Question: Hi,

Please examine file attached.

And, following the thorough examination of the case, please answer the following questions:

(1) Based on the evidence we see, is the hospital correct or mistaken in applying an apparent underlying mood disorder diagnosis to a patient like myself?

(2) Any other commentary?

(3) Any other questions?

Hi,

Please examine file attached.

And, following the thorough examination of the case, please answer the following questions:

(1) Based on the evidence we see, is the hospital correct or mistaken in applying an apparent underlying mood disorder diagnosis to a patient like myself?

(2) Any other commentary?

(3) Any other questions?

Hi, I have provided some attachments. Please review them.

Hi, I have provided some attachments. Please review them.

Hi, I have provided some attachments. Please review them.

Hi, I have provided some attachments. Please review them.

Sending now to the email. Please review. Thanks

Sending now to the email. Please review. Thanks

No symptoms whatsoever.

I am asking for whether you believe that the evidence provided supports such a diagnosis by this institution, or have they overstepped their bounds in rendering such a diagnosis without appropriate supporting evidence and full DSM criteria being met?

Thank you

No symptoms whatsoever.

I am asking for whether you believe that the evidence provided supports such a diagnosis by this institution, or have they overstepped their bounds in rendering such a diagnosis without appropriate supporting evidence and full DSM criteria being met?

Thank you

Dr XXXXXXX

I am considerably surprised at your answer and your position.

Given this, let us examine and scrutinize much more closely the respective evidence and support for each of our two positions, so that we may inevitably reconcile our differing opinions and come to a unified understanding of what the most appropriate course of action for a prudent, reasonable doctor in such a situation would most likely be.

...

(1) First--I ask you to please provide a point-by-point itemization of each piece of supporting evidence that you have clearly identify, which supports the position that it is "beyond any reasonable doubt" that the patient in this case (myself) has a legitimately underlying mood disorder. I will provide my own list to follow--and you are welcomed to rebut and refute each of my own supporting pieces of evidence for my own position as I may do with yours, in an ordered manner until we are left only with those pieces of evidence that were unrefutable. Then, upon reconsolidating them and observing the entirety of what we have, we may both find ourselves to agree on that conclusion which makes the most sense, based on logic.

Thank you for this.

(2) The following is a brief list of my own primary supporting points for my own position, which is the position that an underlying mood disorder is *not* a correct or valid diagnosis:

(a) The doctor writes in the record the following: "[Patient is] well related, calm, cooperative. Patient *not depressed*, *[not] manic*, [nor] psychotic.” Goes on to state, “His aggressive behavior was likely due to alcohol intoxication," which is supported by the earlier observation stated within the same record, that "[the patient]...smells of alcohol." By stating that I am not depressed and not manic, the doctor explicitly acknowledges a lack of evidence and support for a mood disorder diagnosis--or EITHER the underlying OR the substanced-induced variety. (Alcohol-induced "agitation" is not consistent with the overt "mania" phases of mood disorder.)

(b) In the diagnosis for underlying mood disorder (or a diagnosis of underlying mental illness of any kind), the respective DSM-5 criteria ubiquitously, uniformly and consistently states, that, as one of the criteria that must be met in the appropriate diagnosis of underlying disorders, that (--paraphrased), "[for such a diagnosis to be valid] the symptoms [acutely] observed must not be better explained by the effects [either by the presence of or by the withdrawal from] a substance such as alcohol or drugs." Obviously, the presence of alcohol and its clearly manifest effects at the time clouds over a diagnostician's ability to render just about any valid diagnosis of an underlying condition.

(c) The same criteria goes on to state that (--paraphrased), "for the diagnosis of underlying condition to be valid, the symptoms must be observed as taking place for a clinically relevant period of time, usually at least one or two months--and in some cases, as many as six months." The doctors inability to gain any confirmed evidence for any symptomatic disruptions in mood beyond those apparently caused by alcohol at that timeframe (and no confirmed proof or evidence for any timeframe before that).

(d) Generally, to avoid liability, doctors and ERs must show on the record as having offered or prescribed medications for those conditions which are found to legitimately be underlying, such that liability is reduced or mitigated. (Example, a person who is diagnosed with an underlying mental illness but then discharged without being prescribed medications, could reasonably claim that "the doctors found I had so-and-so mental disorder, but did not provide medicine for it and just let me go, thus my disorder became worse and I experienced various forms of damages as a result of lack of treatment via negligence." The important point is this: behaviorally, by the doctor's lack of prescribing any medication, this is an implicit admittance of the fact that no valid, underlying condition actually exists.

(e) The only evidence they had which provided the reason for my own admittance is that police has understood (rather, misunderstood) the claim that relative had made, by reporting that they heard my mother claim that I had an apparent medically-confirmed history (ie, an already-medically-diagnosed condition) of mood disorder and/or bipolar disorder. To this, I have three clear rebuttals:
(i) The doctors never obtained direct testimony from the mother herself;
(ii) The doctors appropriately indicate in the history/narrative at various points in the record that the patient has an "unconfirmed" history of bipolar, meaning that the claim cannot be validated and fully adopted until the status of that claim is upgraded from "unconfirmed" to "confirmed"; and,
(iii) In actual fact and in reality, during the only other prior time that I had ever been under psychiatric care (under voluntary admittance), the disorder of diagnosis of "bipolar disorder" and "mood disorder" was explicitly ruled out--and with the fullest certainly, any miscommunication produced by my mother or any misinterpretation performed by the police in this case, was made in full error and ignorance of the actual truth. ***For proof, I have obtained the record of that original psychiatric stay, and include a picture of the notes wherein the doctors confirm that mood order and bipolar disorder are both ruled out of consideration. I had never diagnosed with such a thing.***

(3) If you were the doctor in this position, before you would produce a final diagnosis, you initially would need to produce a differential diagnosis list, with the most likely possibilities at the top of the list, and the least-likely candidates for diagnosis being either at the bottom of the list, or explicitly ruled out at the outset. Please indicate what your differential diagnosis would be at the outset (with potential diagnoses being presented in the order of likelihood), what you would rule out either immediately or eventually, and which diagnosis you feel you would most likely be left with at the conclusion, to then officially render to the patient.

(4) For reference and comparative purposes: If I were in the place of a medical professional, here is the differential diagnosis list I would provide, with reasoning provided thereafter:

- Agitation/confusion (substance-induced/withdrawal-induced),
- Intoxication of alcohol (-or-) alcohol withdrawal, and/or,
- Mood disorder (substance-induced);
- R/O mood disorder (underlying), and,
- R/O bipolar disorder (underlying)

For the three line items included, they are in the order that they are because the acute effects/symptoms are more apparent than even the suggestion of a "disorder", whether underling or substance-induced. Moreover, the two underlying disorder which are ruled out would be done so on the basis that, by the end of the gathering of all accessible evidence, insufficient evidence of a confirmed nature exists to support a history of mood disorder or bipolar for the patient. However, even if they were not to be ruled out (which is very possible), nevertheless their position on the list would still be on the bottom, behind the more likely entries on the top. Therefore, the top diagnosis would be the ones most likely to remain and be officially rendered, which by their very diagnostic definition must include a ruling-out of an underlying condition. (To paraphrase from authoritative diagnostic criteria: "To diagnose a substance-induced disorder, the observed symptoms must not be BETTER explained by an underlying condition"; in this case, the alcohol does, in fact, better explain the acute symptoms than unsubstantiated allegations of underlying disorder.)

Would your differential diagnosis list, and process of elimination, be any different from mine? If so, how? and why? Please explain and support.

(5) After carefully assessing my points and presentation on the matter, do you find that your assessment of the situation has changed? if so, please indicate.

Thank you for your careful, considerate and thorough response.

-Jonathan

Dr XXXXXXX

I am considerably surprised at your answer and your position.

Given this, let us examine and scrutinize much more closely the respective evidence and support for each of our two positions, so that we may inevitably reconcile our differing opinions and come to a unified understanding of what the most appropriate course of action for a prudent, reasonable doctor in such a situation would most likely be.

...

(1) First--I ask you to please provide a point-by-point itemization of each piece of supporting evidence that you have clearly identify, which supports the position that it is "beyond any reasonable doubt" that the patient in this case (myself) has a legitimately underlying mood disorder. I will provide my own list to follow--and you are welcomed to rebut and refute each of my own supporting pieces of evidence for my own position as I may do with yours, in an ordered manner until we are left only with those pieces of evidence that were unrefutable. Then, upon reconsolidating them and observing the entirety of what we have, we may both find ourselves to agree on that conclusion which makes the most sense, based on logic.

Thank you for this.

(2) The following is a brief list of my own primary supporting points for my own position, which is the position that an underlying mood disorder is *not* a correct or valid diagnosis:

(a) The doctor writes in the record the following: "[Patient is] well related, calm, cooperative. Patient *not depressed*, *[not] manic*, [nor] psychotic.” Goes on to state, “His aggressive behavior was likely due to alcohol intoxication," which is supported by the earlier observation stated within the same record, that "[the patient]...smells of alcohol." By stating that I am not depressed and not manic, the doctor explicitly acknowledges a lack of evidence and support for a mood disorder diagnosis--or EITHER the underlying OR the substanced-induced variety. (Alcohol-induced "agitation" is not consistent with the overt "mania" phases of mood disorder.)

(b) In the diagnosis for underlying mood disorder (or a diagnosis of underlying mental illness of any kind), the respective DSM-5 criteria ubiquitously, uniformly and consistently states, that, as one of the criteria that must be met in the appropriate diagnosis of underlying disorders, that (--paraphrased), "[for such a diagnosis to be valid] the symptoms [acutely] observed must not be better explained by the effects [either by the presence of or by the withdrawal from] a substance such as alcohol or drugs." Obviously, the presence of alcohol and its clearly manifest effects at the time clouds over a diagnostician's ability to render just about any valid diagnosis of an underlying condition.

(c) The same criteria goes on to state that (--paraphrased), "for the diagnosis of underlying condition to be valid, the symptoms must be observed as taking place for a clinically relevant period of time, usually at least one or two months--and in some cases, as many as six months." The doctors inability to gain any confirmed evidence for any symptomatic disruptions in mood beyond those apparently caused by alcohol at that timeframe (and no confirmed proof or evidence for any timeframe before that).

(d) Generally, to avoid liability, doctors and ERs must show on the record as having offered or prescribed medications for those conditions which are found to legitimately be underlying, such that liability is reduced or mitigated. (Example, a person who is diagnosed with an underlying mental illness but then discharged without being prescribed medications, could reasonably claim that "the doctors found I had so-and-so mental disorder, but did not provide medicine for it and just let me go, thus my disorder became worse and I experienced various forms of damages as a result of lack of treatment via negligence." The important point is this: behaviorally, by the doctor's lack of prescribing any medication, this is an implicit admittance of the fact that no valid, underlying condition actually exists.

(e) The only evidence they had which provided the reason for my own admittance is that police has understood (rather, misunderstood) the claim that relative had made, by reporting that they heard my mother claim that I had an apparent medically-confirmed history (ie, an already-medically-diagnosed condition) of mood disorder and/or bipolar disorder. To this, I have three clear rebuttals:
(i) The doctors never obtained direct testimony from the mother herself;
(ii) The doctors appropriately indicate in the history/narrative at various points in the record that the patient has an "unconfirmed" history of bipolar, meaning that the claim cannot be validated and fully adopted until the status of that claim is upgraded from "unconfirmed" to "confirmed"; and,
(iii) In actual fact and in reality, during the only other prior time that I had ever been under psychiatric care (under voluntary admittance), the disorder of diagnosis of "bipolar disorder" and "mood disorder" was explicitly ruled out--and with the fullest certainly, any miscommunication produced by my mother or any misinterpretation performed by the police in this case, was made in full error and ignorance of the actual truth. ***For proof, I have obtained the record of that original psychiatric stay, and include a picture of the notes wherein the doctors confirm that mood order and bipolar disorder are both ruled out of consideration. I had never diagnosed with such a thing.***

(3) If you were the doctor in this position, before you would produce a final diagnosis, you initially would need to produce a differential diagnosis list, with the most likely possibilities at the top of the list, and the least-likely candidates for diagnosis being either at the bottom of the list, or explicitly ruled out at the outset. Please indicate what your differential diagnosis would be at the outset (with potential diagnoses being presented in the order of likelihood), what you would rule out either immediately or eventually, and which diagnosis you feel you would most likely be left with at the conclusion, to then officially render to the patient.

(4) For reference and comparative purposes: If I were in the place of a medical professional, here is the differential diagnosis list I would provide, with reasoning provided thereafter:

- Agitation/confusion (substance-induced/withdrawal-induced),
- Intoxication of alcohol (-or-) alcohol withdrawal, and/or,
- Mood disorder (substance-induced);
- R/O mood disorder (underlying), and,
- R/O bipolar disorder (underlying)

For the three line items included, they are in the order that they are because the acute effects/symptoms are more apparent than even the suggestion of a "disorder", whether underling or substance-induced. Moreover, the two underlying disorder which are ruled out would be done so on the basis that, by the end of the gathering of all accessible evidence, insufficient evidence of a confirmed nature exists to support a history of mood disorder or bipolar for the patient. However, even if they were not to be ruled out (which is very possible), nevertheless their position on the list would still be on the bottom, behind the more likely entries on the top. Therefore, the top diagnosis would be the ones most likely to remain and be officially rendered, which by their very diagnostic definition must include a ruling-out of an underlying condition. (To paraphrase from authoritative diagnostic criteria: "To diagnose a substance-induced disorder, the observed symptoms must not be BETTER explained by an underlying condition"; in this case, the alcohol does, in fact, better explain the acute symptoms than unsubstantiated allegations of underlying disorder.)

Would your differential diagnosis list, and process of elimination, be any different from mine? If so, how? and why? Please explain and support.

(5) After carefully assessing my points and presentation on the matter, do you find that your assessment of the situation has changed? if so, please indicate.

Thank you for your careful, considerate and thorough response.

-Jonathan