Fun Female Patient

[hamstergang]

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I'm sorry if what a neurologist told me in dosing for szs was not what you are familiar with. They must be wrong since you are so familiar.

I'm not sure why you were so hurt by my initial post where I asked you to back up your clinical recommendations with some evidence. You keep posting on and on about seizures (still not supporting the doses you first stated), but this thread is about bipolar disorder. When you finally got around to giving the evidence for Lamictal dosing in bipolar disorder, you proved your initial claim incorrect, and yet this is your response? If you don't know how to treat psychiatric disorders, I don't get why you're posting recommendations for doing so.

 

[Crayola227]

I'm not sure why you were so hurt by my initial post where I asked you to back up your clinical recommendations with some evidence. You keep posting on and on about seizures (still not supporting the doses you first stated), but this thread is about bipolar disorder. When you finally got around to giving the evidence for Lamictal dosing in bipolar disorder, you proved your initial claim incorrect, and yet this is your response? If you don't know how to treat psychiatric disorders, I don't get why you're posting recommendations for doing so.

I admitted I was wrong about 300 mg being the studied and recommended dose. It was 200. I am not wrong that I've seen 300 and 400 used off-label and with seemingly good effect and well tolerated.

I guess I had the sense that people were saying "OMG THAT'S SO HIGH!" so I stated the doses used in szs. I said that was 500-800 mg. That's what I've seen. I backed that up talking to a neurologist. I backed up that 400 mg is an introductory dose in seizures with evidence. I backed up that 500 mg was maintenance in szs with evidence. I backed up that higher doses are safely used with evidence.

This thread is about bipolar disorder, but I hardly think it's inappropriate to consider what doses of a drug are safe by considering how it's used elsewhere. That it might not be applicable in another condition is certainly something to consider.

Listen, I just had this conversation with a psych PA, who was freaking out that a patient had gone from 200 mg to 400 mg (with proper titration). (Not my doing). Basically I tried to give her some perspective that 500-800 mg is used by neurologists and no one dies. Some providers are checking lamotrigine levels (just for a baseline, not for targeting) and I don't know what data there is to that, but she did so as well. Maybe it makes her feel better.

 

[Crayola227]

I'm not sure why you were so hurt by my initial post where I asked you to back up your clinical recommendations with some evidence. You keep posting on and on about seizures (still not supporting the doses you first stated), but this thread is about bipolar disorder. When you finally got around to giving the evidence for Lamictal dosing in bipolar disorder, you proved your initial claim incorrect, and yet this is your response? If you don't know how to treat psychiatric disorders, I don't get why you're posting recommendations for doing so.

So where have I not supported the doses I stated? I admitted I was wrong about 300 mg being the introductory dose for bipolar. 100 mg was not recommened. 200 mg was. 400 mg was studied as well and not shown superior, but it was studied.

I did say that I stand by off-label titration to 300 mg or 400 mg of lamictal if tolerated, this is based on my work with psychiatrists that do so.

I said I was not a psychiatrist to say that I am not an expert. Nor do I think general practitioners should be ignorant about approaches to BPAD, depression, or SAD. I have seen PCPs tackle these issues. Numerous times have I seen PCPs refill someone's psych meds. I don't think it's inappropriate for them to consider if a script of 400 mg lamictal is inappropriate when they do so. My point is that it isn't necessarily.

 

[Crayola227]

I also recommended a website that specifically has a section designed for PCPs, that is written by a psychiatrist and with some citations there.

PCPs treat SAD all the time. Why shouldn't they know that caution may be indicated in suspected bipolar spectrum? Many seem to think light therapy is totally safe and benign - even psychiatric providers.

I brought up vitamin D - or is there no longer evidence that it can be linked to depression?

It's like you think it's totally inappropriate for me to offer my perspective based on my own training because I'm not a psychiatrist. I'm a doctor with interest in the topic. I never said I was perfect and I offered some ideas. I put my advice into perspective. I found you the FDA guidelines and you're still unsatisfied.

I'm also offering this perspective about lamictal dosing because when I was in the ICU in residency, we had to manage many psychiatric meds. I was the one to mention the bipolar patient on lamictal needed that home med restarted and not continue to be held past 3 days, and go down the NG tube, because otherwise they would have to re-titrate.

I admitted a patient that got a full body rash from going up on lamictal too fast. I had to convince the attending that we needed to initiate steroids ASAP for concern for SJS and a stat derm consult. It turned out to be DRESS but the derm agreed with my management.

I was involved in another patient's lamotrigine rechallenge after rash that was also due to improper uptitration.

I admitted where I was wrong but I hardly think I have nothing to add on the conversation about handling lamictal.

Many psychiatrists I know would at least increase that lamictal dose from 100 mg to 200 mg. I said I thought it was useless in my opinion, and it seems that the FDA guideline doesn't seem to think so highly of it if it recommends 200 mg. Perhaps there is some evidence of benefits at that dose. If so, great, stay there. Still, if a patient has room for improvement and there is room to go up on this medication to an FDA approved dose, I don't know why you wouldn't, and I'm not sure the why vitriol that it would likely be safe to move up there. There is room to do so.

If people don't want to be in the camp I'm in with other psychiatrists about off-label trialling up to 300 or 400, great.

 

[Merely]

I admitted I was wrong about 300 mg being the studied and recommended dose. It was 200. I am not wrong that I've seen 300 and 400 used off-label and with seemingly good effect and well tolerated.

I guess I had the sense that people were saying "OMG THAT'S SO HIGH!" so I stated the doses used in szs. I said that was 500-800 mg. That's what I've seen. I backed that up talking to a neurologist. I backed up that 400 mg is an introductory dose in seizures with evidence. I backed up that 500 mg was maintenance in szs with evidence. I backed up that higher doses are safely used with evidence.

This thread is about bipolar disorder, but I hardly think it's inappropriate to consider what doses of a drug are safe by considering how it's used elsewhere. That it might not be applicable in another condition is certainly something to consider.

Listen, I just had this conversation with a psych PA, who was freaking out that a patient had gone from 200 mg to 400 mg (with proper titration). (Not my doing). Basically I tried to give her some perspective that 500-800 mg is used by neurologists and no one dies. Some providers are checking lamotrigine levels (just for a baseline, not for targeting) and I don't know what data there is to that, but she did so as well. Maybe it makes her feel better.

So where have I not supported the doses I stated? I admitted I was wrong about 300 mg being the introductory dose for bipolar. 100 mg was not recommened. 200 mg was. 400 mg was studied as well and not shown superior, but it was studied.

I did say that I stand by off-label titration to 300 mg or 400 mg of lamictal if tolerated, this is based on my work with psychiatrists that do so.

I said I was not a psychiatrist to say that I am not an expert. Nor do I think general practitioners should be ignorant about approaches to BPAD, depression, or SAD. I have seen PCPs tackle these issues. Numerous times have I seen PCPs refill someone's psych meds. I don't think it's inappropriate for them to consider if a script of 400 mg lamictal is inappropriate when they do so. My point is that it isn't necessarily.

I also recommended a website that specifically has a section designed for PCPs, that is written by a psychiatrist and with some citations there.

PCPs treat SAD all the time. Why shouldn't they know that caution may be indicated in suspected bipolar spectrum? Many seem to think light therapy is totally safe and benign - even psychiatric providers.

I brought up vitamin D - or is there no longer evidence that it can be linked to depression?

It's like you think it's totally inappropriate for me to offer my perspective based on my own training because I'm not a psychiatrist. I'm a doctor with interest in the topic. I never said I was perfect and I offered some ideas. I put my advice into perspective. I found you the FDA guidelines and you're still unsatisfied.

Many psychiatrists I know would at least increase that lamictal dose from 100 mg to 200 mg. I said I thought it was useless in my opinion, and it seems that the FDA guideline doesn't seem to think so highly of it if it recommends 200 mg. Perhaps there is some evidence of benefits at that dose. If so, great, stay there. Still, if a patient has room for improvement and there is room to go up on this medication to an FDA approved dose, I don't know why you wouldn't, and I'm not sure the why vitriol that it would likely be safe to move up there. There is room to do so.

If people don't want to be in the camp I'm in with other psychiatrists about off-label trialling up to 300 or 400, great.

Holy balls you need to calm down lol

 

[Crayola227]

I think the confusion is that you initially said that 100 mg is "useless" and that one should get to 300 mg and reassess when discussing a bipolar spectrum case. When this was pointed out that this does not match many of our experiences or understanding of lamotrigine for bipolar, you changed your point to being about safety/tolerability and seizure disorders...

Not sure what to think of 100 mg when 200 mg is the official recommendation. Even the study I came across discussing benefit at 50 mg on sleep, and another saying that some response can be seen at 100 with the up-titration, (essentially saying that patients can get benefit before the end of the many weeks it takes to get the dose all the way to 200, and is a positive sign of responsiveness), doesn't convince me that 100 mg is ideal, especially when the latter still suggests that one continue to the dose of 200 mg as tolerated and not stop at 100 mg.

I also, I guess the 4 psychiatrists that I have discussed this with that told me they use 300 mg per the evidence, were just wrong. Sorry. Glad the rest of you knew better and corrected me. I figure that's the point of discourse.

I started discussing safety/tolerability in sz disorders because one person suggested that one would need evidence to go outside the FDA maximums. We clearly don't agree about off-label going beyond 200 mg for bipolar, or that neurologists sometimes go past 500 mg for szs. I know 1,000 mg was studied as well for side effects, not that I propose going there, but possibly considering safety and tolerability people are willing to go beyond the FDA recommendations because they think it's safe. In szs, you have measurable effect in reducing szs. In bipolar disorder, it might be more difficult to measure benefit going beyond 200 mg. Although one must keep in mind effects of medications and OCPs HRTs in dosing.

I agree to disagree that 100 mg is a good dose of lamictal in someone you are treating for bipolar spectrum disorder who has ongoing sx. I was wrong on the FDA recommended dose but not wrong that 100 is lower than recommended. I still think an off-label 300-400 mg is a reasonable trial to do, especially if someone has exogenous estrogen on board. Higher doses are used elsewhere, with 500 being totally reasonable in another condition. Past 500 as I stated is indeed not included in FDA guidelines but I'll let the neurologists figure out when to go past that, but they do. I do actually know of a psychiatrist in an academic setting who has gone up to 600-800 mg for bipolar depression. Controversial move to be sure.

 

[hamstergang]

I started discussing safety/tolerability in sz disorders because one person suggested that one would need evidence to go outside the FDA maximums. We clearly don't agree about off-label going beyond 200 mg for bipolar

It's very difficult to have a discussion with you when you make multiple rambling posts in a row. If you can slow down and plan your posts, I think we can all learn more here.

FDA guidelines are generally (always?) based on evidence. To suggest going to 300mg for bipolar disorder without stopping at the recommended 200mg should require some evidence of it's own. That's what I disagreed with (you also suggested high doses for seizures, but that's not the focus of this thread), and you've already admitted to having been mistaken about this. Why then are you still arguing with me?

 

[Jules A]

i have seen patients with DID or PTSD with dissociative features who presents with bipolar like symptoms and bpd like personality. exploring those features, and addressing and exploring trauma may be worthwhile.

You've seen patients with DID?

 

[splik]

You've seen patients with DID?

multiple patients 😉

(i actually have seen many patients with a dx of DID. there were certain psychiatrists in the area I trained who were well known for causing DID)

 

[Jules A]

multiple patients 😉

(i actually have seen many patients with a dx of DID. there were certain psychiatrists in the area I trained who were well known for causing DID)

Ahhh yes with the iatrogenic specifier, aka an artifact of therapy. 🙁

 

[Neuro111]

Ahhh yes with the iatrogenic specifier, aka an artifact of therapy. 🙁

hahah, I had my own doubts a month ago. But now I do believe that there is a subset of patients with very severe childhood trauma who have 'different parts.' It is not as dramatic as I thought it would be though. While I still have not incorporated most of the diagnostic questions into my regular psychiatric interview, I've started to ask about memory/time loss especially if I know/suspect trauma. One quick way to assess is to ask something along the lines of if your life could be mapped on to a straight line, are there parts of it missing?

 

[675015]

Not sure what to think of 100 mg when 200 mg is the official recommendation. Even the study I came across discussing benefit at 50 mg on sleep, and another saying that some response can be seen at 100 with the up-titration, (essentially saying that patients can get benefit before the end of the many weeks it takes to get the dose all the way to 200, and is a positive sign of responsiveness), doesn't convince me that 100 mg is ideal, especially when the latter still suggests that one continue to the dose of 200 mg as tolerated and not stop at 100 mg.

Again... you are moving the goal posts... I just pointed out that you started by saying 100 mg was USELESS... as in having no use... some people said that might not be true. Then when YOU posted that 100 mg can be useful in some cases but its still not ideal... which no one every argued...? You also post really long, multiple posts in a row referencing seizures then bipolar then effectiveness data then tolerability data. Its like you keep changing the subject matter to keep an argument. Thats all.

 

[Crayola227]

Again... you are moving the goal posts... I just pointed out that you started by saying 100 mg was USELESS... as in having no use... some people said that might not be true. Then when YOU posted that 100 mg can be useful in some cases but its still not ideal... which no one every argued...? You also post really long, multiple posts in a row referencing seizures then bipolar then effectiveness data then tolerability data. Its like you keep changing the subject matter to keep an argument. Thats all.

Everyone wants to obsess over that fact that my assertion that the recommended dose was 300, not 200. I looked it up and freely admitted I was wrong.

I said 100 mg is a useless dose - and per the FDA, it is. I made a point of mentioning where there were caveats even in that point - because I'm not trying to move the goalposts, I'm trying to make a point while admitting where I am wrong and trying to clarify. People that want to miss the point do so.

Let's make it clear a last time - the lamictal leaflet says that some benefit *may* or *may not* be seen at 100 mg, benefit can be an indication of responsiveness, but that continuing to titrate to 200 mg is recommended.

I didn't look closely at the study that said 50 mg might have some benefit in sleep in bipolar. I still think stopping there is useless in a symptomatic patient because studies support some dose dependent responsiveness, with 200 mg being superior to 100 mg for depression. Again, I mention it because I didn't include it in my first statement about the utility of 100 mg.

So I guess it's not *strictly* useless, but it seems pretty useless to stay below the recommended dose in a symptomatic patient, especially when the guideline says that even with some benefit being seen at 100 mg, that is not an indication to stop but to keep going. Maybe I should have said, "100 mg is a useless dose in a patient with inadequate treatment response to an inadequate dose of medication."

Doing nothing is not the same thing as being useless. I never said 100 mg does nothing.

I brought up szs and dosing to give some perspective on "how much lamictal is a lot of lamictal." 300-400 mg is not a lot of lamictal. 500 mg is not a lot of lamictal. 600-800 mg of lamictal is a lot, but I've seen it. I'm not recommending anything past 400. Just trying to offer some perspective on why I think 100 mg is not a good dose, and I think going up to 300-400 is a reasonable and safe thing to try, as has providers I've worked with. You all may think this is quackery. OK.

Also consider going up on lamictal in patients on estrogen as it can increase clearance up to 2x is what I learned. Perhaps this is why I have seen 300-400 mg so commonly used.

 

[Crayola227]

I think the confusion is that you initially said that 100 mg is "useless" and that one should get to 300 mg and reassess when discussing a bipolar spectrum case. When this was pointed out that this does not match many of our experiences or understanding of lamotrigine for bipolar, you changed your point to being about safety/tolerability and seizure disorders...

Interestingly enough, almost all of the psych providers I have worked with have pushed to lamictal doses of 300-400 mg when the patient has some benefit, but there was reason to think there was room for more improvement. That is why I brought up safety/tolerability, because I thought it was implied that somehow "exceeding the FDA maximum" (actually it's recommendation, not maximum, that really is a difference) was dangerous. This drug this dose, it is not.

 

[thoffen]

Why is this a fun female patient? I'm actually not hoping to go into an exploration of sexism (etc.). It stuck out to me as though very explicitly gendering the patient's presentation has meaning.

 

[hamstergang]

That is why I brought up safety/tolerability, because I thought it was implied that somehow "exceeding the FDA maximum" (actually it's recommendation, not maximum, that really is a difference) was dangerous.

I was not implying that doses above the FDA guidelines are dangerous. What I explicitly stated was that I wanted to see evidence supporting the recommendation to go to those doses. Sometimes, posts really only mean what they say.

 

[MacDonaldTriad]

In conclusion, for bipolar disorder, we really don't have much dose response data to guide us. All of this it should be X. No it shouldn't it should be Y is only based on "because I said so".

 

[aim-agm]

I'd say focus on the "strong [fall/winter] seasonal component." That means her mood is powerfully affected by her environment and her overall state should be labile to therapy or other intervention. She might not have SAD per se, but her condition may be exacerbated of the same mechanisms may be at play so try light therapy.

I'd also consider that her "hypomania" isn't. It's well within the range of normal human behavior and might just seem hypomanic by contrast with her depressive state.

 

[Crayola227]

My opinion, no evidence, that seasonal component can be consistent with bipolar spectrum as well

Hmmm, on OCPs, crying spells... I would want to know more about the triggers for that.

The answers to those questions... sometimes a change in OCPs can help, that would be up to gyn or her PCP if the PCP felt up to it. 38 isn't too early to start to have perimenopausal sx. Just thinking outside the box.

 

[thoffen]

Why is everyone saying that, if the drug treatment isn't very effective, we're either getting the drug treatment wrong or the problem isn't bipolar disorder? Those might be true, but anyone who actually looks at the data of drug efficacy knows that (often) they aren't very effective. We do the best we can with what we got.

 

[Attending1985]

Why is everyone saying that, if the drug treatment isn't very effective, we're either getting the drug treatment wrong or the problem isn't bipolar disorder? Those might be true, but anyone who actually looks at the data of drug efficacy knows that (often) they aren't very effective. We do the best we can with what we got.

I think people are concerned more about approach to treatment. If the treatments are often not effective and always harmful we need a new approach to treatment and we are getting it wrong. This may include defining the problem in a more helpful way. As we know, psychiatric disorders are not diseases so we have some license in how we define and treat these entities which should be based on least harmful treatments not the current dogma.

 

[thoffen]

I think people are concerned more about approach to treatment. If the treatments are often not effective and always harmful we need a new approach to treatment and we are getting it wrong. This may include defining the problem in a more helpful way. As we know, psychiatric disorders are not diseases so we have some license in how we define and treat these entities which should be based on least harmful treatments not the current dogma.

I get it, although I'm not convinced there are newer and better treatments on the horizon that are going to materially change pharmacologic treatment of any mental illness in the future. Certainly we need to scrutinize what we are doing. Often we seem to neglect that the illness is stronger than we are. It's not much different than an oncologist treating advanced cancers in this regard. A dying patient may just be a patient who is going to die, and harm may come out of imagining a different chemo regimen or alternative pathological diagnosis will save the patient. Except the gravity and imminence of our illnesses are further from our view. Still 15 years of life lost and 15% mortality via suicide for bipolar disorder (specific numbers controversial) mean we are treating some extremely serious illnesses. Reverence for that is often lacking in both patient and provider.

 

[Zenman1]

Why is this a fun female patient? I'm actually not hoping to go into an exploration of sexism (etc.). It stuck out to me as though very explicitly gendering the patient's presentation has meaning.

I answered that earlier.

 

[Zenman1]

Eh..... As a VA provider, let me warn you not to make assumptions on that front.

I work on an Army post treating active duty Soldiers and dependents plus a few vets who want to stay on and still think that most who go into combat arms are not passive folks. Some may be and want to learn to man up so to speak and some may be passive when they return from deployment but I bet most want to fight and blow up things.

 

[clausewitz2]

I answered that earlier.

I'm not sure "well I also see male patients" addresses the question or, indeed, betrays any meaningful consideration of it whatsoever.

 

[Attending1985]

I get it, although I'm not convinced there are newer and better treatments on the horizon that are going to materially change pharmacologic treatment of any mental illness in the future. Certainly we need to scrutinize what we are doing. Often we seem to neglect that the illness is stronger than we are. It's not much different than an oncologist treating advanced cancers in this regard. A dying patient may just be a patient who is going to die, and harm may come out of imagining a different chemo regimen or alternative pathological diagnosis will save the patient. Except the gravity and imminence of our illnesses are further from our view. Still 15 years of life lost and 15% mortality via suicide for bipolar disorder (specific numbers controversial) mean we are treating some extremely serious illnesses. Reverence for that is often lacking in both patient and provider.

No pharmacological treatment won’t change there’s very little innovation in that regard. But that doesn’t mean the treatment paradigm can’t change. I disagree with the cancer analogy, again this is not a disease and that’s a very grim outlook. There are many people who live well with severe illness. Our expectations effect our patients expectations and we know how powerful of a neurobiological effect that is.

 

[smalltownpsych]

From my biased perspective, I think the psychological component is missing from the conceptualization of this case. That is what makes for a fun case in my mind. Especially with an interesting and intelligent person with a significant trauma history, I want to have her as a regular psychotherapy patient. She actually sounds like a couple of my current more successful and enjoyable cases. BTW I am one of those rare clinicians who actually enjoys working with Borderline PD and experiences good outcomes. Maybe cause I come at it with a combo of Kernberg, Linehan, and some Kohut for good measure.

Also, wanted to add no patient ever reaches optimal functioning by adjusting medications alone and in fact it can be guide the opposite. Even in my patients with Schizophrenia or Bipolar Disorder, the medication is just one piece of the picture, albeit a vital one in those cases.

 

[splik]

Also, wanted to add no patient ever reaches optimal functioning by adjusting medications alone and in fact it can be guide the opposite. Even in my patients with Schizophrenia or Bipolar Disorder, the medication is just one piece of the picture, albeit a vital one in those cases.

not necessarily even a vital component. medications are way over used in the treatment of bipolar disorder and schizophrenia, especially since many people do not want meds. not that im going to be treating acute mania with psychotherapy lol but psychotherapy is way under-utilized in the treatment of more serious mental disorders

 

[birchswing]

An unassuming ingenue famous for her pluck and beauty went on to marry a man famous for his mystique and rugged good looks. For years she denied this man a baby, and we really don’t know why. Was she as scatter-brained and indecisive as the roles she played on stage? Could it have been a case of wandering womb, or perhaps frank hysteria? The female humors are a mystery.

No longer truly a debutante, she still managed to find a tall, dark man to rescue her from spinsterhood, surely to the relief of her aging parents.

Unfortunately as of this month we learned that she failed at marriage once again. It is perhaps a blessing that her mother died two years ago before this embarrassment, but her father lives on.

The words of Giuseppe Verdi, “La donna è mobile,” ring true through the centuries.

What can be done for this self-possessed yet obviously confused creature who wreaks havoc on her own life and causes destruction for all she comes in contact with?

I have been pondering what advice to give her on Twitter. The vast majority of Twitter users seem to think she should plead return to her first husband to whom she denied child but who is now himself divorced. I hesitate to join the chorus. Perhaps her issues cannot be worked out in the marital framework but must instead be managed medically. Bed rest until death, which is in all likelihood is still about forty years off, may prove most prudent. That raises practical questions such as whether she should be periodically wrapped in cold, wet sheets.

I do feel pain for her and those she has left in her reckless wake, but it is also good fun to watch a freshly caught fish at the bottom of a boat, isn’t it?

 

[birchswing]

Either I bombed, was too opaque, or you guys don't follow the real news:

Jennifer Aniston and Justin Theroux announce they've separated - CNN

Jennifer Aniston-Brad Pitt reunion? Fans in a tizzy after split from Justin Theroux - CNN

and previously:
For The Record | HuffPost

 

[hamstergang]

Either I bombed, was too opaque, or you guys don't follow the real news:

For me, you were too opaque and I don't follow real news.

 

[Crayola227]

No pharmacological treatment won’t change there’s very little innovation in that regard. But that doesn’t mean the treatment paradigm can’t change. I disagree with the cancer analogy, again this is not a disease and that’s a very grim outlook. There are many people who live well with severe illness. Our expectations effect our patients expectations and we know how powerful of a neurobiological effect that is.

I really don't agree that bipolar is not a disease. I agree with the rest of what you said. People can live well with severe illness, and but not everyone can. I think the hope of that should be there, as a hope, not an expectation. I do think physicians can do a lot to help foster that useful hope in patients.

 

[Crayola227]

An unassuming ingenue famous for her pluck and beauty went on to marry a man famous for his mystique and rugged good looks. For years she denied this man a baby, and we really don’t know why. Was she as scatter-brained and indecisive as the roles she played on stage? Could it have been a case of wandering womb, or perhaps frank hysteria? The female humors are a mystery.

No longer truly a debutante, she still managed to find a tall, dark man to rescue her from spinsterhood, surely to the relief of her aging parents.

Unfortunately as of this month we learned that she failed at marriage once again. It is perhaps a blessing that her mother died two years ago before this embarrassment, but her father lives on.

The words of Giuseppe Verdi, “La donna è mobile,” ring true through the centuries.

What can be done for this self-possessed yet obviously confused creature who wreaks havoc on her own life and causes destruction for all she comes in contact with?

I have been pondering what advice to give her on Twitter. The vast majority of Twitter users seem to think she should plead return to her first husband to whom she denied child but who is now himself divorced. I hesitate to join the chorus. Perhaps her issues cannot be worked out in the marital framework but must instead be managed medically. Bed rest until death, which is in all likelihood is still about forty years off, may prove most prudent. That raises practical questions such as whether she should be periodically wrapped in cold, wet sheets.

I do feel pain for her and those she has left in her reckless wake, but it is also good fun to watch a freshly caught fish at the bottom of a boat, isn’t it?

even with the links

wat

 

[hamstergang]

I really don't agree that bipolar is not a disease.

Bipolar disorder is not a disease, by the definition of disease.

 

[Crayola227]

Bipolar disorder is not a disease, by the definition of disease.

How so? Is this like the difference between FDA maximum vs recommended dose?

 

[hamstergang]

How so? Is this like the difference between FDA maximum vs recommended dose?

No. Disease, disorder, and syndromes all have different definitions. This is normally taught in medical school.

Bipolar disorder is defined by a collection of symptoms, with different people meeting criteria for it having different symptoms. There is no supposed pathology underlying the entity of bipolar disorder, and different patients almost surely have different dysfunctions. It meets the definition of a disorder but not a disease.

 

[Crayola227]

eh, perhaps I should have said disorder upon looking this up, however not surprisingly there is not consensus on the term disease in any case

 

[Crayola227]

No. Disease, disorder, and syndromes all have different definitions. This is normally taught in medical school.

Bipolar disorder is defined by a collection of symptoms, with different people meeting criteria for it having different symptoms. There is no supposed pathology underlying the entity of bipolar disorder, and different patients almost surely have different dysfunctions. It meets the definition of a disorder but not a disease.

I think there is plenty of evidence that there is likely a pathology underlying most cases of bipolar disorder.

 

[Crayola227]

No. Disease, disorder, and syndromes all have different definitions. This is normally taught in medical school

Yes, I learned this in medical school. As I said, for funsies, I looked this up and actually the most common definitions I found for disease could include most of what you said in your post.

I'd like to see a citation from you on this, just to see what evidence meets your standard for defining this and about the lack of evidence for a pathology underlying bipolar disorder.

 

[hamstergang]

I think there is plenty of evidence that there is likely a pathology underlying most cases of bipolar disorder.

That's not quite what I wrote. I said "entity" not "most cases." Patients we diagnose with bipolar disorder don't all have the same underlying pathophysiology leading to their varied presentations.

Also, you realize that disorder is in the name, right? And you now have 2 psychiatrists explicitly stating that bipolar disorder is not a disease. If you'd like, I'm sure all the other psychiatrists on this forum will agree.

 

[Crayola227]

That's not quite what I wrote. I said "entity" not "most cases." Patients we diagnose with bipolar disorder don't all have the same underlying pathophysiology leading to their varied presentations.

Also, you realize that disorder is in the name, right? And you now have 2 psychiatrists explicitly stating that bipolar disorder is not a disease. If you'd like, I'm sure all the other psychiatrists on this forum will agree.

Well, I'm certainly glad you picked up on the fact I reached for the wrong word.

I really don't have the eloquence to describe why I disagree with @resident1985 's disagreement with @thoffen above.

 

[Crayola227]

That's not quite what I wrote. I said "entity" not "most cases." Patients we diagnose with bipolar disorder don't all have the same underlying pathophysiology leading to their varied presentations.

Also, you realize that disorder is in the name, right? And you now have 2 psychiatrists explicitly stating that bipolar disorder is not a disease. If you'd like, I'm sure all the other psychiatrists on this forum will agree.

Who cares? It's hardly my point. You seem to be so offended that another physician outside psych would want to discuss the topic or have anything to say about it. It's one thing to correct me, but you absolutely go about it in a very condescending manner.

 

[hamstergang]

Who cares? It's hardly my point. You seem to be so offended that another physician outside psych would want to discuss the topic or have anything to say about it. It's one thing to correct me, but you absolutely go about it in a very condescending manner.

You stated bipolar disorder is a disease. I read it, it's wrong, so I corrected. It has nothing to do with you personally. I only brought up you not being a psychiatrist when you pushed the argument.

Outside of that statement, I've only taken a condescending tone with you after you did to me first. I'm otherwise rather nice.

 

[Crayola227]

You stated bipolar disorder is a disease. I read it, it's wrong, so I corrected. It has nothing to do with you personally. I only brought up you not being a psychiatrist when you pushed the argument.

Outside of that statement, I've only taken a condescending tone with you after you did to me first. I'm otherwise rather nice.

Oh, when I said that I was speaking in generalities outside that statement. Hence why I think I'm likely over-reactive to you and probably was here, so my apologies there.

Fair enough in any case.

 

[birchswing]

even with the links

wat

I dunno. This thread evoked strange and uncomfortable feelings. I wrote several serious replies and deleted them as they seemed too accusatory. And then I wrote something about Jennifer Aniston instead.

Edit: Btw, I hated the conclusion that Netflix's Alias Grace was asking the viewer to make. But this thread forces me to sympathize with it.

 

[Mass Effect]

It’s evident by these responses that a PD diagnosis evokes a lot of emotion not only in patients but in psychiatrists. Like how dare you jump to the awful notion that she has BPD. I think personality is much more malleable than we currently believe and the people we see know something is wrong that’s why they’re in our office. They deserve honest answers not to lie to them to protect them in some paternalistic way.

That comes from the fact that some psychiatrists believe trauma history to be automatically diagnostic of BPD, as if a person with a trauma history can't have a mental illness that isn't a manifestation of a personality disorder.

 

[Attending1985]

That comes from the fact that some psychiatrists believe trauma history to be automatically diagnostic of BPD, as if a person with a trauma history can't have a mental illness that isn't a manifestation of a personality disorder.

I agree that psychiatry does a horrible job of addressing trauma and of course people with trauma can have discrete psychiatric disorders.
What I see most commonly with childhood trauma is that the patient comes to me being diagnosed with a ridiculous combination of ADHD, bipolar disorder, ptsd, etc. Honestly, even if it’s not BPD at least the treatment would be dbt which would be more effective and less harmful than than pharmacological treatment with mood stabilizers, stimulants, benzos, atypicals.
There is a more parsimonious explanation of what’s going on here but right now it’s not addressed. Bessel van der Kolk does an excellent job of describing the phenotype that arises from pervasive childhood trauma.

 

[Crayola227]

BESSEL VAN DER KOLK M.D.

Scientific Publications

Quotes from The Body Keeps The Score

http://www.traumacenter.org/products/pdf_files/neurobiology_childhood_trauma_abuse.pdf

 

[Crayola227]

Reading what he talks about, it reminds me sooo much of the principles behind the 12 Step Group Adult Children of Alcoholics/Dysfunctional Families.

Now, I'm not talking about this for dealing with addiction, I think it's a different beast and I understand the controversies in that approach

Just that the ACA philosophy, approach, literature, seems to have some superficial resemblence to my superficial digging on Van Der Kolk.

I frequently hear that DBT can be difficult for patients to obtain, that there is often a shortage of trained and good providers of it in some areas.

Perhaps ACA would be easier to access for some patients and may do more good than harm. Just 2 cents from a doc who had reason to get involved with ACA and found a lot of benefit from it, and was referred by a psychiatrist they greatly admire who themselves was involved in 12 Step. Whether or not it holds merit for patients I couldn't say. But it reminds me of what I'm reading on Van Der Kolk.

 

[Crayola227]

http://responsesidetherapy.com/pdf/PTSD_and_the_Loss_of_Ontological_Security.pdf

I've made this required reading for my med students on the wards. I have like 3 papers I use this way, one other is the ACE study which not all students have been exposed to.

I don't really know how sound it is from a medical standpoint, but I think the concepts are food for thought in deconstructing what I think can be a negative bias towards patients with COPDiabesity that don't practice good self-care, patients that I think use numbing behaviors.

I've found that the concepts stymie some without a trauma background, but many with it that I've shared it with found it to be insightful. There's a reason I picked this other paper as one of the papers.

I bring it up because it also reminds me of what I'm getting as I skim Van Der Kolk.