Unreal.

[randomdoc1]

Just letting you know it's a bit of a venting post. So, I had an intake yesterday, the guy had classic symptoms of borderline personality disorder, drinks a liter of liquor daily. He demanded to be diagnosed with bipolar disorder and be started on meds for that. I got him admitted for inpatient detox. History gathering showed no major mood symptoms in absence of drinking. I got inpatient doc to call me, he did not bother to read my notes. Didn't bother to even treat the etoh use disorder with plan to start him on naltrexone and/or send to AA or anything. He slaps the guy with a bipolar diagnosis and starts abilify and lamictal. He takes off the antidepressant. I told him he's got a highly suspicious history of borderline PD and a raging etoh issue. If he has a mood disorder, it may be MDD. He goes "well, I think it's bipolar and I'm stopping the lexapro." He did agree with vivitrol shot. But seriously? You diagnose something like that, ignore treating the etoh issue and don't bother to read the outside records? Sorry, just irritated with this.

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[Doc1401]

Just letting you know it's a bit of a venting post. So, I had an intake yesterday, the guy had classic symptoms of borderline personality disorder, drinks a liter of liquor daily. He demanded to be diagnosed with bipolar disorder and be started on meds for that. I got him admitted for inpatient detox. History gathering showed no major mood symptoms in absence of drinking. I got inpatient doc to call me, he did not bother to read my notes. Didn't bother to even treat the etoh use disorder with plan to start him on naltrexone and/or send to AA or anything. He slaps the guy with a bipolar diagnosis and starts abilify and lamictal. He takes off the antidepressant. I told him he's got a highly suspicious history of borderline PD and a raging etoh issue. If he has a mood disorder, it may be MDD. He goes "well, I think it's bipolar and I'm stopping the lexapro." He did agree with vivitrol shot. But seriously? You diagnose something like that, ignore treating the etoh issue and don't bother to read the outside records? Sorry, just irritated with this.

There is a growing amount of psychiatrists who think borderline personality disorder is over diagnosed. I even heard a professor say that he will never diagnose someone with BPD, as it is detrimental to the patient to receive that label. I personally believe that if the patient has the disorder, and this has been demonstrated longitudinally and not on one encounter, then he or she should receive that diagnosis in order to get the proper treatment (eg. DBT). Some inpatient doctors also think bipolar has a better chance of being approved by the insurance companies, which is partly a system flaw.

 

[NickNaylor]

There is a growing amount of psychiatrists who think borderline personality disorder is over diagnosed. I even heard a professor say that he will never diagnose someone with BPD, as it is detrimental to the patient to receive that label. I personally believe that if the patient has the disorder, and this hs ben demonstrated longitudinally and not on one encounter, then he or she should receive that diagnosis in order to get the proper treatment (eg. DBT). Some inpatient doctors also think bipolar has a better chance of being approved by the insurance companies, which is partly a system flaw.

Your last point definitely seems to be true in my area, as a primary diagnosis of a personality disorder will not result in reimbursement for inpatient services at any of the hospitals (apart from the VA) that I’ve worked at. We don’t falsify diagnoses, but we do list something else as the primary diagnosis - never bipolar disorder unless they have a clear, irrefutable history of bipolar disorder, but if they meet criteria for another disorder, that will be listed as the primary diagnosis - and then essentially do brief crisis stabilization.

Frustrating that the inpatient doc essentially blew off your impression based on a one-off evaluation, though.

 

[thoffen]

The training I got said for Inpatient Psych, we can bill a rule out diagnosis as primary. This is what I tend to do and document my thinking about a patient. I am surprised the doc called you. I guess from reading it, you reached out to him. Calling you just to blow you off sucks.

 

[Shikima]

Instagib headshot!

 

[st2205]

Welcome to psychiatry.

 

[Shikima]

Psychiatry has some of the worst Inter-rater reliability testing around.

 

[randomdoc1]

Good god. The patient arrived to my intake with his mother. They both insisted he was bipolar when it was pretty clear from history he is not. He has chronic impulsivity, chaotic relationships and there was a strong history of "mood swings" when drinking. Patients need to understand it's more important to be effective than "right." He's not bipolar and chronic neuroleptics +/- mood stabilizers have risks of EPS and weight gain in an already obese patient. Plus, not treating the underlying disorder is an even bigger risk in my opinion. He can continue to have affective dysfunction, harm himself or others, and impaired functioning overall. Sure, it sounds sexy to have a diagnosis like bipolar and have some sort of miraculous response to the meds, but he's not bipolar...

 

[Madden007]

Good god. The patient arrived to my intake with his mother. They both insisted he was bipolar when it was pretty clear from history he is not. He has chronic impulsivity, chaotic relationships and there was a strong history of "mood swings" when drinking. Patients need to understand it's more important to be effective than "right." He's not bipolar and chronic neuroleptics +/- mood stabilizers have risks of EPS and weight gain in an already obese patient. Plus, not treating the underlying disorder is an even bigger risk in my opinion. He can continue to have affective dysfunction, harm himself or others, and impaired functioning overall. Sure, it sounds sexy to have a diagnosis like bipolar and have some sort of miraculous response to the meds, but he's not bipolar...

I understand your frustration. However, a diagnosis of borderline personality is a tough one to claim on one evaluation, especially when alcohol use disorder is muddying the pond---perhaps finding a middle ground such as diagnosis the patient with Other bipolar and related disorders and r/o borderline personality disorder may have worked too.

 

[st2205]

Good god. The patient arrived to my intake with his mother. They both insisted he was bipolar when it was pretty clear from history he is not. He has chronic impulsivity, chaotic relationships and there was a strong history of "mood swings" when drinking. Patients need to understand it's more important to be effective than "right." He's not bipolar and chronic neuroleptics +/- mood stabilizers have risks of EPS and weight gain in an already obese patient. Plus, not treating the underlying disorder is an even bigger risk in my opinion. He can continue to have affective dysfunction, harm himself or others, and impaired functioning overall. Sure, it sounds sexy to have a diagnosis like bipolar and have some sort of miraculous response to the meds, but he's not bipolar...

“Presents with mother” is a solid part of the MSE.

 

[randomdoc1]

I understand your frustration. However, a diagnosis of borderline personality is a tough one to claim on one evaluation, especially when alcohol use disorder is muddying the pond---perhaps finding a middle ground such as diagnosis the patient with Other bipolar and related disorders and r/o borderline personality disorder may have worked too.

What I told the patient is the ddx is borderline, MDD, and bipolar disorder. Heck, I said he may even have multiple disorders (e.g. MDD/bipolar with borderline). I made it the top priority to stop drinking and recommended therapy. I also made medication recommendations. My encouragement to them was to keep an open mind and I was honest that his history, even though we don't have a solid diagnosis, is *highly* unlikely he has bipolar disorder. The inpatient provider completely missed the boat and didn't care to consider other diagnoses. Like I said, he didn't even bother to treat the alcohol use disorder which I think is concerning. Even more concerning he didn't even read the outside records.

I told him the diagnosis he's walking out with today is:
etoh use disorder (severe)
unspecified mood disorder (MDD versus bipolar versus SIMD)
possible borderline personality disorder

 

[birchswing]

How can you separate alcoholism from BPD? I've never drunk, but 1 liter sounds like a lot. 1 liter of anything is a lot.

Edit: Sorry, I see you clarified it was only on differential vs diagnosis at the same time I posted.

 

[michaelrack]

1. At all of the places I work, you can't bill a "rule out"... you can bill symptoms (snoring/sleepiness in a sleep practice) or for a psych patient bill a code for a diagosis, but indicate in the H and P that it is a provisional dx or unclear dx. for example, sometimes I will put MDD, recurrent (r/o Bipolar 2, depressed) on a psych eval and would bill the code for MDD, recurrent. But medicare will not like if you list a diagnosis of "r/o MDD, recurrent" on the psych eval and then bill that diagnosis. You can write MDD, recurrent (provisional diagnosis).

2. In the patient described, I would have tried to get the inpatient doc to call him bipolar 2

 

[michaelrack]

you can certainly try billing one of the unspecified codes such as unspecified mood disorder; although some insurers especially medicare don't like those.

I agree with the need for a substance abuse dx and tx

 

[randomdoc1]

Couldn't the inpatient doc just start off with etoh use disorder (severe)? That's pretty significant in and of itself.

 

[justabanana]

Just a thought, but what are the odds that he actually follows through with DBT given how convinced he is that he's bipolar? It's only a more effective treatment than neuroleptics if he's going to do it.

 

[randomdoc1]

Just a thought, but what are the odds that he actually follows through with DBT given how convinced he is that he's bipolar? It's only a more effective treatment than neuroleptics if he's going to do it.

That's the problem. Pts need to have an open mind. They need to stop focusing on being right and focus on being effective. If he's going to keep chasing after mood stabilizers and antipsychotics, he'll never get better at this rate. Somehow I feel like this is more common in psychiatry. For example, in primary care, the patient is not going to argue with you if you say they have HTN and it's due to their diet and obesity. Whether or not they follow through with the plan is another story in terms of lifestyle changes, but at least they agree with the dx and may take some antihypertensives. I think it's more in psychiatry given our lack of biomarkers or other forms of proof. If only...

 

[wolfvgang22]

So are you going to follow-up with this patient? If I were you I'd really like to refer Mr. Bipolar back to the doc who decided he is a better psychiatrist than you, the actual psychiatrist.

 

[michaelrack]

That's the problem. Pts need to have an open mind. They need to stop focusing on being right and focus on being effective. If he's going to keep chasing after mood stabilizers and antipsychotics, he'll never get better at this rate. Somehow I feel like this is more common in psychiatry. For example, in primary care, the patient is not going to argue with you if you say they have HTN and it's due to their diet and obesity. Whether or not they follow through with the plan is another story in terms of lifestyle changes, but at least they agree with the dx and may take some antihypertensives. I think it's more in psychiatry given our lack of biomarkers or other forms of proof. If only...

actually, they will argue with you about HTN and its cause

 

[clausewitz2]

actually, they will argue with you about HTN and its cause

"I won't take insulin ever again! I lost my leg after I started that insulin!"

 

[uname943]

2. In the patient described, I would have tried to get the inpatient doc to call him bipolar 2

What evidence do you have for a bipolar 2 diagnosis? Especially considering how his excessive alcohol intake may be muddying the clinical picture? Also, one of bipolar 2's rule out criteria is symptoms severe enough to merit hospitalization.

 

[randomdoc1]

So are you going to follow-up with this patient? If I were you I'd really like to refer Mr. Bipolar back to the doc who decided he is a better psychiatrist than you, the actual psychiatrist.

Awesome idea! I think he does have an outpatient practice actually...I'll discuss that with the patient .

 

[birchswing]

"I won't take insulin ever again! I lost my leg after I started that insulin!"

I remember reading somewhere--maybe AAFP--that telling patients to lose weight is no longer an appropriate intervention because it doesn't work (meaning patients won't lose weight when directed to do so).

 

[milkncookies]

The med choices actually sound like they could be fine. Lamictal and abilify are among the more evidence based meds for borderline personality disorder. The other ones being topamax, depakote, and olanzapine. The issue is that if this pt truly does have borderline but the doctor diagnosed them with bipolar then they won’t get the appropriate therapy referrals: tfp or dbt.


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[Doc1401]

The med choices actually sound like they could be fine. Lamictal and abilify are among the more evidence based meds for borderline personality disorder. The other ones being topamax, depakote, and olanzapine. The issue is that if this pt truly does have borderline but the doctor diagnosed them with bipolar then they won’t get the appropriate therapy referrals: tfp or dbt.


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Low dose seroquel arguably has the most evidence in borderline personality disorder

 

[wolfvgang22]

I remember reading somewhere--maybe AAFP--that telling patients to lose weight is no longer an appropriate intervention because it doesn't work (meaning patients won't lose weight when directed to do so).

 

[thoffen]

Low dose seroquel arguably has the most evidence in borderline personality disorder

In my experience encountering this treatment, 1200mg qualifies as low dose.

 

[randomdoc1]

.

 

[NontradCA]

I remember reading somewhere--maybe AAFP--that telling patients to lose weight is no longer an appropriate intervention because it doesn't work (meaning patients won't lose weight when directed to do so).

Not telling them definitely won’t work.

 

[Armadillos]

Also, one of bipolar 2's rule out criteria is symptoms severe enough to merit hospitalization.

Pretty sure his only applies to the mania right? You can hospitalization a bipolar 2 patient for depression/SI all you want and that doesn’t change the diagnosis right?

 

[splik]

I remember reading somewhere--maybe AAFP--that telling patients to lose weight is no longer an appropriate intervention because it doesn't work (meaning patients won't lose weight when directed to do so).

Incidentally when I was resident, patients could read their notes online. I had one pt I saw who was narcissistic and one day I remarked "you've lost weight!". He told me, "well I saw that you described me as overweight in the mental status exam. I thought 'f*ck him' so I lost 10lbs!"

 

[Mass Effect]

Just letting you know it's a bit of a venting post. So, I had an intake yesterday, the guy had classic symptoms of borderline personality disorder, drinks a liter of liquor daily. He demanded to be diagnosed with bipolar disorder and be started on meds for that. I got him admitted for inpatient detox. History gathering showed no major mood symptoms in absence of drinking. I got inpatient doc to call me, he did not bother to read my notes. Didn't bother to even treat the etoh use disorder with plan to start him on naltrexone and/or send to AA or anything. He slaps the guy with a bipolar diagnosis and starts abilify and lamictal. He takes off the antidepressant. I told him he's got a highly suspicious history of borderline PD and a raging etoh issue. If he has a mood disorder, it may be MDD. He goes "well, I think it's bipolar and I'm stopping the lexapro." He did agree with vivitrol shot. But seriously? You diagnose something like that, ignore treating the etoh issue and don't bother to read the outside records? Sorry, just irritated with this.

I mean, you essentially diagnosed him with BPD and completely ruled out bipolar disorder based on your intake, so you didn't do a bang-up job either, IMO. I agree that bipolar shouldn't be his diagnosis while there's still a substance issue, but neither then should BPD nor Lexapro. The only thing you definitively know is substance abuse/dependence. Everything else is a rule-out substance-induced.

 

[uname943]

Pretty sure his only applies to the mania right? You can hospitalization a bipolar 2 patient for depression/SI all you want and that doesn’t change the diagnosis right?

Yes. Though the OP makes no mention of mood symptoms outside of drinking or SI.

Speaking of bipolar disorder and crappy inpatient care: one of my bipolar I patients developed mania with psychosis and was brought to the hospital by police. The inpatient psychiatrist did not respond to my outreach attempts. In fact, they started my patient on an antidepressant! Then discharged her without any clinical improvement. WTF

 

[randomdoc1]

I mean, you essentially diagnosed him with BPD and completely ruled out bipolar disorder based on your intake, so you didn't do a bang-up job either, IMO. I agree that bipolar shouldn't be his diagnosis while there's still a substance issue, but neither then should BPD nor Lexapro. The only thing you definitively know is substance abuse/dependence. Everything else is a rule-out substance-induced.

Let's see, I asked him about his longest periods of sobriety, during which he's had nearly a year. No periods of manic or hypomanic episodes in that time frame. He may have had an MDE during a period of sobriety. His possible manic/hypomanic symptoms were exclusively while he's drinking. They do not occur in an episodic pattern. They are *chronic* and while he is drinking. Chaotic friendships and relationships, hates being broken up with, he spends his money loosely throughout the entire year. Family feels they constantly have to triple check what they say in fear he'd lash out. He gets angry at the smallest things on a regular basis, he moods fluctuate a lot throughout the day all year long. He gets random tattoos and falls in love hard and spends tons of money on women who aren't good for him. There is *nothing* episodic about this. The chronology is all chronic. Bipolar disorder is highly unlikely in this case.

I told him the diagnosis he's walking out with today is:
etoh use disorder (severe)
unspecified mood disorder (MDD versus bipolar versus SIMD)
possible borderline personality disorder

I was very clear to the patient that it is a *working differential*. I made it very clear to the patient and inpatient doc that the top priority at this point is sobriety and focusing treatment on that in particular. IMO that is a decent start. The inpatient provider had ZERO plan for the alcohol use disorder and didn't bother to read records. I consider that terrible practice...IMO. And no, I did not start the lexapro, he arrived on that from his PCP and I said I was indifferent about what was done with it.

 

[OldPsychDoc]

There is a growing amount of psychiatrists who think borderline personality disorder is over diagnosed.

Not where I'm sitting...

I even heard a professor say that he will never diagnose someone with BPD, as it is detrimental to the patient to receive that label. I personally believe that if the patient has the disorder, and this has been demonstrated longitudinally and not on one encounter, then he or she should receive that diagnosis in order to get the proper treatment (eg. DBT).

This. It's far more detrimental to "diagnose" a patient with an incorrect label that will have them taking toxic medications for the rest of their life than to do a good job of psychoeducation about borderline PD and the life histories that got them there. It's only a detrimental label because WE have made it so.

Some inpatient doctors also think bipolar has a better chance of being approved by the insurance companies, which is partly a system flaw.

I think this is largely mythology. People don't get hospitalized because of a Borderline personality diagnosis. They get hospitalized for a symptom, or behavior. You hospitalize for "suicide attempt", "acute mood disorder NOS", "mania", "psychosis" or the like. You get approved for medical necessity of treating those symptoms in a hospital, not for the diagnostic label associated with them.

 

[randomdoc1]

Yes. Though the OP makes no mention of mood symptoms outside of drinking or SI.

Speaking of bipolar disorder and crappy inpatient care: one of my bipolar I patients developed mania with psychosis and was brought to the hospital by police. The inpatient psychiatrist did not respond to my outreach attempts. In fact, they started my patient on an antidepressant! Then discharged her without any clinical improvement. WTF

Unfortunately there seems to be a lot of crappy inpatient care as well as outpatient providers. People say there's a shortage of psychiatric providers but having bad ones is even worse!

Not where I'm sitting...
This. It's far more detrimental to "diagnose" a patient with an incorrect label that will have them taking toxic medications for the rest of their life than to do a good job of psychoeducation about borderline PD and the life histories that got them there. It's only a detrimental label because WE have made it so.
I think this is largely mythology. People don't get hospitalized because of a Borderline personality diagnosis. They get hospitalized for a symptom, or behavior. You hospitalize for "suicide attempt", "acute mood disorder NOS", "mania", "psychosis" or the like. You get approved for medical necessity of treating those symptoms in a hospital, not for the diagnostic label associated with them.

Absolute myth indeed! There are plenty of other ways to bill without having to resort to fraud by calling someone bipolar just for reimbursement. I've rarely seen someone have a diagnosis of bipolar disorder delayed to the point that it resulted in adverse outcome and had to switch from antidepressant to mood stabilizer +/- antipsychotic. But I see tons of patients who turn out to have MDD +/- poor affect regulation be misdiagnosed as bipolar and suffer from persistent depression. I had a new intake come in my office, after extensive review of his outside records and history gathering, he did not appear to have bipolar disorder but he sure has some bad EPS. One geriatric patient clearly didn't have bipolar disorder, but he was kept on neuroleptics after a poor inpatient diagnosis. And no one bothered to dive further in his records and regather the history. But I did though. He had Parkinson's disease on his problem list. Guess what? I stopped the neuroleptic and wow, no more Parkinson's. To think that this patient could have been wheelchair bound the rest of his life. He's doing great by the way. There's a borderline patient that comes to mind who's over 400lbs due to the antipsychotics. No, she's not feeling any better, she practically lives on the inpatient unit.

 

[birchswing]

Incidentally when I was resident, patients could read their notes online. I had one pt I saw who was narcissistic and one day I remarked "you've lost weight!". He told me, "well I saw that you described me as overweight in the mental status exam. I thought 'f*ck him' so I lost 10lbs!"

Ha!

I got my notes when I left a community services board. I used to have someone come out to the house who would go shopping with me, etc. She wrote that I wore pajamas and had disheveled hair. I don't even own pajamas! I guess whatever I wore looked like it. And as far as my hair, that part was probably true, but as I pointed out (to myself), Bill Gates often has disheveled hair and does quite well. It was fun to get a look inside how other people see you. It's also possible she had to write something negative to keep me in the program because it was supposed to be for people with intellectual disabilities rather than those with crippling anxiety, but I actually found it very helpful.

 

[LasVagus]

Bipolar disorder is painfully over-diagnosed where I am. Many of my attendings love to slap this label on people. I passively fight back through documentation:
"The patient describes her manic episodes as 'angry and like I want to kill myself'. She says that they are triggered by her boyfriend 'being a jerk' and resolve when he 'says something nice or apologizes'. She experiences several of these episodes everyday. There is no associated decreased need for sleep, increase in goal-directed activity, rapid speech, grandiosity, distractibility, or racing thoughts".
This will usually lead my attendings to believe that the patient has ultra rapid cycling. Haha. Whatever. I feel for you, randomdoc1.

 

[ara96]

Did you involuntarily get him admitted for inpatient detox?

 

[randomdoc1]

Did you involuntarily get him admitted for inpatient detox?

He was voluntary. Actually wants to stay for over a month.

 

[uname943]

Bipolar disorder is painfully over-diagnosed where I am. Many of my attendings love to slap this label on people. I passively fight back through documentation:
"The patient describes her manic episodes as 'angry and like I want to kill myself'. She says that they are triggered by her boyfriend 'being a jerk' and resolve when he 'says something nice or apologizes'. She experiences several of these episodes everyday. There is no associated decreased need for sleep, increase in goal-directed activity, rapid speech, grandiosity, distractibility, or racing thoughts".
This will usually lead my attendings to believe that the patient has ultra rapid cycling. Haha. Whatever. I feel for you, randomdoc1.

I don't think this is a ringing endorsement of your residency...

 

[birchswing]

He was voluntary. Actually wants to stay for over a month.

That must be a nice hospital. I've only been in a hospital once overnight after an appendectomy, and it was the absolute worst. I didn't sleep the whole night and was so anxious to leave. If I didn't believe so strongly in the night crew's incompetence, I would tell you they were trying to kill me. I was in countdown mode to leave. They told me as soon as I proved I could eat breakfast and not throw it up I could leave, but I couldn't eat it till 10 AM. I scarfed down the awful food and got out. I used to dream about going to a hospital and finding a doctor like House to find and cure everything wrong with me. Not anymore.

 

[enoughsaid12]

Rule of thumb for psychiatry - when a patient demands they have a certain diagnosis, they usually don’t. Same goes for disability.

Also, I wouldn’t even waste my time with anything other than an unspecified depression/affective disorder diagnosis when a patient is drinking that much alcohol. First and foremost he has a severe alcohol use disorder, cant really go beyond that till he’s sober.

 

[Mass Effect]

Let's see, I asked him about his longest periods of sobriety, during which he's had nearly a year. No periods of manic or hypomanic episodes in that time frame. He may have had an MDE during a period of sobriety. His possible manic/hypomanic symptoms were exclusively while he's drinking. They do not occur in an episodic pattern. They are *chronic* and while he is drinking. Chaotic friendships and relationships, hates being broken up with, he spends his money loosely throughout the entire year. Family feels they constantly have to triple check what they say in fear he'd lash out. He gets angry at the smallest things on a regular basis, he moods fluctuate a lot throughout the day all year long. He gets random tattoos and falls in love hard and spends tons of money on women who aren't good for him. There is *nothing* episodic about this. The chronology is all chronic. Bipolar disorder is highly unlikely in this case.

Not sure how we'd know on intake if all he's had is less than one year of sobriety. But anyway, you're right that it's unlikely. My point is that on intake, when a patient is demonstrating a substance abuse problem to the point that you send him from your appt to detox, I don't see how you can rule anything in or out or feel so confident about your diagnosis that you specifically say what it is or isn't. And I am also of the agreement that BPD is over-diagnosed and even when it's part of my differential, I don't put it in the chart after intake because I feel it's almost always impossible to know for sure until you've met with the patient a couple of times when he/she is NOT intoxicated and has been sober. Yes, there are dangers to not giving someone who legit has it the diagnosis. But there's also a danger in putting it in the chart and having anyone who sees it take it as gospel, even when it's just a differential.

 

[enoughsaid12]

I have a particular distaste for the psychiatrist who gives the diagnosis of bipolar disorder to an amphetamine addict...and then every doctor who sees them continues their zyprexa and lithium without thinking twice ...

 

[DisorderedDoc417]

Bipolar disorder is painfully over-diagnosed where I am. Many of my attendings love to slap this label on people. I passively fight back through documentation:
"The patient describes her manic episodes as 'angry and like I want to kill myself'. She says that they are triggered by her boyfriend 'being a jerk' and resolve when he 'says something nice or apologizes'. She experiences several of these episodes everyday. There is no associated decreased need for sleep, increase in goal-directed activity, rapid speech, grandiosity, distractibility, or racing thoughts".
This will usually lead my attendings to believe that the patient has ultra rapid cycling. Haha. Whatever. I feel for you, randomdoc1.

Ultra rapid super cycling. It’s tough out there.

 

[randomdoc1]

Bipolar disorder is painfully over-diagnosed where I am. Many of my attendings love to slap this label on people. I passively fight back through documentation:
"The patient describes her manic episodes as 'angry and like I want to kill myself'. She says that they are triggered by her boyfriend 'being a jerk' and resolve when he 'says something nice or apologizes'. She experiences several of these episodes everyday. There is no associated decreased need for sleep, increase in goal-directed activity, rapid speech, grandiosity, distractibility, or racing thoughts".
This will usually lead my attendings to believe that the patient has ultra rapid cycling. Haha. Whatever. I feel for you, randomdoc1.

There’s always clozapine. You know...for that treatment resistant bipolar...

 

[DisorderedDoc417]

There’s always clozapine.

Nothing better than a borderline with a bowel sized block of concrete just ready to obstruct on your unit.

 

[smalltownpsych]

Agree with posters that the alcohol use disorder is likely the only clear diagnosis when someone is that heavy a user. Treat that, then re-evaluate. Also, keep in mind that early months of recovery from substances patient can experience dramatic mood swings that are normative for that population. Depends on age in my experience and the literature I have read, the older alcohol users tend to be numb for a while, even up to a year, and the younger ones start bouncing off the walls after about two weeks or so. Too many docs diagnose them as ADHD or Bipolar at that point and can also reinforce the patients’ psychological need to take drugs to make them feel better. The worst is when you give something that tickles the limbic system dopamine receptors again, but of course those will be the meds that the patient say actually work the best.

 

[psyxh]

Rule of thumb for psychiatry - when a patient demands they have a certain diagnosis, they usually don’t. Same goes for disability.

Also, I wouldn’t even waste my time with anything other than an unspecified depression/affective disorder diagnosis when a patient is drinking that much alcohol. First and foremost he has a severe alcohol use disorder, cant really go beyond that till he’s sober.

Yeah, I had a similar rule of thumb/observation. If pt insisted on bipolar, pt was probably borderline. I've also seen people insist on borderline when they were really bipolar.

While I'm at it, I also went through a period in residency where all the bipolar pts seemed to have birthdays in late December. I've always wondered if anyone else noticed these patterns.

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