Did She Really Have Bipolar Disorder?
By Glenn Zielinski, DO, as told to Maryann Brinley
Diagnoses in psychiatry are very social, according to Glenn Zielinski, DO. “Your stress, your environment, your biology, and the psycho-social aspects of your situation all play together to create a diagnosis. These are conceptual illnesses. They are subjective, not scientific. What’s more, some diagnoses don’t even exist anymore,” having been written out of the medical textbooks to be replaced by new, updated variations.
Since he started learning about psychiatric diagnoses in school — which wasn’t all that long ago because he graduated from the School of Osteopathic Medicine (SOM) in 1992 — there have been five revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and another is due out in 2013. Schizophrenia?” he says, “You really should call it a dopamine-serotonin interaction abnormality.” He jokes, “The brain is encased in concrete and you really can’t bust it open to see what’s happening.” Which only makes the job of treating patients that much trickier for this assistant professor of psychiatry at SOM. At the very start of this compelling story, Zielinski cautioned, “Psychiatry is unique in the field of medicine because we have diagnoses which are not, in fact, diagnoses. We have syndromes which are constellations of symptoms that occur together but not necessarily because of a cause.”
This regular feature on the psychiatrically-thorny topic of diagnosing is designed to showcase stories from the files of our UMDNJ physicians. This one takes a hard look at a patient who had been given the diagnosis of bipolar disorder, so common nowadays that as Zielinski says, “It’s thrown around like salt on a snowy day.”
ur patient is an attractive, 33-year-old Hispanic female who has just been released from prison after serving three of a five-year sentence for attempted murder. In the heat of an argument, she grabbed a steak knife and stabbed her partner, the father of her child, in his neck. Both had been cheating. They had lots of issues. He was drunk and slapped her. She became blinded by anger, something that happens often to her as it turns out. This is a woman whose moods can change from minute to minute. Someone sets her off and she gets angry well out of proportion to the circumstances. Her fury can be so intense that she’ll lose consciousness of her actions and find out later that she has thrown or broken something or, in this case, stabbed someone. He called 911. The police came. She was arrested. Her child went into Department of Youth and Family Services care, all part of a sad story which only gets sadder when the details emerge.
Three years later and out on parole, she is referred to me. She tells me she is bipolar and the drug, Seroquel, isn’t working. Even with that ready label of bipolar syndrome in her file, I am intent on uncovering all the criteria which went into this original diagnosis. Psychiatrists are often at the mercy of whatever information comes along and patients, of course, don’t always see themselves clearly. You also have to understand that the volume of patients, time restraints and overwhelming amount of paperwork can suck the compassion from you. But this patient has a multitude of symptoms and I’m an osteopath. We learn to think of the whole person and how symptoms manifest. I always step back and do a bio-psycho-social — looking at the biological aspects, the psychological and sociological, nature versus nurture and how stressors could either bring on or amplify what is occurring in someone’s life. Her psychiatric history is tragically long, complicated and she’s been carrying the bipolar diagnosis since adolescence. Right or wrong, everybody who has mood instability wears the badge of bipolar these days and hers went on that chart when she was forced into a rehab facility after being picked up for prostitution and addiction to illegal drugs.
The diagnosis started her on a litany of medications which is her life now. Seroquel is used to treat mood instability and personality disorders but it’s not working for her. She can’t sleep and has flashbacks to the sexual and physical abuse she suffered as a child living with her drug-addicted mother. One of her mother’s many male friends abused her from age 5 until she ran away at 14. Now, in her 30’s, her dreams are distressing. She wakes to the sensation that this abuser is on top of her. This irritates her but she tries to avoid talking about it. On my prompting, she recognizes that she sees no future, no hope and feels destined to be stuck this way for the rest of her life. She has other symptoms, however. As a child, she would cut or burn herself and as an adult, it continues but via more socially acceptable behaviors like tattooing and piercing.
A bipolar diagnosis requires a manic episode characterized by sleeplessness for a week. But sleeplessness needs to be well-defined here. A bipolar patient has a decreased need for sleep with an elevated mood and lots of goal-directed activity. Someone might repaint an apartment 15 million times, for instance. Of course, I exaggerate but you get the idea. They don’t need to sleep but still feel refreshed. My patient was being awakened by nightmares causing her to lose sleep. Nor did she have rapid, pressured speech, hallucinations, delusions or sensations of grandiosity where she thought she had special powers. The one thing she kept referring to were mood swings and this anger management issue.
Like diabetes, some mental illnesses sit dormant until stress brings them out. You may be genetically predisposed to get one. This girl, under her circumstances, tried to escape by smoking pot and using drugs at an early age which changed her normal brain chemistry, probably irreversibly so. Keep in mind that psychiatric diagnoses are divided by 5 Axes. Axis 1 are genetic or chemical in origin. Axis 2 diagnoses are developmentally-based and you’ll see personality disorders on a continuum here. Many patients fall somewhere between these two groups but Axis 2 patients take quite of bit of work to resolve, while Axis 1 respond to chemical therapy. Bipolar is on Axis 1 but the criteria are set up very specifically so we don’t get sloppy, as happened in this case. A secret: diagnosing someone with a personality or developmental disorder on Axis 2 doesn’t pay well so some patients get passed along, misdiagnosed and treated with medications for shortsighted resolution of symptoms. Yet, one hour or one year may never be enough to completely understand another individual. I was lucky to get a full hour with this patient at that initial visit. Usually, it’s drive-by therapy. These are the challenges and why for so many years, my patient was misdiagnosed.
I feel compelled to tell her that I could be wrong but because she hasn’t experienced a lot of success with medications, maybe she has been treated for the wrong thing. Then I review with her the criteria for borderline personality disorder and she feels as if her picture should be alongside that diagnosis. Next, I read her another set of criteria for post-traumatic stress disorder — because I suspect she suffers from both — and this woman, who is street-wise and hardened, becomes very emotional. She breaks down and cries.
Knowing what causes something does not necessarily bring a solution but it did bring something else to this patient. Even though the diagnosis had been wrong, the treatment for her was still likely to be some sort of anti-psychotic medication. Yet, she felt better about herself right there: just knowing. She wanted a copy of her diagnoses descriptions to take with her. With those in hand, she had a concept of what she had been experiencing for so many years. By understanding her pathology better, she may even be able to make efforts to conceal symptoms or at least to use the knowledge better in therapy sessions. Most people have a hard time seeing themselves as others do. I know that I did not cure her because that is a long process but I hope I gave her insight so that this woman could begin to see herself better. .
Glenn D. Zielinski, DO, is an assistant professor of psychiatry at UMDNJ-School of Osteopathic Medicine (SOM), the clerkship director for third-year students, and the second-year course director for clinical psychiatry. A 1992 graduate of SOM, he completed his residency there in the Kennedy Hospital system in 1996 where he still works as well as with Cape Counseling services in Cape May Court House and the Promise program in Camden.