Mandatory pre-post disclaimer: While I am a physician, I am not your physician, there is not a doctor-patient relationship, and I am not providing medical advice. Additionally, I will not post anything that may violate privacy of current/past patients or is so specific as the name of the group/city in which I’m practicing at this time.
Brief background, I am still fairly early in my career, having been in practice 2.5 years since I finished residency and fellowship. I am based in a combined hospital/clinic setting and spend the majority of my time seeing inpatients on medical and surgical services, performing emergency room evaluations, and performing intakes for new mental health patients.
I love my job – it can be exhausting but very rewarding. Feel free to ask away and I’ll try to answer (as long as I can).
Oh, shit- I predict that this thread will be huge.
Okay- I was concerned that my 13 year-old son might be bipolar. He’s had troubles recently with depression and aggression, and I know that BD can manifest differently in kids. I asked his psychiatrist about it, who asked my son if, after one of his sleepless nights where he just lies in bed awake, he was tired in the morning. My son replied that yes, he would feel tired in the mornings after not sleeping all night. So the doctor concluded that on that basis, he is not bipolar. That seems pretty simplistic to me. Or should I just go with it?
I’d say quirky but not insane… although I understand why the field has a reputation. In training, there were always a few staff physicians who were well, just odd. One attending was absolutely brilliant and I could learn so much from her – when I wasn’t distracted by her very dramatic blue eye shadow and massively poofy hair (for reference this hair would have been huge even by big hair standards of the 1980s and this was the mid-2000s).
Unfortunately, there is likely a segment of psychiatrists who go into the field with main goal of resolving their own issues or (this is more true historically) because they were too “weird” or had personality issues that made matching into a more competitive field less likely. But the cohort of residents (and later fellows) that I trained with were largely smart, nice, and normal people…
Alice the Goon – I’m not a child and adolescent psychiatrist. I did a specified number of months while in training with kids but quickly realized I wanted to stay with adults; however, the issue of how or even if bipolar disorder presents in children is such a huge controversy that even those of us who stick to adults can’t help but keep up with it a bit. Even in the adult population, unless a psychiatrist is witnessing a manic episode or has very strong collateral history about one, it can be a challenge to make the correct diagnosis.
Likely, the psychiatrist was probably trying to tell if your son was experiencing insomnia (basically, inability to sleep when one is tired and feels one needs sleep) and decreased need for sleep (such as staying up for several days without sleep or only minimal sleep and not feeling that one is missing anything). I’ve asked questions that are somewhat similar when trying to tease out what exact sleep problems a patient may be having at that time and while a history of decreased need for sleep (occuring with other manic or, in case of mixed episodes, depressive symptoms) suggests bipolar, it may be going a bit too far to say it is definitely not bipolar if a patient has a history of insomnia. Of course, I don’t know the rest of the history…
Ah, well, if mania in children presents as actual mania like it does in adults, then he’s definitely not bipolar. I didn’t know if mania could take the form of defiance, aggression, irritability… but he does not become manic in the classic sense.
My non-psychiatrist opinion (M.A. in Clinical Psych) - what you saw was an unmedicated manic episode of Bipolar Disorder acted out in public view, in real time, and facilitated by people who should have known better (his publicist, for example). Probably exacerbated by substance abuse. The fact that he’s fallen somewhat off the radar means it’s either in remission, or he’s on the downswing into a depressive episode.
I, too, am not a specialist in children’s disorders, but yes, mania in children and adolescents often presents as irritability.
At the time he was acting crazy, I heard someone (Dr. Drew?) explain drug-induced psychosis, and it made perfect sense. So I’m going with that. He denies being bipolar, for what that’s worth.
Charlie Sheen’s (who is an admitted cocaine user) media insanity started right when “bath salts” or legal stimulants were hitting head shops and internet suppliers across the USA. They have been compared favorably with cocaine by many users and could be bought legally by the kilo, not hard to figure out. Sheen discovered bath salts
I heard crack. His ex, Denise Richards, reportedly called several media outlets to ask that they call it cocaine, and not crack, but that’s what it was. Apparently, when you go on long binges of it, you can really lose it mentally for a period of time.
They are not my favorites but I likely have the strongest emotional reactions to individuals with prominent cluster B traits (histrionic, antisocial, borderline). I generally prefer working with patients with borderline personality disorder over those with mainly antisocial traits.
Unfortunately there is sometimes a perception that individuals with personality disorders just cause others to suffer but do not always suffer themselves. This is very untrue in my experience with the individuals I have worked with who either had a diagnosis of borderline personality disorder or resorted to similar coping skills when under great stress. It takes a lot of work by the patient and the therapist but I have seen patients who have had significant improvement with dialectical behavior therapy or DBT.
I do not think I have had just one “most interesting patient.” I have met some amazing individuals who have allowed me to care from them during just my brief career so far. Not the same as the most interesting patient (in terms of the person themselves) but I have worked with individuals who had very interesting diseases occurring : neuroleptic malignant syndrome, limbic encephalitis, psychiatric symptoms as toxicity from immunosuppressants after transplant, and various neuropsychiatric manifestations from HIV/AIDS and AIDS related illnesses.
I tend not to speculate on the behaviors and motivations of individuals that are not my patients; there are just too many variables of which I could not have knowledge. However, as others have pointed out, either mania from bipolar disorder or a substance induced manic or psychotic episode (particularly from stimulants such as cocaine or methamphetamine) may cause very disturbed behaviors.
I struggle with strong countertransference against child molesters or other sexual predators and other perpetrators of violent crimes. It is one of the reasons I avoided going into forensics or working in a correctional setting. However, in my work I will still encounter individuals who may have had a history of violent or disturbing behavior and I just try to focus as much as I can on helping the patient and not acting out on my feelings of disgust or hate – I wait until I’m running or on my bike and just let it out there. Of course, if there is an active ongoing threat to others and I am able to act because of my role as a mandated reporter, I do.
I don’t always understand the huge rivalry between psychiatry and psychology. There are certain skill sets and knowledge that is more prominent in our training and practice and others in psychology. I have great admiration for the psychologists I work with and we regularly work together in teams to help specific patients.
How much do you take what the patients say at face value?
My MIL is manic depressive and has spoken to me about the sessions she has had with her therapist. It seems to me that her therapists believes everything she says and would have quite a different opinion/offer different advice if she had a more balanced view of the events that MIL describes.
My dear Purple Scottie, it is with trepidation that I inform you that your obsession with the bouffant hairstyle is a classical Freudian example of castration anxiety
But, be that as it may, I’d like your take on the phenomenon of a “paradoxical brain”, whereby brain damage may result in an enhancement of function. This appears to be the case with my youngest daughter, who began excelling cognitively after suffering two strokes by age 14 months.
Back when I was doing clinical work, I never got that, either. Still don’t. Psychologists and psychiatrists are trained to do different things, and when they work together, the treatments are more effective (in most cases). Luckily, most of the psychiatrists I worked with had the same attitude. I was much more likely to encounter negative attitudes from fellow therapists about psychiatrists.
Do you belive that we have a “subconscious” mind-that is constantly at war with us, sabotaging relationships, and working against our conscious minds?
Do you believe in “recovered memories”?
Finally, was Freud right when he declared all pleasure to be sexual?
