Dr. Roach: There are different forms of bipolar
Dear Dr. Roach: Is it possible for a person to reach the age of 70 and just now be diagnosed with bipolar disorder? Are there degrees of impairment, like with autism — some worse than others?
Dear C.S.: The hallmark of bipolar disease is mania. “Mania” has a specific meaning in psychiatry: It’s a very elevated mood, associated with high amounts of energy and an inability to think clearly, especially to see the consequences of one’s actions. Some common features of people in a manic episode include an inflated sense of self-worth, distractibility and racing ideas. People can be very talkative and feel little need to sleep. Dangerously, people in a manic phase can spend large amounts of money and have many sexual indiscretions.
All diseases have a spectrum of severity, and some are quite wide. With bipolar disease in particular, however, there are four distinct forms of the disease. Bipolar I is the classic form, once called “manic depressive illness,” where people have episodes of mania, alternating with periods of normal behavior or depression. People with Bipolar II have depressive episodes and some “hypomanic” episodes: periods of high energy (and sometimes profound productivity), usually without the negative aspects of the “full” manic episode. Cyclothymia is a rapid cycling between hypomania and mild depression. There is a fourth type, “unspecified,” where people have abnormal mood elevations but don’t meet criteria for the other types.
Bipolar disease usually has its onset in early adulthood, but sometimes in teens or even childhood. However, I have rarely seen bipolar disease diagnosed in someone as old as 70. It isn’t always clear whether the disease is just manifesting that late, or whether it has been around for many years, but compensated for by the person. Some people don’t interact with a lot of family or friends, and manic or hypomanic episodes might be missed. It’s possible the 70-year-old in question has a quite mild form.
Treatment for bipolar disorder can dramatically improve the quality of life of the person and of the family and friends affected by the illness.
Dear Dr. Roach: I’m confused! When I go to medical offices, I’m sometimes offered an appointment with the physician assistant. I don’t want to be seen by just the assistant who takes my blood pressure. How do I make sure that I’m seeing a provider who can take care of my problems?
Dear N.B.: I think you may be confusing a medical assistant with a physician assistant. Although the names are similar, and although both play an important role in a medical office, a medical assistant takes brief medical histories and vital signs. He or she may also have other valuable clinical and administrative roles, depending on the office.
By contrast, a physician assistant is a licensed clinician who is capable of providing care largely independently: diagnosing and treating the majority of illnesses and chronic conditions in primary care settings while working with a supervising physician. Other PAs work as part of teams in specialty settings, surgery suites or inpatient hospitals. PAs have extensive training, in many ways very similar to the training doctors receive. PAs are held to the same standard of care as a physician.
As a general internist, I need to be careful about practicing within the scope of my competence. I would never prescribe chemotherapy or attempt surgery beyond minor office procedures. A physician assistant also needs to be aware of practicing within their own level of competence, and just as I would do, a PA should refer to a physician when appropriate.
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