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Good morning, Dr. Mallory.
Good morning. So last time we did an episode on bipolar... I took it upon myself to humbly title it, I think it was like the world's best bipolar expert. Something ridiculous, yeah. I did put a disclaimer that it was supposed to be clickbaity and somewhat in jest, but maybe I should be a little bit more humble in our titles.
Well, you know, I thought that initially, but I think it ended up being like the most viewed of all time out of the ones that we've done together. So, you know, maybe there's something to be said about clickbait. Also, it might be worth mentioning that Kanye just released this lovely little letter, right, in the papers, and he's often referenced with this topic.
Our first episode, we actually discussed Kanye. I have lots of thoughts on Kanye West. And his letter is worth a read. You know, there is some... There's actually... I feel like we could do a whole episode on that letter. There's so much good stuff to unpack. He clearly visited the Amen's Clinic recently.
Well, why don't we save that to the end? I don't want to distract from today's topic. What's today's topic?
So I think today we're gonna be talking about like a structured interview for bipolar and essentially kind of how to get to the diagnosis, I believe is the approach we're taking today.
semi-structured and um i suppose the best thing to label it as is a practical diagnostic approach uh for bipolar disorders and this is a controversial area you know i am sure that at least some people will hear this and they'll say oh you're doing this all wrong or you're going to incorrectly label people as bipolar or you're going to miss people who are bipolar by doing this you know i mean um look that's just the nature of the beast of diagnosis the way we do it today the only way we have to do it i guess the main thing i want to start with is to say that a psychiatrist any diagnostician in mental health needs to recognize that their questions are the exam your questions and the interview every moment of it has its own positive predictive value and negative predictive value and sensitivity and specificity and that's something that's changing live this is true of all medical interviewing so you need recognize that and you need to know your patient population because the positive predictive value the negative predictive value changes based on prevalence So when you see a patient, you should already, based on the information that you have at hand, have some kind of a pretest probability idea of how likely it is to have certain disorders.
That's just practical. And therefore, this thing I'm going to recommend today in the episode, the way I talk about this, it's obviously titrated to my patient population. It might not be suitable for yours, but let's consider it a jumping off point.
Yeah, so let me kind of almost re-say what you said, maybe without trying to not use the terminology you used. Yes, yes. Our tests in psychiatry, we can't do labs, we can't do imaging, so our questions are our tests. And what's confusing is it's not necessarily the explicit answer that they give to the test. So we kind of need to develop ways of translating their answers so that we can develop an output in terms of a formulation.
Another thing is what's important isn't whether or not the questions are answered yes or no or the particular types of answers, but kind of picking up and translating it. So I think to define the problem that we're trying to address, there's patients who kind of say yes to everything, and they'll screen positive on bipolar because... Oh, yeah, there has been periods where I've had tons of energy.
And then there are patients who say no to everything. So it's important to have an approach. It's important to – I think we're going to give – say it's not – a lot of times I see providers ask questions like, what's a question I can answer – get? What's a question I can ask to really differentiate if it's this or this? And I think – I hope I'm assuming our approach is going to be a little bit more nuanced than that.
And, um, you know, there aren't these gold questions that kind of tell us exactly what, what the problem is.
Yeah. Like, even though I'm going to discuss how I ask things, you got to know that how you ask it is going to yield different fruit with different patients, different patient populations and a different asker. It's a very live process, right? Um, to your point, I, you know, there are many patients where you'll even specify time frame at least 48 hours in a row and they'll still say oh yeah i totally had a lot of energy well how long did it last three hours okay you really have to ask follow-up questions uh that's why i'm saying semi-structured structured interviewing in my opinion does not have a place outside of research
Yeah, another big theme that you kind of bring up is pull threads. Don't be satisfied with yes or no answers. As you said, all the time, I'll have patience. I'll take what you kind of say one step further. Did you have a period of a week where you had tons of energy? Yes. Was it all day? Yes. Walk me through that day. I woke up super tired.
And then around 4 , I started texting a lot of people. So it's like you really need to... investigate and and like you said pull threads look look for inconsistencies and have them clarify because if you stop short you you miss the the important part of
the diagnostic process yeah in short get narrative yeah so you know this is a Big topic, I think, that comes up a lot. People think that bipolar diagnosis is inaccurate, that people over-diagnose. Minority probably think people under-diagnose. I'm probably in that minority. But again, it depends on your patient population, right? We don't have a biomarker, so it's impossible for us to actually know what the true population prevalence of something is.
So it's really just all opinion and fluff, ultimately. But what do you see as a major? Go on.
Oh, yes. You're overdiagnosed. Because people are always like, is this overdiagnosed or underdiagnosed? The answer is yes. It is overdiagnosed and underdiagnosed. What we see is patients with a lot of personality pathology, with borderline personality disorder, oftentimes it's overdiagnosed in that context. In those patients in treatment resistant depression, I see it severely underdiagnosed in. So, you know, it's not one like it's not over. It's not one or the other.
It's it is both.
Yeah. Very Taoist. So what do you personally see as the major challenges in accurate diagnosis of bipolar type disorders?
So it depends, again, on the patient population for what the problem is for patients that when I'm trying to figure it out, it's really hard to get a good history. The questions are really tough in terms of saying, like, has has there been a week of of, you know, decreased sleep? where you had a lot of energy, a lot of patients, to no fault of their own, are not good historians, or they can't identify those things.
There's so many times where I'll ask important screener questions, they all screen no, and then when I do a narrative, I hear things that are clear-cut mania. They answer no to all my bipolar screen questions, and then There was this period in college that, you know, for a month, I actually had to, I had to drop out of a few of my classes. I was partying all the time.
I wasn't sleeping. I was having sex all the time. Yeah, I guess, yeah, I was like about like three hours a day. And no, I wasn't, I wasn't that tired. So, If you just ask those screener questions, a lot of times you miss it. A lot of times you'll never get that history. So the stalls thing in terms of diagnosing bipolar, I think is like, who's your daddy and what does your mommy say or something, something cheeky like that.
I kind of remember that. I don't remember what that's about.
The gist is look for family history and get collateral. Those are the most important things because you'll get a history from a patient and then you'll speak to a family member or partner and you'll hear clear cut episodes of mania when in the interview with the patient, you didn't hear anything.
Yeah. That being said, just as an aside, sometimes collateral is not that useful. I've had people just completely not even notice clear disorganized schizophrenia in the family member that they cohabitate with. So it really just depends on the person that you're interviewing.
Yeah. But yeah, to define your problem, anosognosia, the inability to acknowledge your disorder is part and parcel of bipolar disorder.
I guess for me, you're basically talking about one of the major challenges I see, and it's that fundamentally the interviewing process and the data you get from it is relatively unreliable. And there's like three parts to that as I see it. The first part is that people with real bipolar disorders can genuinely lack memory of past episodes. Right. That that's an issue in itself. We don't know exactly why you could come up with psychological mechanisms.
I'm a little bit favorable towards the state dependent memory hypothesis when it comes to mental episodes, mental health episodes. The use of language itself is subjective, unreliable. People use language differently. The simplest and clearest example of this is that most people in the community, at least where I am, when they say bipolar, they mean mood swings of a person with personality type issues or trauma. So people mean and think different things based on the same symbols and language.
And then finally, we generally do not have the luxury time and longitudinal evaluation today. We just don't have that time. It's not afforded to us. That's one thing. But the other part is, of course, mimics. And we kind of touched on that already. Personality can very much mimic this trauma cannon. There's a few other mimics as well that we should talk about at the time.
yeah um totally agree with everything you're saying um well why don't you kind of just jump start us walk us through your semi-structured approach to bipolar all
right so this is again my approach may not work for you. And if you are gonna use anything from it, I recommend that you test it. You see if it works for you and your patients, right? And you tweak it. This is not some kind of gold standard. But it does take a lot from what is or should be standard of care. So keep that in mind.
A lot of people think of bipolar diagnosis as kind of asking about mood episodes. And I actually think that is something that comes second. The first things that you have to do, that you have to prioritize, are getting a thorough medical history, a thorough medication treatment history, including non-psychiatric medications, and probably the most important, depending on your patient population, a really detailed substance use timeline. And you have to know that patients may deprioritize these tasks when you're interviewing about them or even hide information.
So you have to give some education. You have to tell patients how not getting this can result in missing diagnoses or making the wrong diagnosis and therefore getting the wrong treatment and bad effects from it. The substances thing is particularly an issue, I think, because sometimes, particularly heavy substance users, they will not have periods of sobriety beyond just a few months as an adult, right? Bipolar disorders largely do not appear as a minor in adolescence or childhood, so we need to know about adulthood, usually from the 20s and onwards.
A lot of people start using substances and never stop. And then you can't just assume that person doesn't have bipolar disorder, but you also can't assume that they do. So you'll have to really try to nail down periods where they were clearly sober from problematic substances that could likely trigger bipolar type disorder episodes.
Now, I think a thing that's important to emphasize is what you're saying is it's important to approach the medication history and the substance use history as a, like you said, a chronological thing. I'm not asking what substances, how often are you using substances now? I'm not asking what are your prior medications just to get a list. Oh, you've been on Lexapro, Zoloft, and Prozac. Great. I'm asking for a timeline.
And as you said, we keep focusing on narrative, but having the patient elaborate on when they took it, how long they took it for, what their experiences were, how they responded to it. For substances, I'm not saying, okay, you drink two drinks of alcohol on Saturday today. I'm saying, walk me through... Well, sometimes I'll start with what substances are using now. And then I'll say in the past, was there ever periods where there was heavier use?
Was there ever periods where you're using significantly more than that? I don't just stop at saying, like, do you use any substances? I'll talk about alcohol, then marijuana. And then I'll say, was there ever a time that you used anything else like cocaine, drugs? painkillers, methamphetamines, you know, normalize it and make them feel comfortable kind of talking about those things. Don't just say like, what's your drug history?
Yeah, I'll say directly, you know, a lot of these substances, they can cause effects in the brain, sometimes short term, sometimes long term, that can really make things confusing, both in our treatment of you with medications and in our diagnosis. You know, we want to really know what we're working with. I don't want giving anything that's not going to help you or that's going to hurt you.
So it's pretty important that we go over this. I'm not trying to come down hard on anyone for using any substances, you know, something like that. You might think this is incredibly time consuming. It is. So when you don't have a lot of time, you will have to conduct this in a way that's kind of efficient. And so I think that you really do need to focus on identifying either periods of intoxication or sobriety from problematic substances.
And then for sobriety, I try to just kind of use that DSM cutoff. When were you sober from this for at least a month? What are the problem substances? Maybe it's easier for me to say what are not problem substances in my mind. Personally, I think it's extremely... ridiculously rare to see true mania or hypomania happening as the result of cannabis use. Psychosis, yes, and agitation from psychosis, yes, but just plain mania and hypomania, quite unlikely.
Nicotine, similarly, I've not heard of anyone using nicotine to the extent that they would develop mania or hypomania. You can't forget the prescription medications that are being taken by patients that don't consider drugs, even if they are prescribed or are not prescribed to them. Obviously, the biggest ones are stimulants, but we also have to consider the possibility of antidepressant induced mania or happy mania. But of course, personally, I think that should clue you into somebody who's at least at risk for a bipolar disorder.
Don't forget also random herbs and supplements. A lot of these are unregulated and have some stimulant properties. And then finally, steroids, prednisone, or any other more esoteric or unique medications, prescription medications that can cause mania.
One thing I want to just to tack on to what you're saying, with the substances, often I will see an increase in the use of cannabis and nicotine during mood episodes, but I think just to emphasize what you're saying is it's not triggering those mood episodes. We don't think so anyway. Now, and you mentioned like it's really hard. What I typically do is find something to that's a kind of a consistent thing in the patient's life and anchor that to how I'm kind of viewing patients.
Let me make an example. Let's say early on in the discussion, I find out that this patient has mood episodes every year and a half. Then I'll use those mood episodes to create a timeline and then try to fill in the details of those other things. Like you said, it's not like I'm taking the substances and then going chronological through the substances, then chronological through the mood, then chronological through those things.
Usually what I try to do is early identify some theme in their life that I can use as an anchor. And I start there and then I fill in the pictures using that anchor of the other variables. I don't know if that makes sense.
No, yeah, that's really good and practical and, you know. It's similar to what we discussed in kind of the approach to the intake episode. The next step really, or even the step before getting the stuff we just talked about, is the why now question, okay, and the history of both present and past illness. You want to get some kind of timeline. In patients who cannot give me a reliable narrative or any narrative about the timeline, of the illness.
Not everyone has access to that. Their memories can readily tell it as a story. You may want to skip ahead in a sense and go to social history and just talk about their work and school and relationship history. Basically get a sense of their overall functioning over time, because then that can start to serve you as a timeline.
yeah um yeah keep walking us through um so you mentioned to start we're getting a thorough medical history medication history and substance use timeline keep keep
walking us through right so once you have that uh i'm still not going personally to ask about mania or hypomania to be frank i only do that in the beginning when i think with this particular patient there's extremely low Pre-interview probability that they have a bipolar type disorder and I'm just kind of screening for it Okay, when my suspicion is higher and when I'm doing a more directed interview to detect the bipolar type disorder.
The next question I have is not about mania or hapomania. The next topic is history of major depressive episodes. Now, we want to be clear here. We're talking about major depressive episodes, something at least as rigorous as what's defined in the DSM, which is not necessarily that rigorous. OK, but for me, the hallmarks are different than normal self. Almost all day, almost every day, two weeks in a row and changes in any of the following, but distinctly energy, sleep, appetite.
Okay. More of a wholesale change in biological functioning than a subjective state of depression.
Yeah, I think what I see some people do, and this is the absolute worst thing you can do, is say, were you depressed and use that as your screener for depression. And what I recommend is using something like the Madras. So the Madras has questions that are linked to the DSM criteria. And the more you do it, the more you get comfortable with kind of – the more I see that there's a big gap between when patients say they're depressed and when they have major depressive episodes.
So use the Madras as your question – as your thing for do they have depression, not are you depressed, which is, in my opinion, the terrible screener question because, as we mentioned, that's – So major depressive disorder is not just if you're depressed or not. It's those cluster of symptoms that kind of come together.
Yeah, it's an episode. It's something distinct, really, in the ideal case. So what do I ask? Beyond just defining depression that way and asking about it, I want to know when was the first time they had that? I'll say, when was the first time you ever felt sadness, depression, or difficult enjoying things? All day, every day. for at least two weeks in a row. And you also noticed a change in your energy, sleep, or appetite.
When was the first time that happened? And then remember, a yes is not the end. A yes is to start. You say, oh yeah, I probably noticed that when I was 12. Tell me about that. What was that like? What was happening? Why do you suppose that happened? Then I say, well, how often have you had that throughout your life? How long has it usually lasted? How much time do you get in between?
Have you ever felt fully free of the depression for at least a month since the start? How long? You're getting a timeline. You're trying to get a sense from the patient. You're building together the progress of the depression and any major depressive episodes with the energy, sleep, and appetite changes.
Yeah, a comment that I find is helpful here to parse these things out. I'll say, you know, for some people, depression is this, you know, this thing that they kind of feel all the time constantly. And then there's other people who, you know, I have patients who say, when I was 24 years old, when this happened, I was depressed for three months. When I was 30, I was depressed for two weeks.
Are you the type of person who can identify particular episodes? Or is it this kind of thing that's kind of been there all your life and doesn't really fluctuate? And that to me is a helpful screener for major depressive disorder versus dysthymia or another condition. For the patients that I think have major depressive disorder, they usually identify more with what I'm saying, that episodic thing of like, yeah, you know, I think more that I can think of particular episodes.
Then I'll ask them how many and then we kind of go through each one.
Yeah. And, you know, if someone says they've never been free of the depression for at least a month since onset, I don't think your job is done there. You don't just slap MDD single episode on that. OK. At that point, I still ask if the depression has never really gone away. Are there times where nonetheless it's consistently worse in a persistent way for at least two weeks in a row?
And if so, how long does that usually last? And you go through the same questions again, characterizing how long something is persistently worse in an episode. You are looking for major depressive episodes on top of basically a dysthymic picture. Right. And do not be afraid to use and repeat days in a row, almost all day, almost every day, 14 days at least in a row, two weeks in a row.
Those kinds of things to remind people, because often what's happening, in my opinion, is that when you ask your interview questions in psychiatry. People are not necessarily, this is not their fault, responding with a specific question. People aren't robots. Essentially, what you usually do is that you stimulate some kind of memory in them and they're almost free associating and giving you a narrative about that. And that's a good thing.
We don't always want direct answers to our questions. We want to be able to observe the process of the interview and also get information that we didn't know we needed. That being said, in the interest of time, you will sometimes have to redirect, repeat, psychoeducate.
Yeah. And then sometimes on the flip side, we do have patients who are robots and I'll ask those questions you're answering and you get yes. And the best question you answer is tell me more. You know, if they kind of stay with those symptoms, I say, try to try to give me a picture. Let's like give me a give me a visual kind of what was going on at that time.
So keep keep probing.
Yeah. Another thing I like to ask sometimes, because what's interesting is some patients with parent bipolar disorders, if I ask just if I just ask about mania and have mania symptoms, a lot of them will say no. But sometimes if I've gotten the major depressive episode history and then I ask, when it goes away, how do you feel? What's different about what you do? They begin to describe hypomania.
It's rare, but it happens. So, you know, just a little point there about making sure you get more narrative.
Yeah, in my experience, bipolar screener questions are like... they particularly don't work. I feel like the patients that I have answer yes, when I get more narrative, it doesn't at all fit with bipolar. And the patients who say no, if I get more narrative, a lot of times I'll be able to figure out episodes. So screener questions are particularly bad in bipolar.
Yeah. So why is this important? Well, you know, it's interesting to find that the majority of people with a true bipolar disorder, most of them, mostly experience depression, especially major depression and usually major depression in episodic way, discrete episodes, multiple across a lifetime. So if you are able to detect a episodic and recurrent major depressive picture, that starts to raise the possibility that there is a bipolar spectrum disorder or at least a possibility of mixed depression or refractory or biological seeming depression rather than depression secondary to life circumstances or personality.
Yeah, and Emil Kreplin, his formulation of manic depressive illness was defined not by polarity, but by episodic mood episodes. And Nasir Ghaimi is also now a big proponent of this, that bipolar is defined as recurrent mood episodes, not by the polarity of hypomania or mania, and thinks that anyone who has these recurrent episodes is better defined as a bipolar in our terminology today.
Yeah, you may disagree with that, but I just think it's important to note that Kreplin, you know, if you had 10 major depressive episodes equivalent to that, something like that, that got you manic depressive illness. It wasn't necessary that you have one or the other or both. And it is important to note that while we're doing this depression screen and all that, I think it's about four to six percent of people with bipolar disorder never have depression.
interesting there's a pure mania subtype uh pure mania hypomania that is possible and i have encountered that and uh yeah yeah so there's unusual things that escape our current categorization system yeah my my takeaway from
You know, Emil Kreplin's interpretation and Nisir Gamey's interpretation isn't anyone who's got recurrent mood episodes needs lithium or needs a mood stabilizer. But since learning about that, whenever I've heard a patient has had recurrent mood episodes and I see a lot of the previous medication trials haven't worked, I really make sure that there's been a mood stabilizer trial at some point. Yeah. So it definitely has lowered my threshold for trying something like lithium or a mood stabilizer in a patient who's had these clear-cut recurrent major depressive episodes.
Yeah. I mean, the pharmaceutical reps aren't being paid to tell you guys or to boost this, but lithium has evidence for unipolar depression as an augmenting agent, right? So there's probably some, in my opinion, there's probably some percentage of people that have just a really clear-cut unipolar but severe depression, that there's something in there that's a little bit more bipolar. We don't understand it. We don't have the science, but they seem to respond to lithium where other people don't.
Okay, so it is something to consider. And frankly, in my opinion, less side effects than Abilify, no tardive dyskinesia.
Should we start doing ads for non-pharm, like Psychopharm brought to you by lithium? Yeah.
That'd be kind of funny. Yeah, that'd be an interesting idea. Okay. So once you've actually looked over this course of illness and the history of depression, then and only then would I begin to directly screen for mania and hypomania. I like to start with just asking about the most extreme version. I want to say, in your whole life, can you ever remember having a time where where you were totally awake, zero sleep at all for 48 hours, two days in a row at least.
You were awake the whole time. Has that ever happened to you? If they screen positive on this, again, you don't stop there. You say, tell me about that time. What happened? And you get a history of it. This will catch your most severe bipolar ones. I get a sense that a lot of people, especially the ones that mostly work inpatient, kind of feel like this is the only person who should have a bipolar diagnosis.
I think that's a big mistake. There's research to show that, at least to support. that, you know, that severity of bipolar is maybe only a quarter of all bipolar type disorders. Okay. But mostly that one doesn't screen positive. It really only screens positive in my experience with patients who I already know have had multiple hospitalizations and manic episodes. And then a lot of those people will also say, no, that's never happened.
So keep that, you know, the yes or no, it's not the end. Once I've done the total sleeplessness, I will start to screen for basically hypomania. And my way of doing that is... How about... Before you... Yeah.
Oh, sorry. Just want to give some pearls based on what you said. Yeah, yeah, yeah. Go ahead. Oh, no, no. No need to. So some important things based off of that. So as you said... I've never asked, have you ever had 48 hours in a row? I'll typically ask, has there been a period of at least four days where you had less sleep than normal and you felt a little bit more energy, you felt a little bit irritable, you felt different, other people kind of noticed that you were different.
I do find, in terms of the reason why it's important to keep asking questions, patients will say yes, and it's important for you to go tell me about that period and walk me through what happened. a good proportion of my screener questions that flag yes. When I, when they keep going, they'll say like, uh, during finals, like there's nights that I sleep two hours and the next day I'm like totally wired and like feel totally fine.
And it's, it's, it shocks me. And then I go, keep, keep talking to me what happens as you continue and then go like, well, I usually crash at like day two or three, but like during those two days, um, like with my caffeine, I'll feel jittery and alive. So to me, that's not bipolar. That's kind of an expected response. So yeah, One little thing to be mindful of is it's not uncommon for people to sleep two hours, three hours, and if they have something important, to feel wired, to feel energetic, to feel like they have lots of energy, or to compensate with caffeine.
So really look for when that crash occurred because if you keep asking questions, you will see that crash. People will screen yes to having not slept for four days, and then when you get the picture, it's very clearly like, oh, that was a day or two that they had to stay up for whatever reason, and they had a very severe crash. That's normal.
Yeah, narrative is important. That being said, I don't know if the crash is indicative of the lack of hypomania so much as it is that their situation resolved, right? And there was no marked change in functioning or other accompanying symptoms of mania or hypomania. Personally, I don't like the four days. I used to do four days because of the DSM rules. But I think that if you do four days, you're going to miss a lot of low-grade bipolar type disorders that could benefit from low-dose lithium, for example, for their treatment of depression.
Would I call those people bipolar II? Absolutely not. There's a reason why the DSM has these cutoffs. They want to be quite clear that we're not going to call this a full-blown bipolar picture until you have at least DSM-defined pacomania. But keep in mind that the DSM also knows that there is low-grade bipolar disorders. That's why we have a other specified bipolar disorder section. You know, it's short, but it recognizes that there are people who have short duration hypomania, even with the full criteria just lower in duration.
And those people can still have impairments that need and benefit from treatment.
So I continue on with your hypomania screen questions.
Right. So once they've screened negative for mania, then I'll begin to screen for basically hypomania. And how I say that is, has there ever been a time where you were not your normal self for at least two or three days in a row? That's 48 to 72 hours where you slept a lot less than usual. let's say four or five hours or less in the 24-hour period.
Sometimes I adjust to the number I say based on what I perceive the patient's baseline to be like. But during that period, even though you were sleeping less, you were still just as active or even more active than usual. And your mood was better than usual, more confident than usual, or irritable. It's a big sentence, I know. This is just how I do it. You can do it the way you want.
But I will say that, and usually the patient will say, can you repeat that? And I like that because I want to cement this idea in, and I repeat it. And if there's anything for them that says, yeah, then I'll say, okay, tell me about that time. When was it? How long did it last? And what was going on during that time? What did you do activity-wise during that time?
hallmarks of hypomania is not even the sleep necessarily. It's change in activity level. and types of activity together with a change in mood. Those are the hallmarks. Now, the tricky bit is that sleep is the most recalled symptom for people with mania or having mania, changes in sleep. That's the easiest to remember, but it doesn't mean that it will be remembered, and it's also not 100% necessary to be there.
Yeah, and I find that these longer screen questions are helpful. The patient typically, just in terms of their experience of it, they're usually not hearing the whole question. What's helpful is that they're hearing, typically what I see happen is they will hear one or two things, like one phrase in my screener question that rings a bell. Like PTSD, I have a similarly long screener question, and usually it'll just be like one thing that they'll cling to that kind of sticks.
So for these long questions, Like either they'll hear two or three days in a row or they're here four to five hours or they're here more active or irritable or other people notice that you're acting different. So I do find these long questions are helpful because the patient kind of will hear one thing that sticks out to them and then it helps them elaborate.
Yeah. So, you know, in negative and patients who answer negative and you're reasonably sure that the pre-interview probability is low, that's easy. And then if your suspicion is so low that all you're doing is a really fast screen, which can be warranted given the case. I may be even shorter than that. You might just say, ever have two or three days in a row that you're not your normal self, sleeping less than four to five hours in each 24-hour period, still having energy, more active, irritable, feeling better than usual, ever felt that way, different than your normal self?
Most people that have never had anything approaching a mood disorder will say, no, that's never happened to me. the more difficult area is when you have a high pre-injury what's that or if i get
like a tentative yes and a patient who i don't suspect is going on i say like i'm trying to screen for bipolar mania and oftentimes they'll be like oh no no no it was like a day uh it's like just at a wedding so yeah just that's a follow-up
question yeah so the uh the trickier patients i think are where you have a high pre-interview probability of a bipolar type disorder or major mood disorder, right? Those you want to get into some nuances with and spend a little bit more time with. So a few things I wanted to highlight. When you talk about energy, I find that a lot of people often interpret having energy as feeling good.
You have to really drill down on that one. People who have agitated depression, who are very anxious or irritable, they may say, oh, I didn't have energy. Well, what are you doing the whole time? Pacing, walking around, cleaning the house, just felt like I had to keep cleaning, just doing a bunch of projects. But they may not respond to the prompt of have still energy because they felt tired, right?
You need to be clear about activity level.
Yeah, and the more you look and screen for mixed episodes, the more you see them. You know, patients who only report depression, and then when you dive into their symptoms, you do hear hypomanic or manic-type symptoms.
Yeah. Another little detail I wanted to mention is, It's actually, in my opinion, a little bit useful sometimes if someone has a history of stimulant use or stimulant use disorder. Even if they've used, let's say, like meth once, you might say, have you used a stimulant drug or you have used a stimulant drug? Have you used meth? Do you remember what you were like on it or have you seen people on this?
You know how they talk faster, think faster, move around a lot and they don't really need to sleep and they still have energy. Have you ever felt like you were on X stimulant drug for at least two or three days in a row, even though you hadn't used it for at least a month? That sometimes can help you a little bit.
Yeah. And then tangentially related, don't attribute everything to a substance-induced hypomanic episode just because there were medications or substances that could explain it. So when patients are hypomanic or manic, they're more likely to use those substances. even if those substances weren't the trigger. So really try to hone in on when that episode started. Because I know I've seen a lot of patients that it's like, oh, it was all the Adderall I was using.
But you really need to dive in because when patients are manic or hypomanic, they tend to be using more substances naturally. Yes, yes.
Yeah, big point, big point, right? It's the indiscreet behavior, the lack of attention to negative consequences. Very frequently people will begin using substances and we're trying to recall the past. The memory is not going to be terribly reliable, so you can't take everything exactly as reported. So again, if you get any positive screens, don't first go for the diagnostic criteria. That's confirmatory testing in my mind. OK, still get narrative.
Remember, ask what happened. Why? What was it like? What were you doing? Why couldn't you sleep? What happened? And how was it different than your normal self? Right. But once you're done with that, that's when we might want to get confirmatory diagnosis. And then at that point, I think it's appropriate to start going through the sub criteria, the associated symptoms criteria for mania and hypomania. Ask about energy and activity level, but don't ask yes or no.
Say, what was your energy and activity like during that time? What were you doing? Similarly, mood. Don't just feed answers unless you're trying to get a no, because you're really sure that's going to be a no, right? Say, what was your mood like at that time? What were you feeling like most of that time? What was your talking like? Did anyone tell you anything was different about your talking?
What was your thinking like? How was it different than normal? were your thoughts going from topic to topic which kinds of topics why and finally did you do anything unusual out of character for this one i do find that it helps to do some screening people will not necessarily uh give you uh the answers you should give some examples being more sexual even alone people will not count their hypersexuality when alone they think that's only social Spending a lot of money.
Make sure you get an idea of their baseline spending. What do you normally spend? How much and how often? And then how much do you spend during that time, right? Being more social is not exactly indiscreet, but it is something that is possible. Also, we have speeding and getting into fights are some examples. Risky investments are another example. Any other examples that I haven't covered that you like to think of for indiscreet or impulsive behaviors?
I guess I'll just say what I was going to comment. To me, I don't find it helpful at all with bipolar to walk through the specific DSM criteria. I just don't find it helpful. It is for a lot of conditions where you can walk through the symptoms exactly and then see what they say. For bipolar, I don't find it helpful. I do... And I feel like I kind of keep saying this, I do recommend finding screeners that you or questionnaires that you do like that link back to the criteria, because in a pinch, they can help you to like, better ask those questions.
For bipolar, the ones that I've seen used are like the rapid mood screener, the mood disorder questionnaire, the bipolar spectrum diagnostic scale and the hypomania checklist. I like these because they kind of pre-write the questions in a much better way. I do like the bipolar spectrum diagnostic scale where you read a paragraph and see if that person feels like that story fits.
Yeah. And again, I only go through the DSM criteria like that when I'm essentially doing confirmatory part of the interview. I'm already extremely sure they have it. And I want to get, you know, kind of clinched a diagnosis. That's probably more of a habit related to forensic work. You have to show your work. You can't just go like, this is clinically likely. Well, I mean, you hope that's the case, but there's plenty of experts who still do that.
And, you know, we've mentioned a lot that you need some kind of estimate of a patient's pre-interview probability. You should be adjusting your, quote, pre-interview probability of a certain disorder throughout the interview. But to have an accurate view of this, you need clinical experience and you also need basically crystallized knowledge about different conditions. things like prevalence you know age of onset development course differential diagnosis and also just basic facts so you know if you don't know this stuff you got to just read up on manic depressive illness and bipolar disorders uh you know you could think about something like the bipolarity index i haven't found that terribly practical in real use personally any other things that you suggest in terms of resources for people who feel like they want to get a better grasp of how to kind of estimate the likelihood of someone having a mood disorder
I can't think of any particular, like for estimation, Nasir Ghani's mood disorder book was probably the most helpful thing for me to understand bipolar. But I can't think of a particular resource to address what you're kind of talking about.
I like the old school text. Manic, depressive illness is super detailed and it cites its sources, though. You know, you've mentioned Gemi twice now, I think, or at least twice. And I have seen people totally write off that entire textbook because Gemi's name was on it. OK, there are people who really despise him. And I think mostly because of his stronger opinions and his willingness to criticize the ADHD construct.
he's he's a i hope that everyone learns that the way that you uh view experts experts have usually there's this thing where like the smartest people have crazy ideas in other areas so with each expert i'm not saying like they're either right or wrong you you take take from them what's useful and then they can leave the rest
um and that especially applies to yeah if you've sufficiently met thought leaders and experts You know, personally, in your work, you'll begin to understand these are great people, very intelligent, genius sometimes, but they're not perfect. And they're just some guy. Everybody is just some guy or gal.
You know, have you heard of Nobel Prize syndrome? What's that? So people who have won Nobel Prize winners like later in their life will endorse some like completely pseudoscientific crazy idea. The best example is the guy who figured out PCR, Carey Mullis, just went on to have just like wild, wild, wacky beliefs.
Well, you did figure out PCR from doing LSD. Yeah, so it's not a surprise. That's an interesting thing. And personally, I suspect that's because of the crossover autistic traits and, you know, psychosis. But we should leave that aside. That's off topic. Yeah. Okay, let's finish up. I know we're almost out of time. Let's talk about the major mimics of bipolar disorders that you really need to roll
out and consider. Before you jump on this, something I think I want to hear you talk about. What is the typical sleep pattern of someone with hypomania or mania?
Oh, yeah. Now, again, this is just a little pearl that you can use to guide yourself. Someone can have a bipolar disorder without having the sleep pattern. OK, that's my opinion. But the typical hypomania or mania sleep pattern, other than not at all, of course, which is the most extreme, usually it's actually early awakening. Sometimes people can have problems falling asleep. because of increased fast thoughts. But often you'll see they're feeling pretty good and they can fall asleep pretty easily.
But what they do is they wake up in about two or three hours and it's like they're done sleeping. You should ask about the experience of that waking up too. You want to make sure it's not from a trauma nightmare or a panic attack or something like that, because usually they'll just wake up and they don't know why. It feels like it's the end of the morning and I'm done sleeping.
That's more stereotypical. Mm-hmm.
So major mimics.
Yeah, obviously substances, right? This is why you start with that kind of history before you go on. But you really need to consider the possibility of both medication and substance-induced bipolar-type disorders. You should also consider medically-induced bipolar-type disorders, for example, from strokes, head injuries, and seizure disorders. But frankly, those need treatment. So it's a little bit less priority, in my opinion. You should recognize it. You should diagnose it appropriately.
But most of those people need at least mood stabilizers, if not a huge cocktail because of the brain injury to control the bipolar symptoms. So, you know, that's that. Another major mimic that I think you really want to make sure you're not inappropriately treating is severe insomnia related to a trauma disorder. OK, people with a severe trauma disorder can be in such a hypervigilant state that they won't sleep for even a couple of days in a row.
I've seen that reported and I've seen that inappropriately diagnosed as bipolar. But of course, comorbidity is common. Go on.
Yeah, yeah. I was totally agreeing. PTSD is like the great imitator for psychiatry. And you do see patients all the time that it's so confusing because what you're seeing in front of you feels like a mania or hypomania. But oftentimes, it's more, as you're saying, better understood through PTSD. Yeah.
Yeah. You should also consider the common mimic of the pan-positive patient. Some patients will just answer yes to most things they ask them, do the misunderstanding for other reasons. That's something to consider. Psychosis itself can look or sound like mania when it's mostly agitation and insomnia without the manic features. This can get confusing with the schizoaffective spectrum. And don't forget that one explanation for total sleeplessness is perception.
In paradoxical insomnia, patients think they are not sleeping, but they are sleeping. You will discover that through a sleep study. We have very little time left. We should talk briefly about why...
in there is adhd i see every i see it all the time there's been a bunch of celebrities who oh that my diagnosis was wrong they thought it was bipolar it's adhd um do not be one of those providers who hears that the patient can't concentrate and put these people on stimulants i see it all the time it's such a
problem i apologize oh so like a reverse mimic reverse uh calling a bipolar disorder is problems of concentration adhd yes yes very very common especially today please don't do that So we kind of promised to talk a little bit about, I think, pop culture stuff. But I also wanted to say, why do you talk about why patients and clinicians tend to mix up borderline and bipolar?
Yeah, do that. Talk about that first.
We should talk about that one. OK, you know. I've like talked about this before, I think, but I think mostly it's because people are ignoring episodes. They're just taking yeses at face value and they think that mood lability is a major feature in bipolar, which it is for some people. You know, you definitely see labile mood in some people, but largely they're not getting enough time history, I think.
and then of course there's also i think some historical uh evidence for not evidence there's some historical descriptions of people maybe even today but certainly in the past still giving a bipolar diagnosis instead of borderline personality disorder because of stigma or billing so you know i don't have a clean answer for this personally i don't see how these two very different conditions gets confused all the time but i could see why you would if you're not sufficiently clear in your interviewing and understanding about the different disorders and of course comorbidity happens the other flip side this is actually
our first episode ever i talked about this as a problem and i saw this on inpatient patients who some inpatient providers think that pressured speech means the person's talking a bazillion miles per hour there's a lot of patients with bipolar who present with in terms of it just in the moment they feel like they're borderline it's almost it's the flip and this is maybe rarer um but i saw it more in inpatient that uh with collateral to me it was a very clearly defined bipolar but when i talked to them in the interview room i didn't get that pressured speech rapid ideas it just felt like a borderline personality disorder patient um who was using uh typical cluster b defense mechanisms um so be careful of that flip side
Yeah, you can go either way. You know, I've had the patient where you everyone thinks his personality and then a mood stabilizer gets added and then suddenly, well, it turns out they may have those personality tendencies, but without the added weight of a untreated mood disorder, it doesn't really come out with the same severity. So you got to have nuance and you have to monitor or treat and, you know, think over time.
Yeah. All right. I think we are out of time.
hopefully this was a decent one for folks and they're interested if there's anything else that you guys want to hear uh discussed about bipolar type disorders treatment we have several episodes on already but you know you could also let us
know in comments awesome thank you so much dr cool see you next time