Odd encounter with a sleep physician

[Aunt Jobiska]

Hi - I'm here to complain about a recent encounter I had with a sleep physician! I'd seen her two years ago, purely to fill out paperwork for my health insurance company, and she seemed fine, smiley enough. I then saw her recently, with a sleep complaint, which has nothing to do with my mental health, which is stable. When I saw the sleep physician, she said she wanted to communicate with my psychiatrist. I told her she could tell me what she wanted to know, and I'd ask him to write a letter with that information. I could understand that she wanted confirmation from him that my mental health was stable (as if it wasn't, that could have explained my symptoms) and while I might be peeved that she didn't believe me, that she didn't believe my report that I was well and stable, I could accept that, yep, doctors typically don't believe patients. (My psychiatrist's opinion that I'm stable is based on my reports to him that I'm stable, so it's just a case of him reporting what I'm saying, rather than her taking it directly from me... )

However, the sleep physician also said she wanted to know my diagnosis, and differential diagnosis. Huh? What the **** has the DIFFERENTIAL diagnosis got to do with anything? I told her that the diagnosis was not up for grabs, it definitively was bipolar affective disorder, but she repeated that she wanted to know the differential diagnosis. There is absolutely no way that knowing the differential diagnosis is going to change the way she manages my sleep disorder. (FYI it is schizoaffective disorder, but I have never had mood-in-congruent psychotic symptoms, so I categorically do not have schizoaffective disorder.) This is not her laneway; she does not and never will have anything to do with the management of my psych illness.

This does seem like stigma against bipolar. The only time the differential diagnosis might be relevant is where the original diagnosis is doubtful, and there is absolutely no doubt in my diagnosis. It looks 100% like she doubts the original diagnosis, that's the only reason why the alternatives might be relevant. Illnesses that I DON'T have (the differential diagnosis) have absolutely no relevance to my care. And this is totally not her laneway.

Perhaps refusing to tell her my weight (all she needed to know was it was stable) also contributed to her stigmatising, making it easy to label me a difficult psych patient.

[white knight]

Hi welcome

Reading through your post I must say that it is a topic likely to be outside the levels of knowledge that community champions have as it is a specific topic requiring expertise.

Your option is to remove this judgemental person from your treatment. There is a risk to your stability if it is questioned unnecessarily

Good luck and thanks for writing in

TonyWK

[Aunt Jobiska]

Hi Tony,

thanks for your reply. I was hoping there were other people here who were health professionals (on the boards as consumers, not BB staff) or students of the health professions, who would know what I was talking about concerning differential diagnoses. I don't think there is a risk to my treatment, as there's no way she would have anything to do with my psychiatric treatment, I've been a patient of my psychiatrist's for over 8 years, so there's no way that some random sleep physician's opinion is going to affect his management of me (she's trained in respiratory and sleep medicine, she has no psych training). I think she would accept my psychiatrist's opinion that I am well and stable. If annoying at times 😉

It's more my chagrin that because I have a psychiatric diagnosis, she seems to think that it is up for grabs. If someone had arthritis, I just do not believe she would ask for a letter from their rheumatologist stating their diagnosis and differential diagnosis. She'd assume that they diagnosis was correct. But because it's a psychiatric diagnosis, no, she needs to know the differential. And the differential diagnoses are illnesses that I DON'T have, so are entirely irrelevant.

I will look for a new sleep physician. And this time, ensure that the referral doesn't mention the fact that I have bipolar or the psych meds I take. My GP asked if I wanted bipolar and the meds on the referral, and I said yes, knowing that they could be relevant (specifically, poor mental health could cause my symptoms). But she has confirmed that, stable, my sleep issues are independent of mental health. My psychiatrist has warned about being cautious about telling health professionals that I have bipolar and / or are taking psych meds, because of stigma, which can have a negative effect on the care they provide me, and I've certainly experienced that in the past. Whilst the care she provides me may not be compromised, there was an indication that she treated psych illnesses different to physical ones (seriously, asking for the differential diagnosis is not something you do if you think the diagnosis is legit).

The advice re being cautious about disclosing your psych diagnosis and meds to health professionals only applies to consumers with medical/nursing backgrounds themselves - if you don't have that background, then unfortunately, you must disclose, as it could be important - and hope the health professionals don't discriminate against you.

[white knight]

Yes, I hear you. I have bipolar myself so I’ve had similar experiences.

We community champions are indeed volunteer peer supporters/advisers not professional medical people. Essentially we are on the”front line” of beyond blue forums to guide people towards professional help or offer our own experiences on your topic which as I eluded,is unlikely in your case due to the narrow specialised topic it is.

I wish you well

TonyWK

[Aunt Jobiska]

Thanks Tony, your volunteering is very much appreciated. I definitely wasn't expecting anyone to be here in their professional capacity, but there are plenty of health professionals (and students of the health professions) with psych illnesses, and I wondered if they were on the boards in their unprofessional capacity (in my psychiatrist's words: there are 'shitloads' of nurses with bipolar; and I know a GP). They were the people I was interested in getting feedback from.

My GP agreed with me that there is no legitimate reason that she could think of for a sleep specialist to want to know the differential diagnosis for bipolar. And wrote the referral to another sleep physician that did not mention bipolar or the psych meds I take. Whilst I think the previous sleep physician would probably still have provided competent care, and accepted my psychiatrist's judgement that I am well and stable, I was just uncomfortable with someone who seemed to think they would be involved in managing my psych illness - again, the only reason I could think of wanting to know the differential would be for her to put her oar in and say she disagreed with the original diagnosis, and one of the alternatives was more likely.

Clarification for anyone who is interested: right at the beginning, when a doctor is diagnosing someone, part of the process is that they think of a list of potential illnesses they might have, and then from that list whittle it down to the one illness they actually have. That list of potential illnesses is called the differential diagnoses, and if it comes down to two possible illnesses, then the one the patient doesn't have is called the differential diagnosis. So in psych, if someone presents psychotic to an emergency department, the differential could be drug-induced psychosis, manic psychosis, schizophrenia, brief psychotic disorder... usually a few days / weeks / months later a (relatively) definitive diagnosis is given. Just to give people an idea of the way the diagnosis process works, and how completely unhelpful knowing what the differential diagnoses is for someone with a definitive diagnosis.

[White_Rose]

Dear Aunt Jobiska

Hello and welcome to the forum. You are certainly capable of fighting your battles it seems. My suggestion as I was reading through the posts was to simply find another another sleep specialist. But I see you have already taken steps in that direction.

I do agree with your GP about being cautious who you reveal any mental illness to. I have been through an horrendous time because of this and in the end it was decided I did not have this condition. Too late, the damage was done. Not much you can do with this sleep doctor except move on and be more cautious in future.

If you feel strongly about this incident you can always make a complaint to her professional body, probably the AMA. Otherwise move on. I'm not sure what you are looking for in your thread. I think everyone here would agree you have been somewhat bullied and can complain about this also to her supervising body or complain to Australian Health Practitioner Regulation Agency (AHPRA). They take these things seriously and will no doubt take a statement and investigate. It depends on whether you want to go down this road.

In many ways this is a self help forum. There is a small group of Community Champions, about a dozen, who are charged with ensuring everyone gets a response to their thread. The response can come from any of the many hundreds of other people who post here. We write from our own experiences of mental illness, passing on tips, answering questions when we have the knowledge, offering support and generally explaining various aspects of mental illness as seen from their experience. We also have knowledge of different organisations that may help individual people.

Much of this information can be found by exploring the beyondblue web site. As far as I know there are no professional mental health practitioners who write on here regularly. Having said that many of us do find it helpful to learn as much as possible about mental illness. I think you have investigated your circumstances more thoroughly which sounds very helpful to you.

May I ask if you have a specific question you want to pose? I am unsure what to reply to you.

Mary

[Aunt Jobiska]

Hi Mary,

thank you also for taking the time to reply. You asked if I had a specific question, I think if there was a question, it was: can anyone who has a clinical background think of a legitimate reason why a sleep physician would ask a patient's psychiatrist for the differential diagnosis of their long-established bipolar disorder? As I said, my GP and I can't think of one. (I worked in mental health services, I wondered if there were other people who did, who were here in their capacity as a consumer.)

I think I was also trying to figure out what was going on, because requesting the differential diagnosis is suggesting that my diagnosis is not correct, which is a very odd assertion for a sleep physician, who has met me twice, to make. I can only think reflecting her general attitude to psych illnesses. Really, the only time the differential diagnosis is relevant is when the diagnosis is in doubt. I think that made me wonder what was there about my behaviour which made her doubt my diagnosis? Which is an easy way to induce paranoia!

Her request was not unethical, she did nothing unprofessional. I'm sure my psychiatrist could have politely stone-walled her if I wanted him to, and just told her it wasn't relevant / or it was an established diagnosis, and she probably would have accepted that, and gone on to provide competent care. I just didn't feel comfortable with her. Hence I got a referral to a new sleep physician.

I think that you can get away with not revealing your psych illness to some health professionals, especially if you're not taking meds for it. But there's a possibility I have a sleep disorder that requires medication which can induce mania, so a sleep physician really needs to know about a patient's bipolar before they start prescribing those medications. So if I did turn out to have a sleep disorder that required that medication, I would have to 'fess up and tell the new sleep physician that I do have bipolar. Because at that point, I would want my psychiatrist's opinion on the best way to balance the management of my sleep disorder and bipolar disorder.

[White_Rose]

Hello Aunt Jobiska

Thanks for your reply. It does clarify your first post. I can see the link between a potential sleep problem and a mental illness, in this case Bipolar Disorder. Makes sense. Makes more sense of the sleep physician's query/request. It could be interpreted as her knowing more than your psychiatrist. On the other hand it may be she has experience with other patients re Bipolar Disorder not fitting the sleep symptoms you described.

In any event I wonder why she could not simply write to your psychiatrist and explain the reasons for her request. While my experience may not be completely relevant it is an example. I had breast cancer five years ago and after surgery I had radiation treatment. The radiation oncologist then prescribed a preventative medication. Unfortunately it seems there is a relationship between the oncologist's prescription and the SSRI I was taking at the time which resulted in my depression returning with a vengeance and I became suicidal.

I discovered later when I saw the breast specialist who was monitoring my progress who, as soon as I told her what had happened, said this was a well known outcome with that mixture of meds. As you can imagine I was somewhat put out about it. The oncologist was unaware of the potential effect. I know it's unreasonable to expect all specialists to know how all other meds work with their prescriptions but anything that could produce such a serious effect I thought should be known, particularly as I have a track record of bad side effects from quite a few meds which were listed in my referral.

It may be your sleep specialist merely wanted to be certain of your psych diagnosis before prescribing other medications or to prescribe something that would be safe with any potential different diagnosis. She may have felt that if there was a possibility of triggering an adverse she wanted to be as certain as possible this would not happen. It's a pity she did not explain her reason for the request though it may have been to prevent you being alarmed. Who knows.

I hope that puts a different perspective on the matter and that you fare better with your new sleep specialist. In the meantime please continue to write in here if you find it helpful.

Mary

[Aunt Jobiska]

Hi Mary,

I'm sorry for your experience. I would have expected my oncologist to know the potential interaction between the med they prescribed and depression/SSRI - that's what I pay them for! A breast specialist should have no more specialist knowledge about drug side effects or interactions than an oncologist. It would make me very reluctant to take something unless I had run it past my psychiatrist first. There are some situations where a medication that has severe mental health effects is necessary to treat a life threatening physical illness, but you need to be told that, and given the opportunity to make an informed choice.

I have excessive daytime sleepiness - I'm just sleepy all the time. Could possibly be a symptom of depression, but my psychiatrist and I agree I'm not depressed. Could be a symptom of a sleep disorder like idiopathic hypersomnia. Which is why I'm seeing a sleep physician, to get that ruled out.

Re your suggestion that the sleep physician has had experience of other patients with bipolar disorder not fitting the sleep symptoms described - well that's why I'm there! My sleep symptoms have nothing to do with bipolar disorder. If they were a symptom of bipolar, I wouldn't be seeing a sleep physician. And she acknowledged they weren't. They are symptoms of a sleep disorder, though. And the point of bipolar disorder, is that if someone is well and stable, there are no symptoms. So not seeing any symptoms of bipolar simply means the person is currently well. I have bipolar disorder and a (potentially) completely unrelated sleep disorder. People with bipolar disorder can randomly have all other of unrelated physical and mental illnesses. Sometimes, things might go together - like bipolar and migraines - other times they don't.

Bipolar is actually the mental health condition that is most relevant - due to the capacity of medication to induce mania. However I am wondering, because the medication used to treat a possible sleep disorder is S8 and highly restricted due to drug-seekers trying to seek it, whether what she's wanting to know is does he think I'm a drug-seeker? In which case ask that! that would have possible clinical relevance. Don't ask for the differential. But that's scratching the bottom of the barrel, my GP didn't think it likely.

[White_Rose]

I seem to have expressed myself badly. I wondered if the sleep physician wanted to be certain what she would prescribe would not be harmful or interfere with you Bipolar meds especially if there was a chance your diagnosis may change.

I can see how restricted meds can make a doctor a bit edgy about prescribing them. At the beginning of this year I was diagnosed with multiple myeloma which is a blood cancer. My treatment was to take a number of number of pills and have an infusion every four weeks. One of the medications I was prescribed is extremely expensive and I am thankful I do not have to pay the exorbitant cost. Well there is no way I could afford it. However the haematologist had to ask for permission to prescribe and the prescription could only be filled by a registered pharmacy where the pharmacist has completed some very specific training. I have no idea what but it was quite confusing for me at the time.

The prescription had two repeats but I could not get a new prescription until both repeats had been dispensed. These were definitely monitored. The doctor had to get permission every time I had a new prescription though not as much paperwork as the first time.

I have no idea who or what would be interested in using this medication as I had never heard of myeloma or this medication before. But I imagine the reasoning was pretty much the same as that for your proposed meds. However I understand I will not be needing my medication as it has stopped being effective. Changeover on Thursday to another medication which is a nuisance as I will need to go to the hospital twice a week.

Anyway that is irrelevant to our discussion. I was surprised by the conversation you had with the sleep physician and wondered what she was getting at. Much easier to give a full explanation but not everyone thinks of doing this.

Mary