Coming Out of an Evaluation w/This Many Disorders?
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Q:  Coming Out of an Evaluation w/This Many Disorders?

A very close friend of mine went through a mental evaluation yesterday, and came out diagnosed with Type II Bipolar Disorder, OCD, PTSD, and Generalized Anxiety Disorder.

I have never seen her exhibit any manic behavior, even mild.  There is no decrease in "need of sleep", no euphoria, and no over inflated sense of self-worth.  She is deeply depressed, but has a lot of family and work issues on her plate.  Honestly, if I were in her shoes I would be on the brink of a breakdown as well.

I have done some medical research (I'm a psych major - early on), and I noticed that most of these disorders display some identical symptoms.

My question it normal for someone to come out of an evaluation with THIS many disorders?


Dear S' --

Well, on the face of it, I must admit, that looks rather embarrassing for my profession. Perhaps what was going on here is the work of a very thorough clinician who has done a very complete evaluation, and who is trying to flag multiple different conditions as warranting further attention as treatment proceeds. A couple of thoughts about all this --

First, it is important to recognize that there are versions of bipolar disorder that do not exhibit "decreased need for sleep", nor euphoria, nor grandiosity. For the references on this, as you will want to be familiar with it in your field, see my explanation of bipolar II, on a website dedicated largely to that subject, (see the section on "mood swings but not manic".) As you may know, nearly half of all manic episodes are "dysphoric", not euphoric. At these times, people can experience an extreme agitation, and irritability, and difficulty focusing their attention, yet in no other respect do they look "manic". 

The term "decreased need for sleep" does very accurately identify one of the classic features of mania; and yet, many people with bipolar disorder experience sleep disturbance as a desperate wish to be able to sleep more than they find themselves able to. For example, it is common for people to sleep as little as 2-4 hours per night, with tremendous difficulty falling asleep due to unrelenting thinking, or waking up after a few hours of sleep with highly restless and disturbed sleep thereafter. They wake unrefreshed just as those of us might too do not have bipolar disorder, were we to get so little sleep.

My main area of interest in psychiatry is versions of bipolar disorder which do not appear "manic".  There is good evidence to suggest that such variations extend well beyond the boundaries described by the "Diagnostic and Statistical Manual", the DSM-IV, the rulebook of diagnoses at present, as summarized on my website including the references relevant to this assertion.

Indeed, as you will also see on that website under "
Anxiety As a Bipolar Symptom", all of the other conditions which were given as diagnoses for your close friend can either overlap with, or actually be part of bipolar disorder. The latter is a particularly important idea, as it suggests that these are not really separate conditions, and that by focusing on treating the bipolar disorder itself, all of the symptoms which otherwise technically meet criteria for those diagnoses, might disappear. Obviously, this is worth strongly considering, as it suggests (as is the strong recommendation from mood experts around the world), "treat the bipolar disorder first". In other words, although your friend might meet criteria for these diagnoses, she could simply have bipolar disorder and thus explain all the other features which led to all these labels.

On the other hand, does it work the other way around? Could PTSD, for example, be the primary diagnosis, or even the only diagnoses, with symptoms that might otherwise be considered as OCD, or even bipolar disorder? Indeed, that is quite possible. In my view, the key (or a least one key) is to make sure that bipolar disorder is strongly considered among the possible diagnoses/explanations, because it alone, amongst all these labels, suggests that antidepressants might be the wrong way to go if a medication approach is chosen. For all the rest, antidepressants are the standard approach if medications are used. If a psychotherapy approach is used instead, getting the diagnosis right at this point is less crucial, although there are numerous rather specific psychotherapies for these conditions and relatively soon one would want to choose the right one. Even then, however, there is far less risk of making things worse if one chooses the wrong approach.

Nevertheless, you are right: it does look a little odd for someone to get so many labels all at once. Years ago someone did a study showing trainees in Psychiatry a bunch of videotapes of people being interviewed, some of whom did indeed have a diagnosable mental problem, but a few in the bunch were selected for participation because they were "normal", and part of the study was to see whether or not the trainees could recognize them as "normal", and avoid giving them a diagnosis. Unfortunately, every single participant was found to have some sort of diagnosable mental illness. In other words, simply being seen for a mental health evaluation increases one's risk of being diagnosed with something. It is an effect of the context, primarily, I hope, although I recognize that there are other potential interpretations.

Thank you for your question. I hope you'll have a look at some of those webpages. Good luck with your education.

Dr. Phelps

Published July, 2007

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