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Hi, Please Examine File Attached. And, Following The Thorough Examination

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Posted on Wed, 11 Sep 2019
Question: Hi,



Please examine file attached.



And, following the thorough examination of the case, please answer the following questions:



(1) Based on the evidence we see, is the hospital correct or mistaken in applying an apparent underlying mood disorder diagnosis to a patient like myself?



(2) Any other commentary?



(3) Any other questions?


Given this, let us examine and scrutinize much more closely the respective evidence and support for each of our two positions, so that we may inevitably reconcile our differing opinions and come to a unified understanding of what the most appropriate course of action for a prudent, reasonable doctor in such a situation would most likely be.

...

(1) First--I ask you to please provide a point-by-point itemization of each piece of supporting evidence that you have clearly identify, which supports the position that it is "beyond any reasonable doubt" that the patient in this case (myself) has a legitimately underlying mood disorder. I will provide my own list to follow--and you are welcomed to rebut and refute each of my own supporting pieces of evidence for my own position as I may do with yours, in an ordered manner until we are left only with those pieces of evidence that were unrefutable. Then, upon reconsolidating them and observing the entirety of what we have, we may both find ourselves to agree on that conclusion which makes the most sense, based on logic.

Thank you for this.

(2) The following is a brief list of my own primary supporting points for my own position, which is the position that an underlying mood disorder is *not* a correct or valid diagnosis:

(a) The doctor writes in the record the following: "[Patient is] well related, calm, cooperative. Patient *not depressed*, *[not] manic*, [nor] psychotic.” Goes on to state, “His aggressive behavior was likely due to alcohol intoxication," which is supported by the earlier observation stated within the same record, that "[the patient]...smells of alcohol." By stating that I am not depressed and not manic, the doctor explicitly acknowledges a lack of evidence and support for a mood disorder diagnosis--or EITHER the underlying OR the substanced-induced variety. (Alcohol-induced "agitation" is not consistent with the overt "mania" phases of mood disorder.)

(b) In the diagnosis for underlying mood disorder (or a diagnosis of underlying mental illness of any kind), the respective DSM-5 criteria ubiquitously, uniformly and consistently states, that, as one of the criteria that must be met in the appropriate diagnosis of underlying disorders, that (--paraphrased), "[for such a diagnosis to be valid] the symptoms [acutely] observed must not be better explained by the effects [either by the presence of or by the withdrawal from] a substance such as alcohol or drugs." Obviously, the presence of alcohol and its clearly manifest effects at the time clouds over a diagnostician's ability to render just about any valid diagnosis of an underlying condition.

(c) The same criteria goes on to state that (--paraphrased), "for the diagnosis of underlying condition to be valid, the symptoms must be observed as taking place for a clinically relevant period of time, usually at least one or two months--and in some cases, as many as six months." The doctors inability to gain any confirmed evidence for any symptomatic disruptions in mood beyond those apparently caused by alcohol at that timeframe (and no confirmed proof or evidence for any timeframe before that).

(d) Generally, to avoid liability, doctors and ERs must show on the record as having offered or prescribed medications for those conditions which are found to legitimately be underlying, such that liability is reduced or mitigated. (Example, a person who is diagnosed with an underlying mental illness but then discharged without being prescribed medications, could reasonably claim that "the doctors found I had so-and-so mental disorder, but did not provide medicine for it and just let me go, thus my disorder became worse and I experienced various forms of damages as a result of lack of treatment via negligence." The important point is this: behaviorally, by the doctor's lack of prescribing any medication, this is an implicit admittance of the fact that no valid, underlying condition actually exists.

(e) The only evidence they had which provided the reason for my own admittance is that police has understood (rather, misunderstood) the claim that relative had made, by reporting that they heard my mother claim that I had an apparent medically-confirmed history (ie, an already-medically-diagnosed condition) of mood disorder and/or bipolar disorder. To this, I have three clear rebuttals:
(i) The doctors never obtained direct testimony from the mother herself;
(ii) The doctors appropriately indicate in the history/narrative at various points in the record that the patient has an "unconfirmed" history of bipolar, meaning that the claim cannot be validated and fully adopted until the status of that claim is upgraded from "unconfirmed" to "confirmed"; and,
(iii) In actual fact and in reality, during the only other prior time that I had ever been under psychiatric care (under voluntary admittance), the disorder of diagnosis of "bipolar disorder" and "mood disorder" was explicitly ruled out--and with the fullest certainly, any miscommunication produced by my mother or any misinterpretation performed by the police in this case, was made in full error and ignorance of the actual truth. ***For proof, I have obtained the record of that original psychiatric stay, and include a picture of the notes wherein the doctors confirm that mood order and bipolar disorder are both ruled out of consideration. I had never diagnosed with such a thing.***

(3) If you were the doctor in this position, before you would produce a final diagnosis, you initially would need to produce a differential diagnosis list, with the most likely possibilities at the top of the list, and the least-likely candidates for diagnosis being either at the bottom of the list, or explicitly ruled out at the outset. Please indicate what your differential diagnosis would be at the outset (with potential diagnoses being presented in the order of likelihood), what you would rule out either immediately or eventually, and which diagnosis you feel you would most likely be left with at the conclusion, to then officially render to the patient.

(4) For reference and comparative purposes: If I were in the place of a medical professional, here is the differential diagnosis list I would provide, with reasoning provided thereafter:

- Agitation/confusion (substance-induced/withdrawal-induced),
- Intoxication of alcohol (-or-) alcohol withdrawal, and/or,
- Mood disorder (substance-induced);
- R/O mood disorder (underlying), and,
- R/O bipolar disorder (underlying)

For the three line items included, they are in the order that they are because the acute effects/symptoms are more apparent than even the suggestion of a "disorder", whether underling or substance-induced. Moreover, the two underlying disorder which are ruled out would be done so on the basis that, by the end of the gathering of all accessible evidence, insufficient evidence of a confirmed nature exists to support a history of mood disorder or bipolar for the patient. However, even if they were not to be ruled out (which is very possible), nevertheless their position on the list would still be on the bottom, behind the more likely entries on the top. Therefore, the top diagnosis would be the ones most likely to remain and be officially rendered, which by their very diagnostic definition must include a ruling-out of an underlying condition. (To paraphrase from authoritative diagnostic criteria: "To diagnose a substance-induced disorder, the observed symptoms must not be BETTER explained by an underlying condition"; in this case, the alcohol does, in fact, better explain the acute symptoms than unsubstantiated allegations of underlying disorder.)

Would your differential diagnosis list, and process of elimination, be any different from mine? If so, how? and why? Please explain and support.

(5) After carefully assessing my points and presentation on the matter, do you find that your assessment of the situation has changed? if so, please indicate.
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Follow up: Dr. Seikhoo Bishnoi (0 minute later)
Hi,



Please examine file attached.



And, following the thorough examination of the case, please answer the following questions:



(1) Based on the evidence we see, is the hospital correct or mistaken in applying an apparent underlying mood disorder diagnosis to a patient like myself?



(2) Any other commentary?



(3) Any other questions?


Given this, let us examine and scrutinize much more closely the respective evidence and support for each of our two positions, so that we may inevitably reconcile our differing opinions and come to a unified understanding of what the most appropriate course of action for a prudent, reasonable doctor in such a situation would most likely be.

...

(1) First--I ask you to please provide a point-by-point itemization of each piece of supporting evidence that you have clearly identify, which supports the position that it is "beyond any reasonable doubt" that the patient in this case (myself) has a legitimately underlying mood disorder. I will provide my own list to follow--and you are welcomed to rebut and refute each of my own supporting pieces of evidence for my own position as I may do with yours, in an ordered manner until we are left only with those pieces of evidence that were unrefutable. Then, upon reconsolidating them and observing the entirety of what we have, we may both find ourselves to agree on that conclusion which makes the most sense, based on logic.

Thank you for this.

(2) The following is a brief list of my own primary supporting points for my own position, which is the position that an underlying mood disorder is *not* a correct or valid diagnosis:

(a) The doctor writes in the record the following: "[Patient is] well related, calm, cooperative. Patient *not depressed*, *[not] manic*, [nor] psychotic.” Goes on to state, “His aggressive behavior was likely due to alcohol intoxication," which is supported by the earlier observation stated within the same record, that "[the patient]...smells of alcohol." By stating that I am not depressed and not manic, the doctor explicitly acknowledges a lack of evidence and support for a mood disorder diagnosis--or EITHER the underlying OR the substanced-induced variety. (Alcohol-induced "agitation" is not consistent with the overt "mania" phases of mood disorder.)

(b) In the diagnosis for underlying mood disorder (or a diagnosis of underlying mental illness of any kind), the respective DSM-5 criteria ubiquitously, uniformly and consistently states, that, as one of the criteria that must be met in the appropriate diagnosis of underlying disorders, that (--paraphrased), "[for such a diagnosis to be valid] the symptoms [acutely] observed must not be better explained by the effects [either by the presence of or by the withdrawal from] a substance such as alcohol or drugs." Obviously, the presence of alcohol and its clearly manifest effects at the time clouds over a diagnostician's ability to render just about any valid diagnosis of an underlying condition.

(c) The same criteria goes on to state that (--paraphrased), "for the diagnosis of underlying condition to be valid, the symptoms must be observed as taking place for a clinically relevant period of time, usually at least one or two months--and in some cases, as many as six months." The doctors inability to gain any confirmed evidence for any symptomatic disruptions in mood beyond those apparently caused by alcohol at that timeframe (and no confirmed proof or evidence for any timeframe before that).

(d) Generally, to avoid liability, doctors and ERs must show on the record as having offered or prescribed medications for those conditions which are found to legitimately be underlying, such that liability is reduced or mitigated. (Example, a person who is diagnosed with an underlying mental illness but then discharged without being prescribed medications, could reasonably claim that "the doctors found I had so-and-so mental disorder, but did not provide medicine for it and just let me go, thus my disorder became worse and I experienced various forms of damages as a result of lack of treatment via negligence." The important point is this: behaviorally, by the doctor's lack of prescribing any medication, this is an implicit admittance of the fact that no valid, underlying condition actually exists.

(e) The only evidence they had which provided the reason for my own admittance is that police has understood (rather, misunderstood) the claim that relative had made, by reporting that they heard my mother claim that I had an apparent medically-confirmed history (ie, an already-medically-diagnosed condition) of mood disorder and/or bipolar disorder. To this, I have three clear rebuttals:
(i) The doctors never obtained direct testimony from the mother herself;
(ii) The doctors appropriately indicate in the history/narrative at various points in the record that the patient has an "unconfirmed" history of bipolar, meaning that the claim cannot be validated and fully adopted until the status of that claim is upgraded from "unconfirmed" to "confirmed"; and,
(iii) In actual fact and in reality, during the only other prior time that I had ever been under psychiatric care (under voluntary admittance), the disorder of diagnosis of "bipolar disorder" and "mood disorder" was explicitly ruled out--and with the fullest certainly, any miscommunication produced by my mother or any misinterpretation performed by the police in this case, was made in full error and ignorance of the actual truth. ***For proof, I have obtained the record of that original psychiatric stay, and include a picture of the notes wherein the doctors confirm that mood order and bipolar disorder are both ruled out of consideration. I had never diagnosed with such a thing.***

(3) If you were the doctor in this position, before you would produce a final diagnosis, you initially would need to produce a differential diagnosis list, with the most likely possibilities at the top of the list, and the least-likely candidates for diagnosis being either at the bottom of the list, or explicitly ruled out at the outset. Please indicate what your differential diagnosis would be at the outset (with potential diagnoses being presented in the order of likelihood), what you would rule out either immediately or eventually, and which diagnosis you feel you would most likely be left with at the conclusion, to then officially render to the patient.

(4) For reference and comparative purposes: If I were in the place of a medical professional, here is the differential diagnosis list I would provide, with reasoning provided thereafter:

- Agitation/confusion (substance-induced/withdrawal-induced),
- Intoxication of alcohol (-or-) alcohol withdrawal, and/or,
- Mood disorder (substance-induced);
- R/O mood disorder (underlying), and,
- R/O bipolar disorder (underlying)

For the three line items included, they are in the order that they are because the acute effects/symptoms are more apparent than even the suggestion of a "disorder", whether underling or substance-induced. Moreover, the two underlying disorder which are ruled out would be done so on the basis that, by the end of the gathering of all accessible evidence, insufficient evidence of a confirmed nature exists to support a history of mood disorder or bipolar for the patient. However, even if they were not to be ruled out (which is very possible), nevertheless their position on the list would still be on the bottom, behind the more likely entries on the top. Therefore, the top diagnosis would be the ones most likely to remain and be officially rendered, which by their very diagnostic definition must include a ruling-out of an underlying condition. (To paraphrase from authoritative diagnostic criteria: "To diagnose a substance-induced disorder, the observed symptoms must not be BETTER explained by an underlying condition"; in this case, the alcohol does, in fact, better explain the acute symptoms than unsubstantiated allegations of underlying disorder.)

Would your differential diagnosis list, and process of elimination, be any different from mine? If so, how? and why? Please explain and support.

(5) After carefully assessing my points and presentation on the matter, do you find that your assessment of the situation has changed? if so, please indicate.
doctor
Answered by Dr. Seikhoo Bishnoi (31 hours later)
Brief Answer:
Please provide relevant details.

Detailed Answer:
Hello thanks for using ask a doctor service

I have gone through the attachments and these attachments only show screenshots of diagnoses. There were no details of case records so a detailed inference can't be made.

Please provide detailed history about the symptoms. What were main presenting symptoms? How did they progress? Any aggravating factors or relieving factors?

What kind of substance intoxication was that? Any loss of insight during the illness?

Tell me about the patient in details.

Thanks

Please provide details in follow up.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
Please provide relevant details.

Detailed Answer:
Hello thanks for using ask a doctor service

I have gone through the attachments and these attachments only show screenshots of diagnoses. There were no details of case records so a detailed inference can't be made.

Please provide detailed history about the symptoms. What were main presenting symptoms? How did they progress? Any aggravating factors or relieving factors?

What kind of substance intoxication was that? Any loss of insight during the illness?

Tell me about the patient in details.

Thanks

Please provide details in follow up.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Seikhoo Bishnoi (1 hour later)
Sending attachments via attachments email system to yoy shortly.
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Follow up: Dr. Seikhoo Bishnoi (0 minute later)
Sending attachments via attachments email system to yoy shortly.
doctor
Answered by Dr. Seikhoo Bishnoi (20 hours later)
Brief Answer:
Substance intoxication could be the reason

Detailed Answer:
Hello again, now I have few pages which you provided as records

Based upon the information you provided there was no conclusive evidence that you had bipolar disorder. This was based upon your mothers words only. Even you've mentioned this was suspected bipolar and the admission was voluntary. You have not mentioned what were the presenting symptoms at that time. So I don't think this can be labelled in bipolar disorder.

Now coming to the present episode. If we assume the onset then that was in one day only. You were apparently normal when you went for drink and then you have bing drinking and then you were intoxicated (most likely) and there was change in behaviour. Seeing this your mother called police.

Now if you were totally normal and there was no history of symptoms like increased activities, risk taking behaviour, irritability, violent behaviour, over talkativeness, disinhibited behaviour, cheerfulness etc then I don't think this was an episode of mania or bipolar episode. But since I haven't examined you so I can't comment conclusively and with assertion. The treating doctor can comment on this with confidence. If during MSE he found something abnormal which can't be explained by substance use then that could be part of bipolar disorder.

Yes Alcohol use can be the reason of these symptoms if there were no symptoms prior to alcohol intake. Alcohol intoxication can be the reason for this.

Yes probable diagnoses should be formulated first with list of differential diagnosis and then different possibilities should be ruled out.

Thanks

I hope this helps.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
Substance intoxication could be the reason

Detailed Answer:
Hello again, now I have few pages which you provided as records

Based upon the information you provided there was no conclusive evidence that you had bipolar disorder. This was based upon your mothers words only. Even you've mentioned this was suspected bipolar and the admission was voluntary. You have not mentioned what were the presenting symptoms at that time. So I don't think this can be labelled in bipolar disorder.

Now coming to the present episode. If we assume the onset then that was in one day only. You were apparently normal when you went for drink and then you have bing drinking and then you were intoxicated (most likely) and there was change in behaviour. Seeing this your mother called police.

Now if you were totally normal and there was no history of symptoms like increased activities, risk taking behaviour, irritability, violent behaviour, over talkativeness, disinhibited behaviour, cheerfulness etc then I don't think this was an episode of mania or bipolar episode. But since I haven't examined you so I can't comment conclusively and with assertion. The treating doctor can comment on this with confidence. If during MSE he found something abnormal which can't be explained by substance use then that could be part of bipolar disorder.

Yes Alcohol use can be the reason of these symptoms if there were no symptoms prior to alcohol intake. Alcohol intoxication can be the reason for this.

Yes probable diagnoses should be formulated first with list of differential diagnosis and then different possibilities should be ruled out.

Thanks

I hope this helps.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi (9 hours later)
Thank you for your effective and, in my opinioin, very correct, well-positioned, and reasonable conclusion.

I have additional opinions of mine, within the realm of psychiatric diagnoses, that I would like to submit. I hope you will be able to pick these up as I place them in, and also provide excellent analysis and reasonable, fitting conclusions to those as well.

Thank you so much.
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Follow up: Dr. Seikhoo Bishnoi (0 minute later)
Thank you for your effective and, in my opinioin, very correct, well-positioned, and reasonable conclusion.

I have additional opinions of mine, within the realm of psychiatric diagnoses, that I would like to submit. I hope you will be able to pick these up as I place them in, and also provide excellent analysis and reasonable, fitting conclusions to those as well.

Thank you so much.
doctor
Answered by Dr. Seikhoo Bishnoi (18 hours later)
Brief Answer:
You can contact again at any time

Detailed Answer:
Hello again

You can contact again with new information and new doubts.

If there are doubts please upload the files and let customer care know about this.

Thanks
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
You can contact again at any time

Detailed Answer:
Hello again

You can contact again with new information and new doubts.

If there are doubts please upload the files and let customer care know about this.

Thanks
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi (15 hours later)
Hi Doctor,

Just forwarded to you the attachments. Please review whenever you can. Thank you
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Follow up: Dr. Seikhoo Bishnoi (0 minute later)
Hi Doctor,

Just forwarded to you the attachments. Please review whenever you can. Thank you
doctor
Answered by Dr. Seikhoo Bishnoi (7 hours later)
Brief Answer:
Please send to the customer care

Detailed Answer:
Hello again

Again in reports these are not opening.

Please send a mail with attachments to customer care and ask then to forward to my email address. This could be due to some technical issue.

Thanks
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
Please send to the customer care

Detailed Answer:
Hello again

Again in reports these are not opening.

Please send a mail with attachments to customer care and ask then to forward to my email address. This could be due to some technical issue.

Thanks
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
default
Follow up: Dr. Seikhoo Bishnoi (13 hours later)
I have just sent it again. Thank you
default
Follow up: Dr. Seikhoo Bishnoi (0 minute later)
I have just sent it again. Thank you
doctor
Answered by Dr. Seikhoo Bishnoi (31 hours later)
Brief Answer:
Please give me some time

Detailed Answer:
Hello again,

Got the attachments on email just a couple of hours back. This is a long history with details, please give me some time and in the mean time if you have any other doubts please let me know.

Thanks.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
Please give me some time

Detailed Answer:
Hello again,

Got the attachments on email just a couple of hours back. This is a long history with details, please give me some time and in the mean time if you have any other doubts please let me know.

Thanks.
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Seikhoo Bishnoi (15 hours later)
Yes, Doctor. Thank you
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Follow up: Dr. Seikhoo Bishnoi (0 minute later)
Yes, Doctor. Thank you
doctor
Answered by Dr. Seikhoo Bishnoi (23 hours later)
Brief Answer:
This could be delirium due to drugs.

Detailed Answer:
Hello again

I have gone through some part of the report. I have checked available reports about Phenibut and Fasoracetam. The combination results in increased toxic effects and there is one case report available which is same as you provided me in the link.

Fasoracetam is known to increase the response of Phenibut in some reports. This could be the reason for increased toxicogenic effects in your case.

In my opinion the first possibility in your case could be Delirium secondary to toxic effects of both drugs. Due to severe CNS depression such symptoms were seen.

Psychosis due to unknown mechanisms due to Phenibut or Fasoracetam might be the second possible reason.

Thanks, given me some more time till I read whole report, I have completed 10 pages only till now.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
This could be delirium due to drugs.

Detailed Answer:
Hello again

I have gone through some part of the report. I have checked available reports about Phenibut and Fasoracetam. The combination results in increased toxic effects and there is one case report available which is same as you provided me in the link.

Fasoracetam is known to increase the response of Phenibut in some reports. This could be the reason for increased toxicogenic effects in your case.

In my opinion the first possibility in your case could be Delirium secondary to toxic effects of both drugs. Due to severe CNS depression such symptoms were seen.

Psychosis due to unknown mechanisms due to Phenibut or Fasoracetam might be the second possible reason.

Thanks, given me some more time till I read whole report, I have completed 10 pages only till now.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi (18 minutes later)
Doctor,

The patient in that case study IS me. I'm the one who was in that coma, from apparent excessive GABAergic tone caused by the use of both substances.

My case is the only one known in modern medicine where these effects were observed.

So far, it seems from your statement that it is more likely to be a case of delirium (which is a standard and expected phenomenon when withdrawing fro most GABAergic compounds), than a case of psychosis. I agree with you, and this is what seems to be the case.

To further examine the question, what seems to be the difference, diagnostically or criteria-wise, for delirium versus psychosis?

Thank you for your time and dedication
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Follow up: Dr. Seikhoo Bishnoi (0 minute later)
Doctor,

The patient in that case study IS me. I'm the one who was in that coma, from apparent excessive GABAergic tone caused by the use of both substances.

My case is the only one known in modern medicine where these effects were observed.

So far, it seems from your statement that it is more likely to be a case of delirium (which is a standard and expected phenomenon when withdrawing fro most GABAergic compounds), than a case of psychosis. I agree with you, and this is what seems to be the case.

To further examine the question, what seems to be the difference, diagnostically or criteria-wise, for delirium versus psychosis?

Thank you for your time and dedication
doctor
Answered by Dr. Seikhoo Bishnoi (7 hours later)
Brief Answer:
This might be delirium

Detailed Answer:
Hello again

Since both drugs are relatively newer in market and are not very well studied so it can't be commented if the toxic effects of the drugs precipitated psychosis. Any GABA drugs (commonly Benzodiazepines) if used for long regularly and then stopped abruptly could precipitate withdrawal which could vary from mild restlessness to delirium to coma. But the delirium usually sets in 3-4th day of stopping the drug.

Psychosis can be a possibility but even if we assume it was psychosis even then that would go in Acute Psychotic Episode or ATPD and this is not related to bipolar disorder or even schizophrenia directly. In psychosis loss of awareness to surrounding is seen similar to delirium but cloudiness of consciousness is not commonly seen. Other psychotic symptoms like visual hallucinations, auditory hallucinations or suspiciousness etc are seen. Consciousness is relatively preserved.

You have very low heart rate during treatment and were off drugs for that time so yes this could be delirium but psychosis can't be totally ruled out (ATPD more specifically, but yes I will not classify this in bipolar based upon history you provided.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
This might be delirium

Detailed Answer:
Hello again

Since both drugs are relatively newer in market and are not very well studied so it can't be commented if the toxic effects of the drugs precipitated psychosis. Any GABA drugs (commonly Benzodiazepines) if used for long regularly and then stopped abruptly could precipitate withdrawal which could vary from mild restlessness to delirium to coma. But the delirium usually sets in 3-4th day of stopping the drug.

Psychosis can be a possibility but even if we assume it was psychosis even then that would go in Acute Psychotic Episode or ATPD and this is not related to bipolar disorder or even schizophrenia directly. In psychosis loss of awareness to surrounding is seen similar to delirium but cloudiness of consciousness is not commonly seen. Other psychotic symptoms like visual hallucinations, auditory hallucinations or suspiciousness etc are seen. Consciousness is relatively preserved.

You have very low heart rate during treatment and were off drugs for that time so yes this could be delirium but psychosis can't be totally ruled out (ATPD more specifically, but yes I will not classify this in bipolar based upon history you provided.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi (13 hours later)
Thank you. I have an additional question regarding your opinion on various diagnoses rendered to me, from a follow-up stay which took place in 2017.

I am going to forward to you the documents and information relevant to that experience.

Thank you again for your time and dedication, Dr Bishnoi
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Follow up: Dr. Seikhoo Bishnoi (0 minute later)
Thank you. I have an additional question regarding your opinion on various diagnoses rendered to me, from a follow-up stay which took place in 2017.

I am going to forward to you the documents and information relevant to that experience.

Thank you again for your time and dedication, Dr Bishnoi
doctor
Answered by Dr. Seikhoo Bishnoi (11 hours later)
Brief Answer:
Please send the documents on email.

Detailed Answer:
Hello again

Please contact customer care again to send the documents on my email. New documents are not opening.

I am sorry for that.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
Please send the documents on email.

Detailed Answer:
Hello again

Please contact customer care again to send the documents on my email. New documents are not opening.

I am sorry for that.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Seikhoo Bishnoi (16 minutes later)
Ok sending in just a moment. You shall have it soon.
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Follow up: Dr. Seikhoo Bishnoi (0 minute later)
Ok sending in just a moment. You shall have it soon.
doctor
Answered by Dr. Seikhoo Bishnoi (25 hours later)
Brief Answer:
Yes that might be a reason

Detailed Answer:
Hello again

Use of alcohol, many GABA drugs are known to result in acute pancreatitis. This could lead to many serious complications. This can precipitate diabetes in otherwise healthy individual. Yes this might be a cause. But in pancreatitis other symptoms like serious abdominal pain, many systemic symptoms are seen.

I am not a diabetic specialist so I can’t comment with confidence. But this might be a cause. Combination of drugs could increase the risk. Hyperglycemia could be one reason for the delirium too.

Thanks
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
Yes that might be a reason

Detailed Answer:
Hello again

Use of alcohol, many GABA drugs are known to result in acute pancreatitis. This could lead to many serious complications. This can precipitate diabetes in otherwise healthy individual. Yes this might be a cause. But in pancreatitis other symptoms like serious abdominal pain, many systemic symptoms are seen.

I am not a diabetic specialist so I can’t comment with confidence. But this might be a cause. Combination of drugs could increase the risk. Hyperglycemia could be one reason for the delirium too.

Thanks
Above answer was peer-reviewed by : Dr. Yogesh D
doctor
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Follow up: Dr. Seikhoo Bishnoi (1 hour later)
Hi doctor,

This set of documents D01 - D03, is from a separate hospitalization, which occurred a year later, in 2017.

During this hospitalization, I went in to get tests done regarding a potential diahectic condition. Instead, I was held against my will in a psychiatric ward, and given multiple different mental illness diagnoses.

D02 and D03, in particular, highlight the details.

My questions regards this:

(1) Do you think a mental diagnosis of bipolar disorder, schizophrenia, psychosis, hypochondriac, or any other diagnosed illness, was appropriate to give, based on the context?

Please read documents D01 - D03 carefully, and please let me know your opinion, as to whether their position seems like a valid one. Thank you.
default
Follow up: Dr. Seikhoo Bishnoi (0 minute later)
Hi doctor,

This set of documents D01 - D03, is from a separate hospitalization, which occurred a year later, in 2017.

During this hospitalization, I went in to get tests done regarding a potential diahectic condition. Instead, I was held against my will in a psychiatric ward, and given multiple different mental illness diagnoses.

D02 and D03, in particular, highlight the details.

My questions regards this:

(1) Do you think a mental diagnosis of bipolar disorder, schizophrenia, psychosis, hypochondriac, or any other diagnosed illness, was appropriate to give, based on the context?

Please read documents D01 - D03 carefully, and please let me know your opinion, as to whether their position seems like a valid one. Thank you.
doctor
Answered by Dr. Seikhoo Bishnoi (18 hours later)
Brief Answer:
This is not bipolar or schizophrenia most likely.

Detailed Answer:
Hello again

Based upon what you provided I can say this information is not sufficient to make diagnosis of bipolar disorder or schizophrenia. This could be some organic issue secondary to drug overdose or intoxication or this might be some psychosis. But your awareness to surrounding was preserved so the possibility is low.

During the episode with nurse when she called the Emergency response team I can say that this could be due to confusion too. But what the psychiatrist reported at that time carries significance. If there were any perceptual issues or thought distortions at that time on MSE then this can point to some psychotic issue.

Thanks.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
doctor
Answered by Dr. Seikhoo Bishnoi (0 minute later)
Brief Answer:
This is not bipolar or schizophrenia most likely.

Detailed Answer:
Hello again

Based upon what you provided I can say this information is not sufficient to make diagnosis of bipolar disorder or schizophrenia. This could be some organic issue secondary to drug overdose or intoxication or this might be some psychosis. But your awareness to surrounding was preserved so the possibility is low.

During the episode with nurse when she called the Emergency response team I can say that this could be due to confusion too. But what the psychiatrist reported at that time carries significance. If there were any perceptual issues or thought distortions at that time on MSE then this can point to some psychotic issue.

Thanks.
Note: For further guidance on mental health, Click here.

Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
Answered by
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Dr. Seikhoo Bishnoi

Psychiatrist

Practicing since :2007

Answered : 5193 Questions

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Hi, Please Examine File Attached. And, Following The Thorough Examination

Hi, Please examine file attached. And, following the thorough examination of the case, please answer the following questions: (1) Based on the evidence we see, is the hospital correct or mistaken in applying an apparent underlying mood disorder diagnosis to a patient like myself? (2) Any other commentary? (3) Any other questions? Given this, let us examine and scrutinize much more closely the respective evidence and support for each of our two positions, so that we may inevitably reconcile our differing opinions and come to a unified understanding of what the most appropriate course of action for a prudent, reasonable doctor in such a situation would most likely be. ... (1) First--I ask you to please provide a point-by-point itemization of each piece of supporting evidence that you have clearly identify, which supports the position that it is "beyond any reasonable doubt" that the patient in this case (myself) has a legitimately underlying mood disorder. I will provide my own list to follow--and you are welcomed to rebut and refute each of my own supporting pieces of evidence for my own position as I may do with yours, in an ordered manner until we are left only with those pieces of evidence that were unrefutable. Then, upon reconsolidating them and observing the entirety of what we have, we may both find ourselves to agree on that conclusion which makes the most sense, based on logic. Thank you for this. (2) The following is a brief list of my own primary supporting points for my own position, which is the position that an underlying mood disorder is *not* a correct or valid diagnosis: (a) The doctor writes in the record the following: "[Patient is] well related, calm, cooperative. Patient *not depressed*, *[not] manic*, [nor] psychotic.” Goes on to state, “His aggressive behavior was likely due to alcohol intoxication," which is supported by the earlier observation stated within the same record, that "[the patient]...smells of alcohol." By stating that I am not depressed and not manic, the doctor explicitly acknowledges a lack of evidence and support for a mood disorder diagnosis--or EITHER the underlying OR the substanced-induced variety. (Alcohol-induced "agitation" is not consistent with the overt "mania" phases of mood disorder.) (b) In the diagnosis for underlying mood disorder (or a diagnosis of underlying mental illness of any kind), the respective DSM-5 criteria ubiquitously, uniformly and consistently states, that, as one of the criteria that must be met in the appropriate diagnosis of underlying disorders, that (--paraphrased), "[for such a diagnosis to be valid] the symptoms [acutely] observed must not be better explained by the effects [either by the presence of or by the withdrawal from] a substance such as alcohol or drugs." Obviously, the presence of alcohol and its clearly manifest effects at the time clouds over a diagnostician's ability to render just about any valid diagnosis of an underlying condition. (c) The same criteria goes on to state that (--paraphrased), "for the diagnosis of underlying condition to be valid, the symptoms must be observed as taking place for a clinically relevant period of time, usually at least one or two months--and in some cases, as many as six months." The doctors inability to gain any confirmed evidence for any symptomatic disruptions in mood beyond those apparently caused by alcohol at that timeframe (and no confirmed proof or evidence for any timeframe before that). (d) Generally, to avoid liability, doctors and ERs must show on the record as having offered or prescribed medications for those conditions which are found to legitimately be underlying, such that liability is reduced or mitigated. (Example, a person who is diagnosed with an underlying mental illness but then discharged without being prescribed medications, could reasonably claim that "the doctors found I had so-and-so mental disorder, but did not provide medicine for it and just let me go, thus my disorder became worse and I experienced various forms of damages as a result of lack of treatment via negligence." The important point is this: behaviorally, by the doctor's lack of prescribing any medication, this is an implicit admittance of the fact that no valid, underlying condition actually exists. (e) The only evidence they had which provided the reason for my own admittance is that police has understood (rather, misunderstood) the claim that relative had made, by reporting that they heard my mother claim that I had an apparent medically-confirmed history (ie, an already-medically-diagnosed condition) of mood disorder and/or bipolar disorder. To this, I have three clear rebuttals: (i) The doctors never obtained direct testimony from the mother herself; (ii) The doctors appropriately indicate in the history/narrative at various points in the record that the patient has an "unconfirmed" history of bipolar, meaning that the claim cannot be validated and fully adopted until the status of that claim is upgraded from "unconfirmed" to "confirmed"; and, (iii) In actual fact and in reality, during the only other prior time that I had ever been under psychiatric care (under voluntary admittance), the disorder of diagnosis of "bipolar disorder" and "mood disorder" was explicitly ruled out--and with the fullest certainly, any miscommunication produced by my mother or any misinterpretation performed by the police in this case, was made in full error and ignorance of the actual truth. ***For proof, I have obtained the record of that original psychiatric stay, and include a picture of the notes wherein the doctors confirm that mood order and bipolar disorder are both ruled out of consideration. I had never diagnosed with such a thing.*** (3) If you were the doctor in this position, before you would produce a final diagnosis, you initially would need to produce a differential diagnosis list, with the most likely possibilities at the top of the list, and the least-likely candidates for diagnosis being either at the bottom of the list, or explicitly ruled out at the outset. Please indicate what your differential diagnosis would be at the outset (with potential diagnoses being presented in the order of likelihood), what you would rule out either immediately or eventually, and which diagnosis you feel you would most likely be left with at the conclusion, to then officially render to the patient. (4) For reference and comparative purposes: If I were in the place of a medical professional, here is the differential diagnosis list I would provide, with reasoning provided thereafter: - Agitation/confusion (substance-induced/withdrawal-induced), - Intoxication of alcohol (-or-) alcohol withdrawal, and/or, - Mood disorder (substance-induced); - R/O mood disorder (underlying), and, - R/O bipolar disorder (underlying) For the three line items included, they are in the order that they are because the acute effects/symptoms are more apparent than even the suggestion of a "disorder", whether underling or substance-induced. Moreover, the two underlying disorder which are ruled out would be done so on the basis that, by the end of the gathering of all accessible evidence, insufficient evidence of a confirmed nature exists to support a history of mood disorder or bipolar for the patient. However, even if they were not to be ruled out (which is very possible), nevertheless their position on the list would still be on the bottom, behind the more likely entries on the top. Therefore, the top diagnosis would be the ones most likely to remain and be officially rendered, which by their very diagnostic definition must include a ruling-out of an underlying condition. (To paraphrase from authoritative diagnostic criteria: "To diagnose a substance-induced disorder, the observed symptoms must not be BETTER explained by an underlying condition"; in this case, the alcohol does, in fact, better explain the acute symptoms than unsubstantiated allegations of underlying disorder.) Would your differential diagnosis list, and process of elimination, be any different from mine? If so, how? and why? Please explain and support. (5) After carefully assessing my points and presentation on the matter, do you find that your assessment of the situation has changed? if so, please indicate.