Shirah Vollmer MD

The Musings of Dr. Vollmer

Paranoid-Yes: Dementia-No!

Posted by Dr. Vollmer on November 19, 2012

Diagnosis, particularly psychiatric diagnoses, are history based. We have no objective tests. We have no imaging studies. We need to listen, pay attention, gather a history, and pursue collateral information. Yes, you have known me to say this for a very long time. Now, I will tell a fictional story which illustrates my point, since the fire in me pushes me to say it again. Diedre is a 70 year-old longstanding patient who has a long family history of mental illness. Her mother was bipolar. Her father had issues with alcohol. Her mother’s mother also had bipolar illness. Both her mother and her maternal grandmother had a history of long stays in psychiatric hospitals. Diedre, although high-functioning, has, what seems to be a more mild version of her mother’s illness. She does have a history of psychiatric hospitalization, but her mental illness manifests more in paranoia than in mood swings. She has long periods of time where she is quite agitated that institutions, such as the police department, want to hurt her. As a result, I have her on an antipsychotic medication, which, as she reports, makes her “much calmer”. Diedre also has a severe alcohol and prescription drug abuse problem, which she denied for many years, but she knew that I knew that this was an issue. Over a long holiday weekend, her drinking caused a change in mental status, leading to her boyfriend calling 911, and then a subsequent psychiatric hospitalization for delirium. The psychiatric team took her off her medications and she detoxed in the hospital. Although the patient told the team to talk to me, that communication never happened, so even as her mental state cleared, where she returned to her baseline paranoid ideation, the team did not re-start her antipsychotic. Instead, they interpreted her mental state as the beginnings of dementia. They administered one test of functioning, which, by her report, she was too paranoid to cooperate with the questions, so she “failed” the test and was diagnosed with dementia. This resulted in a report to the DMV stating that she was unsafe to drive. This also resulted in them insisting that she transition to a skilled nursing facility, at the cost of many thousands of dollars out of pocket, since the team did not feel she was safe to go home. When she was discharged she returned to me. I told her to re-start her antipsychotic, to return to her previous living situation, and to get private cognitive testing in order to have documentation for the DMV. As expected, she has no evidence of dementia, and although the hospitalization was very helpful in starting her on a sober life, the increase in paranoia was tragic to observe. Histories take a long time to understand. Quick diagnoses are not only wrong, they are harmful. There is a fire in my belly.

2 Responses to “Paranoid-Yes: Dementia-No!”

  1. Shelly said

    What a tragic story (fiction, but based on some reality, nevertheless). It is hard for me to believe that the physicians could be so careless as to completely discount any helpful information that Diedre could contribute to her history, contact you, or anything else along this vein. I am shocked that they would quickly attribute her state to dementia, although, unless she was very young, am not surprised, since dementia in the States seems to be a catch-all phrase for anything from vascular-disease diminished mental functioning to cognitive decline. No wonder you have a fire in your belly.

    • Shirah said

      Thanks, Shelly. Yes, I call this “sloppy medicine”. As you say, the consequences are significant and hence the story is disturbing. Yes, dementia is a “catch-all” term for cognitive impairment. As you noted, psychiatrists should be able to distinguish cognitive decline from paranoia. Understanding these kinds of distinctions is the core of our work.

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