Transcript of Episode 15 of The Mind Itself podcast: Understanding Bipolar Disorder
[07.29.2022]
John Whitbeck:
The Mind Itself is a podcast about mental health, mental health law, and how they affect all aspects of our daily lives. By taking a deeper dive into how our society deals with mental health medically, legally, and practically, listeners gain inside information about one of America’s most pressing and often overlooked issues that affects almost half of all adults in the United States.
Hello, and welcome to The Mind Itself podcast. I am your host John Whitbeck. Today we are going to be talking about bipolar disorder, something that is pervasive in our society, as well as in the practice of law, especially in domestic relations, mental health law, and criminal cases, so I have brought in today a very special guest, Dr. Sumit Anand, who is with Ashburn Psychological Services in Northern Virginia. Dr. Anand and I have worked together on cases in the forensic realm, and I thought he would be an excellent guest to educate all of us on bipolar disorder, give us some background on the disease and how it’s treated, and some good helpful tips if you’re dealing with somebody in your family or friends that’s suffering from what has become a very pervasive disease in our country and around the world.
Doctor, it’s great to have you.
Dr. Sumit Anand:
Thank you for having me.
John Whitbeck:
So, I want to start by just getting some idea of your background, where you came from, where you came up, your education, everything like that to give our listeners a little bit of an idea of who you are and what your skillset is. Why don’t you just give us that background and let’s go from there?
Dr. Sumit Anand:
Sure. I was born and raised in London. I’m of Indian origin. I went to medical school in London, a place called Guy’s and St. Thomas’ Hospital, and that was back in 1992 that I graduated. I then went initially to University of Cambridge for my residency in psychiatry, but at that point I was toying with coming to the United States to pursue my career. I ended up actually coming to the United States eventually, after doing all my exams, in 1998, where I joined UVA, University of Virginia.
I was interested in forensic psychiatry, which is the legal branch of psychiatry. Already I was doing some preliminary research in England. I worked in England actually in a court system, as it were, for minor cases whereby they basically have become entangled in the legal system because of their mental illnesses, would end up breaking laws and minor charges, and I would write brief reports for the court for those and that was very helpful to them.
I ended up finally doing my training at University of Virginia for both my psychiatry residency and my forensic psychiatry residency at the law school along with the med school. I completed that around 2003, subsequently completed my board examinations in psychiatry and in forensic psychiatry by the American Board of Psychiatry and Neurology, and over the years I’ve since gained experience in working with various different groups of patients; adolescents, incorrigible adolescents, patients deemed not guilty by reason of insanity. I’ve worked with families, I’ve worked with adults, I’ve worked with adolescents, and I’ve testified in a number of cases in different US states; District of Columbia, Virginia, West Virginia.
Currently, I’m working full-time in private practice, seeing both patients for anxiety, depression, bipolar, all sorts of mood disorders, and yes, also taking forensic cases in that regard. So, that’s the potted history of me. I’m 54 years old now, married, 17-year-old, family life, all that. So, that’s just me in a nutshell.
John Whitbeck:
Very good. 17-year-old boy or girl?
Dr. Sumit Anand:
Girl.
John Whitbeck:
Very good. I too have a 17-year-old and I am dreading, in a year from now, dropping her off in college. It’s going to be a tough day. But I’m sure you’ll feel the same.
So, Doctor, let me ask you a basic question. And we probably discussed this in a prior podcast, episode, but it’s timely in this episode. What is the difference between a psychologist and a psychiatrist?
Dr. Sumit Anand:
A psychologist and a psychiatrist work in very similar ways in the same field; however, a psychiatrist is a medically trained doctor who prescribes medication. A psychologist is not a medically trained doctor; however, they specialize in the field of human behavior, and they can either have a PhD or what we call a PsyD, which is a kind of a clinical doctorate in that area where they see patients. So, they work together oftentimes. I frequently have many colleagues and friends who are psychologists, who do therapy, but they don’t typically prescribe medications … at least not in the State of Virginia. There is a subset of psychologists who might be applying in different states for licensing privileges, but that’s controversial and not widespread. So, that’s the essential difference.
John Whitbeck:
Okay. And do you do psychological testing as a psychiatrist?
Dr. Sumit Anand:
No, that’s not my area of expertise. I review the results, I try to correlate them with my own clinical findings. That’s the recommendation of anybody who does psychological testing; that you want to correlate what we call the actuarial tests with the clinical findings you find in the patient in front of you.
John Whitbeck:
And let me ask you this. If you are doing forensic work, do you ever perform mental health or psychiatric evaluations of individuals for litigation and different processes?
Dr. Sumit Anand:
Absolutely. I mean, basically, when you’re doing forensic work as an expert … Is that what you’re asking?
John Whitbeck:
In other words, I’ll have cases, and many of the listeners to this podcast who are attorneys and litigants have been through psychological or mental health evaluations by a psychologist where there’s psychological testing, and then of course you did a mental health or psychological evaluation where there wouldn’t be psychological testing because you’re not a psychologist, what is the key difference? If you’re doing a mental health evaluation as a psychologist versus a psychiatrist, other than psychological testing, are there any key differences between the process for both of those?
Dr. Sumit Anand:
There are some key differences. They’re very similar in some ways. For example, diagnostically we would use the same diagnostic rubric, which is the Diagnostic and Statistical Manual, which is compiled by the American Psychiatric Association. So, I’m obviously a psychiatrist, and psychiatrists are medically trained, so we, both psychologists, therapists, and psychiatrists, all use the DSM for diagnostic purposes.
In terms of the evaluation, again, these are similar. We’ve got similar background history. I think, me being a medical doctor, I would zero in a lot on medical history such as head injuries, seizures, co-existent medical problems such as thyroid disease or anemia or … to the extent that they’re relevant to what symptoms the patient’s presenting, or the problem behaviors that are presenting. So, that’s relevant there. A psychologist wouldn’t typically comment on those or would do so very cursorily compared to a psychiatrist in the area.
And of course, medication history, what medications they’ve been on, how they work, whether they’ve been responsive, the doses, things like that that a medical doctor obviously would be more attuned to by virtue of their training.
John Whitbeck:
Right. Right. Well, let’s get into the topic for today, which is bipolar disorder. This is something that I see all the time in my practice, and I’m sure everybody knows somebody who’s suffered with this disease, or suffers from it. I’ve had many, many colleagues in the past, and clients that, through medication and perseverance, have overcome it and controlled it and live very normal lives, and other unfortunately have been just enslaved by it, which is a really, really terrible situation for a lot of folks, and so definitely want to cover this.
Tell us, if you will, Doctor, just this 30,000-foot view, what is bipolar disorder as you understand it?
Dr. Sumit Anand:
Bipolar disorder belongs to the category of disorders called mood disorders. It’s called bipolar because there are two poles classically. One pole is the depressive end, whereby you meet the criteria for an actual depressive disorder, so that would be at least two weeks … This again is defined by the DSM, which is the manual we use for the criteria for diagnosis, and that’s revised every seven to 10 years.
But, classically, the 30,000-foot view, so to speak, is that it’s a mood disorder characterized by two poles. One end is the depressive end, and the other one is the manic or hypomanic end.
Now, depending on the severity of each of the poles, and which presents first or second, that will determine the subtype of the bipolar disorder. For example, there’s Bipolar I Disorder, which is the more kind of classical extreme presentation. Patients who are diagnosed with Bipolar I Disorder will typically end up in the hospital because their symptoms are simply so severe. If they’re manic, their mania will be so severe in their behaviors that they may end up even being psychotic. They’ll certainly come to law enforcement attention, or they’ll be involuntarily committed to the hospital, unless of course they agree to go to the hospital, but typically their judgment is going to be so off by that point, their symptoms so severe, their behaviors so out of control that they will end up being hospitalized.
Now, that’s oftentimes used as a criteria for Bipolar I Disorder. So, their depressions could be similarly very, very severe whereby they have classic withdrawal and aren’t eating properly, they’ve lost weight, they’re very withdrawn, they hardly talk. It’s worrisome, and oftentimes it’ll come to attention of families who will call emergency psychiatric services, or even law enforcement if, for example, they attempt to commit suicide. So, that’s Bipolar I Disorder.
More common than that is Bipolar II, where you will have less extreme versions of that, whereby someone is just merely energized as opposed to thinking they’re a king or a president. They’re merely energized and in a good groove. And we could talk about, again, some of the subtleties as we go on.
So, those are the two broad different types of bipolar disorder. They may have anxious features. They have what we call mixed features. Sometimes they’ve got mixed anxiety and depression. That could be hard to tease out, especially from anxiety. Imagine how anxiety and hypomania or mania could look very similar, because the patient can look very energized and antsy.
So, that’s why we take histories. That’s why psychiatrists sit down with the patient to get a proper history, to get a better feel for, “Okay, what are we treating here, and what subtype could it be?” Hopefully that answers your question from the balcony, as it were.
John Whitbeck:
So, if you’re looking to diagnose someone with bipolar disorder, what are the traits or attributes that somebody would exhibit that you would be looking for to make a formal diagnosis?
Dr. Sumit Anand:
So, it’s controversial actually, because oftentimes bipolar disorder doesn’t present with classic mania. And let me define mania. Mania is defined as increased activity, what we call goal-directed activity; walking fast, talking fast, not needing to sleep. It’s different to insomnia. The patient doesn’t feel the need for sleep for at least four to five days, along with what we call … They’ll describe subjectively what they call racing thoughts. That can be hard to tease apart from an anxiety symptom sometimes, because patients can be ruminating or worrying. That’s not the same as racing thoughts, where they’re literally going at 100 miles an hour, their thoughts, if not more. So, they’re kind of full on. The Energizer Bunny caricature is often used to describe people when they’re in a manic phase.
So, to diagnose bipolar disorder confidently, you want to be able to see at least one manic phase. And the reason I mention this is because oftentimes that won’t occur until people are in their late 20s, perhaps even their early 30s, yet in their adolescent years they may have a depressive episode. It’s hard to predict the future, as it were, to foretell things, but you could be triggered for depression in your early 20s and suddenly you have a manic episode. Or, you could be treated with an antidepressant and you could switch to mania. You can’t foretell these things. But, classically, you want at least one manic episode to be able to confidently say, “This person has bipolar disorder,” whereas depressive episodes alone don’t cut it, so to speak. But, we also know that manic symptoms present later in the lifecycle, and depression presents earlier.
Does that give you a rule of thumb of how we do it?
John Whitbeck:
Other than the timing though, if you were experiencing a depressive episode as a result of bipolar disorder versus depression, how do you tell the difference? How do you say, “Well, this is bipolar disorder versus just depression”?
Dr. Sumit Anand:
They’re indistinguishable actually, clinically. They would look the same. The question would be the timing of it. If you had a depressive episode after you had a manic episode, clearly that would be the bipolar swing into depression, whereas if you’d not had one, then you can’t just say that that is a bipolar depression at the outset. Do you see what I mean?
John Whitbeck:
Right. If you are somebody who has experienced depression in the past and then have a manic episode, is it possible to have a dual diagnosis where you have depression and bipolar disorder, or is it going to be depression that’s related or because of your bipolar disorder?
Dr. Sumit Anand:
That’s where diagnoses change, and I want to emphasize that, because diagnoses like when you see them on the internet look like they’re set in stone with these strict criteria, but actually the way to diagnose properly, or the manual dictates to, advises to psychiatrists, is that if you have something that’s better accounted for by … that’s the verbiage … If it’s better accounted for by, like a bipolar disorder, then give bipolar disorder as a diagnosis, but don’t give bipolar disorder and depressive disorder at the same time. It’s not supposed to work that way. It’s not supposed to be given as an additional diagnosis. It would trump a depressive disorder, because you’d have that as part of the bipolar disorder. Does that make sense?
John Whitbeck:
Right. Right. So, if I were to be experiencing, whether it’s mania, depression or whatnot, are you evaluating whether I have bipolar disorder based on the way I present to you as the patient, or are you relying primarily on ancillary information, like say a friend or loved one or someone else telling you what they’ve seen?
Dr. Sumit Anand:
That’s really interesting actually. Do you remember the Frosties advert where the guy [inaudible 00:15:08] he says, “I’m doing great!” If you ask a bipolar disorder person in the midst of a manic or hypomanic episode, “How are you doing,” well of course subjectively they feel great, because they’re euphoric. They’re on a high without drugs; and you have to tease that apart sometimes, too, because that can complicate the picture. But, you are looking for both subjective accounts … because a patient will tell you how they feel … and you’ll get a flavor.
Doctors don’t make diagnoses based just on criteria, they’re basing it on the totality of what they’re seeing in front of them, right? If you’re seeing a patient who looks highly energized, who’s on a roll, who’s planning to do this, that, and the other, who’s difficult to interrupt in conversation, you can’t get a word in edgeways, they haven’t slept for three or four days in a row and they don’t feel the need to sleep, you are getting a flavor of mania loud and clear.
Now, of course you have to back that up with what others may be telling you; that he’s changed, he or she has changed from their usual functioning. They used to be very calm, collected, logical, clear; now they’re on this roll. What’s happened to them? They haven’t slept in days. Their room’s a mess. They haven’t taken care of themself. You know, something’s changed. They’ve spent large amounts of money on a credit card. They’re highly sexualized. These are observations that they may or may not, because they’re so distractible, they may or may not tell you. They may not remember half these things because their mind’s whirring away at a thousand miles an hour. But the relatives, the spouse, the person who lives with them, the person who’s bringing them to your attention will say, “Hey, something’s wrong here.”
Now, that’s really good to marry up those two bits of information to say, “Okay, that’s a manic episode,” right? Now, DSM allows you to make the diagnosis of bipolar disorder there and then, once you’ve seen one manic episode. In Europe they do it slightly differently with the ICD-10. I don’t want to get into diagnostic controversies here, but essentially, if you’re going to be diagnosed with bipolar disorder, you want to see at least one manic episode based on what you’ve seen, what the patient’s telling you, and collateral information from people who know the patient well.
John Whitbeck:
Right. Right. So, when you get there and you actually diagnose it, what’s the treatment?
Dr. Sumit Anand:
Well, it depends. It depends how severe. If it’s a Bipolar II and it’s mild it may not need hospitalization, it may just need mood stabilizers to kind of bring you back to neutral, the mood to be neutralized, and that can occur with various different mood stabilizers. Your people have probably heard of lithium, they’ve heard of Depakote, they’ve heard of Lamictal; these are mood stabilizers that don’t kick in immediately. They actually take at least a couple of days, if not a couple of weeks to kick in properly, but it may be all that matters if you have a very mild, sort of a Bipolar II Disorder.
Now, if you’re really delusional, psychotic, thinks you’re president or king of the world and you’re tearing down walls and driving at 100 miles an hour, you clearly need to be hospitalized. Now, when you’re … And I’ve worked in hospitals, of course. When you’re hospitalized, you need immediate tranquilization. You may need the high-dose benzodiazepines to really calm you down, and in conjunction with maybe the mood stabilizers, now we use antipsychotics, which also have mood stabilizing properties. People have probably heard of Zyprexas and Seroquels and antipsychotics with mood stabilizing properties. So, those are used acutely in the hospital, and then you bring those doses down to what we call maintenance doses, and you may even discharge the patient from the hospital with such medications; not with the benzodiazepines typically, like your Ativans. Those are only used acutely.
So, that’s for a manic episode that you would treat, depending on the severity.
John Whitbeck:
And, I mean, there’s all kinds of medication out there that I’m sure people are familiar with, but what would be the typical medication treatment that would … What medications would be used?
Dr. Sumit Anand:
There really is no typical treatment. I mean, every medication has its reputation. For example, lithium is particularly good … It’s a very old medication actually, but it’s particularly good if you see maybe lots of aggression in people, because people can present with aggressive behaviors as well in a bipolar manic episode, for example; severely irritable. Lithium has a particularly good reputation for that, for aggression, per se. Depakote, on the other hand, has a reputation for being more calming, or if someone has what we call rapid cycling … in other words, if they’re having three, four or more episodes a year, they’re having it so many times a year … Depakote has a good reputation for rapid cycling episodes. It’s also more calming. It helps people sleep more. Lithium doesn’t have any sedative effects at all. So, you oftentimes tailor it to what you’re seeing, using the reputation of the medication in that direction so that it all helps together, as it were. But then, all mood stabilizers in theory could be helpful. So, that’s how physicians typically make their choices.
I use Zyprexa, which is an antipsychotic with mood stabilizing properties if someone’s so agitated and anxious and they’re not sleeping, as part of maybe a mixed episode, or they’re so hypomanic they just can’t … they’re too restless, sometimes you need that sedative effect to help them sleep, so I’ll use that. And then I’ll lower the dose and discharge the patient from the hospital with that.
John Whitbeck:
Wow. Where I see this most is obviously in the mental health and sort of the crisis cases that I deal with, but I certainly see this a lot too in domestic relations, divorce cases, custody cases where one of the parents, or even sometimes the children, older children, suffer from bipolar disorder, and it can become the key issue, or a major issue in the case. It’s very serious. And one of the things that I’ve always told the folks that I know that are going through this that suffer from bipolar disorder, in terms of treatment and whatnot, is to be proactive, “You’re going to lose custody of your children if you don’t do something about this,” or, “You’re going to make this divorce a heck of a lot harder if you’re not … ” And very often, folks with bipolar disorder, that I’ve experienced, that were my clients or whatnot, have been able to carry through the fog of it and actually proactively go help themselves and get treatment and whatnot.
And I always found it interesting, because most of the time it’s, someone with bipolar disorder doesn’t think there’s anything wrong with them. Is that probably a function of a more mild case, or is it possible to have the kind of insight and self awareness with a severe case where you can say, “Yep, I know what’s happening to me, but I can’t control it”?
Dr. Sumit Anand:
It really is so patient dependent. I mean, I’ve seen patients who are so self aware they will not stop their medications. Other patients, they live in denial that they have a mental illness, because for them it’s stigmatizing, or for whatever reason they feel ashamed of having a disorder or a need to treat it, or they feel they can kind of white-knuckle it. You know, people have different attitudes toward mental illness, so that affects whether they stick with their medications or not, because these are lifelong disorders, and if you have a patient whose insight is not great, what you’ll find is they’ll stop, they’ll start, they’ll stop, they’ll start, and there’s typically a link between when they stop their medications and when the symptoms came back, similar for many diseases; diabetes, hypertension. Bipolar disorder is no different in that respect. If you don’t take your medications, they’re not going to work and your symptoms will come back.
So, yeah, it does very much depend on the patient as to how seriously they are proactive, like you said. For example, many proactive patients will make sure their sleep cycle’s not off. They’ll make sure they don’t have anything disinhibiting, like your marijuanas or cocaines or alcohols that could really tip off their moods. So, you’ve got to be proactive about managing any of this, including bipolar disorder.
John Whitbeck:
Well, Doctor, thank you so much for this overview. It’s been extremely helpful and informative. Can you think of any interesting stories or situations you’ve found yourself in involving bipolar disorder over the years that you might want to share with our listeners? Any kind of war stories you’ve got on this?
Dr. Sumit Anand:
I think my take as a practitioner … I mean, I’ve seen a lot of bipolar disorder. What I’ve seen is either under-diagnosis or over-diagnosis, or misdiagnoses. And this is not unknown, because remember, it’s evolving over the course of a lifetime. So, just because you’ve seen someone at 18 or 25 and they diagnosed you with this, and then they changed and diagnosed you with that, or schizoaffective disorder, or depression, or an anxiety disorder, doesn’t necessarily mean that they were a bad clinician, it means that they may have just caught you in a snapshot in time.
The flip side, however, is this: I think bipolar disorder has entered the public vernacular. In other words, you’ve seen people use it in the movies, you’ve seen people use it in the news, and I think it’s bandied around as a term without as much thought as should be given to it, or respect, as it were. And I say this because the public will come to me and say, “Oh, he’s got mood swings.” I’m like, “What do you mean by that?” “Oh, well, he’ll go from zero to 60 and be very irritable.” Yeah, irritability can be a sign of bipolar disorder, but it can also be a sign of lots of other things … ADHD, anxiety … so, when Spouse A or Spouse B is accusing so-and-so of being moody or bipolar, they’re bandying around a term they may not really fully appreciate.
And especially in teenagers, this is a controversy our profession went through in the 2000s. Bipolar disorder in teenagers was diagnosed 8,000% more in the United States, more than anywhere else in the world, and that’s because it was being applied too liberally for that age group where developmental issues where not being considered. Now, we’ve since pulled back on that, and the diagnosis has been kind of revised in that age group. So, what I’m saying is we need to treat this disorder with the respect it deserves, and be very careful about the criteria that are being used. There can be atypical presentations. And really, you’ve got to know that patient, right? Your doctor has got to know you through ups and downs … and anxiety could be in the mix … to be able to properly diagnose this and treat this, because all our [inaudible 00:25:43] medications are often used for things that … off label. We use, for example, the atypicals for treatment of … low doses of those for treatment of anxiety, for example. That doesn’t mean, just because you’re on a mood-stabilizing agent, that you have to have bipolar disorder.
So, the flip side is true. Underdiagnosis, misdiagnoses … You really have to work carefully with your doctor to give them all the nuances that you’re going through, so you can feel confident that you’re on the right medications and doses.
John Whitbeck:
Absolutely. Doctor, thank you so much for that, and let me just end with this. You do treatment as well as forensic services, so I’d like to give our listeners an idea how to get ahold of you. Can you give them your contact information, where you’re located, how to find you and whatnot?
Dr. Sumit Anand:
I work full-time at Ashburn Psychological and Psychiatric Services, and they can contact that practice. I believe the contact number is (703) 723-2999, and if patients wish to email for an appointment or consultation, they can email APS … That’s A for apple, P for Paul, S for sugar … APSofficemanager@gmail.com, and that’s how you get ahold of myself and other clinicians. I think there are 17 clinicians at my practice, so I think we’ve got a wealth of expertise there that can hopefully be of help to others in the community.
John Whitbeck:
Very good. Well, Doctor, thank you so much for joining us. We look forward to having you back on again soon.
Dr. Sumit Anand:
Thank you so much. It was a pleasure. Take care.
John Whitbeck:
The Mind Itself podcast is unique in that we look at the intersection between mental health and the law, and how it impacts you. Subscribe on iTunes, Spotify, Google Play, or wherever you listen to podcasts, and be sure to leave a comment, rate and review, and share with someone you know. Thanks for listening.
Listen to this episode of the podcast HERE.
To learn how our team can help you, contact WhitbeckBennett by calling 800-516-3964 or emailing clientservices@wblaws.com.
Related Podcasts:
CONTACT US