A question about mental disorder diagnosis.

How hard is it for a physician to diagnose Manic Depression? To me it would seem rather difficult since this illness occurs during the course of months to even years, the “up and down” part specifically. Not to mention there are 4 to 5 different categories for this disease as well. I, II, III, non specific M-D etc…

So what do Physicians do to get their diagnosis for this specific disorder? Do they interview family members as well as friends? What about Patient/Doctor confidentiality?

It would just seem very difficult to diagnosis Manic Depression/Bi-Polar.

The Diagnostic and Statistical Manual IV (DSM-IV) is sort of the bible of diagnosing psychological disorders. It has very specific criteria for each disorder.

You can see the criteria for Bipolar (which is what we now call manic-depressive) at this link: DSM IV Criteria

Physicians or mental health providers are most likely to use a combination of going through the diagnostic criteria with the client plus observation and collateral report. The client may not be depressed at that moment, but is likely to answer questions accurately that provide an historical perspective on his/her moods. In addition, some forms of bipolar disorder have a pretty brief cycle that may be evident even in the course of a brief interview.

Collateral reports (reports by other people) occur in a few ways:

  1. The client’s behavior is observed by family, coworkers, police, etc. and reported to the person doing the diagnostic workup.

  2. The client brings collateral reporters to the interview or provides collateral information to the diagnostician.

  3. The diagnostician requests collateral reports with a release of information or, if the client is evaluated as posing a danger to self or others or having significantly impaired judgment, limited information for purposes of immediate safety and treatment may be sought without release of information (varies slightly by state/province).

The only way this is a violation of confidentiality is if the client is not evaluated as posing a danger to self or others or not having significantly impaired judgment and the diagnostician or other health care provider initiates contact with collaterals or solicits specific health information (note that a general inquiry while standing in the lobby with your family may not be a HIPAA violation, but this is a matter of degree, nuance, interpretation, etc. and IANAL).

Hope that’s helpful.

This post is in response to BlakeTyner:

Right, I understand that there are manuals. But my question is how do the doctors actually know the patient isn’t lying or trying to self diagnose?

I’m sure the doctor could say, “do you have periods of happiness, laughter, feelings of confidence like nothing will stop you and then countered by feelings of loliness, guilt, sadness, anxiety” etc…

But manic depression can take years for it to fully show up.

For instance, I’ve been friends with a person for about two years now, close friends. And I’m just now starting to realize that this person is probably manic depressive. Because for the first 6 months she was happy, nice, outgoing, energetic and basically upbeat.

When she got down and out I thought it’s natural for people to be bummed out, but she was like that for a solid month. Then out of nowhere she boosted back up again for another few months.

This happened over and over again, so I started to think, “I think she has a problem here” it’s not normal to go from happy to depressed, to happy to depressed over the period of two or three months.

Which is why I say, isn’t it hard to diagnose someone with this without knowing them.

I mean hell, just asking a bunch of questions could give you any number of mental disorders. It takes BEING WITH SOMEONE, KNOWING that person’s personality to know something is awry.

See what I’m saying?

Yes, but it’s a both/and phenomenon. Sometimes it’s easier to characterize what the problem is (or for that matter, what’s going well) when you’re close to a person, and sometimes it’s easier if you don’t have a personal relationship. Similarly, someone may tell her mom things she won’t tell her therapist, but the opposite is true as well.

“It is hard to diagnose someone without knowing them.”

You’re right.
It’s a lot easier to diagnose strep throat than it is bipolar disorder. Really, who would expect it to be otherwise?
Doctors screw up ALL THE TIME on psych diagnoses like this one. Schizophrenia becomes bipolar, becomes depression, becomes bipolar, becomes depression again if you swap doctors.
I believe when they ‘calibrated’ the DSM-III’s diagnostics, the APA was proud of the fact that when they had two practicioners interview patients back-to-back, they had a 96% chance of getting the same diagnosis.
That means 4% or more of these diagnoses will, outside of the APA’s clinical trials, be wrong.
I’m amazed they’re that accurate, to be honest.

You mentioned misleading your doctor to get the wrong diagnosis. It might be possible to prevent them from getting a correct diagnosis this way, but it’d be more likely that you’d just lead them to believe you were trying to mislead them. This would probably just slow down a proper diagnosis. They’re not stupid, and they do this stuff all the time.
By the way, you DON’T want an incorrect diagnosis. It’ll just waste your time and money.

As a psychologist - not the clinical variety like Brynda on the boards - I’ll tell you there are very specific things happening in that therapists office when a client comes in for the first time. Usually, the clinician has to make a diagnosis for the insurance agency, then counceling can begin. This doesn’t mean the clinician is going to automatically send the patient to an APRN or Psychiatrist for medication, it just means the clinician is going to get to know the person before making a recommendation for medication. There are acute issues that need meds right away, and there are lesser diagnoses that the need for medication becomes more evident over time.

See what I’m saying?

What significance do you think the diagnosis carries for the doctor? I’m not trying to say that diagnoses are not important, but I think in some cases people are given one because either they or the insurance company need an easy label to go by.

I’m not sure what you’re picturing here. Say you’re a liar and you just want to shrink the shrink. You show up at the psychiatrists office demanding a diagnosis? I think you might get some quick label and a pamphlet on something or other but the only actual diagnosis that’s going to get made is going to be a mental diagnosis of " what an asshole".

I recently did research on overdiagnosis, misdiagnosis and underdiagnosis of bipolar spectrum disorders and all three are prevalent. If you show up with your symptoms, your symptoms will be addressed over time and you might not wind up with a convenient label until you’re at least somewhat better.

What is the specific problem that you’re asking about though? Doctors will go as far as they think is necessary, ethical and prudent to figure out how to help you - which is very subjective when it comes to psychiatry. They might interview friends or family, or they might just ask you about them. They might tell you they don’t believe you, or they might not. In the end it all comes down to the fact that you’re in a psychiatrists office for a reason, and in most cases you came there because you need help with something. How do you tell apart a person with bipolar disorder from a person with i-like-to-pretend-i-am-bipolar-to-get-attention-disorder? I’d guess in most cases it’s pretty obvious because faking something specific is very hard. Will it matter? Probably not – if you’re genuinely asking for help, hopefully you’ll get help. If you’re being an asshole, hopefully you’ll get a mood stabilizer and get sent home. If you’ve self-diagnosed and you’re really wrong, you’ll just make life more difficult for yourself and the doctor but it’s not the end of the world.

And this isn’t a dig at anyone on this board either. Just more like a discussion.

Phlosphr - I think I see what you mean, especially for insurance purposes. So basically you give the insurance company your best diagnosis under short time constraints strictly for insurance purposes, THEN you begin to get to the REAL problem with getting to know the patient, medicating them with proper meds etc… Am I on track with ya? :slight_smile:

I guess my whole issue is that it seems it would be very hard to get the patient the proper medication, the proper diagnosis and the proper overall care for certain mental disorders. Now, something like deep rooted schizophrenia and a multiple personality disorder wouldn’t be AS hard to diagnose because if a person comes in and calls himself Mary (and he’s a man), then it’s a little easier.

And if I have to have a point, I guess it would be, that it must be a damned difficult job being a shrink.

If you actually look at how mental disorders are treated you’ll find the answer to your question. If you have unipolar depression – therapy, antidepressants, mood stabilizers, in some cases stimulants or antipsychotics. Bipolar disorder – therapy, mood stabilizers, antidepressants, and in some cases antipscyhotics. Anxiety disorders – therapy, anxiolytics, tranquilizers, mood stabilizers, antidepressants.

Basically, antidepressants are complex and mysterious and we don’t really know how they work fully, but most of them do what their name implies – they treat depression. They’re not drugs custom tailored to Major Depressive Disorder or some-such, no, they just treat the symptom of depression and have side effects, some good and some bad. If you’re depressed because you have anxiety, or because you’re hearing voices, or because you have tics, or whatever – they’ll help you be not as depressed, perhaps giving you the tools needed to overcome the underlying problem.

Anxiolytics are simpler and also do what their name implies – they treat anxiety. They’re not drugs custom tailored to Generalized Anxiety Disorder or some-such, no, they just treat anxiety. If you have anxiety because you have tics, or because you have phobias, or because you’re depressed, etc.

Etc. etc.

I guess what I’m trying to say is that there’s very few “terribly wrong diagnosis” scenarios that could theoretically occur. You never know if somebody is going to go manic or otherwise react badly – so the doctor has to use their best judgement and experience. Psychiatry is hard, and the field isn’t really bursting at the seams with well defined conditions and specific cures

It is hard to fake the criteria for Bipolar disorder. A person could lie about some things, but others would be difficult. Also, IME, most people with Bipolar Disorder are seen and diagnosed with depression first. The person will usually seek treatment on his/her own for the depressive symptoms. A person on the manic side will usually be referred by someone else such as a spouse, co-worker, or family member. From my experience the person on the manic side does not see anything wrong with his behavior. Fights, excessive spending, promiscuous sex, and little need for sleep are seen mostly by the person as the way they are. The times when they have no energy, changes in eating habits, change in sleep habits, lack of interest in sex, etc are what will usually get a person to see a professional.

SSG Schwartz

I am bipolar and it took me a few devastating years to get diagnosed correctly. However, once you know what it looks like up close and personal, it is extremely easy to see in other people. The symptoms aren’t very subtle. That is one problem with the official diagnostic manuals. They tend to use words like “takes excessive risks” (made up) which could mean that someone drives 20 mph over the speed limit or someone who suddenly takes up BASE jumping from buildings and cliffs for no reason. The Bipolar I in a manic phrase is the latter. During my worst manic phase, I just got in my car one morning and started driving with nowhere planned to go. Nevermind that I had a young daughter and a wife, I toured around 11,000 miles in 3 months acting 100% on impulse. I would leave places at 3 am and arrive at a completely different yet unknown place 12 hours later. My whole personality was changed from quiet and introspective to very aggressive yet slimy and charming.

I checked myself into the hospital as soon as I got back and things improved within days after I started lithium and have been mostly fine ever sense. The good thing about bipolar disorder is that it is about the easiest major mental illness to treat well over time. However, I am also appalled about the number of professionals that can’t see that one in particular because the symptoms are so obvious especially in the manic phase.

Just mentioning that DSM diagnosis uses constellations, so one joyous romp without other qualifying criteria won’t get you a bipolar diagnosis. I agree that clinicians can miss the diagnosis (in a way that I find puzzling), but do want to say that they’re not going to diagnose bipolar disorder on the basis of going 20 MPH over the speed limit in the absence of other behaviors. 100 MPH over, maybe, but still not a given.

A lot of people simply do not complain about their manic phases. They come in depressed, and refer to their manic/hypomanic phases as “the other times I’m fine” or some such.

The thing about mental illness is it’s unique to every person. This really upsets doctors who like to have everything neat & compartmentalized, and unfortunately you can’t biopsy a mental patient like you can with a cancer or virus. So they list a bunch of symptoms and say, like, if you have 7 out of 10, you’re OCD/bipolar/schizophrenic/whatever.

Sometimes you get lucky and your condition just happens to match what they have for bipolar, and the medication actually works, and you’re able to lead a somewhat normal life. Other times it’s just hit-and-miss. Hell, my own diagnosis has gone from bipolar to schizoaffective to asperger’s to “Aw hell, I don’t know, just take some vitamins and call me tomorrow.” And the criteria keeps changing – homosexuality was listed as a mental illness until recently, and Asperger’s Syndrome wasn’t even listed until 1994.

Someday psychiatric medicine will become more precise and reliable, but right now it’s the equivalent of 1890’s medicine. It might help you, it might kill you. Thing is, if a person’s so bad off he might kill himself anyway…what’s to lose?

P.S.: Manic phases rawk. :cool:

As Shagnasty points out, a manic episode is easy to diagnose when you see it, but people in the throes of mania do not present voluntarily for treatment - they think everything is great. They are often brought to the hospital by the police or a family member. They present for treatment when suffering with depression.

However, I work in a facility for drug addicts and virtually every single one of my patients who went to a psychiatrist at any time got a diagnosis of Bipolar Disorder.  This is with no history of a manic episode.  As far as I can tell, it is the *disorder du jour* unless they are just using that diagnosis to placate the insurance companies.  Having seen the devastation of the true bipolar patient, it drives me crazy when the diagnosis is thrown at everyone who ever crashed coming off a cocaine binge.

This is important to point out. In order to collect disability insurance, you MUST have a DSM-IV diagnosis written on a form that’s signed by a psychiatrist. And only certain disorders qualify…bipolar, OCD, PTSD will count, while something like Sociopathic Personality Disorder does not. (My ex-shrink used to threaten me with this whenever I refused to obey him…ain’t modern medicine grand??)

I’m another person who is diagnosed as being Manic-Depressive, only my manic phases aren’t as radical as some people’s can be. It took well over 15 years and three shrinks before I got the correct dignosis as it is a very hard disorder to pin down. Thankfully it is easy to manage with proper medication.

I’ve recently recovered from a manic episode and indeed checking myself into hopsital was the last thing on my mind at the time, despite the fact that (on reflection) I was completely batshit crazy. My doctor was able to treat the mania very easily with a combination of anti-psychotics and mood stabilisers, but it took him a while to decide that I was bipolar. He has since, however, become a bit more circumspect about me being bipolar and I think he may have changed his mind about his previous diagnosis. We’ll see…

My diagnosis was quite straightforward as I was textbook manic, and the doctor had the testimony of the police, the Accident and Emergency people and my family to rely on to arrive at that conclusion. Given how gone I was I don’t think I could have concealed my state if I’d even wanted to.