Bumpy the Bipolar Bear: The Postman Brings Me A Jewel

Bumpy the Bipolar Bear and the Practical Psychosomaticist

I recently received something in the mail which reminded me of the over-diagnosis and under-diagnosis of bipolar disorder. I got a package of materials containing, of all things, a stuffed critter called “Bumpy the Bipolar Bear” apparently addressed by mistake to:

WordPress

Attn: James Amos

200 Hawkins Drive

Iowa City, IA 52242

You should know that WordPress does not have office space here at The University of Iowa Hospitals and Clinics, nor am I a staff member of WordPress. It was from Dr. Igor Galynker, M.D., PhD., the Director of the Family Center for Bipolar Disorder at Beth Israel Medical Center in New York, who obviously has an excellent sense of humor. He wrote a very nice letter to me saying that “It was a pleasure meeting with you back in May for the article, “Scale for Predicting Imminent Suicide on the Horizon.”

Although I’ve not had the pleasure of meeting with Dr. Galynker, the article he’s referring to was a blog post I published in May of 2011, the entirety of which you can read at shortlink http://wp.me/p1glcu-tq. So in a virtual sense, we did meet, sort of. It’s about the cutting edge work he’s done on his very interesting Suicide Trigger Scale (STS). There are no comments attached to the posts at all, not even from Dr. Galynker.

The box he sent me contained (as already mentioned above) a stuffed bear named “Bumpy the Bipolar Bear”, (for the bumpy course in life that those suffering from bipolar disorder often may have; of course it is a polar bear ) and other materials advertising the Family Center for Bipolar at Beth Israel Medical Center in New York. I’m happy to share with you the link to his web site at http://www.bpfamily.org/.

Further, Dr. Galynker and colleagues have a stunning new project called CUBSS (Cannabis Use and Bipolar Spectrum Services) for patients diagnosed with bipolar disorder who believe using marijuana exacerbates or alleviates their mood episodes. He says this is the “first initiative of its kind in NY and in the United States…” It offers education and treatment about marijuana to patients with Bipolar Spectrum Disorder.

The videos above are examples of the perspectives on bipolar disorder diagnosis and, in my opinion, both Dr. Igor Galynker, M.D., PhD and Dr. Mark Zimmerman, M.D. are right. Dr. Galynker quotes Dr. Mark Zimmerman, and the abstracts for Zimmerman’s papers are below.

As a consulting psychiatrist in the general hospital, I often see examples of patients either undiagnosed bipolar disorder, or misdiagnosed with bipolar disorder, and this can lead to complications such as lifelong difficulties with academic and occupational achievement in the former and patients carrying diagnostic labels that are “sticky”, meaning that they tend to follow patients for a very long time, sometimes a lifetime in the latter [1, 2]. Patients with brain injuries such as tumors and strokes, can present with symptoms and behaviors that can mimic psychiatric illness, such as bipolar disorder [3]. Patients also can develop medical disorders from the treatment of bipolar disorder, such as Lithium-induced nephrogenic diabetes insipidus. Both Drs. Galynker and Goldberg emphasize the importance of getting the diagnosis right.

And Bumpy has an honored place on the Geezer’s desk.

1. Zimmerman, M., C. J. Ruggero, et al. (2008). “Is bipolar disorder overdiagnosed?” J Clin Psychiatry 69(6): 935-940.
OBJECTIVE: Bipolar disorder, a serious illness resulting in significant psychosocial morbidity and excess mortality, has been reported to be frequently underdiagnosed. However, during the past few years we have observed the emergence of an opposite phenomenon–the overdiagnosis of bipolar disorder. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we empirically examined whether bipolar disorder is overdiagnosed. METHOD: Seven hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) and completed a self-administered questionnaire, which asked the patients whether they had been previously diagnosed with bipolar or manic-depressive disorder by a health care professional. Family history information was obtained from the patient regarding first-degree relatives. Diagnoses were blind to the results of the self-administered scale. The study was conducted from May 2001 to March 2005. RESULTS: Fewer than half the patients who reported that they had been previously diagnosed with bipolar disorder received a diagnosis of bipolar disorder based on the SCID. Patients with SCID-diagnosed bipolar disorder had a significantly higher morbid risk of bipolar disorder than patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID (p < .02). Patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID did not have a significantly higher morbid risk for bipolar disorder than the patients who were negative for bipolar disorder by self-report and the SCID. CONCLUSIONS: Not only is there a problem with underdiagnosis of bipolar disorder, but also an equal if not greater problem exists with overdiagnosis.

2. Zimmerman, M., C. J. Ruggero, et al. (2009). “Psychiatric diagnoses in patients previously overdiagnosed with bipolar disorder.” J Clin Psychiatry.
OBJECTIVE: In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reported that bipolar disorder is often overdiagnosed in psychiatric outpatients. An important question not examined in that article was what diagnoses were given to the patients who had been overdiagnosed with bipolar disorder. In the present report from the MIDAS project, we examined whether there was a particular diagnostic profile associated with bipolar disorder overdiagnosis. METHOD: Eighty-two psychiatric outpatients reported having been previously diagnosed with bipolar disorder that was not confirmed when they were interviewed with the Structured Clinical Interview for DSM-IV (SCID). Psychiatric diagnoses were compared in these 82 patients and in 528 patients who were not previously diagnosed with bipolar disorder. Patients were interviewed by a highly trained diagnostic rater who administered a modified version of the SCID for DSM-IV Axis I disorders and the Structured Interview for DSM-IV Personality for DSM-IV Axis II disorders. This study was conducted from May 2001 to March 2005. RESULTS: The most frequent lifetime diagnosis in the 82 patients previously diagnosed with bipolar disorder was major depressive disorder (82.9%, n = 68). The patients overdiagnosed with bipolar disorder were significantly more likely to be diagnosed with borderline personality disorder compared to patients who were not diagnosed with bipolar disorder (24.4% vs 6.1%; P < .001). A previous diagnosis of bipolar disorder was also associated with significantly higher lifetime rates of major depressive disorder (P < .01), posttraumatic stress disorder (P < .05), impulse control disorders (P < .05), and eating disorders (P < .05), although only the association with impulse control disorders remained significant after controlling for the presence of borderline personality disorder. CONCLUSIONS: Psychiatric outpatients overdiagnosed with bipolar disorder were characterized by more Axis I and Axis II diagnostic comorbidity in general, and borderline personality disorder in particular.

3. Bunevicius, A., V. P. Deltuva, et al. (2008). “Brain lesions manifesting as psychiatric disorders: eight cases.” CNS spectrums 13(11): 950-958.
Sometimes patients with organic brain lesions in neurologically silent brain areas might present only with psychiatric symptoms, such as depression, anxiety disorders, schizophrenia, anorexia nervosa, or cognitive dysfunction. This study presents eight cases of patients with brain lesions (four cases of meningiomas, one case of intracerebral cysts, one case of anaplastic oligodendroglioma, one case of multiform glioblastoma, and one case of occlusive hydrocephalus) who, for a significant period of time, were diagnosed and treated for psychiatric disorders (three cases of Alzheimer’s disease, two cases of schizoaffective disorder, one case of schizophrenia, one case of depression, and one case of organic emotional lability disorder). When neurologic symptoms developed, they underwent neuroimaging studies and organic brain lesions were diagnosed. Further treatment required neurosurgical interventions. These cases show that brain tumors can be neurologically silent for a sufficient period of time and manifest as psychiatric disorders. Therefore, neuroimaging studies are needed when atypical changes in mental status or neurologic symptoms and signs develop.

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