Reading recommendations for the bipolar patient in denial

[coilette]

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Perhaps because the days are getting longer and the weather is getting warmer but I'm facing a lot of this and am trying to figure out ways to get through to some of my patients. Thanks in advance!!!

 

[Suedehead]

I have the exact opposite problem. My patients are convinced they have bipolar and I keep saying 'read up on borderline personality and let me know what you think.'

Hard for a truly bipolar patient to be in denial about their diagnosis when their mania takes them to the hospital.

And if their mania hasn't taken them to the hospital, perhaps it is we who are in denial.

 

[Chrismander]

Hard for a truly bipolar patient to be in denial about their diagnosis when their mania takes them to the hospital.

Bull****. Loss of insight is one of the commonest features. Not a core feature by DSM criteria, but pretty damn close. Crude rule of thumb: The people who say "Oh i'm so manic right now" as they prance around are 10:1 borderlines. The ones who deny mania are bipolars.

Even when they cycle back into euthymia (with or without meds) the insight can be pretty poor. Maybe even worse, because now they feel fine, and whatever happened to land them in the hospital gets written off. Can't tell you the number of times i've heard the denial expressed in adjustment terms: "I was only acting funny because my parents/boyfriend/boss was so mean to me". And for "acting funny" read: preaching naked in the streets, spending their inheritence overnight, or some such thing.

I just had a 25 y/o OEF/OIF veteran with first episode bipolar come to us. Psychotic, delusional, manic, 20k+ spent in 2 weeks, up for days, too paranoid to be interviewed by more than one person a time. Was stacking cups of urine at home, in the finest traditions of psychotic mania. Family history positive for bipolar. One week of atypical + MS and he's feeling "back to my old self" per self report, trusting staff, only slightly paranoid, no longer hearing stuff, sleeping, talking normal rate. From hospital day 3 onward said "I think I might have bipolar and I know I need to take my meds". We all cheer. Day of discharge: "I've been thinking, I accept that I was psychotic because I was so paranoid but couldn't that just have been caused from the sleep deprivation over there?" Me: "Yeah that's called bipolar switching". Him: "Oh. Well couldn't this all just be PTSD then?". Me: <slap head>. Requested a referral to a second opinion "just to know for sure", etc, right before leaving.

At least he's still willing to take meds at this point.

The involuntary manic patients I saw at our County facility this year would get better quickly with forced meds, but *almost* invariably deny the diagnosis or only partially/tentatively accept it. Every so often there would be a really cute (usually old) manic pacing around saying "I'm so manic, you gotta help me doc". But this was rare. Most just paced and glowered, and after getting better stopped taking their meds, as evidenced by their bouncing back.

If you haven't seen loss of insight in bipolar, you haven't seen bipolar.

 

[Suedehead]

ah, well, you're absolutely right. when they're manic, they've got no insight. And when they're euthymic, I never see them because they don't come in for treatment. I see them when they're depressed or when their family drags them in.

Your case above is a slam dunk diagnosis, by the way.

my point, I guess, was more tedious and off topic... that most patients with bipolar aren't bipolar.

 

[OldPsychDoc]

I have the exact opposite problem. My patients are convinced they have bipolar and I keep saying 'read up on borderline personality and let me know what you think.'
...

You can do better than that--be developing a script for yourself that clearly explains the difference, and more importantly, educates about borderline personality in a non-pejorative way. Let them know that they have a lifelong pattern of problems with regulating their moods and impulses, and that they CAN be helped--not so much with meds, but with consistent retraining of their emotional skills through things like DBT.

Otherwise you'll just be the next doctor that didn't help them with "my bipolar". 🙄

 

[sunlioness]

I did that with a patient a few weeks ago and encouraged her to talk to her therapist about DBT. The patient was very receptive. We'll see how it goes though because according to the patient, her therapist diagnosed the bipolar and told her the reason why she was never manic was because her fibromyalgia dampened the symptoms.

The amount of providers willing to diagnose borderline (and PTSD in many cases) as bipolar and treat it is as such is really perplexing to me.

 

[OldPsychDoc]

...her therapist diagnosed the bipolar and told her the reason why she was never manic was because her fibromyalgia dampened the symptoms.
--.

😱😱😱


And she's going back to that same therapist to talk about DBT?
I'll be surprised if they've even heard about it!

 

[billypilgrim37]

...her therapist diagnosed the bipolar and told her the reason why she was never manic was because her fibromyalgia dampened the symptoms...

I understand the perverse incentives for psychiatrists to diagnose bipolar (billing, pharmacologic interventions, etc.). But I have never understood why therapists do this, although they clearly do.

 

[peppy]

according to the patient, her therapist diagnosed the bipolar and told her the reason why she was never manic was because her fibromyalgia dampened the symptoms.

Any chance that the patient misinterpreted something the therapist said? It's not at all uncommon that patients will put their own spin on things we say. I try to make sure that patients understand my instructions before we part ways, but I still have had some "Wait, I never said anything like that" incidents.

 

[zenman]

ah, well, you're absolutely right. when they're manic, they've got no insight. And when they're euthymic, I never see them because they don't come in for treatment. I see them when they're depressed or when their family drags them in.

Your case above is a slam dunk diagnosis, by the way.

my point, I guess, was more tedious and off topic... that most patients with bipolar aren't bipolar.

How valid do you think the Bipolar Spectrum Diagnostic Scale is and especially if they are not truthful?

 

[zenman]

I did that with a patient a few weeks ago and encouraged her to talk to her therapist about DBT. The patient was very receptive. We'll see how it goes though because according to the patient, her therapist diagnosed the bipolar and told her the reason why she was never manic was because her fibromyalgia dampened the symptoms.

The amount of providers willing to diagnose borderline (and PTSD in many cases) as bipolar and treat it is as such is really perplexing to me.

So, FMS could be a therapeutic intervention....😀

 

[nitemagi]

How valid do you think the Bipolar Spectrum Diagnostic Scale is and especially if they are not truthful?

http://www.ncbi.nlm.nih.gov/pubmed/15708426

No self-report scale is going to be valid for diagnostic purposes if the patient is not truthful, unless the goal is to raise suspicion of malingering.

 

[Suedehead]

http://www.ncbi.nlm.nih.gov/pubmed/15708426

No self-report scale is going to be valid for diagnostic purposes if the patient is not truthful, unless the goal is to raise suspicion of malingering.

well, the scale is very reliable and sensitive and specific. but whether or not its findings are valid wholly depends on the validity of our conceptualization of the bipolar spectrum.

I feel badly, though, that I have been distracting from the OP's very good question and chrismander's excellent description of the problem: how do we deal with the poor insight of truly manic patients? .....tough one...... when you're not getting through to a patient, it seems you have to know the law and know when it's worth treating someone against his/her will.... philosophical quagmire.

 

[sunlioness]

Any chance that the patient misinterpreted something the therapist said? It's not at all uncommon that patients will put their own spin on things we say. I try to make sure that patients understand my instructions before we part ways, but I still have had some "Wait, I never said anything like that" incidents.

Oh yes, it's always a possibility. Like the patient who went to urgent care after seeing me and told the doc there I had sent him there for pain meds. I got a call about that one and I hadn't done it. 🙂

 

[Suedehead]

You can do better than that--be developing a script for yourself that clearly explains the difference, and more importantly, educates about borderline personality in a non-pejorative way. Let them know that they have a lifelong pattern of problems with regulating their moods and impulses, and that they CAN be helped--not so much with meds, but with consistent retraining of their emotional skills through things like DBT.

this is very well said, by the way.

and don't worry, I have a speech I'm proud of....🙂

 

[OldPsychDoc]

this is very well said, by the way.

Well, I've gotten LOTS of practice saying it...

and don't worry, I have a speech I'm proud of....🙂

you too, good.

 

[whopper]

It's possible to have patients on both ends of the spectrum, the bipolar patient in denial and the borderline pt convinced they have bipolar disorder. As was mentioned above, judgment is one of the things that goes in mania, and there is specific neurocircuitry evidence to back this theory in addition to a heck of a lot of cases where this is seen, aside that it's blatantly obvious to anyone who's treated more than a few patients with this disorder.

Personally, I would love to video the person while manic and show them what they were like. I was not able to do this in the state hospital I used to work at because of regulations over these type of things. I've also noticed that when people quickly recover they tend to not remember what it was like to be manic, while being in hypomania for some time allows them to notice they have some symptoms while gaining their judgment back.

Similar to disorganized schizophrenia, when many people with that disorder quickly recover, they don't remember (at least from my experience), unless they've spent some time in an intermediate phase of recovery where their judgment returns but other things have not yet done so, allowing the patient to see they got problems that need fixing.

Good luck. I've seen patients that were in denial of their illness for decades no matter what interventions were done. As for borderline patients, I just had one over the weekend crying in my office, demanding a medication, and I kept telling her there really is no medication that helps with this other than mitigating the symptoms here or there but not significantly. I knew a benzo could've helped her but I refused to give her one because I strongly believe she'll believe that's the appropriate treatment for borderline PD. (She was recently charged with assault and was having panic attacks during her hearing, no she doesn't have panic disorder, she's never had this problem until her arrest). In hindsight I should've offered her vistaril PRN, but did not. I think her screaming at me put up my "anti-med" defense too much so I went too far along that spectrum.

 

[kugel]

Even when there is insight in a patient in a Manic Episode, there is still often denial.
There is a pt here who comes in every few days when he is manic (looking for a particularly pretty nurse), stating he is manic and that he is not taking his meds properly and he is drinking ETOH. However, when he is asked to stop singing at the top of his lungs (and not particularly well) and dancing so wildly that others are in danger, he says, "Why? Don't you want me to be happy? My happiness will make the rest of (the patients) happy, too. Don't you want that?"
His intellectual understanding of his episode does not translate into realizing the need to control specific behaviors.

I don't try to overcome denial in such patients (no less those with zero insight).
I look for rewards, privileges, reinforcers that he wants and make them contingent upon his behavior (no shouting for 30 minutes, sitting in one place for 60 minutes, writing down 3 ways he will assist himself to recover, etc) - whether he understands my reasons for wanting that behavior or not. Often for him, the most salient reinforcer is speaking with me.
"No, I can't talk to you this way. It helps neither of us. When one of the floor nurses tells me you have (insert desired behavior here), then I'll know it's worth your time and mind for me to spend 10 minutes with you."

 

[fiatslug]

Perhaps because the days are getting longer and the weather is getting warmer but I'm facing a lot of this and am trying to figure out ways to get through to some of my patients. Thanks in advance!!!

I was literally going to post this same question last week. I have a pt with clear bipolar disorder who just really wants to believe she's super creative, and is for some reason happily embracing the dx of MDD with psychotic fx, given to her by her PMHNP. Adamantly rejects bipolar d/o. I was tempted to just read her notes from her inpatient hospitalization, but it was clear she'd parry every serve. I did have her read "An Unquiet Mind," and she reports she did, and it confirmed to her that "I don't have bipolar" because her story is not identical to Kay Redfield Jamison's 🙄

I'll offer her neuropsych testing. I can see I'm not going to get much traction with her on this diagnosis--it's clear she also doesn't have a problem with daily MJ and EtOH abuse, and that I'm just harshing on her Jungian mellow

 

[nitemagi]

One thing we used to do, and is really only useful in the inpatient setting, is to videotape a patient during their psychotic or manic episode. After they'd recovered they'd have incomplete memory about how impaired or severely symptomatic they were, or just rationalize away so they didn't have to change their self-image to someone who has a severe disease like that. But showing them video of themselves at their most severe...sometimes seeing is believing.

Going at their irrational use of rationalization with rational arguments doesn't always get through. Especially in those well defended.