Key moments, in order
Training builds our knowledge on the most severe inpatient cases, where you never see people when they are well between episodes. Many practitioners then think that if it is not severe, near-psychotic bipolar, it is not bipolar, and that is a big mistake.
Clinicians rule bipolar disorder out too quickly, as if it cannot exist unless they see mania or hypomania in front of them. What someone does and says in front of you is output, not the underlying process.
Get collateral. It is the main thing that matters in bipolar disorder: a patient can come off as cluster B in the interview, and then a family member or partner describes clear-cut episodes of mania.
It takes much longer to exclude a diagnosis than to recognize one. No one can know your diagnoses with 100 percent confidence after 45 minutes, and you cannot rule conditions out that way.
The reverse happens too. Someone can look perfectly borderline in interpersonal style and defenses while a bipolar process is going on, without pressured speech; the illness is probably aggravating their personality functioning through stress, regression, irritability or paranoia.
The presence of one disorder does not exclude another. Many practitioners prize parsimony, but a patient with pneumonia can still have lung cancer, and the cancer may even be setting the stage for the pneumonia.
Psychiatry has no biomarkers today, and the hope is that diagnostic concepts will be built rigorously enough to eventually find one that both rules in and rules out.
The art of eliciting the right information at the right time and putting it together into a treatment that helps, that the patient will accept, carry through and change with, is the whole of psychiatry.
We may pretend we are playing a biological game, but we are playing a psychosocial game.
Conceptualize what you think is more biological, more social and more psychological. The biopsychosocial approach as a label is too simple.
Your countertransference tells you about the patient's level of personality functioning, but it does not give you a diagnosis.
In the emergency room, do not make the diagnosis unless the chart or records show the pattern.
In the emergency room, risk stratify on case history. You do not need to rule on whether they have a personality disorder.
It is a risk factor, just not as serious a one as severe agitated psychosis with command hallucinations.
A true bipolar disorder happens in episodes: the changes in functioning, mood, activity and sleep come and go as episodes.
Bipolar disorder is present early even if the full syndrome waits until the 20s or 30s: irritability, mood changes, problems with concentration.
Antisocial patterns can wear down: you see the burnt-out antisocial, or the tired antisocial.
When personality improves over time, it comes from opportunity, development and changes in the underlying biology.
In psychodynamic terms, defenses are capacities that can mitigate or sublimate parts of our animal instincts.
Mania does not always look like pressured speech and flight of ideas. It can be almost the opposite: a person who says little and is incredibly quick to violence.
Bipolar I can be understood as two different self-states, two different ways of being, rather than only highs and lows.
Without collateral, do not assume the person presents this way because it is normal for them. That is possible but a minority of cases; compare them to an ordinary, regular person.
Catatonia is actually seen more often in mood disorders than in psychotic disorders, so think of it in mood cases too.
A benzodiazepine dose that looks large can be nothing for some catatonia cases, and younger patients, even adolescents, sometimes need still higher doses.
We think about things as diseases because we want things to be better and to prevent them from getting worse.
Do not restrict yourself to the criteria. Read through all of the DSM, and then read even more.
The DSM is not exactly a scientific document. Science informs it, but it is a product of professional consensus, and it will and must change.
It centers personality pathology on personality functioning, how we relate to ourselves and others. That splits into self-functioning (identity and self-direction) and interpersonal functioning (empathy and intimacy), four elements in all.
These critiques are not anti-psychiatry. They can be abused by anti-psychiatry zealots to cancel out the validity of everything, so do not think in black and white.
Some people lean on the biological label to mean something is wrong with me that I have no control over. People push stimulants because they see a biological illness; if you thought it were purely social, you would change the society instead.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.