Expert: Ivan Goldberg, M.D. - 8/8/2010

Question
Short background: My son, now 29 showed signs of social anxiety (shyness and performance anxiety) since early childhood. Still made friends, played sports and graduated undergraduate college with honors. In early twenties (if not before) exhibited a dysphoric mood most of the time. In mid twenties agitation, extreme anxiety and increased goal setting immerged (probably the beginning of mania, but did not recognize it as such at the time. Looking back, symptoms of mania grew his first semester at Columbia Business School and developed into full blown mania with psychotic episodes his second semester resulting in fossilization in PA and and a diagnosis of Bipolar I with psychotic features. He was discharged ten days later with a medicine regiment of 900 mg of lithium and 20 mg of Abilify. He continued therapy at New York Presbyterian Columbia intensive day program where, upon his request, was taken off Abilify, but continued 900 mg lithium, therapy and support group participation. Second hospitalization four months later at St. Luke's Presbyterian for 21 days. Doctors felt that he, most likely, wasn't stabilized after first episode, and that's what led to the second. St. Luke's continued the lithium but added 20 mg of zyprexa. Returning to our home in PA he saw a PHD/nurse practioner who changed his meds to 15mg Abilify along with the 900 mg lithium...with 5 mg of zyprexa to be used as his discretion for anxiety. He is now back in Columbia Business School doing okay except he has  debilitating social anxiety (especially related to class participation and public speaking# and still exhibits dyshoria. His psychologist/nurse practioner has suggested to me that he might have a disphoric personality disorder that would be difficult, if not impossible to treat. I have found no information to support that there is such a personality disorder #dysphoric)

Question: Is there such a disorder, or could it possibly be that his bipolar disorder is still not stabilized? To my knowledge, and from his words, my son never suffered severe depression.

Question: If a person with bipolar disorder still suffers mild mood swings and is dysphoric with social anxiety, can that mean that he is still not stabilized?

Question: Would my son be a good candidate for your practice and what are your fees?

I have spent months searching for the best care for my son, and feel that you seem to be it. I don't know if there is a limit to questions here, but if you can answer a fourth...My son is considering exposure therapy for his social anxiety and I am worried that it might be added stress at this time because he is already very stressed with school. What is your opinion on this?

Thank you so much,

Joyce



My son is looking for someone to treat him in the New York City area, as he feels traveling to PA is too far and also because he feels treatment options will be better in New York. Question:

Answer
Hi Joyce . . .

It is obviously impossible to make a diagnosis based on info transmitted over the internet. A firm diagnosis can only be made after a psychiatric history has been taken and a mental status examination performed.

It is not unusual for someone to have both a mood disorder and an anxiety disorder such as social anxiety. Generally the presence of significant amounts of social anxiety means that the depressive aspect of the illness has not been adequately treated. I would postpone any specific treatment for the social anxiety, such as exposure therapy, until the mood disorder has been adequately controlled.

The diagnosis of a dysphoric personality disorder (ICD = 301.12) is a rare one and much more often people have double depression. A dysphoric depression complicated by periods of more severe depression (and possible mania).

I would be happy to see you son in my private practice. For information about my fees, please phone my office, 212-876-7800.

Best regards . . .

Ivan
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