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Doc Changed My Dx Without Saying Anything


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Ok, I'm not getting upset.

This is probably not a big deal, because I think I know the basis. But saying the words of the dx sounds bad. This is where undisputable crazyland territory begins, right?

Previous dx: 296.4x BPI, manic, moderate following my April episode

Today: 296.80 Manic-Depressive Psychosis, NOS

The pdoc hasn't said a thing. The only way I picked up on this was that she ordered routine labs, and I noticed the ICD number looked odd on the form.

Last month I mentioned that the sudafed I take occasionally for my allergies had made me hypervigilant, with strong startle response from various sounds in the building and parking lot. That during a week long incident recently I was increasingly afraid someone was going to come into my apartment, and that I kept mentally preparing where the closest knife or pistol was. And on the last night that I ended up having to back up the stairs to bed because I was afraid of the dark. Happens to everyone, right? ;)

Today she spent most of the session discussing that I needed to limit the sudafed (I do), try to reduce my coffee intake (I only drink half a pot), and that getting good sleep seemed to be the most important thing in my staying stable (sigh, no dispute there).

She hasn't changed my meds in over year, and I'm not taking any AP's. I've had to take a small amount of sudafed this week, but these symptoms are creeping in. I don't think that my thinking generally exhibits delusional qualities. Though my frustration level with any job or bureaucratic organization, authority or injustice has become almost zero. I think that is something else.

I think my tolerance to sudafed has been decreasing. Over the last month I realized it is giving me nausea and headaches even at low doses, which it has never done before. Is the paranoia a result of decreasing tolearance?

I'm going to take a deep breath.

- Has anyone else had "psychosis" develop with only a single focus or narrow focus?

a.m.

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hiya am-

i don't know if this is along the lines of what you're looking for, but i never in my life had a psychotic episode until my dad killed himself. then i started having rapid cycling and during my cycles would hallucinate that he was there with me, and i wanted to kill myself desperately to be with him. i had no fear and nothing to stop me from doing it, it was just so brave and cold- i wanted to just do it.

is that what you mean by psychosis frmo narrow focus? it wasn't some general thing that gave it to me, it was his death that put me overboard and made me lose my grip on realilty.

loon

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Well.

My husband is psychotic. Not bad, but he does things that aren't like what is going on with you.

I mean, first of all, according to your post, it has a lot to do with the sudafed. Right? If you weren't on that, your symptoms would go away? The "where are the knives?" and backing up the stairs? You make it sound like, in your post, that you wouldn't experience this stuff if it wasn't for the Sudafed you need to take. That stuff has butt load of caffeine in it. I remember it made my "hair cold" when I took it at work once. ONCE.

Secondly, the "jumpiness". I have GAD, and I'm pretty jumpy. I hate it when people scare me. I startle easily at the shop when people come into my office. And I am not psychotic.

I go back and forth with coffee. About as much as you, sometimes espresso.

My husband on the other hand has had MI issues since he was in his early 20's. He is now in his 60's. He talks to himself. He does this more and more with age and when he's stressed. Sometimes he'll just talk out loud - like I am not there. And he's going on and on about something. Weird. I think stress brings this on. But if he is not occupied, he's talking to someone about something. This is psychosis as far as I am concerned.

He also cries at the drop of a hat sometimes (depression) and we can be ANYWHERE and he'll do that.

He is a delight and he's not BP. But he is psychotic. He has breakdowns every few years. I am hoping we have seen the last of them for awhile.

But see? You are very rational about talking about this and what has led up to it. I don't think Albert could do that. Maybe, but I kinda doubt it. He'll ask me if he was "talking again". I am so used to it that it doesn't bother me. But we can be out with friends and he'll do it. Most of our friends get this.

There was this one bitch woman who he was on a board with. She wanted him off the board because he's smart and was kinda calling her out on the stuff she was doing as director. So she came to me all concerned ;) that Albert might not be well. She wanted to make sure I knew. I knew alright. I knew her job was on the line because of him. And I'm sure she didn't stop with me.

Anyway, I'm kinda rambling. I would ask your p-doc. It obviously disturbs you. And maybe it has a different meaning than you're thinking although I can't imagine what that would be.

Ask her. That oughta settle the situation and you can take the knives out from under your pillow..

Breeze

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You might try stopping caffeine completely. That has helped me a lot mentally. (I know, hard; but do-able).

Also, why would you want to tell your pdoc about a small episode like that? They don't need to know everything! If they did, our diagnosis would always be much worse than it is, and they'd start forcing meds on us that we don't need. Or worse, commit us indefinitely.....so, don't disclose if it could bite you in the ass.

Best wishes ~~

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Thank you ladies, each of you. I truly value your input.

Breeze, Perhaps I'll reduce my coffee further. I've totally quit before for medical reasons, so I can if I have to. To be honest over the last month I have had less of a "need" for it, but end up drinking it just because I made a pot and didn't want to waste it. I'm am incredibly sensitive to stimulants and usually I take a fraction of the recommended sudafed dose.

Mellow, you are probably right about talking to the doc. ;) To be honest the incident happend 3 or 4 months earlier, and at the time, I was so discombobulated I didn't even get around to it in our session. However, I did feel a little unnerved and had wanted to mention it to her. Too my surprise she didn't really even acknowledge my relating it.

LAT: The later initiation after an event is perhaps relevent. Obviously I'll have to see what happens from here.

thanks again. a.m.

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Hi A.M.

You always seem to me, on CB, to be one of the more rational voices and seeing the word "psychosis" in your post kind of gave me a chuckle. Now, what a pdoc thinks is always open to debate, I think...as Mellow said, when we bring something into the therapy session, a pdoc probably wonders why and assumes that it's because it is "significant" and notes it accordingly. So...who knows where that hypervigilance "umm, where'd I put my pistol?" incident figured? Yes?

As for what you put into your system and how it figures into your jumpiness/paranoia/overall-twitchiness picture, well, I have heard from a few places that BP's really have no business eating Sudafed...it's activating. Any other options for your allergic stuff? Anything at all? I know BP's must be able to alleviate snifflies some other way... And caffeine?? Hey now. BP's really ought not take it in if we can avoid it, especially if we suffer from any anxieties or paranoias. I know I do and I went caffeine free years ago...no regrets. These would be my suggestions...but don't smack me for meddling. ;) I just care.

My last meddling...if you think this change in DX is going to mess with your relationship with your pdoc, I would bring it up. Hey, doc, do you really think I'm psychotic? How come? I don't feel like I am. Sometimes I get a little, well, hypervigilant, but I think it was because of this Sudafed and caffeine, but I'm going to cut that stuff out and see how I feel... I wouldn't let this stuff gnaw at you. You're way to level-headed to let this get to you and have your mental health suffer.

Take care, A.M.

~Cat

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Thanks CC.

sudafed alternatives is a sticky wicket. It is almost a unique drug. A stimulant that just so happens to have the unique effect of drying out the mucous membranes of the nose. Try an invent a drug that specific.

One alternative is phenylephedrine, what used to be used Dexeslim as an appetite suppresant. It is also in a combo med for sinusitis called Entex. 10 or 15 years ago I started refusing to take it because it made me scary weird. And this long before I was dx MI.

They introduced a Sudafed PE, with phenylephrine, in attempt to eliminate the meth cookers. I've tried it, and it didn't work. Didn't work. Last month the national orgainization of pharmicists called upon the FDA to withdraw approval, because it turns out that there is no solid clinical studies that it even has decongestant properties. Only 4 studies have been done. 3 showed no efficacy, the 4th, was only slightly better than placebo. Hmm.

My pdoc is a darned good pdoc. Up to date, and she actually gives a damn. We fence about at times, mostly I think with her trying to understand my comments or replies to her comments. The modern psychiatric paradigm is difficult, since you are seen maybe once a month for 20 minutes, and the aim is meds not therapy. So it is often hard for a pdoc to remember who you are, what is going on in your life, and she doesn't have time to have a leisurely conversation of what my life and detailed concerns are. I probably should bring this up and ask her view on this and if it is a limited symptom or if it has broader implications.

a.m.

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Also, why would you want to tell your pdoc about a small episode like that? They don't need to know everything! If they did, our diagnosis would always be much worse than it is, and they'd start forcing meds on us that we don't need. Or worse, commit us indefinitely.....so, don't disclose if it could bite you in the ass.

Erm...welp...y'know, if we don't tell about such things, we may not get help we'll need--sure, once can be an aberration, but it may end up being more than once. me, i told my pdoc once about seeing my fiancee sitting in my office chair--after I'd just left her in the living room. his response? "Well, if it just happened the one time, it's nothing to ne concerned about". Which was nice to hear, because I was concerned.

Non-disclosure can bite you in the ass worse, you know.

Now, then, there's the rub as well: a good pdoc would take the nymber of times, and severity, into account; hell, the DSM-IV clearly delineates between psychoses that are substance induced vs. clearly non-substance induced. If an episode were so directly linked to Sudafed, then it should absolutely not change one's dx; no more than, say, if I got all suicidal after a week-long vodka binge. Or manic after a week-long meth binge. Personally, I would question the diagnosing practice of such a pdoc. (But I'm an asshole...)

ANd if you like coffee, I here there's this thing called "decaf" though I, personally, have never seen the point...

And, furthermore, there is nothing wrong with paranoia, copious guns, knives, other edged, blunt, or makeshift weapons close to hand. or with being too careful. There's a lot of dangerous people in this world.

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it's one thing to suspect bipolar because of bad reaction to serotonin...but quite another to judge by reaction to a stimulant. given enough speed, anyone will get paranoid, jumpy and racy. --> low-threshold to stimulants is not typically an indicator of bipolar. often, med-sensitivity is considered first.

i agree with those who say if you feel differently about the reason for your episode, you should talk to ur doc. as a few have said here already, you are one of the more level people here. and what's so insane about mounting ideas of protection? sometimes external reality is crazier than the pdocs think. maybe your intuition was sensing something.

some ideas (none as good as -ephedrine): saline nasal sprays, neti-pots, vapor rubs, pepper, ...

good luck.

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Oh hello Air Marshall,

Unrelated to sudafed ?psychosis?:

Someone can have a *once only* psychotic episode...

An interesting symptom for "psychosis" can be agitated thinking.

I think paranoia jumps out at psychiatrists...

Sometimes if someone stays up several days, coffee, stress, paranoia & jumpiness occurs.

Psychosis? Then with regular sleep & adequate nutrition, no more nervousness & paranoia.

NOS covers a lot of ground, including (if I am remembering well enough, I do think I am) symptoms due to medical conditions. Chronic, acute, intermittent, transient, whatever. Could be post anesthesia visual or auditory disturbances. Could be medication induced, resolving once the med clears. I don't think it's a big deal. Dx's are snapshots anyway...axis I's I mean, and they can vary. Ok, axis II's...another story.

So you know it's the sudafed, right?

Funny if it were months ago that it happened that pdoc wrote it down at this time. Or maybe I didn't get it right and somehow pdoc thought it was happening with you right now. Oh, I guess you wrote that you'd had a bit of sudafed.

I hope you get to a way of understanding this so that you say, this don't mean a pinch of ***t. And you already know to limit the sudafed...

Repeating myself, I think it's NOS for the medical reason.

Take care AM,

Luli

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Hey, AM,

Seems to me that there must be a lot of subjectivity involved in determining psychosis. You just don't seem to fit the bill. I will chime in with the others in saying that you are incredibly rational and thoughtful, and not just as another nutjob on CrazyBoards, but including most people I know in RL, too.

On the one hand, having to back up the stairs does sound a bit delusional; false beliefs, paranoia, etc., so going by a strict definition, that could be considered as psychosis.

On the other hand, you knew you were being hypervigilant and you knew it was linked to sudafed, and you recognized that you weren't thinking right at the time. That certainly doesn't sound psychotic.

I could understand the change in diagnosis if it resulted in better understanding and treatment. But that doesn't seem to be the case.

I'd ask.

Greeny

And as for the caffeine. I had to give it up during the dark days of never really feeling awake but not being able to sleep either. The best decaf I have found it Peet's. The taste, smell and flavor are wonderful without making you need to check the knives.

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AM I also have a sensitivity to sudafed - though not like yours. Pdoc has told me specifically not to take it with certain meds. But I have those awful sinus headaches. I switched to Guiafen - a mucus thinner, and lots of water. Doesn't work as well but is safe. You might try it if you haven't already. Also the neti pot works well to soothe the sinuses and flush them. All this is harder that taking some sudafed, but....

Sounds to me like the psychosis is med induced (sudafed) and I would ask pdoc to look at it this way. I agree that if I mention something pdoc will take it as really significant and I have to be careful to let him know it was maybe an abberition and I am just mentioning it for the record in case it happens again and to get his take on it.

Good luck

Susie

PS - excuse the typos - I am sleep deprived.

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Just another thought about sudafed alternatives- sudafed made me ridiculously anxiety ridden-panic stricken. I switched to Actifed which is so similar but there is enough differnece that it doesn't freak me out. and it clears my nose.

also -could new dx be a mistake? as you ( or someone) pointed out- pdocs don't always remember details so well when they don't see you often. in any case it is definatly (sp?) worth bringing up with her. always better to know than to guess.

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It's too obvious that it was the sudefed that was the cause and not the bp.

I get like that too, only about going outside in the daytime when I'm sleep deprived. Can't stand people looking out their windows at me so I sneak through back yards which I'm sure attracts more attention than just walking down the street.

Anyway. Think harder. Could she have been going off anything else other than that?

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I have to agree AM, that you are one of the most level headed people on here. You could tell me apples were oranges and I would believe it because you said it was so.

Sudafed fucks me up big time. It makes me manicy, jumpy, paranoid. I avoid it like the plague.

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"my frustration level with any job or bureaucratic organization, authority or injustice has become almost zero"

Hubby gets these phases when he is really manic. We had an appointment at the Social Security office when he was like that once ;) gee was THAT fun having him flip out on this little old lady. Needless to say we did not get our claim taken care of.

"Non-disclosure can bite you in the ass worse, you know."

I am with CNS on this one!

As for sudaphed, it puts me to sleep! But I am weird. The only antihystimine I can take without falling asleep is the cheap Chlortabs you get at Walmart (little yellow pills).

You may want to try a week without coffee and without the sudaphed just to see how you feel.

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Is this something you could ask your pdoc about directly? It might help clear up some of the speculation and stuff. And might be a good opportunity to establish that you would like her to be open with you about changes in diagnosis and the reasons for them.

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Previous dx: 296.4x BPI, manic, moderate following my April episode

Today: 296.80 Manic-Depressive Psychosis, NOS

This is just a thought I had when I read your post:

The fact that you were going for lab work may have been the reason she changed the diagnois code.

Any code that has three number followed by 2 zeros is the lowest reimbursement. Ex. 296.00

The higher the numbers after the decimal point gives more reimbursement.

If an insurance company sees a code of 296.4, they may not cover certain lab test, whereas a code of 296.80 will cover labs ordered.

Insurance companies are very picky about what they will cover. If I diagnose a pt with appendycitis based on clinical presentation and physical exam, insurance will deny payment for a CT. Why? Because they figure if you already know it is appendycitis, why do a cat scan.

If I code it as abdominal pain, then they will cover the CT.

On a side note, if you ever see fatigue as one of your diagnosis (from a med doc), I bet they have ordered either lots of test or an expensive test because the diagnosis of fatigue is a catch all and can be the result of just about any disease, so you have carte blanche at ordering what ever you want.

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That during a week long incident recently I was increasingly afraid someone was going to come into my apartment, and that I kept mentally preparing where the closest knife or pistol was. And on the last night that I ended up having to back up the stairs to bed because I was afraid of the dark. Happens to everyone, right? ;)

I've got six police reports (burglary, B&E), two unreported burglaries, a couple of interrupted B&E,

and window damage indicating at least two other B&E attempts, that all say "It happens"

I think my tolerance to sudafed has been decreasing. Over the last month I realized it is giving me nausea and headaches even at low doses, which it has never done before. Is the paranoia a result of decreasing tolearance?

Maybe not so much "decreased tolerance" as "increased sensitivity"?

Hall's methol+eucalyptus can help nasal irritation too. For full-blown allergy, there's Benadryl,

Claritin, and company.

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Sudafed fucks me up big time. It makes me manicy, jumpy, paranoid. I avoid it like the plague.

ALL of the OTC sleep/decongestants/cough medicines makes me manic. Can others here actually take Tylenol PM or Excedrin PM or even Nyquil? I used to be able to take them all before bipolar really set in! Now what are we supposed to do when we have a sinus infection or cold?

I used to take Nyquil to knock myself out for the whole night and get high while I was sick. Now it does nothing but give me maybe 1/2 hour sleep, or worse, crawl up the walls all night.

Here's a good link on this that explains these medicines thoroughly:

http://familydoctor.org/otc.xml#Cough]OTC Medicines

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So you are laughing to yourself about us all thinking you are level headed? Well, maybe you really are. But I get that you have your ways as well. Backing up the stairs resonated with me. It's not like I think someone is there, but it's possible, and walking backward up the stairs was soothing.

Well I really came over to say I used afrin, hang head over side of bed, one drop in each nostril, while sniffing inward, holding the other nostril closed. Localized effect & very good for drippy schnozzes, sinuses. My doc warned however of rebound drippiness, when stopping the afrin.

It did not have an effect of making me feel speedy or hyper or anything, just nice open air passages! Don't do more than a drip. It's better than an afrin spray cause it really just goes where it is supposed to and not down the throat or inhaled anywhere further...probably has some ephedrine related compound...

LuvLuli

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Since you needed the sudafed so much, how about getting a prescription allergy/sinus med? I use to eat tylenol sinus like candy until I got me some Zyrtec. Now I only need to add regular tylenol or advil when the pollen is really really bad outside.

That much drying of the mucus membranes are bad. Your sinuses are moist for a reason. And you will get rebound problems in you continue taking them that much.

Good luck

Croix

who is allergic to everything outside

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If an insurance company sees a code of 296.4, they may not cover certain lab test, whereas a code of 296.80 will cover labs ordered.

Well I read this, and laughed...maybe this is more appropriate in healthcare sucks, but time for a quick laugh! So Saturday I get a letter from my insurance company (which is great btw)... I went in a couple weeks ago for a lith level blood test. On the scrip for it my pdoc wrote 296.40, bp/ latest/current episode hpyo/manic. They want me to provide proof of preexisting condition, and get in touch with the doc that did the test (got it done at the hospital as per usual) blah blah. Now, this is because of my 2 years of joblessness--had COBRA for 18 months, then like 5 months no insurance then 2 months on another plan then back to these guys, who were my previous insurers. Essentially I'd had continuos coverage (it's complicated) but well I guess their records showed I wasn't covered for the required 12 months previous as needed to be reimbursed for this. Which would be acceptable; I have a letter from the other insurer for just such an occasion.

But it's funny because I also got the statement where they show where they paid, and what my responsibility is, for the pdoc appointment where I got the scrip FOR the lith level test--meaning, they are saying "here, you go to pdoc for your BP 1 med checkup and we'll cover 85% of that appointment, but you have to prove that your BP 1, current or most recent episode manic or hypomanic lithium level (oh and thyroid) blood test was a pre-existing condition".

Funny people, these insurance guys. And I say that, working in state governemnt! Having at one time been told to classify a divorced woman as "never married"!

At any rate, more on-topic...perhaps I should have mentioned earlier: backing up stairs is stupid. put your back to the WALL. Walk sideways up the stairs. Do not expose your back, up or down.

Damn, do you people need paranoia classes? ;)

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For allergies, there is a nasal spray called Nasalcrom that works through physical means, by blocking cells in your nose so allergens can't get to them. My allergy doctor said it's so safe to use they use it on old people and babies. It won't work for severe allergies, but is excellent for mild ones. Since it just blocks cells it has little or no risk of making you manic.

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