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.