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 is...is it normal for someone to come out of an evaluation with THIS
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
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
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
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.
Published July, 2007