Quick summary: A physician with no psychiatric history was given a lifelong bipolar diagnosis on the word of an unverified stranger, even though medication side effects and untreated sleep apnoea were driving his psychosis. The error then passed unchecked through seven more hospital admissions and 18 psychoactive drugs, because each new clinician trusted the previous diagnosis instead of repeating the work-up that national guidelines require. For healthcare practice, the lesson is to verify collateral information, review prescribed medication, rule out medical causes such as sleep disorders, and treat worsening symptoms as a reason to question the diagnosis, since a wrong label can damage a patient’s mental health and well-being for years.

An anonymous man arrives at a psychiatric ward, says he is the patient’s cousin, and hands over a handwritten note stating that the patient has bipolar disorder. Nobody asks him for identification, nobody checks whether he is related to the patient, and nobody confirms the diagnosis with anyone else. The note is accepted as fact, and the patient is treated from that moment as someone with an incurable mental illness.

I was that patient.

I was admitted to Santa Clara Valley Medical Center after months of increasingly paranoid behaviour. I had become convinced that a shadowy alliance involving the Chinese Mafia and the Communist Party was monitoring me. While searching for hidden cameras, I had demolished most of my house, leaving only the external walls and studs. I planned to present myself to the FBI and ask for immediate admission to the Witness Protection Program.

By any objective measure I was floridly psychotic. I was also an older patient with no personal or family history of mental illness, and until recently I had been a practising physician at that same hospital. Bipolar disorder usually first appears in the late teens or early twenties, so the sudden onset of paranoid psychosis in someone in his fifties called for a careful investigation. I assumed that was exactly what a psychiatric ward was for.

How the note shaped everything that followed

Less than two weeks before my admission, Valley Medical Center had fired me because I kept trying to bring my paranoid claims to the hospital’s cybersecurity staff. Now I was in what I took to be the best possible place for help, surrounded by psychiatrists and nurses trained in mental illness. I expected to tell my story in full and without being rushed to a physician who would listen.

Instead, Brian, a former family friend, communicated on my behalf and told the staff three things that were untrue. He said he was my cousin, that I had first been diagnosed with bipolar disorder six years earlier, and that I had suffered from depression for three years. None of it was true, and all of it was believed.

I suspect Brian wanted the staff to take my alarming behaviour seriously, and they did. The first diagnosis at Valley Medical Center, which turned out to be the only one, was bipolar disorder type I. The psychiatrists had a fresh patient and no prior assumptions, so they could have carried out the full diagnostic work-up that national guidelines require, including a considered differential diagnosis. They made a snap judgement on the word of an unknown person instead.

What the guidelines asked for

The work-up was not complicated, and following the American Psychiatric Association guidelines might have spared me years of harm.

• Verify the information: Someone could have confirmed who Brian was and whether anything he said was accurate before giving me a diagnosis of a lifelong illness.
• Rule out medication-induced psychopathology: I arrived taking Mirapex and Provigil at supramaximal doses, prescribed because my sleep problem had been misdiagnosed, along with Prozac. At those doses, Mirapex and Provigil were quite capable of contributing to the paranoid, manic state the staff were looking at.
• Rule out psychopathology caused by a general medical condition: I had severe chronic sleep deprivation from obstructive sleep apnoea that had been misdiagnosed and therefore never treated. The signs were already documented, including worsening hypertension, weight gain, memory problems, and cognitive decline.
• Consider the unlikely presentation: I was in my fifties with no history of mental illness, and sudden florid psychosis at that age should have prompted questions before it prompted a label.
• Reconsider the diagnosis when the patient gets worse: When treatment fails, that is a reason to revisit the diagnosis. In my case each episode of deterioration simply led to another prescription.

7 More admissions and 18 drugs

I was taking four psychoactive medications when I was admitted. I left taking the same four plus Risperdal, Ativan, and Depakote, a combination that made pharmacological chaos close to inevitable.

That first stay was followed by seven more hospitalisations, and over six months I was given 18 different psychoactive medications. The more I took, the worse I became. My doctors did not read this as a sign that something had gone wrong. They read it as proof that my bipolar disorder was severe.

The actual causes, medication-induced psychosis and sleep deprivation from untreated sleep apnoea, were present throughout. The original misdiagnosis kept collecting weight as it passed from one doctor and institution to the next, because each new psychiatrist assumed the previous one had done the necessary checking.

Why this matters for other patients

National diagnostic guidelines exist because psychiatric symptoms can be caused by medications, sleep disorders, neurological diseases, and other medical conditions. Skipping those steps may save time, but it is poor medicine, and the cost falls on the patient. If a physician fluent in the language of medicine can be misdiagnosed this way, other patients may well be treated for years for illnesses they never had.

Scott Standage, MD, is a Stanford-trained rehabilitation specialist whose career ended after a sleep disorder was treated as a psychiatric illness. His book, “White Coats and Black Swans”, argues for diagnostic reform.