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Ask the Mental Health Expert Archives 2001-2004

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Bipolar Nurse

Q. I work with a nurse who has bipolar disorder. She has said that she sees demons and that they look as real as you or I when she begins to see them. Does this sound like bipolar? I thought that visions such as this sounded more like schizophrenia. She has been getting electric shock treatment 3-5 days a week for the last 3 months and will be returning to work this week. Is she safe to work with and also is she trustworthy as a health care provider? I have to work with her alone and feel the facility I work for is scared to fire her for fear of being sued because of her mental health problems. Can you help?

A. No--visual hallucinations do NOT sound like classical bipolar disorder. In fact, visual hallucinations always raise the question of some organic cause, such as complex partial seizures, alcohol withdrawal, use of hallucinogenic drugs, brain tumor, etc. Absent those, some individuals with histories of severe abuse or trauma--usually also with severe character pathology--sometimes describe such dramatic and frightening visual hallucinations.

Although auditory hallucinations (hearing voices) are far more common in schizophrenia than are visual ones, the latter do sometimes occur. It is also possible that this individual may have some type of schizoaffective disorder, which straddles the categories of bipolar disorder and schizophrenia.

Your second question is much more difficult and requires a good deal of caution and tact. In my view--and also in the view of the Americans with Disabilities Act (ADA)--having a psychiatric disorder per se should not be reason to fire an individual, or to refuse to hire that person. In fact, it is illegal to discriminate in that way, and no doubt your facility is acutely aware of this.

There are thousands of individuals with serious mental illnesses--including bipolar disorder and schizophrenia--who are able to work part- or even full-time very responsibly. The question thus becomes: what is the evidence that this nurse cannot do her job effectively, even after reasonable accommodations have been made for her mental illness (as per ADA requirements)? If the answer is that she can do her job reasonably well, then her simply having the disorder is no reason to fire her--or even to feel unsafe working with her. Having a mental illness, as I'm sure you know, does not render someone unsafe or untrustworthy.

On the other hand, if it is clear that this individual is actually responding to visual hallucinations at work, such that she is distracted or unable to concentrate; or, if she demonstrates in any way that she is an acute danger to herself or others (by, for example, lunging at a patient whom she identifies as a demon), that's an entirely different matter. That degree of impairment clearly cannot be tolerated in the work place, and even the ADA (as most courts have interpreted it) does not require an employer to retain such a grossly impaired employee.

But keep in mind: the notion that people with schizophrenia or bipolar disorder are inherently dangerous or violent is largely a myth--though when substance abuse complicates the picture, the risk of violence does increase substantially. I think the best thing to do is to discuss these issues with your supervisor, confidentially, if you are concerned about your own safety or that of the patients. But otherwise, it's probably best to give this individual the benefit of the doubt, and to be as supportive to her as you can be.

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June 2003

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