When You’re Not Really Bipolar After All: Anatomy of the Diagnosis of Bipolar Disorder

For the first few years after I arrived in the DC area, I took call at two local hospital emergency rooms as a way to gain more experience, and build my private practice. One evening I was paged to come into the Emergency Department to evaluate a man who hadn’t slept in 3 days. When I arrived, the ED staff had taken an initial history and reported to me that the man was full of energy, his thoughts were racing out of control, and that he had suffered from episodes of depression in the past. He was also exhibiting signs of grandiosity, with thoughts that were excessively ambitious. The ED staff suspected that this man was having a classic manic episode and asked for a consult to rule out bipolar disorder. But it turned out that after looking at his lab work and a urine sample, this patient was actually found to be intoxicated on cocaine, which mirrors symptoms of bipolar mania. Interestingly, cocaine withdrawal symptoms can produce a severe, but transient depression, that may also seemingly confirm an erroneous diagnosis of bipolar disorder. It was an example of how “checking the boxes” on a list of diagnostic criteria (similar to using an algorithm to solve a math problem) without looking at the patient in a broader context and ruling out other conditions, could lead healthcare professionals down the wrong path when diagnosing bipolar disorder

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