manic-depressive

The DSM (Diagnostic and Statistical Manual) is the ultimate guide to psychiatric diagnoses. This tome has been amended and updated for more than 40 years. The DSM V is soon to be published. Unlike all other fields of medical diagnosis, psychiatric diagnosis is subjective. The diagnosis of a patient is based on symptoms not specific laboratory or radiographic or genetic testing. A reading of the DSM would have you believe that any practitioner could apply the algorithms and come up with an accurate diagnosis.

If the hodge-podge of diagnoses that my patients carry on their problem list is any indication, psychiatric diagnoses are less than ironclad. A recent patient had depression, bipolar, schizophrenia and drug abuse as current diagnoses. The other inconvient and inconsistent problem with the DSM is its mutability. Manic-depressive disease is now refered to as bipolar disorder. The critieria for diagnosis is quite similar, so why the name change.

Bipolar disorder is characterized but alternating periods of depression and mania. Depression is a profound sense of sadness, anhedonia (inability to feel pleasure), and often thoughts of suicide. Sleep disturbances, anorexia, even hallucinations may accompany the depression. Mania is the "polar" opposite. Bursts of activity, sexual, creative and destructive occur. Insomnia is common. Drug use exacerbates the mania. The manic is a danger to himself or herself and to others. These bipolar extremes can last for weeks or months. Medications are prescribed to try and keep the patient on a more level emotional plain. People with bipolar disorder have been prominent in history. Vincent Van Gogh has been retroactively diagnosed woth bipolar disorder by many psychiatric specialists.

An older neurotic condition was labeled cyclothymic personality disorder. This could be applied to anyone who was moody. We all know family and friends who blow hot and cold. The spectrum of bipolar patients can run the gamut from moody to suicidal and self destructive.

Health insurers rarely pay for prolonged psychotherapy, medications are the cheaper solution. Psychiatric medications are very problematic. They are relatively blunt instruments. The mechanism of action is to change the levels of neurotrasmitters in the brain. How these mediations effect an individual patient is very variable. Psychiatrists and primary care doctors try a ever changing combination of meds in an attempt to ameliorate the symptoms of bipolar disorder. Other medications are prescribed to counter the disturbing side effects of the psychotropic medications.

Some combination of antidepressants and antipsychotic are used. Mood stabilizers such as lithium salts and anticonvulsants may also be prescribed. Patients infrequently take their medications as prescribed. The number, cost and scheduling of medications is inversely related to compliance. The more medications prescribed, the less likely that the patient will take the meds correctly.

With strong support from family, friends and both couselors and physicians, bipolar disease can be managed effectively. The tragedy is that very few patients have this level of support. The psychotic and destructive behavior of a manic episode and the frequent "self-medication" with alcohol, cocaine, methamphetamine and other drugs drives people away. The profound depression that is a part of bipolar disorder may make the patient incapable of seeking the help they need.

As I mentioned in my posting "Psi", the ER is the failsafe setting for bipolar patients. Suicidal thoughts or actions, and manic behavior or outright psychosis leads to an involuntary commitment to the local ER. The familiar cycle of assuring the patients safety and health needs, and the search for an in-patient psychitric placements begins.

There are no simple solutions to the inadequacies of psychiatric treatment. The ever-changing diagnostic criteria of the DSM is but one symptom of the illness. Homosexual behavior was considered a treatable psychiatric condition back in the 1960's. An overly strong mother and weak father led to this aberration. Psychiatry is now much more enlightened. When the diagnosis of a "disease" is based on subjective criteria, there is room for disagreement between clinicians. Watch court TV shows to observe the experts for the defense and prosecution give opposing diagnoses of the defendant.

The greatest dilemma in my dealing with bipolar disorder is the diagnosis and treatment of children. Preschoolers are now being diagnosed with bipolar disease. They are being given the same medications as adults. These drugs have never been tested for long term safety in children. I am an unwilling witness to this travesty. A recent criminal trial took place in the death of a four year girl. She died from an overdosing of her meds for bipolar disease.

A community hospital ER is not the ideal setting for quality psychitric care. Counseling and medication supervision would be an effective first step. Insurance coverage at least equal to any other chronic medical condition and treatment for comorbid factors, such as drug abuse would add greatly to good management. I would also ask that we all educate ourselves about bipolar disorder. Be informed, be compassionate, be involved.