Is Bipolar Disorder Sometimes Overdiagnosed?

In my opinion, Bipolar Disorder is sometimes over diagnosed or too quickly diagnosed.  Although there are diagnostic criteria, testing, surveys and questionnaires as well as clinical history from patients and clients, I feel that in the current process of public Psychiatry and individual practice this disorder is all too quick to be given medications and to a person is sometimes too quickly labeled "bipolar".

There is no question that the classical syndrome of bipolar disorder is complex and often requires clinical time, expertise and even trial and error to deal with all that is involved including medication management, therapy and all of the responsible interventions we do in this field.

I am speaking though of various situations and inner symptoms, experiences and  issues which make the diagnosis more difficult and challenging to sometimes define and treat.  There are many personality disorders that can resemble bipolar disorder and also substance drug and alcohol use that can mimic its issues--- particularly if there are periods of withdrawal, sobriety and/or any cycle in between.  Anxiety and ADDHD can also resemble bipolar traits and issues in adulthood and even childhood, along with other diagnoses and so these matters need to carefully be sorted out over some period of time.

Some clients have many stressful and intense adjustment issues in their lives to work, money and relationships.  They can have unresolved past grief, trauma, anger and unresolved feelings to past abuse, misuse, stemming from anything and everything.  There is unresolved issues of parental divorce, discord with relatives and friends and many unresolved therapy issues that can be at hand. Self esteem from any and all levels can be undermined and if there has not been healing in this area it can also manifest as bipolar traits in many ways.  And, many who do come to treatment sometimes want a quick and fast medication relief regimen to issues that require a lifetime of healing through therapy, Self-help, supportive groups, their own research and reading, and Spiritual interventions.  Many issues have not occurred overnight and will not and cannot be healed overnight as well.  And I feel we have stepped away from non-pharmacological interventions or we do not have enough time to understand where someone is in their healing process aside from medications.

In addition, nutritional and lifestyle factors do play a role.  In my opinion, Psychiatry should be at the forefront of these matters in bridging these medical/psychiatric factors with other medical fields, but I feel and find that this is lacking---often for many reasons-including--over-focus on medications, lack of interest and time, need for more education on the part of the clinicians and better reimbursement models and support to execute and practice what the recommendations are for lifestyle change.

So when a patient comes in and says they are irritable, edgy, frustrated; that they have mood swings, ups and downs; that they are labile, quick to react and have anger outbursts and of lack of sleep--when they complain of having pressured and racing thoughts and thus all the "buzz words and check list items" for bipolar---it is all too easy to give this label too quickly.

In this day and age of short medication evaluation and management visits and often stops and starts and various other resistances to individual and group therapy---medications sometimes I feel are given too fast, too many, and too much.  Sometimes a messy soup is created where one does not know fully what one medicine does or not--and often there is higher risk for drug interactions when this is the case.

Mood stabilizing medications in various classes are powerful chemicals that do have long and short term side effects and need to be carefully given/prescribed.  All too often, I see children and adults given anti-psychotic/mood stabilizing medications right away without turning to more traditional medications.  While all medications have their risks and benefits, in my opinion the anti psychotic/mood stabilizing medications have very important and serious issues to contend with and should be used slowly, carefully and with a lot of thought---not just a knee jerk reaction because of what physicians in this are conditioned to think sometimes about starting these medications through various channels.

Yet, in our current rushed, and yes, sometimes haphazard, limited,
and plastic model with little diagnostic and supportive time with people (usually about 20 -30 minutes initially and 15 minutes or less for followups---unless there are other arrangements made)---We have to be careful and considerate in separating out what is actually Bipolar Disorder and what are other factors contributing to the complex areas of mood, anxiety, psychosis and other symptom categories.

DR. R

Psychiatry in a new Paradigm has the Opportunity to Focus on Wellness rather than Illness DR. Rama

11/16/13

Psychiatry has made many important advances over this past century in the treatment and diagnoses of psychiatric disorders.  And, I feel that these discoveries will only increase and unfold over time on all levels. 

Yet I wonder if the field of Psychiatry has gone to an extreme of sorts.

There is so much focus on symptoms, illness and disease, have we forgotten about psychiatric wellness and prevention?

Psychiatry I feel needs to move to the forefront of wellness and prevention but instead I feel lags behind in its focus and mission.

Other fields like Internal Medicine, Family Practice and overall Primary Care are at least stepping into the paradigm of prevention, wellness and Integrative Medicine and I feel it is important that Psychiatry even take a lead role.

Fifty percent or more visits to Family Medicine and Primary care have their origin in depression, addictions, and anxiety--- and related issues and these issues can be both covert and above board---- disguised behind medical problems.

In our current system, many receive medications but very little else---in primary care--after checklists of symptoms reveal mood and anxiety. Patients are often given medicines that are being shown to be about 50/60 percent effective and that too useful if they do not have side effects that are not often well tolerated for the long haul.

And, by the time patients and clients come to Psychiatry for treatment (if at all), they have often been through many trials and tribulations of various treatments and medications.

Individual and group therapy abounds but the question is whether people are regularly using these services or whether visits are hit and miss, brief or interrupted for a variety of reasons. 

In my experience there are many internal and external blocks to regular one one one and group therapy and it is often not clear what the ef fectiveness is with therapy in its present states.

Mainly I have found finances, logistical headaches with insurance coverage, transportation to and from the office, severe anger, resentment and disdain from patients at resultant "NO-Show" fees if they do not come to a scheduled therapy appointment,---in general---  resistance to treatment for various reasons all play a key role.

And, over the years I have found that no one component of anything is enough for one's journey in health and healing.

Psychiatry maintains the need for medication management and therapy as the cornerstone of treatment. There are other modalities but they is not as much focus on other methods in a typical psychiatric practice or treatment setting.  But what does "going to therapy"--really mean?   A few visits?  Lifelong interventions?-- Six months, 7  months and so on? Group interventions in an inpatient setting which are often superficial, outdated and cursory at best, unless much time energy and thought is placed into them by the therapist, institution and so on.   Issues then continue to abound things get complex and so the therapist or client sometimes just wind down and say things are better or even sometimes worse?  And what is really gained from therapy in these once or twice hourly sessions --or even 4/5 times per week in classical psychoanalysis?

All of these questions are of course up to the individual--as there is no one prescription, method or journey.  Progress in therapy, medications and recovery is subjective on all levels but sometimes objective as well.

Psychiatry in my opinion is over-focused on medication management.  There are general principles in Psychiatry and a limited range of medicines for various Psych categories that have varying percents of effectiveness.  There is no way to predict individual effectiveness despite studies because in Psychiatry no one medication or combination has the identical effect for another based on multiple genetic, personality, and other biological factors. Insurance companies although they have recently changed coding and billing ---still dictate what happens with time and reimbursement in offices that take insurance.  And, with ever increasing pressures on Doctors and Nurse Practitioners to see high volumes of patients just to keep their doors open---brief med medication still abounds (15 min. or less) ---and this leaves little room to think and practice "outside of the box...."

While medications discovered and applied in Psychiatry have dramatically helped there are still many loopholes including complicated subtle and overt side effects, long term effectiveness, compliance with treatment, wear off and withdrawal issues to name a few.

And there is a limited armementarium of conventional medications for various problems that are circulated over and over again.  In my opinion the poorest options are for sleep and for anxiety---these I feel are the MOST problematic in Psychiatry (except for psychosis)--- and have the least options and the most unclear long term treatment outcomes.

Often people get benefit against a smoldering backdrop of overt and background subtle side effects that they have to bear just to keep functioning---often cognitive slowing and related symptoms, sexual side effects of all kinds and of course dreaded muscle movement problems with anti psychotics that people are at risk for for the long term.  Metabolic syndrome with weight gain, obesity, elevated glucose, lipids and other factors are rampant with anti psychotic/anti manic medications and drug companies have spent and earned billions promoting their medications that have these common ongoing risks.

The key in my opinion is that we have to expand consciousness and creativity in Psychiatry.

We have to encourage new models that are funded by patients, grants and private support that foster Psychiatric Wellness.

This means addressing everything conventionally but stepping above and beyond the disease and treatment symptom model.  It means managing and raising dollars to create positive self and pre-paid groups to address Self esteem, positive thinking and coaching, lifestyle choices and behaviors, dealing with underlying emotions and issues that fuel current patterns of living-----practice of Yoga and other Spiritual methods of any kind---all to name a few.---all outside the usual loopholes of third party payers ---that often ultimately undermine and block various creative treatment potentials.

In the new model clients and patients have to take financial responsibility to create these centers of Psychiatric well-being and realize that the days of third party payors is archaic and cannot be completely depended upon..

New models with new ideas and deeper interventions and treatments require dollars like anything else and Psychiatry is no exception to this.

The new model needs to be holistic to incorporate the vast storehouse of untapped knowledge and principles of prevention and treatment according to Chinese Medicine, Ayurveda Medicine and Naturopathic Medicine.  And, it needs to incorporate treatments that involve the creative arts in the healing process.

We have to completely transform thinking to help clients, and all involved that Psychiatric symptoms and issues are not just  a checklist of symptoms and then a squelching of symptoms through medications or a rambling journey through choppy and inconsistent therapy that has many stops and starts---mostly stops in my experience.

There are many clues in integrative and holistic medicine that psychiatric issues are the result of intense difficult lifestyles that involve severe stress and other negative emotions, the direct result of diet and nutritional issues, unresolved trauma and pain, lack of family, social and cultural connections, divorcing from one's creative hobbies and interests, and many other angles including lack of social skills, inability to empathize with others and so on.

The new model needs to have on site abilities and services for people to go to practice various methods of healing for themselves and have a venue of respite through various programs designed for ongoing practice and support in addition to the usual physician and therapy visits.  They need to be teaching centers on diet and nutrition and exercise

and be facilities where people can actually learn and practice how to actually change their negative and challenging personal habits that have been entrenched over time.

The new models above all need to focus on strengths, positive abilities, hopes dreams, aspirations and wishes and do anything and everything that focuses on reaching one's highest potential.

Psychiatric illness can then transform into Psychiatric wellness over time.

Dr. Rama  

New Website: www.drramamdessenceofenlightenment.com

I have a new website: www.drramamdessenceofenlightenment.com which contains all my blogs in one website a simple and unique meditation room and I will add many things in the weeks, months and years to come.  Hope it is inspirational to all.

Thanks--Hope all tuned in check in !  thanks

Dr. R

11/8/13--WIth the World Waking up to Holistic Health and Enlightenment--Is it Translating into Clinical Environments? Dr. Rama

My entire life has been guided and molded by many great and wonderful blessings, insights, teachings, guidance, sacredness, education, thoughts, mentoring on all levels---- so that I would have the best chance at sharing my abilities to help patients, clients, and those I come across in my day to day. 

Hope that I do share in the right way at least part of the time !  :) :)

I just got back from great review course in integrative and holistic medicine, with many great speakers and very inspiring colleagues and it was great to reflect on every possible angle of holistic health, medicine, healing and Spirituality during this time.

The challenge which I have felt over many years lies is in how to create, implement, and incorporate all of the new findings, recommendations, teachings, and practices into a clinic, spa, ashram, center, or any locus of healing.

There is much out there to help people deal with the entire spectrum of holistic but how to make it practical, accessible, yes even affordable remains the challenge.

This challenge and task is to provide the right guidance, suggestions, interventions, therapies, protocols, prescriptions, advice, experience, wisdom, diagnoses, and holistic treatments that are both intuitive but also evidence based and have all these interventions in whatever form have a lasting impact on the patient and client's life and world.

This calls for a new model that could include the following.

1. Holistic practitioners who individually initially interview and review with patients and clients their central issues, difficulties and diagnostic problems---who then review these with physicians to bring out the best treatment suggestions based in evidence based medicine ---conventional and complimentary while not ignoring the spiritual and intuitive side of healing that often does not fit into a test tube  :)

2. One on one time with a physician  who offers their best experience in dealing with many complexities of clients' needs---one heart at a time.  There are not generalities or cookie cutter tables for such care.  One has to to go in the moment and work on a consistent basis for transformation and change at all levels.

3.  A sacred space and facility with mentoring so that people come to practice what they learn and receive as prescriptions.  Let's face it, giving out lists to people often does not work; one has to work through many layers and levels of issues to remain consistent with any modality of treatment or intervention, just like playing a piano....it takes practice and an environment that fosters this practice.  On one's own alone does not work, otherwise our world would be in a very different state of health!

4.  Constant opportunities for healing endeavors and modalities that offer a wide variety of supports for people even after they have active visits one on one with clinicians and practitioners. --an entire clearing house and array of services for every type of problem and issue.

5. In reality, a mini village of all transformational protocols, procedures, paths and methods that allow people to pick and chose their way of healing based on their needs interests and affinities for what works best for them---

6.  Spiritual transformational work as a whole to awaken dormant inner faculties including the light body and kundalini that would reconnect body and mind with the cosmic Heart, and this in itself would create a core transformation from deep inside Soul into the physical and thus the external world-----

I have only scratched the surface---in this blog------but these kinds of ideas brought into manifestation are paramount if we are to foster transformational healing in any real and practical basis---for a new paradigm of health in the 21st century

Dr. Rama

Dr. Rama's Feelings and Issues of Psychiatric and Medical Treatments Over the Years part 1--Anxiety Treatment In Psychiatry is Challenging and Limited--Dr. Rama

10/17/2013


This is a new series I would like to write about many nuances, issues, thoughts, opinions, feelings, suggestions and future vision of Health, Healing, Enlightenment, and Medicine.  I am starting with a series of treatments for various psychiatric medications and what I have learned and experienced over much time in practicing in this field.

Let it be first and foremost said that I advocate the middle path in treatment and I do not go to extremes in any case.

Conventional medicines of course I feel have their pluses and minuses--

In this blog post I am only rendering my opinions, thoughts, views, expressions, examples, insight and experiences over many years.

I am well aware it is always a blend of risks and benefits to patients with medications and various studies show mixed results, hopefully more positive with each med that is on the market.

However I would like to share what my feelings and thoughts are based on many years of treating patients in many settings and levels.

I am starting with anxiety treatment---


Anxiety in my opinion is one of the most challenging problem that faces physicians and health providers.  Psychiatry has had some breakthroughs but I find it the hardest to treat with conventional medicines

Benzodiazepines like valium, klonazepam and alprazolam, have their place and some people need short, medium and long term treatment.  Yet, I often find them difficult and problematic.  Often there is sedation, heaviness, sluggishness and fatigue (despite small doses) wear off and tolerance, cognitive confusion and memory changes.  Dependency on higher and higher doses do occur and when people try to stop or reduce benzodiazepines they have to go through slow tapers to avoid severe withdrawal side effects.  Also the problem is that there are ceilings of doses that most physicians do not step out of.  So then one is stuck with the situation where wear off has occurred and the person still has marked anxiety.

The other two knee-jerk, fairly vague and uncertain treatments in my opinion are to give hydroxyzine--an archaic antihistamine and Buspirone which is an anxiety medicine that acts on certain receptors in the brain to help with anxiety.

Hydroxyzine often does not work in my experience, is often a very temporary fix at best and causes dry mouth, dizziness fatigue sedation and confusion

Buspirone sometimes works for people but causes dizziness, foggy feelings, dry mouth and again some cogntive changes.

In medicine today it is quite cookbook and there are often a certain pattern in prescribing.  MD's go up the ladder to try various medications.

So sometimes the above medications are tried but sometimes antidepressants are initially used along with a benzodiazepine.

In my experience 50-70  percent give or take of patients do well on antidepressants to treat anxiety but more do better with combined benzos.  Sometimes all four medications are given--

The problem is is that it is easy to say that antidepressants like paroxetine, fluoxetine, sertraline, escitalpram, citalopram, and other related medications in the SSRI's family as well as venlafaxine, desvenlafaxine, and duloxetine SNRI medications work---..............

Yet in my experience many cannot tolerate these medications.  The main side effect?  Sexual of course!!--including a few other major side effects

We are in a society in a dilemma of sacrificing sex and sexuality or feeling better with these types of meds....

I often cross my fingers and hope that one or a combination of meds will help, but often I deal with highly variable with results.

Then when they do work, many people have the problem of battling with the decision to have long term maintenance therapy versus times when they taper off and see how they do.

Patients often tell me they often have to tolerate subtle background side effects because many tell me that they would rather feel better with meds than to give them entirely for the issue of experiencing on grade low dose toxicity or side effects.

Many people struggle with this issue of long term medication use;the usual answer given to patients is that people with diabetes, high blood pressure and so on have to take meds for the long term and it is the same with anxiety and depression---

And when people come down from antidepressants and anxiety medicines, whether they are controlled substances or not, many, many people have severe withdrawal effects.

In my opinion, the SSRI and SNRI side effects can be equally as difficult as the benzodiazepene withdrawal issues.

So there is often a merry go round circus of deciding if people's depression is due to relapse of  depression or whether it is the difficult symptoms of withdrawal when medications are lowered that people experience difficult symptoms---that is often a dilemna and often a question.  Sometimes it is one, neither or both......

I have found over many years that therapy interventions like psychotherapy, cognitive therapy, group support therapy are very hit and miss. 

Patients often say they "cannot afford therapy, the therapist is out of town, the patient is going on vacation or is too busy at home and work for therapy, there is no therapist available on their network, that they do not want to pay for Self therapy-or they say that they saw a therapist once or a few weeks or months ago but have not followed up--"---Self-help is also hard to gage---and patients and clinics including primary care tend to focus heavily on medications. Most of the time there is very LITTLE communication between therapist, MD and patient.  And also many psychiatrists find it hard to handle therapy issues when they are pressed to sometimes see anywhere from 15-40 people per day to keep up with their office costs and so on, as managed care is still volume driven with small amounts of time spent with patients.

This is changing somewhat---with a little more reimbursements for MD level extended med checks and therapy ---and with Obama care it remains to be seen if this can be improved or not.


Yet with all this, anxiety is one of the most common problem in the entire world.

I think there is a better model for all this ( I have a few ideas of course-----:) :) :) ) and I think that more and more natural treatments will continue to evolve and expand --- I think that natural interventions including natural plant and herbal extracts, the emphasis on gentle Yoga type practices, protocols from natural Western Medicine and ancient Eastern Medicine and other natural interventions need to be made more available and affordable.  Places where people can practice and reinforce these interventions is what is needed

Mastering anxiety is genetic but also under one's ability to improve, grow, change and transform.

I think what the main problem is is that conventional medicines go only so far and we are society that still depends on quick fixes.  It is up to the individual to take action and help as they feel ready and motivated. 

Centers now and in the near future I feel will provide atmospheres of growth and change and provide ongoing support for people to maintain changes in attitudes, behaviors, feelings, emotions, choices, thoughts along with both conventional and direct natural treatments

Dr. Rama

Hard to Maintain the Positive When We Are Bombarded by the Negative--Dr. Rama

It is hard to maintain positive thinking and positive energy when we are inundated by negative media and shows on a daily basis.

Think about it folks it is like we are living in a modern primitive society.

Almost every city wakes up to the same media style where fires, murders, robberies, disasters, car accidents, rapes, and so on are at the top of the news.  We wake up to this and are then flooded all day by cable shows and so on that reflect negativity.

Have you also noticed how much is dominated by frivolous news about those beings in the entertainment and sports world ---constantly through reality shows and so on?  In a way such items mask what is really happening in the world...and keeps us from remembering positive everyday stories that can touch our minds and hearts in profound ways.

It is not to say that we should not hear about these events and issues or that we should not empathize with those who are victims.

But must this be the focus of the day where every angle of misery, gossip and so on that is sent through the media to the entire globe?

What are the titles of some prime time shows?  "Deception, Scandal"  etc.  all negative states of lower consciousness, lower Self energies that keep us hypnotized and chloroformed into dark thinking and lifestyles.

How many movies and TV shows are filled with unbelievable violence and we are flooding our minds and hearts with these images and impressions?  Where can an enlightenment dawn inside us with these kinds of energies constantly reaching our brain?

We need to lead with positive news and shows about what is happening in the world in inspiring, uplifting, educational and positive direction that stress inspiration, creativity, and above all hope, trust, and security, not energy based in fear....I feel first.  This should be the dominant force in today's media and shows.  We need to hear triumphs and not mainly tragedies.

As a planet we cannot evolve unless we take a higher consciousness and practice its presence within our being.

And it begins by what we let into our minds and hearts on a daily basis.

We can choose to watch or not watch but we can also voice our view on what media emphasizes and what is coming through our airwaves as well.

Dr. R