Health and Psychology

Psychiatric terms get changed when they get caught up in the mainstream.  So people start reporting normal mood fluctuations as "bipolar disorder,"  normal concerns about germs or a desire for order as "OCD", concerns about finances as "Posttraumatic Stress Disorder or panic disorder."  No.  Not remotely.

I sat down with a client reporting serious concerns about finances, worrying dreams about money, and being afraid every time he opens a bill.  "I'm traumatized," he said.  He came close to needing to file bankruptcy after medical bills pushed his finances to the brink.  But he's recovering.  The criteria for PTSd is a life threatening situation.  His illness wasn't life thretening.  He can manage his finances but will have to use restraint for a few years.  It's unexpected, but it doesn't equate to being shot, raped, stabbed, or having to be cut out of a car.  It's not PTSD.  On testing it's a good degree of anxiety.  But when I go through the criteria step-by-step with him, he can tell it's not the same thing.

A couple of years ago I went car shopping.  I seriously considered a Nissan GT-R.  Pretty car.  It was actually set up in the dealer behind velvet ropes.  There needed to be an appointment to touch it.  $72,000 sticker and a $40,000 dealer mark-up.  Really.  $72,000 was a bit above my budget.  $110,000 took it way outside.  Had I purchased the car it would have been a bad decision.  I would have regretted it.  But it wouldn't have been evidence of bipolar disorder.  I bought a Mustang GT instead, and a Mercedes C280-(used).  The Mustang actually cost more than the Mercedes.  Both cars together came in well under the Nissan's sticker price without the dealer mark-up.  I haven't regretted either purchase.  

So what is bipolar disorder if it's not wasteful spending and dreaming big, falling short and having regrets?  It's having a manic episode.  Mania is a form of psychosis.  It's over the top.  There are a lot of medical conditions that can produce a pseudo-mania, so I have some idea.  It's the client who proposed marriage to me when I greeted him in the hospital at our first meeting.  His speech was so rapid he was hard to understand.  It's the client at work who stripped off all her clothing in the waiting room so that we "could see the real her."  It's my friend who calls me at 3:00 in the morning to tell me the cat is looking at her.  It's the 23rd cat she's decided to "rescue" in the last two weeks since she's been having difficulty sleeping and decided she really didn't need her lithium.  Her words are slightly slurred. "Call your psychiatrist, stop drinking, take your meds and go back to bed" I tell her.  Psychological testing confirmed she has substance abuse problems in addition to bipolar disorder.  I'm not sure her MD knows she's drinking again.

How about bipolar two disorder?  Maybe that accounts for too much wine, women, and car shopping?  For bipolar 2 disorder I'm looking for a hypomanic episode.  2-3 hours of sleep a night.  Grandious plans, increasing irritability, multiple projects started and not completed.  It's not general immaturity and lack of planning.  It's still over the top.  It's just not quite as a colleague put it "fruit loops crazy."  Testing can show the presence of hypomania.

A few years ago I was given prednisone (a steroid) for breathing problems.  To say I was confused and a tad irritable would be an understatement.  What happened with the steroid induced psychosis is similar to a Bipolar 2 disorder.  I didn't completely stop sleeping, but I just didn't need much sleep.  I started getting irritable.  Everything annoyed me.  Traffic signs, my front door, people, mainly everything.  To this day I don't know how I broke the leaf springs in my car, and I'm vey glad I realized I was heading the wrong way onto the freeway off-ramp and managed to turn the car around and get off the freeway and no one was hurt.  By the time I started hallucinating weird visions, I knew what was happening and called my MD for an emergency visit and within a couple of days all the symptoms had stopped and I was back to normal, with my chart flagged-"history of steroid induced psychosis."  So I'm listening for the impaired judgement-like thinking the off-ramp is an on-ramp.  I'm listening for the irritability.  If it's not there then I'm going to question the diagnosis.  Since there are about 75 conditions that can produce something that looks like mania a history can help differentiate the diagnosis and testing can help confirm the mania or hypomania.

Many people I know put their spices in alphabetical order.  It makes things easier to find.  It's not Obcessive Compulsive Disorder (OCD).  Lots of people use hand sanitizer.  Not everyone who does has OCD.  OCD is characterized by a thought process marked by obcessions and compulsions.  These are irrational and interefere with daily functioning.  It's internally punitive.  "If it's not perfect, I can't do anything else," a friend said.  "I just have to keep doing it over and over again until it's correct. It can take me hours."

I don't generally treat psychiatric conditions in my practice unless they occur with medical conditions.  The exceptions are psychiatric conditions that do not improve with evidence based treatments.  Those circumstances may require diagnostic clarification.  Psychological testing can confirm diagnoses and rule out underlying medical conditions producing psychiatric or psychological symptoms.  If you've been in treatment and haven't been improving, before adding yet another medication, it may be time to ensure the diagnosis is correct.