Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for the ‘Bipolar Disorder’ Category

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.

Posted in Bipolar Disorder, Schizophrenia, State of Psychiatry | 2 Comments »

Is It Severe ADHD or Childhoood Bipolar? The Case For A Longitudinal Assessment

Posted by Dr. Vollmer on November 10, 2011

Alan, now eleven, has seen me since he was four years old. Zane, his dad, was diagnosed with ADHD when he was thirty. Zane does well on stimulants, such that he reports that “they changed my life.” Theresa, Alan’s mom is a speech therapist, specializing in children with special needs. Beth, their younger child, has no issues that concern them. By contrast,seven years ago,  Zane and Theresa reported that Alan’s behavior was “really not normal.” They continued to state “his moods shift rapidly. “We cannot handle him. We think there is something seriously wrong with him. He gets upset at the slightest thing. He is not like the other kids. He throws chairs when he does not get his way. He cannot focus on “anything he has no interest in.  We know he is smart, but that does not seem to help him. His tantrums are simply out of control. Maybe he is bipolar or something.” Theresa tells me her frustrations with Alan, with tears in her eyes and a look of deep concern. “I work with special needs kids, but I have never seen anything like this,” she tells me.

I do my usual investigative work: I talk with Alan’s teachers. I see Alan myself. I gather more information from concerned relatives. Based on my review of the history and my observations of Alan, I conclude that he has ADHD and he needs a stimulant. We do a stimulant trial and Alan gets worse. “You see,” Theresa tells me, there is something else going on.” “Not necessarily,” I explain. The fact that he did not respond to stimulants may mean that his brain is too young to reap the benefit, so that maybe as his brain matures, he will be able to handle a stimulant better.” I explain. Theresa and Zane are not convinced.

  Fast forward five years, and we repeat a stimulant trial only this time, it is a remarkable success. Alan is doing better handling frustration and focusing at school. Fast forward two more years, and Alan is back to where he was at four, only now he is approaching puberty. Once again, Theresa and Zane believe that his behavior cannot be explained by ADHD alone. They are deeply concerned about  whether Alan has a chronic mental illness such as bipolar disorder, even though there is no known family history of this diagnosis. “I think he needs a higher dose of his stimulants. I also think that puberty has exacerbated his mental state, such that with time, his brain will mature and his frustration tolerance will improve.” I explain, again, not convinced that his low frustration tolerance is related to childhood bipolar disorder.

  Alan only tantrums when he does not get his way; when he is not the center of attention. Theresa and Zane are admirable parents, but they need to understand that raising Alan is more demanding because of the severity of Alan’s ADHD. They need to work harder at  providing consistency and structure. We have talked about these parenting skills and they are on board, but still skeptical of Alan’s future mental functioning. “I think time is going to be on our side,” I say, explaining the wonders of maturation. “Medication will also help,” I say, agreeing with them, that parenting alone is insufficient to deal with the severity of Alan’s behavior.

Theresa and Zane, after much discussion, feel a bit relieved that we are still dealing with the same issues that we were dealing with seven years ago. Alan too, looks forward to increasing his medication, as he says “I don’t like that I behave this way. I really don’t,” with shocking insight into his difficulties. There is hope in the air. We will see how it goes.

Posted in ADHD, Assessment, Bipolar Disorder, Child Psychiatry | 2 Comments »

Whose Mania Is It?

Posted by Dr. Vollmer on January 10, 2011

   Barry, sixty-one, divorced three times, has one eighteen year old son, Casey, now living with his girlfriend, Jennifer,  of two years has escalated into mania. He sleeps four hours a day. He has lost twenty pounds in two weeks. He bought a brand new motorcycle, draining his bank account. Barry has a positive family history for bipolar disorder and he has had five prior manic episodes since the age of seventeen. Barry does not want medical attention, “everyone else is the problem” he says. This is Jennifer’s first experience of mania; she knew Barry had a history, but she did not  know what that meant. Now she knows, and she is frightened and paralyzed. Casey is scared too. Barry is still friendly with his first ex-wife Michelle, not Casey’s mother. Michelle lived through three or four manic episodes with Barry; she is also scared, but not paralyzed. She wants to help him, but she has no legal rights as they are no longer related. Barry is a gentle soul, but when he is manic, he is scary and potentially dangerous. “It is time for the police,” I say to Michelle, with a heavy heart. “He needs to be hospitalized and contained so he can de-escalate,” I say, knowing that every option seems so unsettling. Most of the time Barry is competent to make decisions about his medical care, except not when he is manic. The laws in our country make it difficult to assume responsibility for an adult’s care in the absence of a life-threatening emergency and without a conservatorship. Hence the intervention, when it comes to psychiatric illness, often involves law enforcement. Barry needs to be protected from harm, both self-harm and harming others. He needs a locked unit. Most of the Barry’s in the world end up in the criminal justice system, not the mental health system. Without an advocate, Barry ‘s behavior would be misunderstood as criminal, rather than symptoms of a  psychiatric illness. I do not have answers or ideas about how to change things, only sorrow for the individuals and the families that live anxiously awaiting some relief.

Posted in Bipolar Disorder, Musings | 2 Comments »

 
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