Episode 8 – What Is Misdiagnosis?

The podcast and articles by Dr. Bhatt are intended to be strictly informative, and will not provide any diagnosis, treatment recommendation, or directed medical advice. Unfortunately, not all messages can be addressed, and no message is guaranteed a response. Information provided by Dr. Bhatt in articles and podcasts is intended to address common questions of general applicability, and may not apply to your unique situation. As a result, please do not use the advice or conclusions found in any articles and podcasts on this site as a substitute for professional personal medical advice. If you are looking for treatment, please call.

Transcript

Hayley: Hello, everyone. You’re listening to Straight Talk With The Doc, a podcast that talks about addiction, mental health, and treatment. My name is Hayley and I’m joined by our content director, Jeff and our medical director Dr. Bhatt, how are you guys doing today?

Dr. Bhatt: I’m great. Hayley, how are you? How are you and Jeff doing?

Jeff: I’m doing well Dr. Bhatt, it’s a good day, certainly a good day today.

Hayley: Great. So, Dr. Bhatt, as an addiction medicine specialist, you’ve encountered people coming to you who have been misdiagnosed, and unfortunately it is something that happens sometimes. This can have a huge impact on the rest of someone’s life, if they don’t receive the right diagnosis and treatment for their mental health disorder. So today I wanted to talk about that, and I wanted to start by asking you why does misdiagnosis happen?

Dr. Bhatt: That’s a good question because when we’re speaking about mental health disorders and addiction issues, I think the biggest problem that occurs is that often one can mimic another. And so if you look at substances of abuse, when somebody is using, for example, something that could make you sedated or depressed, often times that obviously can mimic a primary psychiatric condition, like a major depressive disorder. Similarly, if you’re using a drug that is something that can speed you up or stimulate you, that can make a mimic other mental health conditions, like anxiety conditions or bipolar disorder. I think what happens is due to the nature of substance use and mental health conditions going together often times it is not seen clearly by the practitioner because the symptoms can mimic one another, and they’re often used together. It takes a very sophisticated diagnosis and time with the patient to really separate the times where symptoms have occurred while using and while not. And I often think that based on the way healthcare goes nowadays, it often is not occurring in that manner.

Hayley: Give an example of a certain drug that would mimic say, depression. Also, I’m wondering do people go in and try to get a diagnosis, but they’re not completely honest about substances that they may be taking?

Dr. Bhatt: Yeah, that’s a two part question. So I’ll go with the first part; there are many drugs that can mimic primary psychiatric conditions and let’s just use, for example, cocaine. Cocaine is a stimulant drug, and it causes symptoms where people can have increased energy. They can feel very good. They can often become paranoid, they can start to behave irritable or reckless. And if you look at those cluster of symptoms, it can often mimic somebody who might have a primary psychiatric condition called bipolar disorder, where if they’re in their manic phase, they can be again, irritable, euphoric, very happy, very overly energized, talking very quickly, but at the same time, in certain parts of mania, it can even get to the spectrum of psychosis where they become paranoid. And we can really look like somebody who’s using a stimulant like cocaine or even an amphetamine product.

So that’s an example where it could be hard to distinguish the two, if one is coming into an emergency room, for example, and they’re high on that stimulant product. And a doctor is just looking for a real quick answer. A patient could not be as forthcoming because they’re not in the right state of mind. And they could even come in with a previous misdiagnosis that gets repeated just due to the complexity of teasing that out on the time that it takes to figure it out. This can happen often. And then the second part of your question, what was the second part?

Hayley: That people might not be completely forthcoming, they’re seeking a diagnosis for a mental health disorder, but they’re also abusing drugs or alcohol. Are people sometimes not completely as blunt as they should be?

Dr. Bhatt: Yeah, that’s definitely happened. That happens a lot in substance use because in general, substance use disorders, people have a lot of denial. They have a lot of denial about what they’re doing and how they’re using it. So they often minimize. Either due to shame or guilt, embarrassment or whatever, just even perceived by society, something somebody’s doing wrong. It’s hard to divulge that, Hey, I’m using an illegal product or I’m doing something that is so frowned upon. And so yes, they do withhold a lot of the specifics and that is why often it would push somebody else to go away from a substance use disorder, more to a primary mental health diagnosis.

Jeff: I was just going to add that, I don’t know your thoughts on this Dr. Bhatt, but I had been told by several therapists and treatment center type things, they will not actually even diagnose someone conclusively with a mental health disorder until they have been sober for six to 12 months, simply because the effects of so many substances so closely mirror that of mental health conditions, that it’s pretty hard to get an accurate diagnosis as to whether like they’re actually experiencing this mental condition, or if they’re just somehow going through either use of the drug or withdrawal or post withdrawal syndrome.

Dr. Bhatt: Yeah. You asked a good question. And I think that there is some variability in how people approach that. So, if we just look at it from the diagnosis statistical manual for diagnosing psychiatric and substance use conditions, the DSM 5, you should not have a primary mental health diagnosis if you think or suspect that the symptoms could be caused by a substance, either through its intoxication or through its withdrawal. And you kind of think that it could extend 30 days in a direction even when somebody stopped. Six months to 12 months might be a little farfetched because it could be very difficult to track that individual, follow that individual, or even be in a therapeutic alliance relationship with that person. But if you took the time and the person is clear enough, ask them in a chronological fashion to try and elicit symptoms that did occur while they were intoxicated or going through withdrawal.

And if that person is capable, they can provide those. But yeah, usually we don’t try to make a specific diagnosis right away if we feel the person’s symptoms are secondary to the substance of abuse or coming off withdrawal. And we try to let that provisional stage of diagnosis extend through about 30 days. I also think that if somebody is not intoxicated and depending on their degree of impairment and effect, many patients are able to, through the right guidance, through the right questioning, tease out how they feel. And remember a lot of these times these are working diagnosis. If you stipulate that, if you don’t make the person believe or hold on to that and, and let them know, look, we are figuring this out. It happens in medicine all the time. Sometimes we have to further investigate as the disease or the course of any symptoms evolve.

We try and give a rule-out, we try and entertain a spectrum of diagnosis to not label somebody inaccurately. Unfortunately, though, that can happen when people are just jumping. So, it’s better to rule out anything that could be secondary to a medical condition, secondary to a substance of abuse before making that primary mental disorder, but necessarily waiting six to 12 months, it seems a little long. I think people can be in a state where they can provide symptoms if asked correctly in a shorter amount of than that.

Hayley: Right. Especially because people may be self-medicating, struggling with depression and drinking a lot of alcohol to try and make themselves feel better. In reality, it’s probably only gonna make them feel worse, but they might have a harder time stopping, compared to somebody who doesn’t have depression. Can you talk a little bit about that? Like the self-medication?

Dr. Bhatt: Sure. I think many people when we suffer with addiction, we’re dealing with negative feelings we’re dealing with stressful situations, not just because of why we start using a drug or alcohol in the first place, but often secondary to the consequences that are created from the substance use, right? So when you think about it, you might’ve started using to pursue some sort of pleasure, some sort of happy feeling or recreational use, as that starts to become detrimental as that starts to gain momentum and you start using in excess most of the time, these do have negative consequences that you have to live with. We didn’t want to drink or use drugs to escape those things. So right there many people have a perpetual, an additional reason to keep escaping from dealing with what’s happening in real life.

If you complicate this with other primary mental health conditions prior to even starting using, once you do use, if you end up mitigating your depression somehow by using a substance that takes away those symptoms. Yeah. That can reinforce us using again, because many people who use, for example, cocaine, they often either are pursuing a high that they’re getting when they’re manic and they’d like to replicate it, or they’re often trying to escape from maybe a depressive disorder that they might have in that cocaine brings them up to maybe a normal level. Other reasons for example, somebody who might be anxious and ends up having a drink or two and starts to feel that calming effect of alcohol, that can end up creating this negative relationship with alcohol, where you end up using to take away those uncomfortable feelings. So, it was really this mismatch that occurs, or maybe they look at it as a match that occurs where the right drug at the right time. Unfortunately, you can further reinforce somebody to use and yes, self-medicating to take away negative feelings.

Jeff: So I know that you’ve mentioned several different examples, but are there any particularly common examples that you can give of a mental health disorder that is often misdiagnosed, as a result of substance abuse or vice-versa?

Dr. Bhatt: Well, when you look at the more common mental health conditions, like people seek help for depression or anxiety, many people might be labeled that while under the scope of a substance use issue. I know I’m repeating myself somewhat, it takes a sophisticated trained individual to ask the proper questions and put them in the right context in order for us to make an accurate diagnosis. But depression, anxiety being that they’re more common also are more commonly diagnosed in the scope of addiction and substance use, they could be missed miss attributed to the side effects or the symptoms created by the substance. So those two in itself, depression and anxiety are often given very quickly. That’s not saying that they might not have an accurate one, but often depending on where the person is being evaluated, often that’s a quick diagnosis to give, but then there’s conditions like bipolar disorder. Bipolar disorder is a disorder where you have periods of sustained elevated mood and periods where you can have depressive symptoms.

Now they call it bipolar because of that difference in polls of the higher end mania and the lower feelings of depression. And that often is mimicked when you’re using substances, the minute you’re using something that lifts your mood and makes you act erratically or with a lot of irritability, and it’s sustained with grandiosity and you jump from one task to another, that happens when people are using. And then when the drug is removed, they can drop down and be in a state of depression and dysphoria. And that can look like bipolar disorder. And that often is a diagnosis I believe that’s really inaccurately diagnosed and often, quickly put down on paper or an electronic health record, prematurely.

And I’m not saying that people who get diagnosed with bipolar disorder and who are using are all getting an inaccurate diagnosis. No, I’m just saying that it can’t happen because they can look alike. Also ADHD, when somebody is using drugs and alcohol, they have a lot of attentional issues and they can, because of the withdrawal, become very restless and very fidgety. A lot of times, even though ADHD is classically a condition that starts in childhood, a lot of times we see people who maybe are not suffering from a true ADHD diagnosis, get falsely diagnosed with that. There is a list that I think we can exhaust here while we’re online. But this is just a few examples that we have to be cautious, that the clinician has to be prudent to make sure that we are aware of what symptoms can be produced by substances. And are we really putting them in the right context and not prematurely or falsely attributing that to a primary mental health diagnosis. Even though oftentimes they are co-occurring with people who suffer from a substance use disorder.

Hayley: I wanted to ask because you brought up for example, bipolar disorder, how does that affect somebody in the long-term if they receive a misdiagnosis of bipolar disorder, when they’re younger, how is that going to impact the rest of their life? Emotionally, and as well as with medication?

Dr. Bhatt: That becomes very complicated because even though medicine has so much advancement, and especially when it comes to more tangible medical conditions where you can see on an x-ray or look at blood work, mental health conditions unfortunately don’t have that level of concrete diagnostics yet. Although there are many advancements of the way we understand mental health and addictive disorders. And the reason I prefaced this is that a lot of times when people get first exposed to psychiatric practitioners or the need to be psychiatrically evaluated is often when they’re in a state of despair or they’re in a state of symptoms, which makes somebody or themselves seek out help. So if this is during the time that they’re intoxicated or they’re high on a substance, for example, that leads them to go to the emergency room or leads them to seek quick psychiatric evaluation.

It can be difficult because the person can be impaired still under the influence of drugs and alcohol, still have the residual effects of being on a substance. And it might be hard for them to even articulate or for themselves to distinguish that. So, when they’re labeled incorrectly, they’re exposed to not only the stigma of a mental health condition, they themselves now think that’s what they have. They’re taking medications that often may not work because they’re being given for a disorder that they don’t have. And unfortunately, this can lead to a pattern of frustration, lack of remission of symptoms, and it can lead to failure of dressing the primary underlying condition that could be this substance of abuse, or even the lack of effectiveness of the medication in the event that it is co-occurring with the substance that’s happening, when you’re using at the same time, your medications aren’t going to be effective. So, it can lead to a pattern of despair, frustration, just negative consequences from acting out on your substance use disorder or not having the primary mental health condition truthfully addressed. Until it actually gets teased out somewhere along the line, it could take years, until they meet a proper practitioner or they’re in the right situation where somebody untangles all of them.

Hayley: That kind of brings me to the second part of this, how does somebody get the right diagnosis if they’re listening to this? And they’re thinking, I’m not sure if I really have this, how do they seek that out? Where do they go?

Dr. Bhatt: If a patient or somebody listening to this, they really should go to a proper addiction professional or a psychiatric professional that deals with mental health conditions and substance use disorders. A lot of times when we are suffering from addiction, we end up not really following a primary mental health provider, either a therapist or a medical doctor, physician, who has the expertise in this. Not to say that adequate mental health care can’t happen with your primary care physician. But if I’m diagnosed with cancer, hopefully I am going to go to an oncologist. If I have an eye illness, I hopefully will go through an eye specialist, ophthalmologist, similarly, finding a professional that specializes in those conditions versus going to the ER for example.

I’m not holding it against anybody, this is something that, unfortunately, when we’re suffering with something that affects our mind, we’re not thinking correctly, we’re not looking out for our best interests. We only might seek out help when we’re in difficult situations when they’re in their extreme. And it doesn’t just happen in addiction. We see that often in many other chronic illnesses where people only seek help when they get so bad that it ends them up in the emergency room. It’s about really managing that. With addiction, the difficult part is it alters the way we think, that separates it from many other disorders in the fact that the way we behave in the way we think is secondary to something that’s affecting our mind. And unfortunately, that doesn’t often lead us to seek the specialist that we need or often puts us in circumstances where we only receive care when it’s an emergency. It’s really looking out and trying and connect with the trained professionals to help.

Hayley: Is there anything a patient can do to help their clinician make a more accurate diagnosis?

Dr. Bhatt: If there’s a period of lucidity and queerness to really write down what you feel. It applies to seeking out healthcare anywhere. Oftentimes we get to the doctor, or the therapist or clinician, whoever, and we forget what was happening. And often just because there’s this white coat syndrome, there’s this barrier to really disclosing so many different things. It’s best to remember, write it down, keep track of things and help the practitioner out by having something there, which you can refer back to because oftentimes it gets a little stressful and we can’t really relieve. And we’re like, Oh my God, I didn’t say this. I should have told them this. So keeping track, journaling and writing down: when do the symptoms occur? What are some of the things that trigger the symptoms? What are some of the things that make the symptoms better? What are they associated with? There’s so many different variables that you can look at, but keeping track of those measurements, those metrics as it relates to one’s symptoms. And in what context, either while abusing or while not, can help a clinician tease out the diagnosis.

Hayley: Is there a certain amount of time that you think somebody should write all of this down for, would it be a few weeks, a few months, before they take this to a specialist?

Dr. Bhatt: That’s hard to say, I guess the longer the better, but hopefully somebody is not waiting so long that they’re not getting the help that they need. That’s an individualized question, case-by-case basis based on the person. If you’re suffering with something, try and keep track of why you’re seeking the help in the first place. And again, it’s not easy often when our mind is hijacked by an illicit substance or alcohol but keeping as long of a track I think would be very useful, especially when we’re trying to look at and diagnose a disease by your chronological history. And also the presentation when you get to the doctor, the doctor’s going to be asking you questions about what’s going on now, and what’s happened in the past as it relates to your symptoms and other parts of your health.

It’s important. And I should include this, is listing the medications that you take, listing the other medical conditions that you may have, talking about if you use any caffeinated products, or tobacco products. You have to be willing to disclose not just parts of your life, because I think what happens is this selective disclosure that takes place. Doctors are human, so they can’t always grasp everything on the first time. It’s important that the patient does their best, to be honest and keep track as long as possible of their symptoms. And also be prepared to talk about any other medical conditions, social habits, family history of certain things that can help guide a practitioner to the accurate diagnosis.

Hayley: I think honesty is just so important in that process.

Dr. Bhatt: Of course, and again it’s very hard for people who might be feeling, I can’t say this because I’m going to be judged by somebody. That’s often the fear of people who suffer with addiction and mental health have is that they think they’ve done something wrong. And although this has evolved in the United States and all across the world in accepting mental health issues and substance use disorders, still the person who’s suffering with it, it’s not easy to, to talk about. Often when you’re so depressed and whatever’s going on in your mind, it may be not allowing you to get through. Talking with supportive family members, reaching out to people in your support system, it could be anybody from clergy to your friends to anybody that you can trust. Having their support also can help you get some resonance and some feedback and get pointed in the right direction.

Hayley: Absolutely. Shouldn’t just sit on it alone. Is there anything on misdiagnosis that I didn’t ask you or bring up that you want to talk about, or you think people should be aware of?

Dr. Bhatt: At the end of the day, as I speak to everybody, it’s a difficult thing to do accurately. Mental health conditions are something that’s a product of our mind and it’s an abstract thing. It’s hard for people to really just check off. And I think in the attempt to simplify things, people are using just check-off lists or symptom recognition and putting them in a cluster and saying, that’s it. But that isn’t it. Especially since we’ve talked about it here, so many different substances can look like mental health conditions and underlying mental health conditions can push somebody to pursue substances. It’s really important that a clinician take the time necessary to go through a chronologic history from hopefully birth till the present moment. We have a tendency to look backwards, but also maybe to help put things in order for somebody do it progressively going from birth to the present moment, because it helps put things in chronological order of how they occurred.

I think a lot of times we’re pushed due to medical records or patient load or whatever, but people who practice mental health treatment need to be prepared to invest the time in spending with somebody because that’s the only diagnostic tool we really have that we can rely on is that diagnostic interview, which is an interaction with the patient. Also going out to corroborate information, not simply talking to a patient who might be intoxicated or in an emergency situation but reaching out to family members and collateral information from previous treatments to see what’s substantiated and what’s not, what’s accurate, what’s not. And the patient be prepared to provide that information and not feel as much as it’s easy to say here, but not feel ashamed or guilty to disclose that information and help the practitioner out by being prepared, putting things in order for them and highlighting what the problems are. So not to get tangled up when they get to that moment where they actually have somebody who can help them.

Hayley: Because that’s how you get the right treatment plan.

Dr. Bhatt: Exactly.

Hayley: Well, thank you for talking with me today, Dr. Bhatt, um, and thank you for everyone that tuned in. You can check out more of our podcast episodes at addictioncenter.com and I will see you next time on another episode of Straight Talk With The Doc.