Saturday, July 24, 2010

Counting Symptoms that Don't Count

A horrible trend has been taking off for the last decade in psychiatric offices across the country. As fees for psychiatrists were ratcheted down by managed care insurance companies, especially for psychotherapy, psychiatrists have tried to keep up their income by becoming primarily prescription writers and seeing as many patients per hour as they possibly can. This has let to the infamous ten or fifteen minute "med check." In this short period of time, the context of the patient's life experiences as it affects a patient's psychological condition is seldom even evaluated, let alone taken into account, in making a determination of which medications and dosages are appropriate for a particular patient.

The time squeeze has also adversely affected the patient's initial diagnostic evaluation. A comprehensive evaluation takes at least forty five minutes, even if the doctor only superficially touches on all the relevant information that needs to be elicited from the patient. Initial evaluations now are often squeezed into a half hour, which often includes the time the doctor has to write his note, return phone calls, and/or go to the bathroom. If any reader plans to see a psychiatrist who does not schedule an hour for a new patient, I would advise that reader to run as fast as you can in the opposite direction!

So what does a doctor who spends so little time with a patient do to save time? I mean besides completely ignoring the patient's relationships, history of truama, humanity, etc. (One of my patients reported being screamed at by his last psychiatrist, "I don't want to hear about your mother!! I just do meds!"). Well, one thing they can do is ask only about symptoms, and blindly accept the patient's yes or no answer without even checking to see if the patient understands the difference between a transient mood state and a psychiatric symptom. Better yet, before the doctor even sees the patient, he or she can have the patient fill out a symptom checklist, and base his diagnosis entirely on that. (Of course, his secretary could make a diagnosis doing that, so the patient really wouldn't even have to talk to the doctor at all).

So, is it not true that the DSM, the diagnostic Bible in psychiatry, just lists symptoms as diagnostic criteria, and says how many of them you need to make a given diagnosis? No! It requires a doctor to also make a clinical judgment about the diagnostic significance of any symptom a patient reports. This involves asking follow up questions like a good newspaper reporter. Just because a patient reports staying up all night without feeling tired for seven days in a row does not mean that the patient also remembered to report that he was sleeping during the day, or was on a cocaine binge.

To illustrate better what I mean, I would like discuss the contents of an article called Avoiding Diagnostic Deficit Disorder in Bp Magazine. Bp Magazine is a periodical about patients' experiences with bipolar disorder. The disorder, which used to be called manic depression, is characterized primarily by distinct periods of severe mood elation and other periods of severe depression, separated by normal periods (euthymia) in between.

I was not able to find much online about the publishers of this magazine, and what I found may be faulty, but apparently the publisher, Green Apple Courage Inc., was founded by one Bill MacPhee, a patient with schizophrenia who was finally stabilized on medication and became productive again.

The primary advertisers for BP Magazine were listed on one web site as "Platinum sponsor Pfizer Inc. and Gold sponsors Bristol-Myers Squibb Company, Otsuka America Pharmaceutical, Inc. National mental health association advertisers include the Child and Adolescent Bipolar Foundation, Depression and Bipolar Support Alliance, Mental Health America and the National Alliance on Mental Illness." I started getting the magazine in the mail for free unsolicited, which usually means a pharmaceutical company is paying for mailing the publication to psychiatrists like me. Draw your own conclusion about whose interest the magazine might be best serving.

Anyway, the article expresses concern that bipolar patients might be misdiagnosed with something else, when the real danger nowadays is that a patient with something else will be misdiagnosed as "Bipolar II," which in my humble opinion is part of the Bipolar, My Ass Spectrum Disorder.  So it advises potential patients to tell their doctor about symptoms such as agitation, impulsivity, racing/obsessive/cluttered/busy thoughts, hypersexuality, hyperbuying, euphoria, decreased need for sleep, and use of alcohol or other agents to relax.  It advises that they report these other symptoms last: depression, anxiety, panic, and trouble concentrating.

The article neglects to point out the fact that in mania, these symptoms all have to occur at the same time, and be totally atypical for the way the person normally functions. I mean, true bipolars are like Jeckyl or Hyde (not both at the same time) for an extended period of time.  They do things while manic that are totally out of character for them. These characteristics of the symptoms are absolutely essential for determining their diagnostic significance.

We speak of the three p's: pervasiveness, persistence, and pathological.  The symptoms of mania in particular have to affect every aspect of the person's life regardless of the person's changing external circumstances, they have to continue for a full week at the very minimum, and they have to cause significant distress or impairment.  (Hypomania, hallmark of bipolar II, only has to last four days.  Not four minutes, four days.  It is the only condition in the entire DSM that does not require distress or impairment).  One also has to take into consideration the state of a patient's current relationships in order to rule out normal reactive mood changes.

But wait, there's more!  Every symptom that the article recommended reporting first is non-specific.  That means that each and every one of them can be symptoms of several different psychiatric disorders, depending on their other characteristics, or they may just be normal personal variants or the result of having a bad day.  I mean, anyone here ever go on a spending spree and buy more than they should have?  The nation's huge credit card debt screams out that this is hardly a phenomenon only seen in manic or hypomanic patients.

Let's take irritabilty, for another example. It can be a symptom of mania, but it can also be a symptom of major depression, dysthymia, generalized anxiety disorder, panic disorder, a personality disorder, the abuse of a variety of different drugs and alcohol, side effects of medications, having just had a big fight with your mother, or just feeling irritable for that day for no particular reason at all.

Now, the doctors who think everyone who comes to them is bipolar and is in serious need of drugs object to the DSM bipolar criteria for duration of symptoms.  That may be a legitimate criticism, but so far there is not a single shread of evidence linking brief mood swings like going into a rage to true bipolar I disorder.  The doctors pushing this idea basically pulled the idea that they are related out of their asses. 

To prove this, however, they do studies in which they diagnose people who do not meet the duration criteria for mood episodes as "bipolar not otherwise specified (NOS)," which is a diagnosis that is listed in the DSM.  What the NOS designation is supposed to be used for is people who just barely miss DSM criteria, like someone having manic symptoms for six rather than the required seven days. It is not supposed to be used for people who miss the criteria by a country mile, like a person having a ten minute mood episode.  I would call the tactic of using the NOS category for patients like that as Nothing Other than Stupid.

They then do studies which include patients that they have diagnosed with their version of the NOS disorder, thereby gathering a sample of subjects that contains a certain number of people who have ten minute mood swings.  They then look at their overall sample to see how many of their "bipolars" have this symptom, and voila!  A significant percentage do, therefore "proving" that bipolars can have ten minute mood swings.  If you don't understand the term circular argument, you can look up the term circular logic.  It might say that circular logic means the same as circular reasoning.  If you don't know what circular reasoning means, you can look that up and find out that it means the same as circular argument.

One blog reader asked me why I do not believe in brief mood swings.  Of course I believe in them.  They are just not symptoms of bipolar disorder.


  1. Word. What i have been wondering is, why does this happen? People don’t do things (in this case, prescribe patients with bipolar) for no reason. The doctor must be getting some sort of feedback that this treatment “works”, that their patients feel better. Or maybe, with treatment resistant patients, it’s comforting to have a diagnosis to blame their treatment resistance on (It’s because he/she was never “properly” diagnosed!). Or… something; i'm just brainstorming here. Because i can’t think of any intrinsic reward to giving the patient any diagnosis other than the right one.

    Yes, i'm playing Shrink the Shrink. Is it annoying? I can tone it down.

    One doctor's basis for diagnosing me with Bipolar II was (1) he thought i was lying about having never been manic and (2) i had admitted to getting a bit anxious right before my period (?). He dismissed my concerns and prescribed me Lamictal. Well, what else was i going to get out of that hospitalization? I took the Lamictal.

    I should mention that i have taken lithium in the past -- that's probably where he got the idea that i was bipolar and lying, though a better liar would've just _not mentioned the lithium_. Anyway, lithium turned me into a zombie, and all i remember about that time was people telling me how much happier i looked (that, and a lot of cutting), which makes me wonder if there's some, like, cosmetic effect of prescribing a mood stabilizer to a depressed person. I mean, i might have felt better for all i know; if you're exhausted from being constantly slammed by depressive thoughts, it might feel nice to take a little numbed-out break.

  2. S - Your comments are not in the least annoying, and your observations are actually quite insightful. Your basic question is a good one, but there is no simple answer - there are multiple reasons for this state of affairs. That's what my upcoming book is all about.

    One of the basic reasons for psychiatrists putting nonsensical diagnoses on patients is that most of them have stopped doing psychotherapy. When all you have to offer is medication, everything looks like a brain disease.

    You are absolutely spot on about patients being numbed out with medication, although lithium usually doesn't do that as much as it seems to have done with you. Most of the drugs for bipolar are very sedating, so the patient looks calmer for a time.

    Unfortunately, the sedative effects start to peter out after a month or two, which is why patients diagnosed with bipolar II have their medications changed all the time or are put on bizarre cocktails of several different drugs. It's glorified dope dealing, as I said in a previous post.

    BTW, if you are cutting, that's NOT a symptom of bipolar disorder, and you should have been referred to a psychotherapist who specializes in patients who do that.

  3. No need for concern; the self-injury is in my past. Though on a side note, i suspect the self-injury may well have been one of the reasons i got those bogus diagnoses (schizoaffective and borderline, in addition to the bipolar), because the providers were freaked out by the behavior (and possibly the fact that i tended not to mention it unless directly questioned).

    To get more squarely back onto the original topic, do you have any thoughts on whether it is mostly the "treatment resistant" patients who get hit with a bipolar diagnosis of this sort? I don't know how anyone could easily find this out.

    The reason i ask is that it's the easiest scenario for me to understand. I can imagine that it would be very, very frustrating for a psychiatrist to run out of options with this kind of patient, and maybe that frustration could drive them to stretch a diagnosis just to come up with some kind of answer. Also, i think many patients don't understand that depression can wax and wane, and some people seem to think that the "feeling better" times are a type of mania. (Having met and interacted with a few people who are bipolar, i simply cannot imagine the two states being comparable.)

    These are just my thoughts from chatting with various friends and acquaintances -- none of whom are psychiatrists, and it is so interesting for me to see the "other" side of things! Thanks.

  4. S - How kind of you to want to give these psychiatrists the benefit of the doubt. Unfortunately, many of the patients that are being labeled "treatment resistant" are actually being given horridly inappropriate treatment in the first place because they have been mis-diagnosed. Of course the wrong treatment won't work.

    Some patients are difficult to treat even when given an appropriate treatment. In the case of conditions more amenable to psychotherapy than meds, it is convenient for the doctor to blame the patient instead of the current state of our knowledge about treatments or the doctor's own inadequacy or incompetence.

    The term "treatment resistant" should in my opinion be reserved for patients who have conditions like schizophrenia, major depression, or true mania that are known to respond to specific drugs but for which the drugs don't work in the particular patient.

    As for mania being compared to the waxing and waning of depression or other mood states, you are soooooo right! The differences are not subtle at all.

  5. hope you don't mind me commenting so long after the fact, but this post really affected me.

    i was a psychology undergraduate student and began, of course, taking 'abnormal psych' type courses. like alot of other students, i would hear symptoms, and think, 'wow, that sounds like me'. so when my gynecologist examined my sexual history, and suggested i see a school psychologist, I did. Besides, I was doing practica at the local veterans' hospital, then inpatient psychiatric units, and wanted to see what those patients felt like.

    long story short, i found myself exaggerating my 'symptoms' to sound like/ look like textbook BPD (any insight on why I would do this?) and leaving out important details. Well, the 'psychologist' bought it and I was sent to the psychiatrist. He asked me a few questions and within 15 mins I was told I had BPD II with OCD-like symptoms, and was prescribed Lamictal.

    Mind you, he never found out that I had been sexually abused as a child for over 6 years and was finally confronting my sexuality(albeit in a completely different culture thousands of miles away from my home country), had recently been diagnosed with diabetes and polycystic ovarian syndrome and had thousands of dollars in hospital debt, had recently had to bail a sibling out of jail (as a college student, this financially crippled me), experienced the death of three close friends, etc. In retrospect, I'm surprised I wasn't more depressed than I was. Anyone would be.

    Long story short, I 'internalised' the diagnosis and started acting 'crazy'. I lost many friends, hurt my family, got kicked out of school, etc. The ensuing events after the 'diagnosis', if anything, almost sent me over the edge. It really should be a crime. I wish I had read this post about 2 years ago. But at least now I can look back at the whole thing and understand that I really was just going through a tough time. Now if only I an convince everyone else of that...

    Thanks for this!

  6. Anonymous-

    That's quite a story!

    I can't speculate on why you, in particular, ran with the diagnosis and acted out. It is not at all a rare phenomenon, but there are a lot of different possible reasons, and I would have to interview you in great detail in order to offer even a preliminary opinion (check out my post, "Don't Ask, Don't Tell" from August 3 for some of the possibilities).

    I hope you are doing well now.