Health and Psychology

I am as appalled by the media coverage of the Pulse Nightclub massacre and the Stanford Rape case as I am of the events themselves.  I'm chairing a dissertation on rape and I have a clinical practice that is LGBTQIA friendly.  The media turns these events into single incidents rather than common place occurrences.  The rape case stands out only because of the articulate first person account of the victim.  Rarely do we hear the words of the victims.  And 7000+ words not only captured the nation but put focus on the judge for handing down the light sentence to Brock Turner.  And there is a discussion about rape culture and the misrepresentation of men like Brock as boys and just drinking too much, and not as the face of the rapists they are.  So that discussion is well needed.  But the sentence itself is common.  The rapist I saw a week or so ago was given 3 years for breaking a woman's jaw twice during her rape.  He was out in less than two years.   He's already violating his parole.  I'll see 2 or 3 more just like him over the next few months.  It's common.  So women don't get to feel safe because we know.  We know that reporting gets nothing more than a slap on the wrist.  That going to court gets a laughably light sentence.  That we will be blamed for the rape instead of the rapist.  We know that.  I was told my rapist couldn't be convicted so no charges were brought.  He raped acquaintances.  I know three other women he raped.  There were no charges brought by the State.

The massacre at the Pulse Nightclub is marked by the lack of media coverage of it being a place of safety for people within the transgender drag Latinx community.  It was a continuation of the violence that has been historical from the time of colonization on.  It was the continuation of violence against the community that occurs within a daily basis.  This is a community that wakes up knowing people want to kill them every day. It's not about guns or Muslims.  It's about a massacre that normally happens piecemeal.  The media usurps the community by not naming them. By not calling this what it was, part of the ongoing massacre of people of color, of the homosexual and transgender communities, of the marginalized.

My cisgender white male friends of privilege do not understand.   They think nothing of walking outside, alone, at night.  They think nothing of going to a nightclub and maybe having a drink.  They do not understand why I own a gun, why I'm afraid, or what it means to be a survivor of crime.  A survivor of rape.  They think the police the police will help if something bad happens.  They think the police will come.  But what the media gets so wrong is that as members of these communities, we know the police will not come, if they do come they will come late and ineffectively, they will blame the community, and if we defend ourselves we will be vilified.  The script the media endorses is that these are gun crimes or terrorist activites or the problems of mental illness.  No.  They are the problems of marginalization and dehumanization.  There are countless murders and countless rapes.  It's not about guns, or terrorists or the mentally ill.  It's about a lack of safety and a lack of awareness of how often these crimes are occuring.

Patient shaming. This time it happened to/about my cat. This happens by physicians (or vets) when they don’t know what is going on and all the treatment options they know of have been exhausted. It usually happens to people on the fourth visit either when there isn’t a diagnosis or the treatment is ineffective.

I ‘ve had Tatum since she was just under 2 years old. She was a hot mess. She was in several foster homes. The rescue organization referred to her as medically fragile. She had a couple of common cat conditions, namely cat acne, and bilateral herpes of the eyes. But she was ripping her face and ears open and the go-to diagnosis was some sort of unseen parasite. She was subjected to scrapings, dips, multiple medications and a food diet so extreme that she was only eating one brand of cat food and only turkey pate at that. She still had all the conditions. The rescue person dropped her off, did a cursory look at the house and ran out yelling “Start the car. They took the cat.”

I kept up with all the craziness for a year. Then I stopped the pills. I stopped the drops. I kept her eating out of ceramic or glass dishes. I started varying her food. No change. She ripped her face open and I took her to two vets. No parasites. It’s stress. Cat self-harm. Cat trauma. New people trigger it. Sometimes the other cat triggers it. Sometimes it’s a thunderstorm. She eventually gets over it. She’s been fine for the last several days.

She just turned five and I took her to the vet. New vet. “She should be on L-Lysine twice a day” she said.

“I did that,” I said. “It does nothing.”

“She’s ripping her face open because of the cat acne. It’s painful” she said.

“No,” I said. “She rips her face open when she’s psychotic.”

“We can treat that. There’s medication for it” she said.

“I’ve given her creams and drops for a year. It does nothing. No thank you.”

“So you want your cat to be in pain. I guess you know everything.”

“She’s here for vaccinations. Can you do those?”

“Yes,” she said.

Stalemate.

It’s annoying. It happens because doctors are taught in medical school that they have to know everything. For many it hinders later collaborative practice. They blame patients with chronic medical conditions that don’t respond to typical treatment. They blame parents for children not improving. They blame people when they can’t diagnose. They refer to therapy as a last resort rather than as a first line of options. Switching doctors happens with disgruntled patients or being referred out to specialists is the common practice for physicians. It fragments treatment, limits history, and results in poorer medical care. As more physicians integrate psychologists into their practices hopefully this will lessen.

We're setting up a new phone system.  Someone suggested the voice mail include the phrase "In case of emergency call 911."  When I asked why they would want that, they mentioned that everywhere else where they worked had that.  It's a convention.  But none of the staff in my office would actually call 911 unless they had a medical emergency.  What we all had was a list of people, therapists, colleagues, agencies, or groups we would call in case of psychological emergency. 

I remember the story I heard about someone cutting their holiday ham in half because "that's how it was always done."  They came to find out, it was done that way because there wasn't a big enough pan to fit a large ham.  The call 911 message is done for risk management at large agencies, not because it's helpful, but because it mitigates risk.  

911 gets you the police, maybe an ambulance, maybe the fire department.  If you're sad or suicidal it may get you a trip to the hospital.  If you are angry or homicidal it may get you arrested or killed.  So a friend of mine has his voice mail message that says:  "In case of emergency call 911, and good luck."  Mine just says I'll call you back as soon as I can.  It's my cell phone.  I answer it most of the time.  Sometimes it goes to voice mail.  I get back to them when I can.  If it's urgent people call me then text me.  Psychological emergency calls about other people the kind where we've been fighting and now I'm afraid for them, or my child is out of control and I don't know what to do, just mean the person is out of resources.

I don't have "In case of emergency call 911" in my voice mail message.  If I had to have a voice mail system that tells someone who to call in case of an emergency it wouldn't likely be 911 unless there was a dangerous situation.  It would likely be "if this is a psychological emergency call everyone you know and call a crisis line. I'll call you back as soon as I can, but in the meantime go do something that makes you feel worthwhile, or helpful to someone, or go out in nature and find something beautiful.  If you are feeling really angry or hurt, go watch a cartoon, find something to laugh at, go for a walk, be in the moment with your surroundings, go play with an animal.  Write down everything you are angry about.  Write down all the different ways you can choose to feel instead of being angry.  Write down all the things you want to live another day to experience.  If you have a blank page, you don't have enough things to do.  

And maybe "If your psychological emergency is about someone else, please do the following assessment:  First make sure you and the other person are physically safe.  If there is a weapon, leave and call 911 if you can't get them to put the weapon down.  If you are safe and there is no weapon, then just say "Let's take a break and calm down. I don't want to fight."  Or "This is scaring me."  Or "I know you're upset, but I'm overwhelmed."  Second, call a crisis line if someone is suicidal.  If someone is psychotic or under the influence, get them to a hospital if you can do that safely.  If they are psychotic or under the influence and dangerous, call 911.  

I had a new person coming to seek treatment the other day.  I explained that the concept of privacy is a myth.  Let me explain further.  In this profession confidentiality is important.  People would like to believe that the things they tell to their therapist will not be told to anyone else. Unfortunately that hasn't been true for the past decade or so.  It's not that therapists are running around telling people everything the person they are treating says.  It's that the person they are treating has signed away their rights to privacy.  In addition the government has passed laws that limit how much information can be kept private.

If you use insurance to pay for therapy, the insurance company knows how much time you spent in each session, and your diagnosis.  That information is uploaded to a computerized billing system, a claims processing department, and a computer algorhythm for claims processing.  It may go to an employer paying for insurance premiums.  In small companies that makes you identifiable.  The insurance comapny may ask for session notes in order to process payments.  They don't always do this but they can.

If you are involved in a lawsuit, the attorneys for either side can ask for your therapy notes.  If you are indicating you had stress, anxiety, depression, or anything as a result of a personal injury, malpractice case, wrongful termination case, or any other legal case, the attorneys often want session notes.  They get them from a court order. 

If the government thinks you are connected to someone that may have an evil intent toward the goverment, they will ask your therapist to collude with them in their efforts to collect your personal information.  This is the result of the Patriot Act which was enacted following 911.  You don't have to be a terrorist for the government to attempt to collect information about you.  You can work in a sensitive job with a security clearance.  You can know a lot about computers.  You can have the same name as a terrorist.  All or any of those will allow the government to seize your clinical information down to session note levels and NOT inform you.  Your therapist faces prison time if they disclose to you that Homeland Security has paid them a visit.

The government routinely monitors phone calls, collects massive amounts of computer data, and aggregates data.  We now allow massive data collection on an unprecidented scale.  We have homes that are connected to the internet.  We have smart phones, smart appliances, smart homes, smart cars, and health care data on electronic health records on the internet.  Data breeches are common.  If your data hasn't already been hacked you don't have a cell phone, and live in a remote location.  More than 80 million people have had their data compromised.  It's more likely that almost everyone has had their data compromised.

Companies that have their data hacked may not inform the country that their data has been hacked.  We know about Blue cross, Blue Shield, the government employment data bank for sensitive jobs in the CIA, NSA, FBI, the Veteran's Administration, Target, some banking systems, several retail outlets, local gas stations, several websites data banks including Ashley Madison.  But those are the ones we know about.  I know about the local gas station because purchases were made on my credit card on cities where I don't live or shop.

There are limits on confidentiality to attempt to save lives and ensure public safety.  Suicidal, homicidal, people who abuse children or adults can be reported by therapists to law enforcement.  those limits to confidentiality are almost always discussed at the initial session in therapy.  The other limits to confidentiality aren't discussed as much.  They are often in long documents.  In cases where attorneys seize records kept in diaries, chat room logs, and session notes, clients feel betrayed.  They had no idea that trying to get justice for one set of wrongs would open up all their records to scrutiny.

If you haven't had the discussion with your therapist about what they are keeping in session notes, you might want to.  Therapists are making notes available to clients, so they know the content, and so that the client understands the treatment plan.  Rather than acting like everything is private, having a discussion about what is being disclosed and what isn't being disclosed in notes is important.  If you are using insurance to pay for therapy, you may want to think about how much access you are granting your employer to your personal life.  If you are involved in litigation you may want to understand what your side and the other side will do as strategy.  You may want to talk to your representative aout limiting the Patriot Act from it's massive data collection.  And you may want to think about how much Echo, Siri, map my drive, and all the other applications, devices, and smart connected appliances know about what you are doing, where you are at any given moment, and what you are doing.  

Yes, I have Echo, Siri, Map my Drive, Hue, WeMo, and other connected appliances.  I like being able to control the lights in my house from my office in Glendale.  I check in with location features on Facebook and Twitter.  My computer is password protected.  My computer is encrypted. My office is locked and alarmed.  My files are in a locked cabinet.  If needed I can get office space for an hour and see someone in a different location.  Therapy helps.  It can be wonderful and life changing.  But if you aren't aware of who can get access, it can be hurtful.  Talk to your therapist about what they are doing or not doing to protect your privacy.

This past weekend, The Hoffman Report http://www.apa.org/independent-review/APA-FINAL-Report-7.2.15.pdf was leaked to the New York Times.  The report details the collusion between the American Psychological Association (APA) and the Department of Defense (DoD) specifically the CIA and the Bush Administration in collaborating to use enhanced methods of interrogation otherwise known as torture.  This practice was lied about to the general membership of the APA.  Several members of the American Psychological Association, also members of the Society for Social Responsibility, spoke up against the APA in it's dealings with the DoD.  Some resigned their membership.  Others continued to press for disclosure, transparency, and openness with the membrship and the public at large.  Those that spoke up publically were subjected to ridicule, harassment, and questions of ulterior motives.

As the APA attempts to recover from this debacle, more serious issues of ethics arise.  The difficulties took place over a 9 year period. Wholesale changes to the ethics code were made to permit collusion with governmental agencies.  Historically when laws and rules collided with ethics, psychologists were supposed to do their best to uphold ethics and attempt to work to change laws. The events of September 11th and the attack on the World Trade Center changed what people thought.  Getting information at the cost of civil liberties seemed to be a fine trade-off for many. Then Edward Snowden stepped forth and explained how far that "information gathering" had been taken.

Doing the right thing is a complicated process. Standing up for principles is never easy, is often met with harassment, job loss and vilification. Doing the right thing means to be open, to be transparent, to have input from others, to allow questions, and to take a fierce look at what is happening and how it works or doesn't. It's noticing power disparities, and what happens to dissenters.  Our job as professionals is to stand up for those principles in every day life.  To question data, people in power, people who abuse authority, and to provide science to attempt to provide reasoned influence to the law and to legal processses.  Wrongful or eggregious behavior has a hard time standing up in the face of the light.

APA has issued public apologies that indicate they are disheartened to hear of what transpired.  That it was a select group.  That several people are resigning or have been fired.  It's not enough.  People in leadership have known or should have known for almost a decade.  The time is right for contrition, accountability, transparency, inclusiveness, and genuine change.  That new spirit needs to filter down to undergraduate and graduate programs in psychology, to field placement, internships, residencies, and full and part time positions.  All too often, psychologists fearful of rocking the boat are asked by others in positions of authority to do things that are unethical, harmful, or illegal and feel they have little alternative but to comply.  The APA and all state associations need to provide clear direction going forth about the standards of the profession, the requirements of ethical citizenship and return to clearer values for the profession as a whole. 

I'm increasingly concerned about professionals posting about standards of ethics that have nothing to do with the ethical standards of the profession.  In many cases the professional has a specific theoretical orientation they adhere to that proscribes how to do psychotherapy.  In other cases they are applying standards they learned from a supervisor for their professional practice in that setting.  In these cases these professional approach ethics as if situations are either ethical or not.  Ethics is not that simplistic.

There are basic ideas woven into the ethics codes of a variety of mental health professions.   Among these are concepts of not harming people, knowing what we are doing when we provide treatment, not taking advantage or having undue influence on someone, being fair, being honest and being respectful.  These are complex ideas that are not black and white.  They resist being put in boxes in a simplistic fashion.  While simple yes it's ethical or not it's not ethical ideas are easier, they are often incorrect.  What's required is a discussion about the principles and about what is in the best interest of the patient and the profession and society at large.   So the next time someone says something isn't ethical, ask them to cite the ethics code section that idea comes from.  What is any competing ethical code?  Have the dialogue.  There are few situations that are black and white.  Most are shades of gray.  Have the discussion.

I provide objective evaluations for the State of California for people who have applied for Social Security DIsability.  These evaluations are referred to as Consultative Evaluations.  I provide the same kind of limited evaluation privately at my office in Glendale, CA.  The only difference between the evaluations I do in my private practice than the evaluations I do for the State of California, is that I'll help someone ensure they have provided an adequate history.  There's no difference in the reports, the psychological testing, or my role other than that.

There are several misconcentualization about Social Security Disability.  The first is that everyone is entitled to get it.  Not true.  

Social Security Disability is available to people:

1. Who have been employed with sufficient employment credits within the past 10 years, were incarcerated and out of the labor market,  or were never employed because they were supported by someone else-housewife, domestic partner, dependent child that's now an adult.  
2. It's also available to children who are not able to be in a regular classroom due to a severely disabling condition or collection of conditions and whose family meets income limitations.  
3. Adults under category 1 above must also be no longer able to do simple work.
4. Adults under category 1 above must be expected to be disabled for 12 months or longer.

I usually tell patients upfront that they have limited privacy.  Therapy notes are priviliged and confidential except when they aren't.  There's a long list of circumstances when they aren't.

The times people expect:

• Suicidal
• Homicidal
• Gravely disabled
• Harming a dependent child
• Harming a dependent adult
• Billing insurance

The following information is from http://www.Patientprivacyrights.org.

What information can be found in my health record?

A: A health record is created any time you see a health professional such as a doctor, nurse, dentist, chiropractor, or psychiatrist. You could find the following in your health record:

• Your medical history and your family’s medical history
• Labs and x-rays
• Medications prescribed
• Alcohol use and sexual activity
• Details about your lifestyle (smoking, exercise, recreational drug use, high-risk sports, stress levels)
• Doctor/nurse notes
• Results of operations and proceduresGenetic testing
• Research participation
• Any Information you provide on applications for disability, life or accidental insurance with private insurers or government programs
• Driver’s License
• Social Security Number
• Financial information such as credit cards and payment info

Q. Who has access to my health records?

A. Many more people than you would ever want, including people outside the health care industry.

• Insurance companies
• Government agencies especially if you receive Medicare, Medicaid, SCHIP, SSI, Workers Comp or any local, state or federal assistance
• Employers
• Banks, Financial Institutions
• Researchers
• If you are involved in a court case, your health records can be subpoenaed and available to the public
• Marketers
• Drug companies
• Data miners
• Transcribers in and outside the U.S.
• Many health websites collect information about you

Q: Can my personal health information be used and disclosed without any notice to me or without my informed consent at the time of treatment?

A: Yes.

The Amended HIPAA Privacy Rule states only that you must receive a Privacy Notice telling you how your personal health information will be used and disclosed. Section 164.520(c) (2) (i) (A).

Privacy Notices are often mistaken for consent forms, but they are simply notices telling you what will happen to your medical records.

Example: information about a depressed person’s attempted suicide and hospitalization can be used and disclosed without any notice to him/her without his/her consent and even if he/she objects.

Q: Can my insurer or employer get my health records without my permission?

A: Yes.

The Amended HIPAA Privacy Rule gives health plans and self-insured employers broad authority (“regulatory permission” to get information without consent that is far more extensive than is needed for billing or any other reason related to a specific individual’s health care. Other uses for which health plans and employers are authorized to obtain use and disclose an individual’s health information without consent include:

• Due diligence in connection with the sale or transfer of assets;
• Certain types of marketing;
• Business planning and development;
• Business management and general administrative activities; and
• Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance. Section 164.501

Example: A depressed person’s health plan or employer would have regulatory permission from the federal government to obtain the information about his/her attempted suicide and hospitalization without his/her knowledge or consent if the information was needed for any of the above business purposes, as well as for treatment or payment.

Even more disturbing, the Amended Rule would authorize the individual’s health plan or employer to use and disclose that information even if the suicide attempt and hospitalization occurred before the Amended Privacy Rule went into effect on April 14, 2003.

Q. What is a “self-insured employer”?

A. A self-insured employer does not contract with an insurance company to insure their employees. Instead they have enough employees to do their own risk pooling like an insurance company would. These employers are called “Self-Insured.” During the past couple of decades, the number of employers who have become self-insured has increased dramatically, starting with large employers and spreading to those with fewer employees. Some examples of self-insured employers are: Walmart, Microsoft and IBM.

Q: I thought I signed a Privacy Notice at my doctor’s office giving consent to use my information. What’s in that Privacy Notice?

A: Those are not “consent forms” but a list of the ways in which your doctor or provider may use or share your information.

“Covered entities” are required to provide notice to individuals of the uses and disclosures of identifiable health information that may be made under the Amended HIPAA Privacy Rule as well as the rights of the individual and legal duties of covered entities. Section 164.520 (a). These notices are called Privacy Notices.

Covered entities must “make a good faith effort” to obtain written acknowledgement of receipt by the individual of the Privacy Notice. Section 164.520(c) (2) (ii). When you sign those notices you are only acknowledging that you’ve received a copy of the many ways your provider may use your information.

Privacy Notices are likely to be lengthy, because HIPAA authorizes so many broad uses and disclosures of identifiable health information. Unfortunately, your rights are quite short. You cannot REQUIRE anything of your provider. You can only make REQUESTS.

These are NOT consent forms. You no longer have the “right of consent” with the Amended Rules, effective April 2003.

Q: What is a “covered entity”?

A: According to the amended HIPAA Privacy Rule “covered entity” is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Over 4 million businesses, corporations, government agencies, professionals, and individuals handle personal health information (PHI) electronically and therefore must comply with the HIPAA Privacy Rule.

Consultations between direct and indirect treatment providers are expressly permitted under the Original Rule. 65 Fed. Reg. at 82,510. The Amended Rule did not change this permission.

Q: Can I prevent my doctor from reporting a certain procedure to my insurance company?

A: No. The Amended HIPAA Privacy Rule does not provide any method for an individual to prevent any procedure, treatment, medical test, or prescription from being reported to his/her insurance company.

• This is because the Amended Rule provides regulatory permission for the individual’s insurance company to obtain virtually any personal health information from an individual’s doctor as long as they can assert that they need it for treatment, payment or health care operations.
• Even if the individual asks the doctor to not report the procedure, the doctor need not agree. Any medical treatment can be reported over the individual’s objections.
• Even health information about procedures paid for privately can be reported. The original Privacy Rule stated that information about procedures paid for out of pocket would not be disclosed, but that statement was in the context of a discussion of the right of consent which was included in the original Rule but repealed in the Amended Rule. See 65 Fed. Reg. at 82,512.
• Since the Amended Rule allows for the use and disclosure without consent of personal health information for the insurance company’s business operations, clearly such information can be used and disclosed regardless of whether the individual paid out-of-pocket.

Example: a depressed patient could not prevent the health information about his/her hospitalization from being reported by his physician to his insurance company.

Q. Are my prescriptions private?

A. No. All 51,000 pharmacies in the U.S. are wired for data mining. You cannot keep your prescriptions private, even if you pay cash. Selling prescription records is a multi-billion dollar a year industry: In 2006 IMS Health reported revenues of $2 Billion for selling prescription records (that’s just one company!).

"Can you test me?"  I get this question often.  It comes in a variety of forms.  "Can you test me for _____?"  and "Can you test my child for _____?"

The short answer is yes probably.  The longer answer is "Then what?"  And it's the answer to that question that tells me what to do.

I literally have hundreds of tests, measurements, screening items, and questionnaires.  Literally.  I bought new file cabinets to hold them all and will probably need to buy more.  Online I have access to thousands.  So knowing these tests I have to select the correct test or tests to measure the correct things in the best way possible.  

Let me give an example:

Example 1:  "Can you test my child for ADD/ADHD?"

Yes, probably then what?  If you now know your child has ADD/ADHD then what happens?

"Oh I want them to get special accommodations for school."  

Oh okay.  That's a 40 to 60 page forensic report designed to go to an Administrative Law Judge who specializes in Special Education law and Disability Law under the Americans with Disabilities Act.  It's a 10 hour evaluation documenting the need for special accommodations and what happens if accommodations are not provided. It's set up as a repeaed measures experiment with a single subject under accommodating and non-accommodating conditions.

Example 2:  "Can you test my child for ADD/ADHD?"

Yes, probably then what?  If you know your child has ADD/ADHD then what happens?

"Oh, I'll take them to a psychiatrist for medication."

Oh Okay.  I have a continuous performance test that will do that.  It's about an hour.  I can give you a rating form for your child's teacher to complete so the psychiatrist can track the response to medication.  We can also retest your child under medication to ensure that inattention is eliminated with medication.

Example 3.  "Can you test my child for ADD/ADHD?"

Yes, probably then what?  If you know your child has ADD/ADHD then what happens?

I want to make sure they have it.  I want to know what it's doing to them.  I'm not looking for medication, but maybe some form of rehabilitation to help them.  

Oh okay.  I have a continuous performance test that can tell me within a great deal of certainty if your child has an attention difficulty.  I can do an cognitive test that will tell me if their working memory is impacted as I would expect it to be in an attention disorder.  I can also do some testing of executive dysfunction.  I'll need a copy of their last complete physical with standard complete blood count laboratory results and metabolic panel. I also want their oxygen saturation level documented.  That will allow me to rule out most medical conditions that can contribute to inattention.  It will take 3-4 hours, and wil include a 10 to 12 page report.  I can then talk with you about rehabilitation and various options available.

So all three start off with the exact same question.  But they want different things after the question is answered.  Knowing what they want next changes what I do to address those issues.

Here's a final example:  "Can you test my child for ADD/ADHD?"

 Yes, probably then what?  If you know your child has ADD/ADHD then what happens?

I'd like early intervention.  Right now my child is 6 months old.  

ADD/ADHD doesn't get diagnosed at this age in children.  I can evaluate cognitive, language and motor skills in very young children, down to preterm infants in a neonatal intensive care unit.  So I can tell you how your child is doing compared to other children at 6 months.  Early intervention services are generally done for cognitive delay or deficits in language skills or motor skills.  The evaluation will take about an hour or so.  I need birth records and recent laboratory records. If there is an issue at this age with alertness, visual tracking, attending to the environment, or motor movements, your child may qualify for services by Regional Center.  My report can help to document any delays your child may have.  

If you are interested in an assessment, feel free to contact our office. 

I evaluate all ages from preterm infants in neonatal units of hospitals to the old old.  A parent brought in their one year old for an SSDI evaluation because they believe their infant has bipolar disorder.  

Bipolar disorder previously was known as Manic Depressive illness.  The diagnosis generally starts in someone's 20's and lasts throughout their life.  It is characterized by a manic phase in which someone has difficulty managing their internal state and things spin out of control.  They can't sleep and engage in grandiose fantasies.  Their thoughts run so fast they can only speak in snippits of unintelligible conversation.  In prolonged manic phases the person can die of manic exhaustion.  This phase can last for a few days to a week.  The other phase is a depressed phase that can range from a psychotic level of depression to a more mild depressive state that can last longer.  Episodes of mania that occur more than twice a year are referred to as rapid cycling.

A few years ago, there was an article on children with bipolar disorder.  The article targeted irritability and mood swings.  Something almost every child has temporarily at points in their childhood.  The diagnostic category has little clarity and doesn't seem to corellate with later diagnoses of bipolar disorder in adults.  In addition there seems to be some confusion about the diagnosis of personality disorders such as borderline personality disorder and bipolar disorder.  There also appears to be some diagnostic confusion with ADHD diagnoses and with psychotic disorder such as schizophrenia.    There are about 11 forms of ADHD, one of which presents with mania.  Schizophrenia can have a mood disorder component including a bipolar component, the diagnostic label changes to schizoaffective disorder.  

I've evaluated one infant in my 30 year career that appeared to have symptoms of mania.  I suspect the infant had a neurological disorder.  Since the infant was in foster care, the request for medication evaluation to help the child sleep and reduce the level of frantic activity went through court order as did the request for neuroimaging.  I don't know the outcome of the case.  I've evaluated lots of infants in my career.  Many of the infants with reported psychological difficulties actually have neurological impairment.  Psychological and neuropsychological testing can clarify learning problems, neurological difficulties localized to areas of cortical functioning, and problems with parenting and parental attachment.

In other cases there are children with psychotic symptoms and severe sleep disorders that have had neuroimaging showing abnormal brain structures.  This is not a bipolar disorder diagnosis.  This is a neurological condition.    Seizures and sleep apnea can cause symptoms that look like ADHD or mania in children.

Psychological or neuropsychological testing can bring clarity to diagnostic issues.  No the infant didn't have bipolar disorder, or ADHD.  But the relationship between the mother and the child was problematic and would benefit from early intervention and treatment.  The infant was anxiously attached to the mother and was seeking attention, soothing and comfort.  The mother was distant and uninvolved.  She seldom looked at the baby.  He kept calling "mama" and at one point hit her to gain a response.  She explained he "always" did that. He came over to me and patted my arm and looked at my bracelet.  He made good eye contact.  He was not frantic in his interactions with me.  I talked to him and he related socially in a normal way.  He spoke in two word phrases.  He seemed bright for his age and well within normal limits of temperment and engagement.  It was only with his mother that he started being frantic and attention seeking.  During the one hour evaluation, she spoke to him one and didn't interact with him at all.  No he's not bipolar.  He has an anxious attachment with a mother that is indifferent. 

Psychological and neuropsychological testing can assist in diagnostic clartification.  If you are interesting in having yourself or your child evaluated please contact our office.