- The Dangers of Bipolar Disorder Misdiagnosed as Depression
- Bipolar Disorder: Why It’s Often Misdiagnosed
- What does onset of bipolar disorder look like?
- How is bipolar disorder diagnosed?
- Misdiagnosing bipolar depression as major depressive disorder
- Why Trauma-Related Emotional Dysregulation is frequently misdiagnosed as Bipolar Disorder
- Bipolar Disorder and Misdiagnosis
- Why Bipolar Disorder is Difficult to Diagnose
- Misdiagnosis of Bipolar Disorder
- Some conditions misdiagnosed as bipolar disorder
- Overdiagnosis of Bipolar Disorder: A Critical Analysis of the Literature
- 1. Introduction
- 2. Methods
- 3. Rates of Overdiagnosis of BD: A Review of the Evidence
- 4. Factors Involved in the Overdiagnosis of Bipolar Disorder
- 4.1. Personality Disorders as a Possible Confounder in the Diagnosis of Bipolar Disorder
- 4.2. Substance Use Disorders and the Diagnosis of Bipolar Disorder
- 4.3. Attention-Deficit Hyperactivity Disorder and BD in Children
- 4.4. Limitations of the DSM-IV Criteria for Bipolar Disorder
- 4.5. The “Bipolar Spectrum” Concept
- 4.6. Other Issues
- 5. Optimizing the Diagnosis of BD
- 6. Conclusions
- Why Is Bipolar Disorder Overdiagnosed?
The Dangers of Bipolar Disorder Misdiagnosed as Depression
If you suspect that you or a loved one is struggling with bipolar disorder misdiagnosed as depression, it can be difficult to know where to turn. Your existing mental health care professional may not have the resources or training to make an accurate diagnosis and the nature of outpatient care often does not provide opportunities for optimal diagnostic clarity. Residential mental health treatment facilities with comprehensive diagnostic procedures can be the best setting in which to find answers.
At Bridges to Recovery, we understand that healing can only begin when the true nature of your illness has been identified. That is why we offer in-depth neuropsychological and psychodiagnostic evaluations for all of our clients using a range of sophisticated, broad-spectrum tools to achieve diagnostic clarity. Our assessments rely on the most advanced screening tools and assessment techniques available to get a complete picture of your psychological health, personality traits, and cognitive function; these include not only standardized questionnaires that can give important clues about the nature of your depression and identify manic or hypomanic symptoms, but also examining your medical history and conducting clinical interviews with both you and your loved ones. These pieces are crucial to uncovering bipolar disorder symptoms that may not be immediately apparent or recognized by patients themselves; even the exact presentation of your depression can provide invaluable information about whether or not you are suffering from bipolar disorder or unipolar depression. At the same time, we can identify any co-occurring disorders to address the full scope of your needs.
By engaging in comprehensive and holistic assessment, our team is able to gain a detailed and nuanced picture of your mental health early on in the treatment process and craft a personalized treatment plan to guide you toward recovery. The close contact you maintain with clinicians and staff throughout your stay also allows us to continuously monitor your response to treatment and any new behaviors that could have important implications for diagnosis, giving us the opportunity to rapidly reassess your diagnosis if necessary and modulate your treatment to optimize outcomes.
But we also offer more than diagnostic tools and clinical excellence; we provide a warm, inviting atmosphere in which you are valued, supported, and honored. At Bridges, you do not have to be reluctant to share the parts of your illness that have caused you shame. You do not have to be frightened of your diagnosis. Here, you are given the resources you need to unlock your true potential, overcome your challenges, and find joy, stability, and self-acceptance.
Bridges to Recovery offers comprehensive residential treatment for people struggling with bipolar disorder as well as co-occurring impulse control and eating disorders. Contact us for more information about our innovative treatment program and to learn more about how we can help you or your loved on start the journey toward healing.
Image Source: Pexels user Hannah Morgan
Bipolar Disorder: Why It’s Often Misdiagnosed
Bipolar disorder is a mood disorder characterized by dramatic highs and lows — periods of depression alternating with mania, or extremely elevated mood.
Bipolar disorder usually develops in adolescence or early adulthood — the mean age of onset is 18, and between 15 and 19 is the most common period of onset. But the disorder’s first signs are very often overlooked or mischaracterized. At the outset, bipolar symptoms are commonly mistaken for ADHD, depression, anxiety, borderline personality disorder and, in its more severe manifestations, as schizophrenia.
That’s because the first symptoms of this disorder are unusually varied. Only over time does the pattern of alternating high and low moods become clear, meaning that in many cases people with bipolar disorder are left waiting months, or even years, for an accurate diagnosis. And that waiting can have serious consequences, including treatment that’s not effective.
What does onset of bipolar disorder look like?
In some patients, the first sign of bipolar disorder is what appears to be a major depressive episode. Others experience full-blown mania or hypomania — a less extreme form of mania. Still others experience a confusing combination of symptoms called a “mixed episode,” which has elements of both depression and mania.
Here is a closer look at what a first episode might look like:
Depression: When the first episode of bipolar disorder is depression, symptoms can develop slowly, reports Michael Strober, PhD, who is Distinguished Professor of Psychiatry, and Senior Consultant to the Youth Mood Disorders Treatment and Research Program at the David Geffen School of Medicine at UCLA. Bipolar depression usually includes not only the sadness or irritability we associate with depression, but delusions of failure, exaggerated feelings of guilt, mental confusion and profound physical slowness.
Despite these differences, Dr. Strober notes that symptoms of bipolar depression are often misdiagnosed as major depressive disorder early on, because alternating periods of mania (or hypomania) may not appear until months or years later.
Mania: Unlike the gradual descent into depression, when the initial episode is mania the onset can be “like a thunderclap,” says Wendy Nash, MD, a child and adolescent psychiatrist at the Child Mind Institute. An initial manic episode might be characterized by grandiose thinking, risk-taking, accelerated speech and thought, and euphoria or irritability.
It’s not unusual for the behavior to be so extreme that the patient ends up hospitalized — or even arrested. Dr. Nash gives an example of a college student who inexplicably shifts from normal behavior to overdrive: Suddenly he’s up all night, hyper-talkative, loud, and combative, maybe even getting into fights, acting so rashly and erratically that police are called.
In younger children, mania may be misinterpreted as the hyperactivity and impulsivity of ADHD.
Hypomania: Sometimes the initial episode of bipolar disorder is the less extreme form of mania called hypomania, and these episodes are often missed, Dr. Nash notes. The person may be talkative, grandiose, highly productive, a little moody and irritable, but the symptoms aren’t as disruptive or dangerous as in full-blown mania, and patients themselves don’t perceive themselves as disordered.
“Hypomania is trickier to diagnose,” adds Jill Emanuele, PhD, director of the Mood Disorders Center at the Child Mind Institute. “Adolescents with hypomania aren’t as flagrantly out of control as those with full-fledged mania, who can be dangerously impulsive and reckless.”
Mixed episode: Finally, some people with bipolar disorder experience what’s called a mixed episode, which includes characteristics of both depression and mania. In a mixed episode, a patient has a depressed mood but racing thoughts and speech, agitation, and anxious preoccupations — what one patient describes as being over-caffeinated and tired at the same time.
In a mixed episode, obsessive negative thoughts can be misdiagnosed as anxiety, notes Dr. Strober.
Psychosis: Some first episodes of either mania or depression can be so severe they include psychotic symptoms — breaks from reality such as hallucinations or delusions. When this happens, it can be misdiagnosed as schizophrenia.
How is bipolar disorder diagnosed?
A diagnosis of bipolar disorder is based on a detailed history that tracks changes in mood over time; as one expert puts it, think of it as a movie, not a snapshot.
“You need to get the timeline of mood shifts,” notes Dr. Emanuele, “and that takes a very careful diagnostic assessment.” Without treatment, bipolar episodes usually last from several weeks to several months. Periods in between episodes, without symptoms of either mania or depression, can last weeks, months or years.
Interviewing family members or friends can be important, since patients themselves may not recognize manic or hypomanic symptoms as harmful or disordered. Eliciting a family history is also important because bipolar disorder is more common in people who have first-degree relatives (a parent or sibling) with the disorder.
To determine whether elevated or depressed moods meet the criteria for bipolar disorder, a clinician looks for these criteria:
Signs of mania:
- Drastic personality changes
- Inflated self-confidence
- Extremely energetic
- Grandiose/delusional thinking
- Decreased need for sleep
- Increased talkativeness
- Racing thoughts
- Scattered attention
- Psychotic episodes, or breaks from reality
Signs of depression:
- Depressed or irritable mood
- Loss of interest or pleasure in things once enjoyed
- Marked weight loss or gain
- Decreased or increased need for sleep
- Prolonged sadness
- Feelings of hopelessness, helplessness, worthlessness
- Excessive or inappropriate guilt
- School avoidance
- Avoids friends
- Cloudy or indecisive thinking
- Preoccupation with death, plans of suicide or an actual suicide attempt
- Psychotic episodes — breaks from reality
These criteria describe the most severe form of the disorder, called bipolar I disorder. People may also be diagnosed with bipolar II disorder, in which less severe episodes of hypomania replace manic episodes.
One of the most concerning things about bipolar disorder is that the lifetime suicide risk is 15 times that of the general population. Factors which elevate this risk for individuals include the severity and persistence of depression and the presence of mixed episodes, which combine depressive symptoms and the activation of mania.
While medication has for many years been the first-line treatment for bipolar disorder, over the last several decades specialized forms of psychotherapy have been developed to work alongside medication. Research shows that the most effective treatment for bipolar disorder combines medication and psychotherapy.
Medication: The go-to treatment for bipolar disorder is usually a group of medications called mood stabilizers, including lithium and some drugs called anticonvulsants. Mood stabilizers are generally effective at treating manic symptoms and lowering the frequency and severity of both manic and depressive episodes. But the depression is tougher to treat than the mania, and antidepressants are sometimes added to treat bipolar depression. Given alone, antidepressants can trigger manic symptoms, so they need to be prescribed with great care.
Atypical antipsychotics are also used, especially in adolescents, Dr. Nash reports. While mood stabilizers are very effective in adults, she says, in adolescents an atypical antipsychotic is often more effective.
Many people with bipolar disorder take more than one medication and the drugs can have complex interactions, leading to significant side effects if they are not effectively monitored by an experienced clinician.
Therapy: Several forms of psychotherapy adapted for bipolar disorder have been shown to speed recovery from an acute episode of mania or depression, delay recurring episodes, decrease suicide attempts, and increase medication adherence.
“A major challenge to treatment is compliance with medication,” notes Dr. Emanuele, and psychotherapy increases compliance. It also helps people make changes in their lives to avoid triggering symptoms. “Psycho-education helps people manage their lives with the disorder, and psychotherapy helps them deal with thoughts and feelings.”
An NIMH-funded study of bipolar patients found that treatment with one of three psychotherapies along with medication “significantly enhance a person’s chances for recovering from depression and staying healthy over the long term.”
The three therapies are:
- Family-focused therapy (FFT): FFT engages parents and other family members in keeping track of symptoms and improving communication and problem-solving in the home, to avoid spikes in family stress, which can lead to episodes.
- Cognitive behavioral therapy (CBT): CBT focuses on helping the patient understand distortions in thinking and activity, and learn new ways of coping with the illness
- Interpersonal and social rhythm therapy (IPSRT): IPSRT focuses on helping the patient stabilize daily routines and sleep/wake cycles, and solve key relationship problems, to avoid triggering an episode.
IPSRP, the most recent of these therapies, is based on the concept that a healthy person has regular social rhythms — when you get up, eat meals, go to school or work, see other people, sleep, etc. — and bipolar disorder may be caused by those rhythms being destabilized.
IPSRT focuses on helping patients reduce interpersonal stressors and disruptions to a stable lifestyle, in order to forestall new episodes of mania or depression. Patients learn to improve relationship skills and keep regular patterns of eating, socializing and sleeping.
While IPSRT was developed for adults, it has been adapted for adolescents and is especially suited to the latter, notes Ellen Frank, an expert in mood disorders treatment at the University of Pittsburgh who, with colleagues, developed the therapy. Adolescence is a particularly sensitive period for interpersonal turmoil, and adolescents are prone to chronic sleep deprivation and radical shifts in sleep patterns, she writes. “They often have very dysregulated sleep and social routines that would be especially harmful for a teenager with BD.”
Contrary to earlier thinking, research shows that the course of the disorder is no different whether it develops before or after age 18, Dr. Strober reports.
Bipolar disorder is a chronic disorder, but with a combination of medications, psychotherapy, stress-management, a regular schedule and early identification of symptoms, many people live very well with the diagnosis.
Misdiagnosing bipolar depression as major depressive disorder
The therapeutic consequences can be depressing!
A study published recently found a difference in brain blood flow between unipolar depression, also known as major depressive disorder (MDD), and the depressive phase of bipolar I (BD I) and bipolar II (BD II) disorders, known as bipolar depression.1 Researchers performed arterial spin labeling and submitted the resulting data to pattern recognition analysis to correctly classify 81% of subjects. This type of investigation augurs that objective biomarkers might halt the unrelenting misdiagnosis of bipolar depression as MDD and end the iatrogenic suffering of millions of bipolar disorder patients who became victims of a “therapeutic misadventure.”
It is perplexing that this problem has festered so long, simply because the two types of depression look deceptively alike.
This takes me back to my days in residency
Although I trained in one of the top psychiatry programs at the time, I was never taught that I must first classify my depressed patient as unipolar or bipolar before embarking on a treatment plan. Back then, “depression was depression” and treatment was the same for all depressed patients: Start with a tricyclic antidepressant (TCA). If there is no response within a few weeks, consider a different TCA or move to a monoamine oxidase inhibitor. If that does not work, perform electroconvulsive therapy (ECT).
Quite a few depressed patients actually worsened on antidepressant drugs, becoming agitated, irritable, and angry—yet clinicians did not recognize that change as a switch to irritable mania or hypomania, or a mixed depressed state. In fact, in those days, patients suffering mania or hypomania were expected to be euphoric and expansive, and the fact that almost one-half of bipolar mania presents with irritable, rather than euphoric, mood was not widely recognized, either.
I recall psychodynamic discussions as a resident about the anger and hostility that some patients with depression manifest. It was not widely recognized that treating bipolar depression with an antidepressant might lead to any of four undesirable switches: mania, hypomania, mixed state, or rapid cycling. We saw patients with all of these complications and simply labeled their condition “treatment-resistant depression,” especially if the patient switched to rapid cycling with recurrent depressions (which often happens with BD II patients who receive antidepressant monotherapy).
Frankly, BD II was not on our radar screen, and practically all such patients were given a misdiagnosis of MDD. No wonder we all marveled at how ECT finally helped out the so-called treatment-resistant patients!
Sadly, the state of the art treatment of bipolar depression back then was actually a state of incomplete knowledge. Okay—call it a state of ignorance wrapped in good intentions.
The dots did not get connected…
There were phenomenologic clues that, had we noticed them, could have corrected our clinical blind spot about the ways bipolar depression is different from unipolar depression. Yet we did not connect the dots about how bipolar depression is different from MDD (Table).
Treatment clues also should have opened our eyes to the different types of depression:
Clue #1: Patients with treatment-resistant depression often responded when lithium was added to an antidepressant. This led to the belief that lithium has antidepressant properties, instead of clueing us that treatment-resistant depression is actually a bipolar type of depression.
Clue #2: Likewise, patients with treatment-resistant depression improved when an antipsychotic agent, which is also anti-manic, was added to an antidepressant (seasoned clinicians might remember the amitriptyline-perphenazine combination pill, sold as Triavil, that was a precursor of the olanzapine-fluoxetine combination developed a few years ago to treat bipolar depression).
Clue #3: ECT exerted efficacy in patients who failed an antidepressant or who got worse taking one (ie, switched to a mixed state).
A new age of therapeutics
In the past few years, we’ve witnessed the development of several pharmacotherapeutic agents for bipolar depression. First, the olanzapine-fluoxetine combination was approved for this indication in 2003. That was followed by quetiapine monotherapy in 2005 and, most recently, in 2013, lurasidone (both as monotherapy and as an adjunct to a mood stabilizer).
With those three FDA-approved options for bipolar depression, clinicians can now treat this type of depression without putting the patient at risk of complications that ensue when antidepressants approved only for MDD are used erroneously as monotherapy for bipolar depression.
These days, psychiatry residents are rigorously trained to differentiate unipolar and bipolar depression and to select the most appropriate, evidence-based treatment for bipolar depression. The state of ignorance surrounding this psychiatric condition is lifting, although there are pockets of persisting nonrecognition in some settings. Gaps in knowledge underpin and perpetuate hoary practices, but innovative research—such as the study cited here on brain blood-flow biomarkers—is the ultimate antidote to ignorance.
Why Trauma-Related Emotional Dysregulation is frequently misdiagnosed as Bipolar Disorder
At PCH Treatment Center, we are often referred clients who are diagnosed with “Bipolar II” due to poorly regulated or “dysregulated” mood states. Most of these clients are on multiple medications for Bipolar Disorder that don’t seem to be working very well.
Diagnostic criteria for Bipolar II include at least one episode of major depression and at least one episode of hypomania (a less severe form of mania). However, we find that many clients are misdiagnosed with Bipolar Disorder because careful attention has not been paid to their symptomatology. Rapid mood changes or dysregulation is mistaken for “rapid cycling” and is followed by a diagnosis of the mania commonly associated with Bipolar II.
Clients with a history of psychological trauma are also often labeled with “Borderline Personality Disorder (BPD).” BPD is a commonly used diagnosis for mood instability, difficulty in regulating emotional states, and being easily triggered. These are also symptoms of psychological trauma which, in our view, is a more empathic and accurate diagnosis. At PCH Treatment Center, we believe the term “Borderline Personality Disorder” is pejorative and counterproductive to healing. We refer to a client who is experiencing emotional dysregulation or the symptoms related to ‘Borderline Personality Disorder’ as suffering from psychological trauma and treat that accordingly.
In a person with a history of trauma who is easily triggered or dysregulated, it is crucial to properly identify the cause of their internal conflict and avoid disparaging diagnoses. Throughout their life, every individual is repeatedly exposed to disruptive or upsetting events, such as conflict in a relationship, stressful events, or personal criticism or bullying. A person with poorly regulated emotions will react in an exaggerated manner to environmental and interpersonal challenges through bursts of anger and crying, withdrawal, passive-aggressive behaviors, or creation of chaos or conflict. These reactions point to underlying relational psychological issues intertwined with dysregulated emotions and not necessarily Bipolar Disorder.
It is important to carefully dissect out the timeframe of these emotional states and potential triggering events in order to differentiate between trauma-related emotional dysregulation and the symptoms of Bipolar Disorder and reach an accurate diagnosis.
- For example, clients with trauma and emotional dysregulation will have high emotional energy states for short periods of time (even fluctuating within the course of hours or a day).
- This is important to distinguish from a true Bipolar illness, where clients have manic and irritable mood states that last days to weeks to even months in the case of major depression.
- Clients with emotional dysregulation can often identify a triggering event such as the breakup of a relationship, criticism or failure at work or school, or family stress.
- Bipolar Disorder, on the other hand, is a mood disorder with less day-to-day volatility around mood states (though it is often triggered by stress).
When emotional dysregulation is mislabeled as Bipolar II, psychiatrists and physicians treating mental health problems will often medicate their clients in accordance with this diagnosis. Frequently-used medications in the misdiagnosis of Bipolar II include Lithium, antipsychotics, and anticonvulsants (medications initially used for seizure disorders). However, these medications do not effectively treat emotional dysregulation, and psychiatrists believing the patient to have Bipolar II often make the mistake of adding more medications to try to stabilize the client. Because their cocktail of medications provides little to no positive results (and often increasing side effects), these clients become more frustrated and hopeless than before the start of their medication regimen. Psychological trauma and emotional dysregulation are resolved through psychotherapy and other modalities; medication is not the primary treatment modality and it may actually worsen the person’s psychological well-being due to side effects such as anxiety, mental confusion, and other somatic symptoms. The best way to address psychological trauma is through various therapeutic modalities.
At PCH Treatment Center, our psychiatrists frequently take clients off of these unnecessary medications once we have determined the proper diagnosis and treatment plan for those symptoms potentially misdiagnosed as Bipolar II. There are many modalities of psychotherapy that we apply to clients with trauma and emotional dysregulation. Psychodynamic (relational) therapy, somatic therapies such as somatic experiencing, sensorimotor therapy, and Eye Movement Desensitization and Reprocessing (EMDR) have been shown to be useful individual modalities for those suffering from what was thought to be Bipolar Disorder. Trauma groups, trauma timelines, and process groups, along with mentalization and Dialectical Behavioral Therapy (DBT), help clients reach a point where they can regulate their emotions within a normal range and manage their Bipolar-related symptoms.
Trauma-informed yoga, neurofeedback, art therapy and an arts program also provide emotional support for our clients. By addressing core issues, many of which stem from early childhood events, our clients will be equipped with the tools to lead happier and more emotionally balanced lives.
To learn more about how we avoid misdiagnosing psychological trauma-related emotional dysregulation as Bipolar Disorder, as well as the appropriate treatment that they each require, visit our website at www.pchtreatment.com.
Bipolar Disorder and Misdiagnosis
In Mental Health May 17th, 2018
When someone is suffering from symptoms of a mental illness it can often be complex and difficult to identify their specific issues. Many disorders can have similar signs and symptoms and can cross over into one another. For example symptoms of depression or anxiety can occur in a number of other illnesses as part of a greater disorder.
With illnesses such as bipolar disorder, it can often take a number of years for people to get an accurate diagnosis because it is such a complicated and sometimes misunderstood illness. When someone with bipolar disorder is misdiagnosed, they end up receiving ineffective treatment and their symptoms may begin to worsen. Bipolar Misdiagnosis can be disastrous for those who are already suffering from a debilitating psychiatric illness.
Unfortunately, arriving at a diagnosis of having bipolar disorder can be a difficult endeavor because people in the medical field may misinterpret symptoms. There are not yet any biologically based tests that could result in a definitive diagnosis and genetic testing is not yet at the point where it could reliably predict the presence of the disorder. Psychiatrists must diagnosis patients based on their observations when speaking to them and assessing their mental health.
A clinical interview with extensive inquiry along with consideration of as much data as possible is the only way to diagnose a patient with bipolar disorder. However, even a very thorough evaluation performed by a seasoned mental health expert can lead to a bipolar misdiagnosis. Frustratingly for many people, the average time between the initial onset of symptoms and an accurate bipolar diagnosis is as much as ten to twelve years.
Why Bipolar Disorder is Difficult to Diagnose
Bipolar disorder is a complex issue and it is often misdiagnosed for a number of different reasons. One of the reasons why bipolar disorder misdiagnosis is that it has to do with broad patterns that exist over a long period of time rather than individual symptoms that a person might currently be experiencing. A patient’s mood in the present may indicate that they are in state that is temporary and may change within a few months or even years.
People with bipolar disorder have different patterns of mood and behavior that can vary dramatically depending on when they are interviewed. They may go through months and months of severe depression followed by episodes of mania. Their symptoms can vary in duration and in the way they manifest through different episodes.
Bipolar disorder is also hard to diagnose because it often coexists with other psychiatric illnesses so that people experience a layering of different symptoms from other disorders. It can be challenging for a mental health professional to sort out the various symptoms that the patient is experiencing and how they are related to specific disorders. The symptoms the patient has may also frequently change, making it even harder to pinpoint their exact issues.
Most Common Bipolar Misdiagnosis
There are certain mental illnesses which are most often confused with bipolar disorder or tend to coexist with it in one individual. The most common is unipolar or clinical depression which is only one component of a person’s bipolar symptoms. Because people who are bipolar experience long periods of depression and often shorter mania episodes, their psychiatrist may diagnose them with depression and fail to recognize their issues with mania.
When someone with bipolar disorder is thought to have depression alone, they may not be getting the proper treatment to deal with their manic symptoms which can wreak as much havoc on their lives as their depression. They may engage in risky or impulsive behavior during a manic episode and not know how to manage their own actions. Their mania can cause a lot of negative repercussions if it is not treated properly.
One the other hand people with bipolar disorder may be misdiagnosed during a period of mania as having attention deficit- hyperactivity disorder. If they have racing thoughts, excess energy and trouble focusing during their manic episode a psychiatrist may believe that they have ADHD. Although they may appear to have some of the symptoms of ADHD, these symptoms will shift when they enter an episode of depression.
Sometimes bipolar disorder misdiagnosis for people with personality disorders such as borderline or narcissistic personality disorder. Some of the characteristics of these disorders may seem similar to what a bipolar person exhibits at certain points in their life.
It is important for someone with a mental illness to receive an accurate diagnosis in order to get the treatment they need to minimize their symptoms. It can be difficult to recover if you are not receiving the right medication and the best therapy for your specific disorder. If you think you might have been misdiagnosed, seek a second and even a third opinion from a mental health professional.
Misdiagnosis of Bipolar Disorder
Across the web you’ll find increasing attention being given to the identification of bipolar mood symptoms and patterns. Solid educational information is important for those who are concerned that they may have bipolar disorder.
Even the best diagnosticians find that arriving at the diagnosis is a difficult endeavor. We’re not yet at a point where we have easily obtainable biologically based tests that result in a definitive diagnosis. Similarly, we’re far from being able to predict the disorder based upon genetic testing.
We’re still faced with the reality of a mental health clinician sitting with a patient and relying upon clinical interview to come up with a clear picture to identify or rule out the presence of bipolar disorder. Sometimes even with extensive inquiry and careful consideration of the data obtained, clinicians still miss the bipolar diagnosis. It happens even with the most seasoned mental health professionals. I’d be dishonest if I said it’s never happened to me. Longitudinal studies have shown us that the average time from initial onset of symptoms to an accurate bipolar diagnosis is ten to twelve years!
The reality is bipolar disorder is usually difficult to diagnose based on just an initial diagnostic interview with an individual. The diagnosis has to do with very broad patterns that exist over time. When meeting with a patient for the first time, all I’m really able to see is his or her behavior and mood state in the present, which excludes about 90% of the additional information that’s required to ascertain the diagnosis. The acquisition of that 90% relies upon the clinician’s ability to ask the right questions and the patient’s ability to provide comprehensive and accurate answers. Even then, careful attention is needed before the bipolar picture can coalesce with validity.
Bipolar symptoms present in many different forms and patterns. Each individual brings his or her own unique stamp to the clinical picture. We see variance in symptom acuity, symptom duration and symptom manifestations. While symptoms such as elevated energy, decreased need for sleep and accelerated thinking are common to most bipolar elevated mood states, one individual’s hypomania/mania may be evident through euphoria and grandiosity while the mood elevation of another may entail irritability and outbursts of anger. Still a third may manifest his or her symptoms primarily through hyper-sexuality and impulsive spending. Further compounding the diagnostic challenge is the fact that the disorder often coexists with other psychiatric diagnoses such that we get a layering or commingling of symptoms from different diagnoses. The mental health professional is then faced with sorting out what symptoms belong to what diagnoses and how the different sets of symptoms may possibly potentiate each other.
I find that the three diagnoses which are most often confused with bipolar disorder or potentially coexist and therefore interfere with the diagnosis are: 1) unipolar depression, 2) attention deficit-hyperactivity disorder and 3) the group of personality disorders. In this latter realm, the individuals we most often see coming in for treatment are those diagnosed with borderline and/or narcissistic personality characteristics. There are certainly other personality disorders that can come into this mix but we find that individuals with borderline/narcissistic features tend more often to seek psychotherapy. Additionally, some of the symptoms within these two personality types can easily be mistaken as belonging to the bipolar continuum (see previous Bipolar You blog: The Relationship between Narcissism and Bipolar Disorder).
So the question for the remaining discussion is: What are some of the guidelines that help us distinguish between straight depression, attention deficit-hyperactivity disorder, personality disorders and bipolar disorders?
Let’s start with the most common: unipolar depression. More often than not, bipolar disorder begins with episodes of depression. In fact, we may see adolescents go through a few years of intermittent depressive episodes during high school before they manifest the kind of mood elevation which tips the scale towards a bipolar diagnosis.
There may also be some symptoms within the overall depressive profile that can tip us off to the underlying bipolar disorder. I’m referring to things such as periods of feeling energized while also being irritable, angry and very pessimistic about life. With these people, their depressive symptoms have not flattened them out. It’s more like the intense negative feelings are accompanied by a degree of agitation. These individuals may also find that their agitation interferes with their ability to get a good night’s sleep. But, these small clues, in and of themselves do not rise to the level of a bipolar diagnosis. They are just features that should garner our attention and possibly alert us that there is more present than easily meets the eye.
The next essential element is to obtain information about the broader family history of psychiatric diagnoses, and particularly bipolar disorder. If someone comes in presenting primarily with depressive symptoms but he/she has a parent, a sibling, a grandparent or even an aunt or uncle with bipolar disorder, then one has to approach the initial unipolar presentation of depression as if it may part of a broader bipolar disorder. I think of this as “bipolar brewing” where someone has the genetic predisposition but they’ve not yet manifested the full range of bipolar symptoms. In these instances the individual wouldn’t be diagnosed with the disorder simply because of his/her genetics, but the treatment approach would likely be different than if there was no mood disorder evidence in the family background.
The other diagnostic piece that needs to be asked of almost any patient who comes into treatment is: “What is your mood and behavior like when you’re feeling really good?” To take that even further, the individual should be asked, “Does your mood ever become more intense or more elevated than what you normally experience when you’re in a generally good mood.” You’d be surprised how often that simple line of questioning is omitted. After all, when someone comes in seeking help and everything he or she is talking about looks like, sounds like and feels like depression, it’s easy to conclude that the individual should be treated for depression and possibly even be prescribed an antidepressant.
Here’s the rub: Antidepressants, when prescribed to someone who is genetically predisposed towards bipolarity, may indeed precipitate hypomanic or manic symptoms, thus bringing about the bipolar diagnosis. We can’t ever know with certainty whether that individual would have manifested bipolar symptoms if antidepressants were not prescribed. Had the right questions been asked up-front, the same individual may have been prescribed a mood stabilizer prior to the utilization of an antidepressant and his or her progression into hypomania or mania may have been averted.
The second complicated diagnostic issue involves attention deficit-hyperactivity disorder. This is a neurologic disorder which manifests through symptoms of attention and hyperactivity. With regard to attention we see behavior such as: poor attention to detail, frequent inattention or losing focus, difficulty following through with instructions relating to tasks, chores or homework, difficulty with organizing tasks and activities, frequently losing or misplacing things and consistent forgetfulness. In relation to hyperactivity we see: difficulties sitting still, tendencies to move around or be excessively active in situations where this is inappropriate, difficulty engaging in quiet leisure activities, excessive degree of physical activity – often acting “as if driven by a motor,” and excessive talking. There is a further variation on hyperactivity including impulsivity. This can entail: tendencies to blurt out answers to questions before they have been completely asked, difficulties awaiting one’s turn and tendencies to interrupt or intrude on others. Impulsivity can also entail rapidly making choices that do not reflect good judgment. Most of the preceding symptom descriptions reflect ADHD criteria from DSM-IV TR (American Psychiatric Association).
What’s complicated about the above symptom list is that many of the same ones can be present during a hypomanic or manic episode. An individual’s physical energy can be so elevated that he or she can easily appear to be hyperactive. There is also such cognitive acceleration and mood intensity that an individual’s memory, attention to detail, capacity to remain focused and ability to appropriately inhibit action are all impaired. So how do we distinguish these sets of symptoms that can look so similar to each other?
The first part of the answer involves an important caveat: the distinction does not readily apply to those who are diagnosed with childhood bipolar disorder as such can exert its influence just as early as does ADHD. The salient differences are that feelings of grandiosity, intense elation and/or intense anger, racing cognition and lessened need for sleep are more salient in childhood bipolar than they are in attention deficit-hyperactivity disorder. This doesn’t mean there won’t be any of these themes in the attention deficit-hyperactivity realm but the preceding symptom cluster will likely have a stronger presence in childhood bipolar disorder as opposed to attention deficit disorder.
Now let’s return to distinctions between attention deficit-hyperactivity disorder and bipolar disorder in adults. It’s actually rather simple. The adult with bipolar disorder who did not have childhood bipolar disorder will have experienced a point of symptom onset sometime after mid to late adolescence. The implication here is that if I’m inquiring about symptom onset and the individual being assessed reports that none of his or her symptoms were present prior to some point in adolescence or early adulthood, then it’s not likely that symptoms being discussed are reflective of ADHD.
A second key distinction is that many of the attention deficit-like symptoms that are typically present during elevated mood phases are absent during midrange mood and to a lesser extent, depressed mood, though sometimes depression does interfere with attention, concentration and memory so we can see what may appear as an overlap of ADHD and bipolar symptoms during depressed mood. The one obvious period of time when the attention-deficit-like symptoms are absent for the bipolar individual is during mid-range mood. This isn’t the case for someone with attention deficit-hyperactivity disorder because their symptoms are part of their baseline functioning. They don’t experience periods of time when their ADHD symptoms are absent. That’s not to say there isn’t some variability of symptom intensity, but the attention deficit individual won’t have periods where attentional, focusing, organizational and impulse inhibitory functioning are perfectly normal. Keeping the above distinctions in mind, the tuned in diagnostician can usually tease out the differences between ADHD and bipolar disorder.
The differentiation of personality disorder symptoms from bipolar disorder entails two key variables, one of which is similar to the ADHD distinction. That is, if an individual struggles with personality disorder symptoms, their struggles will typically be ongoing. Similar to ADHD, there may be some variability in symptom acuity, but the individual typically won’t have times where he or she is not under the influence of the psychological processes underlying the personality disorder. Individuals with personality disorders don’t get to have a vacation from their personality dynamics. Conversely, the bipolar individual whose symptoms (impulsivity, hypersexuality, anger/irritability, tendencies towards idealization or devaluation, feelings of grandiosity, etc.) may look like they belong to a personality disorder diagnosis will present with enough of a difference within mid-range mood that most of the same symptoms will be absent.
The second critical distinction between the personality disorders and bipolar disorder is that all personality disorder issues manifest in relation to interpersonal relationships. The struggles which may activate strong personality disordered symptoms are almost always within the interpersonal realm. While there is some overlap here with bipolar disorder in the sense that interpersonal stresses may activate a shift in mood phase, bipolar individuals will also tell you that there are times when the onset of their symptoms, whether elevated or depressed, will seem to come out of nowhere. There is no obvious trigger or precipitant for their mood destabilization. The only reliable explanation is that there’s been an endogenous shift in their brain activity and their neurochemistry.
The above discussion is by no means exhaustive regarding differential diagnostic distinctions between bipolar disorder and other psychiatric disorders that share similar symptoms. But it should give you a good sense of the kinds of issues the clinician will be looking at when trying to sort through whether one has bipolar disorder, another diagnosis or coexisting diagnoses.
I recommend that you be cautious if a mental health professional arrives at the bipolar diagnosis after only a short period of time with you or with a family member. The narrow exception here would entail someone with a strong genetic bipolar background who presents with hallmark bipolar symptoms in the absence of any other issues that may stimulate questions about comorbidity. But even here, in the name of thoroughness, diagnosticians should nonetheless be cautious about reaching conclusions prematurely.
Once a mental health professional has arrived at a valid bipolar diagnosis I feel most comfortable when the diagnosis is presented as a strong possibility along with a clear explanation of the basis upon which the conclusion has been reached. The patient should also be cautioned that the diagnosis will only be conclusively ascertained over a more extended period of time and that both patient and clinician will be looking at this together as treatment proceeds.
One last thing to keep in mind: If the diagnostic conclusion of your mental health professional doesn’t ring true for you, if you do not get a thorough and detailed explanation as to why the bipolar diagnosis is likely, it is absolutely appropriate to pursue a second opinion.
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Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA (www.RussFederman.com). He is co-author of Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger Publications). www.BipolarYoungAdult.com
Some conditions misdiagnosed as bipolar disorder
NEW YORK (Reuters Health) – A study published last year suggested that bipolar disorder may be over diagnosed in people seeking mental health care. Now new findings shed light on which disorders many of these patients actually have.
Bipolar disorder, also known as manic depression, involves dramatic swings in mood — ranging from debilitating depression to euphoric recklessness.
In the original 2008 study, researchers at Brown University School of Medicine found that of 145 adults who said they had been diagnosed with bipolar disorder, 82 (57 percent) turned out not to have the condition when given a comprehensive diagnostic interview.
In this latest study, published in the Journal of Clinical Psychiatry, the researchers used similar standardized interviews to find out which disorders those 82 patients might have.
Overall, they found, nearly half had major depression, while borderline personality disorder, post-traumatic stress disorder (PTSD), generalized anxiety and social phobia were each diagnosed in roughly one-quarter to one-third.
When the researchers then compared the patients with 528 other psychiatric patients who had never been diagnosed with bipolar disorder, they found that those in the former group were nearly four times more likely to have borderline personality disorder.
They were also 70 percent more likely to have major depression and twice as likely to have PTSD.
Some of other diagnoses were less common but still seen at elevated rates among the patients previously diagnosed with bipolar disorder. These included antisocial personality disorder and impulse-control disorder.
Over diagnosis of bipolar disorder is concerning, in part, because it is typically treated with mood-stabilizing drugs that can have side effects — including effects on the kidneys, liver, and metabolic and immune systems, explained lead researcher Dr. Mark Zimmerman, an associate professor at Brown and director of outpatient psychiatry at Rhode Island Hospital.
In addition, he told Reuters Health in an email, over diagnosis means some patients are likely not getting the appropriate care for the problems they do have.
Bipolar disorder shares certain characteristics with some other psychiatric conditions. Borderline personality disorder, for instance, is marked by unstable mood, impulsive behavior and problems maintaining relationships with other people.
But Zimmerman and his colleagues suspect that some doctors are over diagnosing bipolar disorder because — unlike certain other causes of mood disturbance — it does have effective drug therapies.
There are no medications approved specifically for treating borderline personality disorder, for instance, but research suggests that some forms of “talk therapy” are effective.
“We believe that clinicians are inclined to diagnose disorders that they feel more comfortable treating,” Zimmerman explained.
“The increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication-responsive,” he added.
This “bias,” Zimmerman said, is reinforced by drug company marketing, which highlights certain studies that have suggested that bipolar disorder goes unrecognized in many people.
SOURCE: Journal of Clinical Psychiatry, online July 28, 2009.
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For the first few years after I arrived in the DC area, I took call at two local hospital emergency rooms as a way to gain more experience, and build my private practice. One evening I was paged to come into the Emergency Department to evaluate a man who hadn’t slept in 3 days. When I arrived, the ED staff had taken an initial history and reported to me that the man was full of energy, his thoughts were racing out of control, and that he had suffered from episodes of depression in the past. He was also exhibiting signs of grandiosity, with thoughts that were excessively ambitious. The ED staff suspected that this man was having a classic manic episode and asked for a consult to rule out bipolar disorder. But it turned out that after looking at his lab work and a urine sample, this patient was actually found to be intoxicated on cocaine, which mirrors symptoms of bipolar mania. Interestingly, cocaine withdrawal symptoms can produce a severe, but transient depression, that may also seemingly confirm an erroneous diagnosis of bipolar disorder. It was an example of how “checking the boxes” on a list of diagnostic criteria (similar to using an algorithm to solve a math problem) without looking at the patient in a broader context and ruling out other conditions, could lead healthcare professionals down the wrong path when diagnosing bipolar disorder.
Bipolar disorder is a distinct and specific mood illness
Bipolar disorder is a distinct, specific mood illness that requires a detailed history by clinicians who have had both experience treating the condition in an acute setting such as a psychiatric emergency department or an inpatient setting and in the outpatient psychiatric setting. Dr. Guillermo Portillo, who treats patients with bipolar disorder at our practice, finds that the condition is routinely misdiagnosed because of incomplete workups. “I’m bipolar” often is a catchall phrase for patients who may be suffering from a different psychological illness such as an addiction, a medical condition presenting with psychiatric symptoms, a personality disorder, unipolar depression or explosive anger problems. Many of our new patients have already been diagnosed with bipolar disorder by another physician before coming in, but after a thorough interview and careful review of their medical history, medical records, collateral information from friends and family, and psychological testing, we discover that there may be another explanation at play.
Concerned about a bipolar disorder diagnosis?
If you are concerned about your diagnosis, first ensure that you do your homework on your treating physician to determine his or her level of experience with treating bipolar disorder. Your doctor should try to rule out possible medical conditions that could be contributing to your symptoms. For example, if you have with an overactive thyroid it could look like mania, and alternatively an underactive thyroid could resemble depression; and certain vitamin deficiencies, especially the B vitamins (such as B9 which is folic acid) can also mimic some bipolar symptoms. Some patients presenting with delirium could in fact be suffering from a change in mental status caused by a medical condition like cancer, interactions among medications, an infection, or even an electrolyte imbalance. In other cases, substance abuse, seizures in the temporal lobe section of the brain or conditions like Wilson’s Disease (an inherited disorder that causes too much copper to accumulate in your liver, brain and other vital organs) could be contributing factors.
Ask about psychological testing to confirm diagnostic accuracy
Your doctor can use psychological testing to help make this “differential diagnosis,” which is the process of distinguishing one particular condition from others that present with similar symptoms. Two of the most common tests, the Minnesota Multiphasic Personality Inventory (MMPI), and Millon Clinical Multiaxial Inventory (MCMI) test, are tools designed to confirm diagnostic accuracy. The MCMI-IV, the fourth and latest edition, has 195 true-false questions and takes only about 25–30 minutes to complete.
It may sound odd, but when patients who have thought for years that they had bipolar disorder discover that they in fact do not, the news can be devastating at first because it has been a part of their identities for so long. But ultimately they begin to feel empowered with the knowledge of their misdiagnosis because they realize that there is a reason that they are not getting better, and look forward to starting a new treatment regimen. Billy Crystal, one of my favorite comedians, once said, “What’s so fascinating and frustrating and great about life is that you’re constantly starting over, all the time, and I love that.” Sometimes starting over is a good thing.
Overdiagnosis of Bipolar Disorder: A Critical Analysis of the Literature
Bipolar disorder (BD) is considered one of the most disabling mental conditions, with high rates of morbidity, disability, and premature death from suicide. Although BD is often misdiagnosed as major depressive disorder, some attention has recently been drawn to the possibility that BD could be overdiagnosed in some settings. The present paper focuses on a critical analysis of the overdiagnosis issue among bipolar patients. It includes a review of the available literature findings, followed by some recommendations aiming at optimizing the diagnosis of BD and increasing its reliability.
Bipolar disorder (BD) is a chronic, recurrent mental illness first described by Jules Falret in 1854 as Folie Circulaire (circular insanity). Later, it was renamed as manic-depressive Psychosis. Nowadays, BD is considered one of the most disabling mental conditions, with high rates of morbidity, disability, and premature death from suicide . Although the traditionally accepted prevalence of BD ranges from 0.5 to 1.5%, more recent epidemiological studies suggest that these rates may be as high as 10%, depending on which diagnostic criteria are adopted.
These discrepancies in prevalence point to a lack of consensus on the current definitions of BD, which may favor the overdiagnosis of major depressive disorder (MDD) in detriment of BD . Based on the literature findings, the rates of bipolar patients mistakenly diagnosed with MDD ranges from 10 to 40% , with some authors suggesting even higher proportions of misdiagnosis. For example, one study reported that almost 60% of bipolar patients were initially misdiagnosed with other conditions, particularly MDD .
Over the last decade, however, BD has been progressively incorporated by culture. Patients with BD are now commonly displayed in the media, and allusions to this condition are frequently found not only in the scientific literature but also in autobiographical books and fictional writing. This trend has drawn attention to the possibility that, regardless of well-demonstrated rates of underdiagnosis, BD could be overdiagnosed in some settings.
The potential downsides of overdiagnosing BD are several. They include the negative effects of unnecessary labeling, the risk of harm related to unnecessary treatments, and the misuse of health care resources, with important human and financial implications .
The present paper comprises a critical analysis of the overdiagnosis issue among bipolar patients. We begin with a review of the available literature findings, followed by some recommendations aiming at optimizing the diagnosis of BD and increasing its reliability.
The database PubMed (1990–2013) was searched, using the MeSH terms “bipolar disorder” and “diagnosis.” In addition, we carried out a manual search of bibliographical cross-referencing. The papers obtained were manually screened, aiming at identifying original articles, reviews, and case reports focusing on the overdiagnosis of BD.
3. Rates of Overdiagnosis of BD: A Review of the Evidence
We identified seven studies that included data on the overdiagnosis of BD (Table 1). The results of these studies point to considerable variability in the rates of overdiagnosis, which seems to range from 4.8 to 67%. Most of the studies identified focused on outpatient populations and addressed the misdiagnosis of BD among patients with other psychiatric conditions (e.g., MDD and attention-deficit disorder).
|BD: bipolar disorder, SCID: structured clinical interview for DSM-IV disorders; PPV: positive predictive value; NPV: negative predictive value.|
Table 1 Studies addressing the overdiagnosis of bipolar disorder.
Two of those studies utilized the structured clinical interview for DSM-IV disorders (SCID) as a gold standard and included that on the positive and negative predictive value of the diagnosis of BD made by clinicians. The evidence suggests that while clinician’s diagnosis has a high negative predictive value, its positive predictive value is relatively low. In other words, if a psychiatrist had not diagnosed a patient with BD, most likely the patient did not have that diagnosis as per the SCID, whereas if a clinician diagnosed a patient with BD, the chance that the patient effectively met criteria for that diagnosis according to the SCID was modest. The implications of those findings are addressed in Section 5 of the present paper.
4. Factors Involved in the Overdiagnosis of Bipolar Disorder
4.1. Personality Disorders as a Possible Confounder in the Diagnosis of Bipolar Disorder
The phenomenological distinction between BD and some personality disorders may be challenging, not only because of the overlap between some personality disorder features and the diagnostic criteria for mood episodes but also because of the lack of reliability of the time criteria for BD. For example grandiosity is a common feature in narcissistic personality disorder, and patients with histrionic personality traits can be mistakenly diagnosed with mania . Anger and impulsivity, often present in patients with antisocial personality disorder, may be misinterpreted as irritable mood .
Maybe the most important debate regarding the interface between BD and personality disorders is related to the issue of differential diagnosis versus comorbidity. That is particularly true when it involves patients with borderline personality disorder (BPD). While the cooccurrence of BPD and BD seems to be quite common , the similarity between borderline personality and bipolar disorder may contribute to the diagnostic confusion involving these two conditions. Instability is a core feature in BPD, and one of the most common complaints among these patients is the occurrence of “mood swings.” Although there are major differences between the affective instability of BPD patients and the classic cycling patterns of BD, some authors pointed to the existence of “ultrarapid cycling” among BD patients, which would be virtually indistinguishable from the mood shifts reported by patients with BPD. Moreover, impulsivity, a hallmark of BPD, is also increased among bipolar patients, even during periods of euthymia . In a recent study, nearly 40% of BPD patients were found to have a mistaken diagnosis of BD , whereas other studies reported an even higher rate (56%) of over diagnosis of BD .
On the other hand, the multiple similarities between the two disorders have raised the issue that BD and BPD actually belong to the same spectrum, therefore representing different presentations of the same basic condition . While this point of view is not supported by the current psychiatric nosology, it can affect clinician’s diagnostic rationale, contributing to the blurring of the diagnostic limits between these two conditions .
4.2. Substance Use Disorders and the Diagnosis of Bipolar Disorder
The rates of comorbidity between substance use disorders and BD are extremely high . On the other hand, the behavioral effects of several psychoactive substances can easily mimic the mood symptoms usually found in patients with bipolar disorder. Patients often describe typical manic or hypomanic symptoms associated with the use of cocaine and stimulants, and alcohol has well-described depressive effects on mood. Although DSM-IV recommends the diagnosis of mood disorder secondary to substances in patients whose mood symptoms seem to be restricted to periods of substance use, this distinction can be difficult in clinical practice. In a study assessing 21 patients diagnosed by their clinicians as suffering from BD and comorbid substance abuse or dependence, it was demonstrated that only 9 (42.9%) actually met full criteria for BD as per a structured diagnostic interview . Similar findings were obtained by another study which retrospectively analyzed the records of patients with BD admitted to a dual diagnosis inpatient unit. The authors found that only 33% of the patients with a previous diagnosis of BD effectively met criteria for that condition.
4.3. Attention-Deficit Hyperactivity Disorder and BD in Children
There is a marked trend toward increases in the diagnosis of mental disorders in children . Specifically in regard to BD, a recent study documented a fortyfold increase in the diagnosis of bipolar disorder in children . ADHD symptoms, such as irritability, rapid or impulsive speech, physical restlessness, impaired attention, and sometimes defiant or oppositional behavior, can be mistakenly interpreted as resulting from BD . It has been suggested that some symptoms such as grandiosity, elated mood, hypersexuality, flight of ideas, and decreased need for sleep can help in the differentiation between BD and ADHD . BD should also be suspected in the presence of psychotic symptoms, severe mood swings, sudden-onset or late-onset (after age 10) ADHD symptoms, strong family history of BD, and lack of response to stimulants in a child with a history of positive response to them .
4.4. Limitations of the DSM-IV Criteria for Bipolar Disorder
DSM-IV criteria have been widely used for the diagnosis of psychiatric conditions over the last two decades. Although the reliability of its criteria for the diagnosis of BD, especially in the presence of mania, has been extensively demonstrated, there is evidence suggesting that some of its criteria may lack validity . A recent study using combinatorial analysis highlighted that, given the extremely high number of possible criteria combinations in order to characterize core mood episodes, the validity of the DSM-IV diagnosis of BD may be questioned.
Furthermore, some of the criteria used to characterize manic or hypomanic episodes are unspecific, such as decreased concentration, racing thoughts, and psychomotor agitation. These symptoms can be found in several different conditions, such as anxiety disorders and attention-deficit disorder. Moreover, the distinction between hypomania and nonpathological behavior is often problematic, which can sometimes result in the overdiagnosis of BD type II.
Perhaps the most important limitation of the DSM-based diagnosis of BD comes from its inability to identify bipolar patients without a typical history of classic manic or hypomanic symptoms, that is, a patient whose index episode is depressive. Attempts have been made to minimize this limitation through the description of features that, if present in a patient with depression, are highly suggestive of bipolar disorder . Among these features, we can find family history of BD, psychotic symptoms, atypical features, history of manic/hypomanic symptoms induced by antidepressants, and postpartum onset . In its original form, this concept helps alert clinicians in regard to a possible diagnosis of BD, reducing the risk of underdiagnosis. On the other hand, it is possible that the misinterpretation of the appropriate relevance of these features may contribute to the misclassification of unipolar patients as suffering from BD in certain circumstances .
4.5. The “Bipolar Spectrum” Concept
The concept of “bipolar spectrum” represents the antithesis of the issues exposed above in regard to the limitations of DSM-IV criteria for BD. Based on a dimensional approach, it expanded the diagnosis of BD beyond the categorical framework established by DSM-IV, based on the assumption that individuals with a strong genetic load for BD can experience different varieties of bipolarity. Consequently, many patients who do not meet criteria for BD based on the DSM-IV criteria may be diagnosed as suffering from “soft” forms of BD, which sometimes can overlap with the patient’s temperament . Of notice, as the concept of bipolar spectrum is progressively expanded, the diagnosis of unipolar depression becomes extremely restricted and tends to disappear.
Despite the controversy surrounding this concept, it has gained immense popularity over the last decades, and many clinicians adopt this model to formulate (or sometimes justify) their diagnosis of BD. Despite sometimes minimizing the diagnostic labeling represented by a categorical approach, a dimensional diagnostic model (such as the one represented by the bipolar spectrum concept) tends to blur the boundaries between different diagnostic concepts and normalities, decreasing even more the diagnostic reliability across different providers .
4.6. Other Issues
There are several additional possible reasons for overdiagnosis. For example, disability awards especially due to mental illness are on the rise. Between 1987 and 2005, the share of Supplemental Security Income’s adult caseload disabled due to a mental disorder rose from 24.1% to 35.9%. In a recent study, 172 patients on disability due to a diagnosis of BD were assessed, and only 47.6% of them actually met criteria for BD .
5. Optimizing the Diagnosis of BD
The recent publication of DSM-5 was expected by many as a promising step in improving the diagnostic accuracy of BD. Increase in energy and activity was included as a core symptom for the diagnosis of mania or hypomania, in addition to elated mood. Mixed episodes were removed from DSM-5. Instead, the presence of mixed features became a specifier, which may be present among patients with manic or depressive episodes . It is still early to assess the impact of these changes on the diagnosis of BD by clinicians.
On the other hand, the medical literature is scant in regard to interventions aiming at minimizing the overdiagnosis of BD. In a recent paper it was argued that the low specificity of the diagnosis of BD based on structured instruments/criteria (including the DSM proposed criteria for BD) is inherent to the relatively low prevalence of the disorder in the population in question, which automatically implicates in a lower predictive positive value of the criteria in question. The authors conclude that the goal of improving the diagnostic accuracy of BD can be accomplished not by improving the specificity or increasing the diagnostic threshold of that condition, but through increasing the prior probability of the diagnosis before applying diagnostic criteria. This could be accomplished, for example, by educating clinicians in regard to the identification of soft signs of bipolar disorder, careful documentation of family history of bipolar disorder, and close attention to features suggestive of underlying bipolarity among patients with depression.
The “two-step diagnostic process” described above could also be accomplished through the systematic administration of a screening instrument for BD, such as the Mood Disorder Questionnaire prior to applying structured criteria. Screening instruments usually display high sensitivity but low specificity and can therefore aggravate the problem of overdiagnosis if isolatedly applied, since clinicians tend to interpret a positive screening as indicator of diagnosis, again ignoring the fact that the positive predictive value of a screening tool is directly correlated with its prevalence.
Furthermore, over the last decades, considerable advances have been made in the better understanding of the pathophysiology of BD through neuroimaging studies, analysis of neuropsychological findings among bipolar patients, genetic analysis, and several other biological measures. Whereas it is expected that these progresses bring about increments in the diagnosis of BD in the long term, it is unlikely that a single biomarker might be able to identify patients with BD, given the biological and clinical heterogeneity of that condition . On the other hand, considerable research has recently focused on an integrative approach, aiming at the identification of biosignatures, which would encompass, for example, findings regarding neurocircuitry abnormalities, measures of oxidative stress, and genetic markers . Despite how promising this approach might sound, it is still in its childhood .
Given the current status of BD as a construct, diagnostic errors and the mistaken identification of patients as suffering from that condition are likely to occur. Nevertheless, improvements in the nosological and psychopathological characterization of BD, as well as clinician education on the correct interpretation of the different factors involved in the detection of BD, may increase the reliability of that diagnosis. Similarly, the identification of biological markers for mood disorders represents a promising area of research and will likely bring about improvements in the precision of the BD diagnosis in the near future.
This study is partly supported by 1R01MH085667 and Pat Rutherford, Jr Chair in psychiatry at UTHealth.
An 18-year-old female student was referred to a mood disorders clinic by her psychiatrist with a diagnosis of bipolar disorder, type II, characterized by prominent “mood swings” for which she had been started on quetiapine (900 mg/day).
Her “up” swings consisted of periods lasting up to 2 hours when she felt “happy, positive and more outgoing.” Her friends agreed that she was happy during these times but not out of the usual. She also had episodes lasting less than 1 hour of anger, frustration, irritability and occasional yelling; these episodes were always triggered by routine interpersonal interactions, such as difficulties with customer representatives and fights with her boyfriend. She had never been physically abusive but had occasionally been verbally abusive. She denied doing things she regretted during these times. Further inquiry yielded no more “manic or hypomanic” symptoms. In particular, she had no decreased need for sleep or increased energy or grandiosity.
The patient’s “down” swings consisted of several months of sadness and anhedonia after moving provinces for her studies. She denied neurovegetative symptoms, but she had occasional, fleeting thoughts of suicide but no attempts. She remained functional in school and tried to make new friends.
She was raised by a single mother who was not supportive, and her angry outbursts since childhood received no attention. Her maternal grandmother had a history of depression.
This case exemplifies 2 disturbing trends in bipolar disorder diagnosis and treatment. First, there are reports in the medical and psychiatric community about bipolar disorder that have created the impression of a rise in its incidence and prevalence, particularly in the pediatric and young adult populations.1,2 The serious implication of this potential (over)diagnosis has led to a second disturbing trend: the use of monotherapy atypical antipsychotics for the initial treatment of bipolar disorder3 in the absence of adequate trials of mainstay mood stabilizers.4,5
As is the case for all psychiatric disorders, bipolar disorder lacks pathophysiologic indicators or tests that provide a gold standard for diagnosis. Its diagnosis, therefore, remains predominantly clinical. The increased awareness of bipolar disorder in the medical and public realms can influence the tendency to diagnose — and potentially overdiagnose — bipolar disorder.6 Additionally, the diagnostic criteria of bipolar disorder and its categorical distinction (v. schizophrenia spectrum disorders) are being disputed by growing evidence from longitudinal and family/genetic studies that challenge their validity.7,8 To address potential overdiagnosis, clinicians should carefully and systematically collect diagnostic criteria and other symptoms in the individual context of the patient. They should observe, pinpoint and document the origin and fluctuation of symptoms. In this patient, the diagnosis of bipolar disorder was not retained because her “mood swings” were of a short duration, of a severity within the normal range, in keeping with the context of difficulties of daily life and were not associated with impairment. No DSM-IV diagnosis was given.
With respect to the increasing use of monotherapy atypical antipsychotics, this may originate from several sources: the ease of dosing and monitoring (i.e., no mg/kg initial loading, no blood levels required for titration, no narrow therapeutic windows for toxicity, less baseline work-up, availability of depot formulations for non-compliance); more sedative effects to control manic irritability and disruptive activity; updates from practice guidelines regarding trials with their use;9–11 and popularization of their use through pharmaceutical promotion.12
It thus becomes understandable that these drugs are being more commonly used and as first-line therapy. However, given their strong association with cardiovascular morbidity risk factors (obesity, diabetes, hyperlipidemia, metabolic syndrome13,14), clinicians may be trading the work of prescribing traditional mood stabilizers for managing other diseases that compete with bipolar disorder at the levels of chronicity, impairment and disability. Our patient was instructed to discontinue quetiapine and to start psychotherapy to help with her anger.
As gatekeepers to diagnosis and experts responsible for treatment, clinicians should remain stable and vigilant about the potential for overdiagnosis and be judicious and cautious prescribers of medication that has been clearly associated with other chronic disorders.
Why Is Bipolar Disorder Overdiagnosed?
Bipolar disorder used to be called manic depression because it is characterized by bouts of depression and bouts of mania. Patients experience dramatic mood swings between euphoria and severe depression; they may have hallucinations or delusions.
Patients with anxiety, agitation, irritability, and restlessness that does not persist are sometimes misdiagnosed with bipolar disorder, Zimmerman says.
“These could be symptoms of bipolar disorder. But they really have to be accompanied by other criteria, such as hyperactivity, feeling energetic despite just a few hours of sleep, or inflated self-esteem,” he says.
Ironically, one reason the disorder is being overdiagnosed is “because so much has been written about it being under-recognized,” Zimmerman says.
The increased availability of medications for the treatment of bipolar disorder may also play a role in overdiagnosis, Zimmerman says. “Physicians have a tendency to diagnose something that they feel they comfortable treating,” he says.
So what should you do if you think you’ve been misdiagnosed with bipolar disorder?
“If you’re at all uncertain about the diagnosis, speak to your doctor and make sure you understand why you’ve been given that diagnosis. If you remain unconvinced, get a second opinion,” Zimmerman says.
What you shouldn’t do, he stresses, is just stop taking your medication.
A systematic look at bipolar diagnostic accuracing found that if you stick to the DSM-IV diagnostic rules, more than half of all patients now being considered “bipolar” are “over-diagnosed”.Zimmerman But Dr. Zimmerman also found a 30% underdiagnosis rate, and an 86% accuracy rate for bipolar diagnosis overall. So the story is not as bad is it sounds. Yet according to other experts, we’re asking the wrong question, with all this over- versus under-diagnosis talk. We should be asking “how bipolar are you?” and using a different system to characterize the answer. Then there wouldn’t be “overdiagnosis”. There would be ineffective diagnosis.
A recent research study found that over half a group of patients who had been told they had bipolar disorder did not meet official standards for that diagnosis. This result was announced widely, including in the Los Angeles Times (May 7, 2008):
Bipolar Disorder Overdiagnosed?
Study Shows Many People Who Are Told They Have the Disorder Don’t Meet Standard Criteria
That’s odd. Until recently, most research seemed to show that bipolar disorder was underdiagnosed, not over-diagnosed.
Here’s what Zimmerman and colleagues found (and published). Seven-hundred psychiatric outpatients were asked if they’d ever been told they had bipolar disorder. All 700 also met with a trained interviewer who used a well-respected tool called the Structured Clinical Interview for Diagnosis (SCID), which applies the official rules for diagnosis in a systematic way. The SCID was used as the standard for determining whether a patient really had bipolar disorder, or not. The results that got all the press are shown below.
As you can see, 82 patients who’d been told they had bipolar disorder did not actually have it, according to the SCID. For 63 patients, the SCID diagnosis confirmed what the patient had been told. Conclusion: over half of the patients had been “overdiagnosed” with bipolar disorder.
Also found underdiagnosis
Not reported in the press was the next finding, though this was fairly presented in the research team’s paper:
Here we see the percentage of patients who were accurately detected as having bipolar disorder, 63 out of 90. Another 27 patients had bipolar disorder, according to the SCID. But they had not been recognized as bipolar. Thirty percent of the bipolar patients had been missed: “underdiagnosis.”
Overall, reasonably accurate?
Finally, one can look at the folks who don’t have bipolar disorder as an entire group, to get an idea of what percentage of these folks were incorrectly diagnosed as having bipolar disorder. For that, look at the numbers in red below:
Of all the patients who didn’t have bipolar disorder according to the SCID, 86% were correctly diagnosed. This is far from perfect, but it is in the range of some lab tests used in other areas of medicine. Not so bad.
Over- or under-diagnosis? Wrong question
The real problem is, we’re asking the wrong question. The term “overdiagnosis” itself strongly suggests that bipolar disorder is a thing, that you either have or do not have. Granted, that is how our DSM diagnosis system works, but it was never intended to imply that bipolar disorder is a thing. It is an agreement among members of a committee. The reality is more complex. For example, a recent genetics research team found 226 genes with some connection to bipolar disorders.Nurnberger Imagine all the tiny variations you could create by mixing up 266 different genes (its 35,000 permutations. And that’s if each gene only had one variation; some have several).
By contrast, at Harvard’s mood clinic, they ask a different question: “how bipolar are you? how much bipolarity do you have?” (as shown in this interview with their director, back in 2004). I think that’s the direction we ought be pursuing. How many bipolar factors do you need to have before antidepressants are so unlikely to work, or so likely to cause significant problems, that you should start with a different treatment instead? Diagnosis should move toward the way they’ve been doing it at Harvard for over 10 years, using their Bipolarity Index.