of.

Misdiagnoses happen all of the time, and often nobody is to blame. Of course you can’t rule out everything when presented with a complicated case, but go ahead and order the neuro consult, neuropsych testing, or get a second opinion if you are the least bit unsure about a highly unlikely diagnosis. This psychiatrist elected to do none of this and instead gave the client increasingly large doses of antipsychotics which likely accelerated his decline. Really, has anyone ever heard of a patient who functioned without impairment for 58 years and then suddenly developed schizophrenia?

 

[BPKurtz]

I was pretty surprised at the amount of late-onset first break cases that I admitted and cared for in the inpatient unit. A lot more 30's and 40's, even 50's aged first breaks. Of course as is mentioned by OldPsych, I feel at least a good portion of these are folks that "slipped through the psychiatry cracks."

I've read that in women, there is a bimodal age distribution of onset for schizophrenia.

bpkurtz

 

[16846]

Of course you can’t rule out everything when presented with a complicated case, but go ahead and order the neuro consult, neuropsych testing, or get a second opinion if you are the least bit unsure about a highly unlikely diagnosis.

I don't nec. agree with this. If the patient can handle the financial burden (Has decent HI, Willing to spend the money, Is covered under a state/federal/county program) then I don't see a reason not to, but you shouldn't put a patient through all that testing/add. consults if they can't afford the financial burden associated with it.