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Posted by Phillipa on August 27, 2009, at 20:40:27
What some docs say about diagnosing bipolar. Phillipa
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Discuss the Diagnosis of Bipolar Disorder with Dr. Perlis
Started By: rperlis, Psychiatry/Mental Health, 10:26AM Jun 15, 2009
(This Discussion will be open from June 30, 2009 July 30, 2009)
Patients who will eventually be diagnosed with bipolar disorder may not present in the acute manic phase associated with bipolar I disorder; depressive symptoms are more commonly seen. Before arriving at a diagnosis, clinicians must consider a differential diagnosis of psychotic or personality disorders, other mood disorders, substance abuse, and comorbidities. Establishing the presence of at least 1 past manic or hypomanic episode may require a structured clinical interview, use of clinical scales, corroboration from family members, or monitoring over time before an accurate diagnosis can be established. What strategies do you use when faced with a difficult diagnosis? What symptoms have challenged your diagnostic skills? View the related educational activity, then discuss your experiences with diagnosing bipolar disorder and pose questions for Dr. Roy Perlis in this interactive discussion board.Poll: Which of the following strategies do you find most helpful in your practice when considering a diagnosis of bipolar disorder? Structured or semistructured clinical interview|Interviews with family members|Mood Disorder Questionnaire|Hypomania Checklist|Young Mania Rating Scale| Poll
Which of the following strategies do you find most helpful in your practice when considering a diagnosis of bipolar disorder?
Structured or semistructured clinical interview
Interviews with family members
Mood Disorder Questionnaire
Hypomania Checklist
Young Mania Rating Scale
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#1 of 8, Added By: yvesjeanbaptiste, Family Medicine, 3:33PM Jul 01, 2009I usually do both. Question family members and patient about symptoms and mood swings
Report Comment Reply#2 of 8, Added By: An_15198282, Psychiatry/Mental Health, 2:22PM Jul 13, 2009
the progam was helpful
Report Comment Reply#3 of 8, Added By: rperlis, Psychiatry/Mental Health, 9:18PM Jul 13, 2009 Replying to:
Reply to: #1 by yvesjeanbaptiste
I usually do both. Question family members and patient about symptoms and mood swingsGlad to hear it. Collateral information from family members can really be crucial in making the diagnosis, especially when it's difficult to get a clear history. I can't resist pointing out one caveat, though: 'mood swings' has become one of those terms linked with bipolar, but not necessarily indicative of bipolar. Abrupt shifts in mood (on the order of hours) can certainly be seen in bipolar disorder, especially in mixed states - they're there in Kraepelin's descriptions 100 years ago. Remember, though, that the differential diagnosis of mood swings can also include anxiety disorders (often with intermittent racing thoughts), personality disorders, major depression, and substance abuse, among others. So definitely ask about mood swings - but be sure to follow up with questions to nail down mood *episodes*.
Report Comment Reply#4 of 8, Added By: pilardelrio, Psychiatry/Mental Health, 12:22PM Jul 14, 2009
Thanks for the program.
For me most difficult symptoms are irritability and anxiety, specially in outpatient setting, where you need to adress symptoms fast, in order to let patients go back to work. This makes the diagnosis difficult, because once symptoms are gone, patients tend to minimize past episodes or not want to talk About them.
Another hard thing is to convince hypomanic people to get treatment once they´re no longer depressed. They love that state, and don`t want to be "euthymic".
A helpful strategy, besides the ones already mentioned,for making diagnosis, are clinical meetings where you can discuss difficult cases. Other people usually point out things you haven´t noticed.
Thanks again for your help!
Report Comment Reply#5 of 8, Added By: stehr-green, MD, Preventive Medicine, 6:59PM Jul 15, 2009
This program comes at a good time. I am an public health physician (focus epidemiology!!) coming out of a lengthy retirement to volunteer at our local free clinic. In the short time I have been at the clinic, I would guess that at least one-quarter of patients are being treated for depression. We have limited time with patients, follow-up likely is not as good as with typical outpatient care, and the patient is likely to see a different practitioner each time they come to the clinic.
Two patients have given me pause ... leaving me with a lingering feeling that they could be bipolar.
- One was a 60 y/o woman in a deep depression when first seen. She wasn't a good historian. Recently had to move to a shelter for women. She was started on an SSRI by another practitioner for depression. (I was observing, however.) I saw her 2 weeks later and the change was dramatic. She was bordering on euphoria, extremely talkative with self-reported behaviors that seemed a little inappropriate to me. I made no changes to her treatment but had her return in another month. But I have not seen her at follow-up appointments.- The other patient was a young man in his early 20s. He reported a long history of depression (from his teens) with a suicide attempt in the past. He was no longer on medication. (He had discontinued treatment because he found it not effective. He did not know what he had been treated with.) He presented to me with classic depressive symptomatology. He did not really report any manic-like episodes (I don't think) but when I delved a bit (not very smoothly, I am sure) about impulse control (giving the classic example of spending money you don't have) he reported that he did overspend and had outrageous credit card charges. When asked about episodes of elevated mood he reported being in a band and getting into the music with almost feelings of being high. He had a history of substance abuse but denied current use. I deliberated and decided to start him on an SSRI. But the onset of his depression in his youth, lack of successful treatment, and other things have me thinking.
In follow-up to these cases, I subsequently did some reading about diagnosis of bipolar vs. depression. One source made it sound like treating for depression and watching to see what happens might be ill advised. Maybe I am not interpreting the literature correctly.
Coming out of retirement, my middle name is humility. Any guidance on how to approach these patients or patients presenting with depression in our particular setting would be appreciated.
Thanks for this good CE and for your help.
Report Comment Reply#6 of 8, Added By: lisamathews43, Nurse, Public/Community Health, 7:24PM Jul 21, 2009
This program was very helpful and informative. As a practicing RN of 20+ years, I am impressed by your humility and your willingness to continue gathering information after your initial diagnosis. I have seen practitioners happy to quickly stamp a diagnosis on someone and never re-evaluate. Your patients are blessed.
Report Comment Reply#7 of 8, Added By: rperlis, Psychiatry/Mental Health, 9:19PM Jul 21, 2009
Great comments and lots to talk about.
pilardelrio: you bring up a few key points. First, not all that's irritable is bipolar - when we asked ~4000 patients with unipolar depression, ~40% reported significant irritability. Hearing about irritability should prompt a closer look for manic/mixed symptoms - but doesn't clinch the diagnosis by any means. As far as patients not wanting to give up hypomania - certainly it can be a problem. I tend to spend most of my time talking to them about the depression, and stressing that we need to find ways to prevent it. And yes, there's no substitute for being able to discuss a tough case with colleagues.
stehr-green: those two cases would have been perfect for our broadcast. One of my mentors used to describe the first one as 'I woke up, the colors were brighter, the birds were chirping, and I felt great!'. His advice would be something along the lines of celebrating the rapid improvement by decreasing the antidepressant dose, and seeing the patient again in a week. Some would argue to stop the antidepressant immediately - but you risk relapse in someone who's not *necessarily* hypomanic. Others would suggest adding lithium or another antimanic immediately - but I'm still not certain we're bound for hypomania. The truth is, the literature doesn't help much here. The bottom line is to be systematic in screening, and when in doubt, close follow-up. For the second case: those individual symptoms do give one pause, but remember they all need to occur *during the same period*. In the absence of a clear-cut episode, I'd err on the side of antidepressant here, but again with close follow-up. Others, including some bipolar experts, would already have started the lithium!
lisamathews43: unfortunately it's all about humility with this diagnosis - 100 years later, we realize that Kraepelin had most of the clinical picture nailed - it just took us awhile to realize it!rp
Report Comment Reply#8 of 8, Added By: peterparry, MB, Psychiatry/Mental Health, 8:44PM Aug 09, 2009
Whilst much good in the discussion by Frye, Zimmerman & Perlis, what struck me is what always seems to be the case in this current era of decontextualised Axis I DSM reductionism (and I am not denying the existence of true bipolar cases) is once again the lack of any reference to attachment, psychodynamics, family dynamics and trauma. Whatever happened to concepts of hysteria and the "manic defence" that we can all employ at times of severe stress?
Obviously this is particularly apropo when we move away from Bipolar I and further out into the putative bipolar spectrum
Posted by gibbons482 on August 27, 2009, at 21:02:51
In reply to Bipolar Behind The Scenes Discussions By Docs, posted by Phillipa on August 27, 2009, at 20:40:27
Thanks for the post; it was very interesting. Wherever did you find it?
Posted by Phillipa on August 27, 2009, at 21:27:27
In reply to Re: Bipolar Behind The Scenes Discussions By Docs » Phillipa, posted by gibbons482 on August 27, 2009, at 21:02:51
Gibbons came with one of my newsletters. Phillipa
Posted by floatingbridge on August 28, 2009, at 1:32:07
In reply to Bipolar Behind The Scenes Discussions By Docs, posted by Phillipa on August 27, 2009, at 20:40:27
Yes, Phillipa, I liked it too, especially in light of my recent dx change. Thanks again--you are the google queen!
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Posted by Phil on August 28, 2009, at 6:07:20
In reply to Re: Bipolar Behind The Scenes Discussions By Docs » Phillipa, posted by floatingbridge on August 28, 2009, at 1:32:07
Didn't read it. If docs were such genius' it wouldn't have taken them 15 years to dx me right.
I was showing blatant manic signs to my 1st pdoc.
It took a lady pdoc to say, bitch, you're manic.
God, that first bout of mania was 30 days of outdoor bliss.
Since then...sucks.
Posted by Sigismund on August 28, 2009, at 22:36:33
In reply to Re: Bipolar Behind The Scenes Discussions By Docs, posted by Phil on August 28, 2009, at 6:07:20
>God, that first bout of mania was 30 days of outdoor bliss.
Does anyone ever get mania without any depression (as a consequence, or whatever the relationship is)?
Posted by Phil on August 29, 2009, at 8:44:33
In reply to Re: Bipolar Behind The Scenes Discussions By Docs, posted by Sigismund on August 28, 2009, at 22:36:33
Can't say. Right after that run I got s i c k.
Real sick.Rash, joint pain, and fever up to 104.3.
I was seeing an infectious disease specialist that thought it might be Still's Disease or Lymphoma.
She never could diagnose it and said it must have been an unidentified flying virus(Austin..rolls eyes)
I wasn't depressed even though so sick.
The doc was stunniing so I looked forward to the frequent appts.
Posted by floatingbridge on August 29, 2009, at 11:32:51
In reply to Re: Bipolar Behind The Scenes Discussions By Docs » Sigismund, posted by Phil on August 29, 2009, at 8:44:33
Phil, I hate to say it--because others often do, but what about lymes? You know--yard work=joint pain + rash.
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Posted by Sigismund on August 29, 2009, at 15:35:42
In reply to Re: Bipolar Behind The Scenes Discussions By Docs » Phil, posted by floatingbridge on August 29, 2009, at 11:32:51
These ticks you get there, do they live on deers only?
We have ticks that live in trees. We call them shellbacks, although there are a few different types. They are toxic and rarely can give you something called tick typhus.
Posted by Phil on August 29, 2009, at 17:21:18
In reply to Re: Bipolar Behind The Scenes Discussions By Docs, posted by Sigismund on August 29, 2009, at 15:35:42
You know, we discussed all that. I was ripping down limbs, near old piles of limbs, leaves, and wood and she wasn't buying any of it. I was surprised but Jesus, she ran TONS of blood tests, CT scan, etc.
I've talked to other medical people that say she's one of the best, if not the best, in Austin so I had to go with what she said.
This town attracts great docs.
She said another thing that surprised me. Something to the effect that mold was more of a boon(?)for lawyers than a threat to your health.
That could be a bit out of context but she said it.
IDS work like detectives. No physical exam. They have that info. They ask questions and go from there.
I still think it was a tick or something but I never saw a bite mark or a tick.
Whatever, I was tripping sick. The highest fever, 104.3, hit on a late Sunday night. I was scared because I didn't know what to do. I just rode it out.
Maybe there is a God.
Posted by Phillipa on August 29, 2009, at 19:38:55
In reply to Re: Bipolar Behind The Scenes Discussions By Docs, posted by Phil on August 29, 2009, at 17:21:18
Phil when they discovered I had bona fide lyme's disease I wasn't ill. But Had had a strange fever and chest pain a few months back. I went from lying on the couch to acute anxiety at which time they found the hasimotos thyroiditis and still disn't know I also had lymes. On a routeine lab since after that time of illness I'd had a deer tic on my arm the pdoc ran a Western Blot which was poitive was treated with doxycyclline for l0 days that was it. A few years later retest showed positive at which time was hospitalized and in there a month had a pic line rocephin Iv for a week and then oral biaxin xr for two years three months at a time. To This day still test positive. And the health dept always calls and asks if being treated the docs won't treat anymore say it's the remaining titer. So since originally from CT where lyme's originated they feel I could have had it dormant for many years. North Carolina does not recognize that lymes is all over the world. And Sigi rodents also carry it. Phillipa
Posted by Phil on August 29, 2009, at 20:18:03
In reply to Re: Bipolar Behind The Scenes Discussions By Docs » Phil, posted by Phillipa on August 29, 2009, at 19:38:55
YIKES!! That sucks!! Whatever I had she must have cured it.
Before I saw her, my doc prescribed Avalox and I had a severe reaction. Full body rash-felt awful.
I put on some wrinkly clothes, went to his office, and asked to be put in an exam room now. They did it.
I laid in the fetal position until my doc came in. He's a sweet guy. Phil? Phil??
He later told me he was very worried about me.
They gave me prednisone I think. After things cleared up I could eat hamburgers by the dozen. Damn that stuff makes you eat.
I guess I've had some pretty wicked stuff over the years.
You're a smartie Phillipa.
Sorry about the never ending illness. What a nightmare.
Posted by Phillipa on August 29, 2009, at 20:34:06
In reply to Re: Bipolar Behind The Scenes Discussions By Docs » Phillipa, posted by Phil on August 29, 2009, at 20:18:03
Phil and I'm so glad your're well now. I do mean that. Love Phillipa yup lymes is a sneaky disease.
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