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Zenman1

Zenman1

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Saw a 31 yr old male today for the second time. Initial visit was over a month ago and I diagnosed him with Anxiety disorder, NOS and Insomnia. This was same dx he was given 3 years ago after presenting with same symptoms. At that time he was started on Zoloft which he stopped after one month as he wanted to keep drinking. He had been drinking since 15-16 years of age. He had also been given Wellbutrin at some point in the past but stopped it as he didn't like the way it made him feel.

He stopped drinking for 28 days after our initial visit, then had an argument with his new wife, started drinking, accidently discharged a firearm, then took several firearms and went looking for an LEO for "suicide by police." Luckily a state trooper arrested him without incident. He was jailed overnight and admitted to hospital the next day and diagnosed with Bipolar I disorder. I swear I asked this fellow about any Bipolar symptoms and he denied them. He says I didn't but I take notes with my cheat sheet template. He's doing great on Seroquel. Still a bummer though.
 
It's hard to get a good history on someone with substance disorder like that. He had been drinking steadily since he was a teenager at the time you saw him, which clouds everything. The symptoms that led to his hospitalization also aren't necessarily clearly manic, either -- seroquel might be helping something else. Seems more to me like a complicated case than something clearly missed by you if you did as you said and screened for past manic/hypomanic symptoms.

Sounds like a scary case regardless. Thank goodness no one got hurt.
 
Was there evidence of mania? I find screening for mania quite useless as those who have truly been manic are insightless and those who haven't screen positive superficially. I find the only thing reliable is seeing the patient manic, seeing notes that document someone seeing the patient manic, or collateral info giving a manic picture.

I wouldn't beat yourself up over it. I'd be willing to wager your initial impression of anxiety nos and the drinking more approximates what's going on than some inpatient provider's likely dubios bipolar diagnosis.
 
Insight is typically lost in the manic phase which is why standard screening does not always pick it up. Plus you have an active substance use disorder which further obscures the clinical picture. Patients can present with disinhibition, agitation, depression, anxiety, insomnia, memory loss etc. Inpatient has the advantage over you because of 24 hour monitoring.
 
I get bipolar patients that argue with me all the time "it's not bipolar. It's adhd and insomnia". They get hospitalized for suicide attempt. Hyperverbal. They get released. "It's not bipolar. It's adhd and insomnia." lol.
 
Zenman1 said:
Saw a 31 yr old male today for the second time. Initial visit was over a month ago and I diagnosed him with Anxiety disorder, NOS and Insomnia. This was same dx he was given 3 years ago after presenting with same symptoms. At that time he was started on Zoloft which he stopped after one month as he wanted to keep drinking. He had been drinking since 15-16 years of age. He had also been given Wellbutrin at some point in the past but stopped it as he didn't like the way it made him feel.

He stopped drinking for 28 days after our initial visit, then had an argument with his new wife, started drinking, accidently discharged a firearm, then took several firearms and went looking for an LEO for "suicide by police." Luckily a state trooper arrested him without incident. He was jailed overnight and admitted to hospital the next day and diagnosed with Bipolar I disorder. I swear I asked this fellow about any Bipolar symptoms and he denied them. He says I didn't but I take notes with my cheat sheet template. He's doing great on Seroquel. Still a bummer though.
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The BP Dx is used because it's easy to throw on the chart and given reimbursement for. You can suppress the diagnosis and continue to work with your original plan.
 
st2205 said:
I don't understand it. Is it reimbursing better or something? We use unspecified depressive disorder and unspecified mood disorder all the time.
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Maybe the thought is insurance companies are more likely to approve more treatment with a bipolar versus nos mood diagnosis. Not a big deal for initial/infrequent evals but an issue if you're seeing someone more frequently or keeping them in the hospital longer.

Random question -- do you all believe in mixed episodes?
 
Doctor Bagel said:
Maybe the thought is insurance companies are more likely to approve more treatment with a bipolar versus nos mood diagnosis. Not a big deal for initial/infrequent evals but an issue if you're seeing someone more frequently or keeping them in the hospital longer.
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My take on that is that anyone with an unspecified diagnosis (sans psychosis, but I don't call anyone unspecified psychosis if they're not really psychotic) is not going to get any benefit from a prolonged (i.e. longer than 2 days) hospital course and would likely reinforce maladaptive behaviors. If someone isn't really bipolar (i.e. just about everyone) then further hospitalization isn't the answer. Naturally this changes by facility and $$$ reasons.
 
Doctor Bagel said:
Random question -- do you all believe in mixed episodes?
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yes absolutely.about a 1/3 of manic episodes are dysphoric manic episodes. kraepelin described 6 types of mixed episode which he saw as transitions between different states: depressive mania, excited depression, mania with poverty of thought, depression with flight of ideas, and inhibited mania. He also noted that pure states of mania or depression were rare and it was common for manic patients to be fleetingly despondent but this would not be described as a mixed state.

The concept has been corrupted by people jumping on the bipolar bandwagon during the earlier part of this century seeking to expanding the concept of bipolar disorder and also to push newer drugs (depakote was marketed as being superior to lithium for mixed states, and tegretol and atypical neuroleptics have followed suit). DSM-5 has not helped this situation by going too far, though the previous allowance of mixed states in the DSM only allowed for those who met manic (not hypomanic) AND depressive criteria at the same time was too restrictive. mixed states are important as they confer significant suicide risk, associated with more psychotic symptoms, are more resistant to treatment, seem to respond more poorly to lithium, are more common in women. Akiskal has argued that mixed states occur from the superimposing of an alternate affective state onto the usual temperament of the patient. There may be some truth to this. The term is certainly abused and the reliability goes way down when you start departing from the criteria, but mixed states of course exist and have been described even beofre the time of Kraepelin.
 
Do you all ask a lot of dissociation questions, like finding objects they don't remember buying or deja vu? It's been kind of hit or miss for me when digging for a mania history from someone.
 
Flushot said:
Do you all ask a lot of dissociation questions, like finding objects they don't remember buying or deja vu? It's been kind of hit or miss for me when digging for a mania history from someone.
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Like never. Do you? My routine screening stuff -- mood disorders (depression, mania), anxiety (GAD, OCD, panic), trauma history (PTSD -- I'm at the VA most of the time these days so, yeah, you've got to screen), psychosis. I'm also always assessing for personality disorders, but I don't screen in an ROS manner for these. I feel like I could be better at screening for eating disorders. Oh yeah, I always screen for substance use disorders. I generally try to get a pretty good developmental and social history, and I think ADHD stuff comes out there.
 
Doctor Bagel said:
Like never. Do you? My routine screening stuff -- mood disorders (depression, mania), anxiety (GAD, OCD, panic), trauma history (PTSD -- I'm at the VA most of the time these days so, yeah, you've got to screen), psychosis. I'm also always assessing for personality disorders, but I don't screen in an ROS manner for these. I feel like I could be better at screening for eating disorders. Oh yeah, I always screen for substance use disorders. I generally try to get a pretty good developmental and social history, and I think ADHD stuff comes out there.
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I did once so far, but I was kind of prompted. I had asked about spending money and he tells me he doesn't really but finds himself with more and more stuff around the house than he remembers buying, mostly from online shopping. I'm still in the inpatient trench so I guess it would be possible to see more bizarre things but who knows. I hadn't thought about it being something standard though. If suspicion is high, I thought maybe it would be worth looking into if the pt just doesn't remember.
 
Many times on the inpatient unit I lack information on the time course of the illness to make a diagnosis other than unspecified/NOS when it relates to Bipolar or Psychotic illness. These patients frequently are unable to give me this information, and without collateral there's nothing you can do.

Back on topic OP, it sounds like the patient may have just gotten drunk and had fallout I see in dozens/hundreds of patient a year that stabilizes without meds once a patient sobers up. And how can the inpatient unit diagnose Bipolar I when he's been drinking and it hasn't been a week of manic symptoms? It's just as likely this was substance induced vs a primary mood/psychotic episode.
 
I don't routinely scour for dissociative disorders because it's too nonspecific. Borderline PD, PTSD, Severe anxiety, Bipolar, Psychosis...list goes on. *shrug*

Regarding the Bipolar Dx, that is one of my pet peeves. A label of bipolar disorder (whether Dxd by a Psychiatrist or Oprah) is the only disorder in all of medicine which has a NEGATIVE PREDICTIVE VALUE for ACTUALLY having it.

But what really bugs me about it, is it's typically someone with trauma, neglect, or attachment issues who has a pervasive pattern of interpersonal dysfunction mediated almost entirely by psychological states of functioning. They typically exhibit an extremely externalized locus of control, poor self-mastery, and a low sense of agency. Allowing them to blame this behavior on an external force (which, psychologically, Bipolar is) is in fact enabling and further pathologizing the person. We shouldn't be knowingly making patients worse, which is what we do when we attach questionable Bipolar labels to people.
 
Agree with MOM. It's sad how poorly it's diagnosed.

Particularly when you've had the opportunity to deal with people truly in crisis due to actual bipolar. Whenever I hear someone catching someone in a manic state and say, "but I gave him Risperdal 2mg and now he's good," I always grind my teeth. It's amazing how challenging it is to bring down someone who is truly manic. It puts meth to shame.
 
F0nzie said:
Insight is typically lost in the manic phase which is why standard screening does not always pick it up. Plus you have an active substance use disorder which further obscures the clinical picture. Patients can present with disinhibition, agitation, depression, anxiety, insomnia, memory loss etc. Inpatient has the advantage over you because of 24 hour monitoring.
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I figure this is true with this fellow. I'm betting he really wants that Bipolar dx now to help him with his legal problems.
 
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