[PsychoPhil]

I am high functioning autistic and am suffering from mood swings that could just be part of my condition, or possibly point to a bipolar comorbidity. I am concerned medication for better focus and lessened social anxiety, such as stimulants or antidepressants, might cause me a manic episode because I think I had one decades ago. I also had various depressive episodes and some possibly hypomanic ones.

My family doctor dismisses the possibility of (hypo)manic episodes as well as benefits from medication based on a psychiatric assessment, the results of which I learned with months delay. The PDoc saw me for no more than 15 minutes, described me as anxious, awkward, not suicidal, and diagnosed "personality disorder unspecified with avoidant and compulsive traits, no meds needed."

The diagnosis for autism came from a 4 hour psychological assessment (ADOS-2), which my family doctor dismisses as invalid for public health purposes because only psychiatrists can diagnose. Though quite rude, I must give the PDoc credit for coming to a similar conclusion as the psychologist in such a limited time. But I'm not sure whether a 15 minute interview could possibly rule out benefits of medication, and also wonder why my family doctor would consider the conclusions of the quite knowledgeable psychologist as practically useless.

As it now looks like, it will be difficult to get another psychiatric referral through the public system because I already had one, and even if I could get one I doubt the next guy would have more time for cases deemed non-suicidal, non-violent and not obviously psychotic like mine. There are no options for private referrals in my region.

Anyone any opinions? Am I too quick to pass judgement on my family doctor as not too helpful, on that PDoc for jumping to conclusions that might well make my life more difficult, and on our public health care that effectively bars me from treatment options with its monopoly position and lack of resources?

Is it actually possible for a PDoc to diagnose in just 15 minutes?

[TheSeaCat]

Hello Phil; I would say that anyone that can get you out of there office in fifteen minutes is not a good pdoc.

I personally just saw a Psych PA; a physician assistant that specialized in psych; he came very highly regarded and our first appointment together was an hour and a half. Granted that last thirty was because I was the last appointment of the day; he's like any psych worker worth any salt spends at least 30 first appointment to really get to know the patient; an hour it the best for first appointments.

Now for med adjustments he's like 15-30 is the best for those.

Like you I was very dependent on my primary doc for psych care since some psych places are anti certain insurances. I would say try another primary doc that listens to you and tries to understand the issues you are facing and there are some excellent primary docs that do know and understand psych. I would just say try another and just keep taking until you find something that works. I deal a lot with referrals with my job and I know first hand how hard it is to get a psych appointment for them and for myself. Don't give up hope; there is someone that wants to help you.

[AspiringAuthor]

No, a PDoc cannot diagnose in just 15 minutes. A bipolar diagnosis (or coming to the conclusion about the absence of such a diagnosis) requires extensive history taking, for one, and, ideally, observing the patient in different phases. So - no.

I thought that autism is a neurological diagnosis, but might be wrong. At any rate, a 4 hour psychological assessment from a reputable psychologist outweighs a 1/4 hr from a rude pdoc. I do not see how the PDoc and Psychologist arrived at the same conclusion: the Psychologist dx'd with autism and the pdoc with an Axis II personality disorder / traits. There might be observational equivalence between compulsive and avoidant traits and high-functioning ASD presentation, but that is where repeated observations and history taking would come in handy, but how would you pursue them in the state mental health system?

All in all, it seems that the core of the issue is that your family physician is dismissive. With a more attentive, caring and, I 'd add, 'worrying', family physician, you'd fare better.

It is also not clear where the initial idea of medication came from. You wrote that a stimulant for better focus (ADHD?) and lessened social anxiety might as a side effect cause a manic episode. You also wrote that the family doc sided with the pdoc who said no meds needed. If that is the case, who is the proponent of the idea of stimulants or antidepressants?

[Victoria'smom]

My pdoc took an hour the first time then 15 min after that every 2-6 months after that. In my area certain psychologists can diagnose. My sons is currently trying to get my son into a psychologist for testing. The test will take 6+ hours over 2 days. I would go to therapy and when your comfortable with him/her tell them what happened and ask for their advice.

[Guiness187055]

My intake appt was a hour long and my pdoc pretty much nailed my diagnosis. He has since added to my diagnosis since then.

[Wander]

Nearly an hour for me with my current pdoc and that was after a referral from another pdoc that clearly demonstrated possible mania and psychosis. He didn’t read the referral till after he interviewed me anyway. It took a lot of questions on my history from childhood to now plus symptoms. I would try to get into another pdoc if I were you. That’s unprofessional.

[sarahsweets]

30 seconds.... JK. My doctor took about an hour for the initial followed by 3 monthly half hour follow ups and now for med checks 15 minutes every three months.

[Gabyunbound]

I don't think 15 mins is nearly enough. I would look for a new PCP, as others have suggested. If you were to do that, could you get a referral for another pdoc where you live? You could also ask your current pdoc for a longer assessment, though I can understand if you would be uncomfortable doing that, given how dismissive he has been.

I was initially diagnosed as having depression, and then years later as Bipolar 2. When I brought up BP a couple of years in, that pdoc dismissed it out of hand, saying "BP is found under every rock," in other words it's over-diagnosed. He was the one who later diagnosed me as II. If he had diagnosed me earlier, I would have had the proper treatment and not have to go through the hell I went through. He prescribed Lamictal, which did wonders for my depression (though didn't help with hypomania).

Then I moved and was evaluated by another pdoc. He did a good, long evaluation and initially diagnosed me with Bipolar NOS because he hadn't witnessed anything. After having a manic episode, he diagnosed me as Bipolar I and prescribed an AP along with the Lamictal and Klonopin. I subsequently had 2, clearly delineated, hypomanic episodes with him.

Then I moved again and saw someone who specialized in BP. She did an hour-long evaluation and kept my diagnosis, although I was stable for the 2 years I saw her.

Moved again (!). The pdoc I see now did a relatively short initial evaluation, I think about half an hour. She later saw me have psychotic symptoms with lack of sleep and upped my AP (goodbye 3 years of stability!) I'm quite sure she'd agree, now, that I have BP I. I've never asked her about diagnosis.

I just hope you get the treatment you need, whatever that may be, to lead a peaceful and fulfilling life.

[HALLIEBETH87]

Where I live psychologists and therapists can diagnose.

[MickeyCheeky]

I'm so sorry, PsychoPhil I agree with all the others that 15 minutes is absolutely not enough for a Bipolar diagnosis. When I saw my Pdoc for the first time (not Bipolar) it took almost an hour as well. So I definitely understand your doubts and I think they're totally valid. How difficult would it be for you to look for another Pdoc exactly? If you have the option, definitely look for another one. I'm so sorry, I know it's not easy, but if you can, I'd say go for it. Don't give up your search. I hope you'll find the right fit for you. Also, like Miguel'smom adviced, I'd suggest to talk to your therapist about this and see how it goes from there. Maybe that could helpWish you good luck! Let us know how it goes. Sending many hugs to you

In my Abnormal Psychology class it described a psychiatric assessment used for diagnosis. I don't believe that if done thoroughly, it would only take 15 minutes. Also, given the similarities of some symptoms across various disorders, which cause differential diagnoses, I think it crucial for a doctor or psychologist to be especially careful in asking the right questions.

Ideally, a physical exam and blood work should be done before bipolar disorder is diagnosed. Even if a person currently presents as manic to the doctor. Hyperthyroidism, drug/supplements reactions, and even certain physical illnesses could be the cause.

When I was diagnosed bipolar, I did not offer that to tge psychiatrist as a possibility. At the time, I didn't even know what bipolar disorder was. I knew I had had intermittent depressions and anxiety throughout my life, and had some stories of frantic "breakdowns", but I had little insight into the more typical hypomanias and manias. I recognized periods in my life had ramifications, but that's it.

I really think it took at least the equivalent of hours to get my bipolar diagnosis. Maybe that psychiatrist suspected bipolar disorder at first, but didn't officially diagnose me with it until he saw me hypomanic with his own eyes.

During my first hospitalization, the hospital psychiatrist gave me a small physical, did the blood tests, called the psychiatrist I mentioned above, and witnessed me in a manic episode with mixed features. I had told him about my diagnosis in our first meeting.

[cashart10]

It was a little different for me because I was a teen so it took more than a year for the diagnosis. However, every single pdoc I’ve ever seen has always had an hour long intake.

[sophiebunny]

A way to think of this is how many minutes should it take your primary care physician to diagnose you.

I've written extensively about the psychiatrist -patient relationship. I had a book recently released by Trigger Press and I've written two blogs on the subject for PsychCentral. If you are interested, search for my blogs.

Tova Feinman

[wiretwister]

well mine met me on ip intake ... to be truthful I do not remember how long ... as I was not talking ... probabily not very long ... been six years and in that first meeting he nailed it ... maybe how severe you were while they first met you may play a large part in getting it right ... not sure ...

I hope you find peace ... it's your quality of life not your dx that matters ...

Tigger .

[PsychoPhil]

Originally Posted by AspiringAuthor

I do not see how the PDoc and Psychologist arrived at the same conclusion: the Psychologist dx'd with autism and the pdoc with an Axis II personality disorder / traits. There might be observational equivalence between compulsive and avoidant traits and high-functioning ASD presentation, but that is where repeated observations and history taking would come in handy, but how would you pursue them in the state mental health system?

The PDoc specializes in personality disorders, mainly BPD, and so he diagnoses personality disorders. Mental health is the only field I know of where practitioners might scrape by on this approach. Imagine an internist diagnosing only stomach issues when patients might just as well be suffering from pancreatitis and recommending treatment only if there is imminent danger of death.

Still, out of personality disorders he picked the one closest to ASD in under 15 minutes, for which he deserves some credit. Not that I'd recommend or would want to see him again.

[PsychoPhil]

Originally Posted by AspiringAuthor

All in all, it seems that the core of the issue is that your family physician is dismissive. With a more attentive, caring and, I 'd add, 'worrying', family physician, you'd fare better.

It is also not clear where the initial idea of medication came from. You wrote that a stimulant for better focus (ADHD?) and lessened social anxiety might as a side effect cause a manic episode. You also wrote that the family doc sided with the pdoc who said no meds needed. If that is the case, who is the proponent of the idea of stimulants or antidepressants?

I tend to upset people without noticing, so the communication disaster may be partly my fault. Unfortunately I cannot change family doctors just like that. She said she wanted to refer me to another PDoc, let's wait and see.

In the autism assessment I mentioned sleep and concentration issues as well as social problems at work. Therefore the psychologist's suggestion for ADHD medication.

The initial idea of medication was actually my family doctor's a good year ago. She suggested an anti-depressant, which I declined for fear of adverse effects. I tried fluoxetine some 15 years ago and felt unstable on it. Sometimes I had tremors or psychomotor agitation, at other times I was too high, and I also experienced minor visual hallucinations.

I'm btw not convinced I am bipolar. I'm just afraid I might be and that stimulants and anti-depressants could trigger mania.

Just before the possibly manic episode, many years ago, I was in an elevated mood, and it struck me that I later didn't recognise some people I had met and talked to. During a party with speedy electronic music I had had a smoke and absolutely no recollection of what happened shortly afterwards. I should add I consumed no drugs, not even coffee or alcohol, for at least 10 days before the initial phase of elevated mood, and otherwise only shared a smoke every now and then. I had walked from a beach into a club and started dancing. Next thing I remember I was still dancing, no idea for how long, and that I was hallucinating. I felt terrible, went back to my place, and eventually was able to sleep. Next day I was still not myself; a crack in a toilet door turned to eyes and then into a face that jumped into me, and similar fun. Hallucinations stopped after another day or two, but a month later at a student club I was again in a very high mood, so energetic that complete strangers were startled by my behaviour. This was only really over after about 6 months.

I've had various depressive episodes, some of them with delusions on appearance, see other threads on BDD. I've also had crazy **** episodes, like buying a racer motorcycle in a snap decision and then ride 6000km in a week. At work I had a period where I worked until very late, once until sunrise, with overall poor judgement and results. I also earned a terrible reputation for my attitude, which I think is mainly due to irritability and autism related communication shortcomings. Just last year an episode with sleep issues, where I was awake around 3am with partly paranoid thoughts and then irrational decisions.

Whatever I'm really having, I would much prefer not to experience what I described as possibly manic again. A more stable and less irritable mood would likely benefit me at work, and I suggested to my family doctor that a mood stabilizer might be a more suitable treatment for me.

Again, opinions welcome.

My mom has instable moods with unpredictable rage, her sister is also known for erratic behaviour, and her brother had periods of depression with binge drinking until advanced age. See other threads, my brother's suicide was triggered by one of my mom's shouting fits, and my afore mentioned aunt also had a son who died under unclear circumstances, quite possibly suicide as well. So it's not like mood disorders are unusual in my family.

[sarahsweets]

Originally Posted by PsychoPhil

I'm btw not convinced I am bipolar. I'm just afraid I might be and that stimulants and anti-depressants could trigger mania.

I can only share my experience but I am BPII along with ADHD, GAD, PTSD and probably something else mixed in there. I have been treated for all of that for nearly 18 years with the same doctor. What I can tell you based on experience and what my doctor has told me (i do not have science sources for this) is that generally, SSRI's arent so good for bipolar. My doctor told me that SNRI's are one of the best for bipolar and also tricyclics. I was put on a combo that includes cymbalta last time in the hospital (15 years ago) and within days I was a new person. it was like the dread and heaviness just lifted. Cymbalta is an SNRI. I also have taken adderall for adhd for about 13 years. In the beginning my doctor had me check in by phone once a week and saw me every month for three months to closely monitor for any sort of mania or psychosis. I think if you are closely monitored by a doctor the possibility of stimulants for a bipolar person exists. I know it isnt this way for everyone but I would say you have a good chance at having it work out. I also know that in extreme treatment resistant depression cases, stimulants have sometimes worked when nothing else has. My doctor made me very aware of potential signs for mania or psychosis and we went really in depth about it so I knew what to look for. She also met with me and my husband so he knew what to look out for. Unfortunately for me, my husband has always spotted the mania before I even see it on the horizon. ("why cant I just be in a good mood-why is always you thinking its mania!?"{those words end up biting me in the *** sometimes})
My point is all is not lost. I really think with careful monitoring you can take medications like stimulants and antidepressants.

[PsychoPhil]

Originally Posted by sarahsweets

Unfortunately for me, my husband has always spotted the mania before I even see it on the horizon. ("why cant I just be in a good mood-why is always you thinking its mania!?"{those words end up biting me in the *** sometimes})
My point is all is not lost. I really think with careful monitoring you can take medications like stimulants and antidepressants.

But isn't it great having someone notice upcoming episodes and watch out? I have no such feedback and it hadn't even occurred to me that others might see mood swings much earlier than me. Thoughts and decisions always seem sensible at the time, I think that's the core of the problem with those episodes.

First and foremost I need something to lift my moods without making me more irritable or unstable. My family doctor cut me off as soon as I asked whether it might make sense for me to try some mood stabilizer, perhaps just at a low dosis. Is that because drugs like Lamictal are inherently dangerous? I don't think it's commonly abused or sold in the streets?

[sophiebunny]

There is a misunderstanding on many of we patients' part about what we should expect from our psychiatrists. Psychiatrists are physicians. They are in this field of medicine to diagnose and treat mental illnesses with medication. Therapists use words to resolve life issues and deal with mental illnesses. Most psychiatrists spend close to an hour with a new patient and ask diagnostic questions. The answers from those questions come from us. We are 50% of the psychiatrist-patient relationship. Some psychiatrists may take several sessions to make a diagnose. Once the psychiatrist uses his knowledge base and expertise to diagnose and prescribe a treatment, based on the information we share, then monitoring occurs. The purpose of monitoring is to determine if a treatment is working or needs to be adjusted. Patient-psychiatrist communication is critical especially for monitoring because time is so short. When a monitoring appointment is typically 15 minutes, walking into our appointments prepared to discuss treatment problems is essential. Writing down our concerns before the appointment is a smart strategy. Psychiatrists are not therapists. We aren't going to spend an hour a week with them exploring whatever issues we want to deal with.

Psychiatrists and therapists should talk on a regular basis so both professionals are on the same treatment page. If there is a conflict in diagnosis, it's the professionals job to resolve. I once had a PhD psychologist insist I had schizophrenia but refuse to talk to my psychiatrist about it. It was a bad misdiagnosis that ended up in my medical record and had to be expunged by my psychiatrist. The insurance company had to be corrected as well. The misdiagnosis did a lot of damage to me. If my PhD psychologist had called my MD and discussed it, the harm never would have happened.

Psychiatrists are also crisis managers for people with severe illnesses. I would never call my psychologist if I'm in a manic-psychotic episode. If I tried, she'd call my MD. Any smart psychologist knows that the intricacies of active psychosis and treatment, for example, is an MD's responsibility. Therapists play an important supporting role, or should.

Psychiatrists and therapists do a duet. Each has a role and those roles should not be confused. We harm ourselves when we mix up the roles.

[AspiringAuthor]

Phil,

I can easily see why you would not want antidepressants or stimulants. Note that mania can come with partial amnesia, so that you have memory lapses from the episodes is not inconsistent with mania, but at the same time if you do not remember at all what was happening, a neurological issue might be at play. Dissociation can create memory lapses as well - it is very complicated. Based on personal and family experience, I am a very strong "minus one" on using tricyclic antidepressants with even a slight possibility of bipolar. Anyway, to sum up, you have such a complex family history that you need the best possible treatment team.

[PsychoPhil]

AspiringAuthor,

I agree I will have had something other than mania during the completely blank period. Just as you say, it's complicated. I would quite probably benefit from psych meds, but shouldn't take any without careful monitoring and assessment. One would think that those were the cases that warranted some psychiatrist's time, but seemingly not in our public health system.

[Goforward]

My initial visit took one hour.

[yellow_fleurs]

Well my initial diagnosis was maybe 30 minutes filling out paperwork and talking with the assistant, 30 minutes with the psychiatrist? He was thorough, but also my symptoms met the criteria for MDD/GAD so I got misdiagnosed. Not his fault based on my symptoms i reported, really. Took another 6 months maybe of trying 2 meds and frequent appointments to figure out I had bipolar, then another 4 months or so before we discussed it seems like I might also have OCD.

[Fuzzybear]

I would say that 15 minutes and a ? Diagnosis ? Likely indicates a sub optimal “p”doc.

I received an adequate service and diagnosis when I paid a shrink for one hour.

[BipolaRNurse]

My initial intake appointment was 90 minutes, and the psychiatrist and I covered a LOT of ground. At the end he diagnosed me with bipolar NOS, which was a provisional diagnosis that basically meant it looked like bipolar, but it didn't fit into any other category. Two and a half years later I was given the bipolar 1 label in the hospital and have been re-diagnosed with it by several more providers. Sometimes it takes months or years to flesh out the picture of a particular patient's illness, which is how it was for me. I'd be highly suspicious of any pdoc who gives a diagnosis in 15 minutes.