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    Dr.G -Questions re:initial dx w/a family history
    skypper posted:
    Hi Doc!
    I hope you don't mind I have 2 topics I'd like to ask about.

    My 1st topic/questions are: When one 1st sees a medical professional like a psychologist and/or psychiatrist for say, they've been quite depressed and it's affecting their life and work/school performance and they have a family history of bipolar disorder, is it accurate to automatically say they have bipolar as well?

    Isn't possible that they may only have uni-polar depression that needs treating?

    What in your opinion are some questions that a patient may want to ask or topics to discuss at an initial meeting to distinguish this?

    Personally, I don't think it's right to assume that if one parent has a mood disorder that to jump to the conclusion that the child must have it as well was an accurate way to clinically diagnose a person.

    I always thought that starting off with therapy would be a good way to distinguish individual issues and then if needed seeing a psychiatrist for medications if needed.

    What is the most common protocol for this in your experience?

    2nd topic: Once someone has been diagnosed and treated for bipolar disorder my understanding is it then becomes a lifelong diagnoses. It seems that once I put that on my medical forms whichever doctor I'm seeing or talking to takes it as gospel and never seems to question or investigate further.

    It then always goes into the medication management game of try this med, try this dose, how is this working for you, ok let's try this instead, let's try adding this...

    So what I wonder is, how do you get a psychiatrist to do further evaluations?

    Although I have never been told by a professional that I have PTSD, I am pretty sure that I do. Does that or could that be what makes finding medications that work well for me more difficult?

    I have tried so many different ones and some worked ok, but the side effects were not tolerable and many did not and I'm about to switch insurance and start all over with new doctors so I though this would be a great time to ask for advice.

    Thank you very much Doc G~!

    When nothing's going right, go left!
    Joseph F Goldberg, MD responded:
    Dear Sky,

    The only way to diagnose bipolar disorder is to verify the presence of a lifetime manic or hypomanic episode, based on the constellation of 8 symptoms that define mania/hypomania (mood elevation/irritability, decreased need for sleep, indiscretions, grandiosity, fast thoughts, fast speech, distractibility, overactivity) which represent a change from someone's usual state. Having a family history can be somewhat helpful (of any diagnosis) can be helpful to support a diagnosis (eg, if dad had schizophrenia, it increases the chances son will too, from about 1% to about 10% -- ditto for bipolar disorder). I would not agree that having a family history of bipolar disorder in itself confers any direct information at all about whether or not someone with depression may also have bipolar disorder. The standard diagnostic system used in the US and Europe also attaches no direct diagnostic relevance to family history.

    When someone has any initial diagnosis it can be tempting for future clinicians to take it on faith that that prior diagnosis was accurate, but that's seldom a good general rule. Diagnoses can also change. A competent clinician does their own diagnostic evaluation. If they neglect to do that then one might say they are being sloppy. A good psychiatrist ought to know how to do a proper diagnostic interview for any psychiatric disorder, including bipolar disorder, without having to rely on the patient for anything other than accurate answers to their questions. It's not the patient's job to train the doctor how to do a diagnostic interview.

    PTSD is a disorder involving an abnormal stress response to a specific situation that threatens their fundamental safety and welfare, and involves specific domains around startle response, avoidance, reexperiencing/reliving an event, etc. There are a number of FDA-approved treatments, usually SSRIs or SNRIs, along with many experimental therapies. Exposure therapy, and sometimes EMDR, are the usual forms of psychotherapy to counteract the symptoms. It is quite different from bipolar disorder, but can certainly co-exist with it or any other psychiatric disorder...and again, requires a careful, thorough diagnostic interview to make an accurate formulation.

    Dr. G.
    snowyowl33 replied to Joseph F Goldberg, MD's response:
    Hi Doc,

    I am curious, the 8 symptoms that you state are used to help dx bp, also seem to be ones that could possibly be associated with ADHD (with the exception most likely with the indiscretions) in someone you didn't know (especially a child for example).

    I realize they are two very different things, but do you ever find they're are times when it's not so clear as to which one it might be, especially where hypo mania is concerned? (obviously I'm not taking about florid mania, or suicidal depressions, but the more in between grayer areas).

    Just curious....Thanks

    People take different roads seeking fulfillment and happiness. Just because they're not on your road doesn't mean they've gotten lost. Dalai Lama
    skypper replied to Joseph F Goldberg, MD's response:
    Thank you for your detailed response, it's quite helpful and informative.

    Now out of these 8 things you've listed (mood elevation/irritability, decreased need for sleep, indiscretions, grandiosity, fast thoughts, fast speech, distractibility, overactivity) say a person has the mood irritability, decreased/disrupted sleep and distactibility only out of these 8, that's less than half and to my untrained self seem to coincide more with unipolar depression even with a family history.
    When nothing's going right, go left!
    Joseph F Goldberg, MD replied to skypper's response:
    Dear Sky,

    One or two symptoms can't be taken out of context from the constellation, just as coughing and shortness of breath alone do not differentiate pneumonia from asthma, or sneezing and a runny nose don't distinguish allergies from a cold. Many experts, including the writers of the DSM-5, identify increased energy and purposeful activity as a key symptom of mania/hypomania, upon which the other symptoms depend. So, decreased sleep is insomnia if you want to sleep but can't and are consequently tired the next day (in depression) versus not needing sleep (and instead doing activities at night, and feeling no fatigue the next day), as occurs in mania/hypomania. Irritability, distractibility, and agitation per se can occur either in depression or mania/hypomania, so we look to the other symptoms (high energy, fast thoughts, euphoria versus low energy, slow thoughts, despair) to identify a syndrome of mania/hypomania versus depression, versus their combination (mixed features).

    There are many things other than symptoms that can help to support, but not make, a diagnosis of mania/hypomania -- including family history, age at onset, recurrence patterns, and response to treatment, among others -- but none of these in themselves equals a diagnosis itself.

    Hope this helps.

    Dr. G.
    Joseph F Goldberg, MD replied to snowyowl33's response:
    Dear Snowy,

    ADHD, by definition, starts in childhood and can persist into adulthood in about half of cases. Bipolar disorder usually starts in late adolescence or young adulthood. About 90% of kids with bipolar disorder would also meet formal definitions for ADHD, but most kids with ADHD don't have bipolar disorder. While some symptoms can overlap (notably, inattentiveness and hyperactivity), bipolar disorder requires other symptoms that ADHD doesn't have -- such as, requiring very little sleep to feel rested, grandiose ideas (eg, "I can fly"), hypersexuality, psychosis ("the phone is tapped"; "I hear God talking to me"), and suicidality, among others. Inattentiveness alone is probably the single most common symptom found in almost every psychiatric diagnosis, and it alone isn't much help in differentiating one condition from another.

    Dr. G.
    skypper replied to Joseph F Goldberg, MD's response:
    That actually helps a lot! Thanks doc, you are awesome for helping us here!

    When nothing's going right, go left!

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