Unreal.

[Crayola227]

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...

lol hardly... fighting a solid diagnosis of HTN or HLD and its tx is just as popular
same with abx... they don't just demand them, but they also try to REFUSE them when it's the only thing for what ails them
if it doesn't lead to anything they need hospitalization for in these cases, they "win" by being "right"

even obesity they might fight you on

you can't win these days in any field of medicine because of all the superstitious thinking

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[OldPsychDoc]

...
you can't win these days in any field of medicine because of all the superstitious thinking

...and blatant ignorance.
This was posted on my FB feed by an RN, mind you. So much wrong with this.

 

[Shikima]

Cluster B in group the other day demanding to be placed on Lithium because of his mood swings and his daughter's are diagnosed with Bipolar.
<roll>

Btw, isn't it funny the Doc's who are insistent on wrong diagnosis and treatment, are usually the most narcissistic and in the most need of MOC?

 

[hamstergang]

Another side effect of misdiagnosing adults with bipolar is the impact on their childrens' diagnoses. I have seen at least 3 kids with emotional dysregulation/irritability (likely combo of depression/anxiety and oppositional behaviors) whose parents wanted me to diagnose them with bipolar disorder because "I have finally been diagnosed with bipolar disorder and I was just like that when I was younger."

I doubt the parents actually have bipolar disorder but they have bought into it too strongly. To suggest their kids don't have bipolar disorder suggests they don't either, and they didn't like hearing that from me (I don't explicitly state that the parents don't have the diagnosis, I haven't evaluated them to make that determination).

 

[michaelrack]

Another side effect of misdiagnosing adults with bipolar is the impact on their childrens' diagnoses. I have seen at least 3 kids with emotional dysregulation/irritability (likely combo of depression/anxiety and oppositional behaviors) whose parents wanted me to diagnose them with bipolar disorder because "I have finally been diagnosed with bipolar disorder and I was just like that when I was younger."
.

it's situations like this that the DMDD diagnosis is well-suited for

 

[hamstergang]

it's situations like this that the DMDD diagnosis is well-suited for

But that's not bipolar disorder and not treated with mood stabilizers so while it satisfies me, parents still don't like it.

 

[randomdoc1]

Hey folks, just an update about the case. So the psychiatrist who diagnosed him as bipolar, I found out has a reputation for diagnosing just about everyone with bipolar disorder. According to some respected psychiatrists in the community, he has his own theory of bipolar disorder and does not follow clinical guidelines. Now...I'm a little worried in the long run about having other patients present to the psychiatric hospital he practices at. Anyways, I guess I'll sort this out later. The patient discussed is not feeling that much better on the mood stabilizer + antipsychotic too...

Ethically is there something I should do after finding out this additional information about this psychiatrist? Out of my conscience, I could not refer this patient to someone who has their own "theories." I had more discussions with the family and they are becoming more receptive to having an open mind about the diagnosis and for sure prioritizing the sobriety.

 

[nexus73]

Hey folks, just an update about the case. So the psychiatrist who diagnosed him as bipolar, I found out has a reputation for diagnosing just about everyone with bipolar disorder. According to some respected psychiatrists in the community, he has his own theory of bipolar disorder and does not follow clinical guidelines. Now...I'm a little worried in the long run about having other patients present to the psychiatric hospital he practices at. Anyways, I guess I'll sort this out later. The patient discussed is not feeling that much better on the mood stabilizer + antipsychotic too...

Ethically is there something I should do after finding out this additional information about this psychiatrist? Out of my conscience, I could not refer this patient to someone who has their own "theories." I had more discussions with the family and they are becoming more receptive to having an open mind about the diagnosis and for sure prioritizing the sobriety.

You mean "hypotheses"...theories are backed up with at least some evidence.

 

[thoffen]

If you have concrete reason to believe someone is exposing patients to harm by providing diagnosis and treatment that does not meet standard of care, then you should act on this. If talking to the provider directly does not fix the problem, then you should report them to the state medical board.

 

[michaelrack]

so you guys advocate reporting a doctor too the state medical board just because he doesn't worship at the altar of DSM 5???

 

[randomdoc1]

so you guys advocate reporting a doctor too the state medical board just because he doesn't worship at the altar of DSM 5???

Well, the DSM V is there for a good reason. If my experience with that psychiatrist is representative of how he typically practices then that is concerning. Diagnosing someone as bipolar and immediately starting mood stabilizer plus antipsychotic in context of someone who’s been drinking 1L liquor daily as well as not bothering to review records on a relatively complicated patient is not very kosher. As was his completely neglecting to treat the etoh use disorder. Freely giving out SSRIs is one thing. Mood stabilizers and antipsychotics another. Not only does it delay appropriate treatment but there’s risks of things such as EPS, metabolic syndrome, toxicity, hypothyroidism, hyperparathyroidism, thrombocytopenia, etc. What was all that emphasis in residency and medical school on evidence based medicine for anyways? When I talked about this case to a colleague, he told me other psychiatrists consider him a joke. Not exactly a ringing endorsement of his ability as a physician. I personally prefer to stay out of the medical board, but this is not a light matter either.

 

[Crayola227]

I didn't read this as taking someone to the altar of DSM 5

I'm not a psychiatrist and this just sounds sloppy to me. Like, even a non-specialist would likely figure out you need to review the chart, and try to get this guy's drinking under control.

Don't get me wrong, I have seen severe substance abuse that was absolutely being driven by BPAD and getting that under control was actually key to the rest of it. This doesn't exactly sound like that, though. Or DSM 5 heresy. Just slop.

 

[watto]

I have found that one way for me to address this cognitive dissonance has been to do the occasional Independent Medical Exam for my state's Workers' Comp organization. You get to really call out sloppy diagnoses made by prior "providers" (have to put in quotes as I hate that word but I have seen so many crummy diagnoses by LCSWs as well as MDs that they all get grouped into one chum ball) and clarify how you need to rule out X, Y, and Z before coming to a conclusion.

It's actually pretty rewarding work if you are a stickler for precision of any kind in psychiatry.

 

[michaelrack]

while not addressing ETOH is a problem, I think we should be careful not too be too hard on doctors who have a different concept of bipolar than in dsm 5. After all, if you treat a patient with zoloft, lamictal, and abilify (or seroquel), does it really matter if the dx is MDD vs Bipolar 2?? I do feel that the greater emphasis on the mixed features specifier and greater incorporation of the spectrum theories of bipolarity is an improvement of DSM 5 compared to DSM 4.
And there are an awful lot of psychiatrists out there who are jokes. but I think state medical boards would be more interested in those overprescribing benzo's and stims than those overusing mood stabilizers and atypical antipsychotics.

 

[michaelrack]

When I have studied for my sleep and IM board recerts (both of which I passed), I had to learn a lot of advances in medicine and sleep, with only a little bit of time memorizing new diagnostic criteria for sleep medicine.
I also recently passed my psychiatry recert board exam (november 2017). While I enjoyed learning about advances in psychotherapy and reviewing psychopharmacology, I resent the excessive amount of time I had to spend memorizing the changes in DSM from the previous edition. But I guess it is good that I spent the time memorizing DSM 5 criteria, it will make my Consult Psychiatry (previously psychosomatics) board recert exam a little easier this April.

 

[Mass Effect]

Well, the DSM V is there for a good reason. If my experience with that psychiatrist is representative of how he typically practices then that is concerning. Diagnosing someone as bipolar and immediately starting mood stabilizer plus antipsychotic in context of someone who’s been drinking 1L liquor daily as well as not bothering to review records on a relatively complicated patient is not very kosher. As was his completely neglecting to treat the etoh use disorder. Freely giving out SSRIs is one thing. Mood stabilizers and antipsychotics another. Not only does it delay appropriate treatment but there’s risks of things such as EPS, metabolic syndrome, toxicity, hypothyroidism, hyperparathyroidism, thrombocytopenia, etc. What was all that emphasis in residency and medical school on evidence based medicine for anyways? When I talked about this case to a colleague, he told me other psychiatrists consider him a joke. Not exactly a ringing endorsement of his ability as a physician. I personally prefer to stay out of the medical board, but this is not a light matter either.

Have you picked up the phone to actually speak to this psychiatrist? Have you even given him a chance to explain his line of thinking to you? Before we go reporting people to state medical boards, I think it's important to listen to what they tell you.

 

[randomdoc1]

Have you picked up the phone to actually speak to this psychiatrist? Have you even given him a chance to explain his line of thinking to you? Before we go reporting people to state medical boards, I think it's important to listen to what they tell you.

while not addressing ETOH is a problem, I think we should be careful not too be too hard on doctors who have a different concept of bipolar than in dsm 5. After all, if you treat a patient with zoloft, lamictal, and abilify (or seroquel), does it really matter if the dx is MDD vs Bipolar 2?? I do feel that the greater emphasis on the mixed features specifier and greater incorporation of the spectrum theories of bipolarity is an improvement of DSM 5 compared to DSM 4.
And there are an awful lot of psychiatrists out there who are jokes. but I think state medical boards would be more interested in those overprescribing benzo's and stims than those overusing mood stabilizers and atypical antipsychotics.

Yes, I have spoken to this psychiatrist. His thinking was very black and white and it was not a spectrum. I am open to other work I've heard about like Dr. Phelps. I actually think Dr. Phelps makes some excellent points and find many other aspects/diagnoses in psychiatry are not as black and white as the DSM can make things seem to be. This guy is no Dr. Phelps. But as crayola said, the management of this case was slop. He was not receptive to us discussing the differential, he was treating this patient as a bipolar I after one visit. Like I said, my preference is to stay out of it, I am opting towards just referring patients/providing a list of inpatient hospitals that do not have this psychiatrist. Will it guarantee better psychiatric care? No, but at least I have some idea of a place to steer clear of. Fortunately, it is exceptionally rare for my patients to wind up inpatient. Other psychiatrists have talked to this psychiatrist in question and expressed their concerns with the hordes of people leaving on mood stabilizers and antipsychotics as well. I asked a question, I did not say I was going to stalk his house with a pitchfork and fire because he did not worship at the DSM V altar. Your words, not mine.