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Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change. (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)
This week, Dr. Pat has asked Megan Riddle, M.D./Ph.D., to advise a woman whose 63-year-old friend has acquired alarming swings in mood. Could she have bipolar disorder? Dr. Riddle is a psychiatry resident at the University of Washington and a graduate of the Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional MD-PhD Program.
Dear Dr. Pat:
I am worried that my friend might be bipolar. She can be really moody, and it doesn’t take much for her to explode. Her mood will swing wildly; she’ll be fine one moment, but tearful and anxious the next.
I’ve known her for years—we used to work together—and this really isn’t like her. Of the two of us, she was always the calm and sensible one, but this has been going on for a while now . . . for at least the past year or so. We had lunch together last week, and she looked terrible. She has lost a lot of weight, and she says she isn’t sleeping.
She’s 63 years old. We both went through menopause a number of years ago, so I don’t think that’s what is going on. I’m worried about her. Could she have developed bipolar disorder?
I would really appreciate your advice. Do you think she should see a psychiatrist?
Karen
Dr. Riddle Responds:
Dear Karen:
While I am a great proponent of timely psychiatric care, the first appointment your friend needs to make is with her primary care doctor. While the symptoms you describe – intense irritability, insomnia—are consistent with a diagnosis of bipolar disorder, I am more concerned that there may be an underlying medical problem leading to your friend’s symptoms. There are a number of medical conditions that also cause significant changes in mood and behavior and can masquerade as a primary psychiatric problem.
There are several clues that would make me think your friend may have an underlying physical illness.
First, her age. Although there are mental illnesses that develop later in life, most appear at a younger age. According to the National Institute of Mental Health, a full 75 percent of people with mental illness develop the disorder by the age of 24. Thus, although it’s not impossible for your friend to have developed a bipolar disorder, for anyone over 40 years old without a previous psychiatric diagnosis there should be a strong suspicion that something else may be going on.
Second, you mention that she has experienced weight loss. Although some mental illnesses, such as depression or an eating disorder, can lead to weight loss, significant changes in weight make me suspicious that she could have a primary physical illness. Whenever a mood change is accompanied by physical symptoms, one must not overlook these potential diagnostic clues. She should be sure to mention to her primary doctor any other symptoms she might be having, such as headaches, changes in her skin, weakness, dizziness, fever, or abdominal distension. While they may sound like red herrings, sometimes these are just the clues needed to make the diagnosis.
A surprising number of illnesses can cause changes in mood and behavior. For a patient like your friend who is experiencing such symptoms, her physician should conduct a thorough workup before making a referral to a psychiatrist. In addition to a careful history and physical exam, the physician would likely include blood work to look for metabolic, endocrine, and immunological disorders, among others.
- Hyperthyroidism [overactive thyroid], for example, can cause the kind increased irritability, anxiety, insomnia, and weight loss you describe in your friend. If this is the case, she would need treatment for a thyroid problem rather than a prescription for an antidepressant.
- Age-appropriate cancer screening—as well as further testing, depending on specific physical symptoms—is advisable, since some cancers are notorious for causing changes in mood. Infectious sources may also be considered, particularly if the changes have been more acute.
- Another underappreciated cause of psychiatric symptoms can be prescription medications. For example, steroids, prescribed for everything from arthritis to inflammatory bowel disease to sarcoidosis, are notorious for causing a variety of psychiatric issues, including anxiety, depression, and even psychosis.
- Finally, misusing prescription medications or using drugs of abuse can result in significant alterations in personality.
A correct diagnosis is important, because without it, appropriate treatment is not possible. One study found that nearly 1 in 10 patients at an outpatient psychiatric clinic being treated for mental illness had an undiagnosed physical illness that could explain his or her symptoms. That study was done nearly four decades ago; let us hope that doctors have become more rigorous about working up those presenting with mood and behavioral changes. It is important that your friend advocate for a thorough physical workup.
Treating the underlying physical condition will often lead to resolution of the psychiatric issues as well, although a psychiatrist can be helpful at managing any remaining symptoms. If no physical cause is found for her symptoms, she should definitely make a visit to a psychiatrist.
Thank you for your concern for your friend. Please encourage her to see her primary care doctor, and support her in the process.
Megan Riddle, M.D., Ph.D.
References
- Hall RC, Popkin MK, Devaul RA, Faillace LA, Stickney SK (1978): Physical illness presenting as psychiatric disease. Archives of general psychiatry. 35:1315-1320.
- Morrison J (2014): Diagnosis Made Easier: Principles and Techniques for Mental Health Clinicians. Second ed. New York: The Guilford Press.
- National Institute of Mental Health (2005): Mental Illness Exacts Heavy Toll, Beginning in Youth. http://www.nimh.nih.gov/news/science-news/2005/mental-illness-exacts-heavy-toll-beginning-in-youth.shtml
