Overdiagnosis Examine the Assumptions, Anticipate New Bipolar Criteria - Psychiatricanswers

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Overdiagnosis: Examine the Assumptions, Anticipate New Bipolar Criteria.
By James Phelps, MD  
March 13, 2013


 

Comments on the Psychiatry times web as a respond to the article...


Manuel Mota-Castillo said:
I want to start my response to this Commentary by quoting a 1994 editorial in The American Journal of Psychiatry (By Dr. Nancy Andreason) which stated the following:
"The Ahistorical Fallacy rests on three faulty assumptions. The first assumption is that 'proposition X' must be true because it is what the 'experts' are teaching. The second assumption is that 'proposition X' must be true because it is the most recent one to be put forth. The third assumption, which buttresses the first two, is that 'if information increases, knowledge increases as well."
Based on the outcome from the management of thousands of patients with mood problems, I believe that it is fallacy to assume that psychiatrists are over diagnosing Bipolar Spectrum Disorders. But I don't expect that Psychiatric Times readers are going to take my word to the bank. I will suggest that we go back and read "Antidepressants in Bipolar Depression: A Meta-Analysis for an Old Controversy" (S. Nassir Ghaemi, Psychiatric Times, January 3rd 2011) and two papers by Dr. Ronald Pies: "Antidepressant-induced dysphoria and agitation" (ARAD) and "Are we Misreading the Signs in Psychiatry?" Furthermore, I want to call your attention to a frequently quoted research conducted by Dr. Robert Hirschfeld and several prominent psychiatrists that yielded a commonly ignored data: 70% of bipolar patients had to wait more than 10 to receive a correct diagnosis from the first time they saw a mental health professional.

For reasons that escape my understanding the DSM-5 committee decided to ignore the ground-breaking work of Dr. Hagop Akiskal that led to the introduction of the concept of bipolar spectrum disorders. Instead, they kept the centuries-old criteria that connect the bipolar diagnosis to a narrow scope of symptoms and miss those "subtreshold" cases that do not meet its requirements. I see this kind of individuals every day as they come to me with a history of having failed all kind of antidepressants (at times powerful combinations such as sertraline, bupropion and trazodone). Those are the ones that developed the "ARAD" described by Dr. Pies, that can't sleep "because I can't turn my brain off." They are also easily agitated, short-tempered and many times labeled as Borderline Personality Disorder because of the impulsivity and lack of improvement "despite adequate treatment." Unfortunately, they are also prone to attempt suicide, out of desperation or impulsivity.
This "tunnel vision" of bipolarity explains the author's assertion that "bipolar disorder is like bacterial sepsis or mononucleosis: a patient either has it or he does not." Despite how solid this statement appears to be, at times we have a bacterial invasion that is repelled by our immune system and sepsis never manifest. On the other hand, if we remember the 90s when AIDS patient began to manifest symptoms of Tertiary Syphilis and fungal infections, the comparison is not that clear cut as Dr. Phelps would like it to be. But even if the entire "anti-bipolar spectrum activist" are correct, would not be appropriate to suspect this condition when the family history is positive and the symptoms are highly suggestive?
I hardly ever use an antidepressant with my bipolar spectrum patients and in the 3 cases (in the past 15 years) that I have prescribed bupropion for 1-2 weeks I had to d/c because of emerging "ARAD" symptoms.
Sadly, like the Spanish poet Leon Felipe said:

"The old good boys who re-write history to fit their ideas, refused to listen and covered their ears with cement, but still they dare to ask: "Why are the Spaniards so loud."

I strongly believe that we all can learn a great lesson by reading this unique poem "Porqué habla tan alto el Español?"
March 16, 2013
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Ronald Pies said:|
Thanks to Jim Phelps for an enlightening piece, and for exposing some of the philosophical assumptions--I might say, fallacies--underlying some claims of "overdiagnosis"and "false positives" in psychiatry. These terms are commonly thrown around without much critical scrutiny, whether in bipolar disorder or any other psychiatric disorder. Psychiatric disorders are not like microorganism-based diagnoses, such as tertiary syphilis; if they resemble disorders in general medicine, they would be closer in kind to, say, hypertension, which exists along a continuum of symptoms and severity, as well as underlying etiologies. Perhaps this will change, as we uncover more and more microscopic etiologies for psychiatric disorders but we will never be removed from the clinical decision-making process of determining a patient's degree of suffering and incapacity i.e., whether "disease" (dis-ease) is present, and how that disease is uniquely experienced by the particular patient.

Thanks, too, to my friend Dr. Mota-Castillo, for the "call out" to my articles on BP disorder, ARAD, etc.!

By the way, for fans of bipolar screening scales, this study may be of interest:
J Affect Disord. 2011 Aug;132(3):445-9. doi: 10.1016/j.jad.2011.03.014. Epub 2011 Mar 26. Sensitivity and specificity of the mood disorder questionnaire and the bipolar spectrum diagnostic scale in Argentinean patients with mood disorders. Zaratiegui RM, Vázquez GH, Lorenzo LS, Marinelli M, Aguayo S, Strejilevich SA, Padilla E, Goldchluk A, Herbst L, Vilapriño JJ, Bonetto GG, Cetkovich-Bakmas MG, Abraham E, Kahn C, Whitham EA, Holtzman NS, Ghaemi N.
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