Diagnosing Bipolar Disorder: Problems and Common Mistakes

It can be difficult to make a diagnosis of bipolar spectrum disorder (BSD). In fact, the chances are that BSD isn't the first diagnosis you received from a mental health provider. Studies have shown (and most patients know) that getting the right diagnosis can be challenging. Some research suggests that up to 50 percent of individuals who eventually are correctly diagnosed with a BSD were first incorrectly diagnosed with depression.

Why is it so confusing? The causes for the underlying disorder are not yet known, and there are no standard tests of brain functioning that can diagnose BSD. The disorder comes with a broader range of symptoms than initially recognized. The symptoms wax and wane over time. At any one point in time, it can be hard to determine exactly what the diagnosis should be: major depressive disorder? bipolar I? attention deficit disorder? or some other choice entirely?

So it isn't surprising that it may have been difficult for you to get an accurate diagnosis. It can be useful to consider what might go wrong along the way to a correct diagnosis. This can help you evaluate your own symptoms and make sure you and your doctor are on the right track. And it may help you put your own treatment history into perspective. Let's look at some common issues that arise during the initial process of diagnosis.

BSD or Major Depression?
Symptoms of depression in BSD are much more frequent and more distressing than doctors previously realized. And depressive symptoms are more common than the cardinal symptoms of mania (for example, a very elevated mood or reckless behavior) that would trigger a diagnosis of BSD.

In one study, scientists asked people with BSD to keep track of their symptoms every week for several months. They found that people reported having symptoms in about half the weeks. For most of those weeks, the symptoms were symptoms of depression. Other studies have found that more than 80 percent of relapses in BSD appear to involve depression. In addition, when people go to the doctor for help, they are more likely to go when they are in distress. (People rarely get treatment when they feel the elated or positive moods they may experience in hypomania or mania.) This means the symptoms of depression may be much more obvious to you and your doctors than some of the other difficulties you are experiencing.

And here is where the difficulty lies. The treatments for depression can sometimes make bipolar worse. You may be depressed and have major depressive disorder. But it is also worth considering that you may have depression in the context of BSD or you may be in a mixed state as part of bipolar I. That is why it is important to consider all your symptoms, including signs of excess energy, hypersexuality, or racing thoughts. Your symptoms may not perfectly match the DSM-IV-TR diagnostic criteria, but if you suspect they may be signs of a mixed state or if you think you have had a manic or hypomanic episode, share your thoughts with your doctor. Together, you can evaluate the meaning of the symptoms.

BSD or a Personality Problem?
Is it a personality problem, or are the difficulties really symptoms of BSD? The diagnostic criteria for BSD require that the symptoms must cause changes in behavior that are noticeable to other people. The difficulty is that other people, including close friends and relatives, don't necessarily regard changes in behavior as symptoms. They may think that these actions or attitudes are just aspects of your personality-"That's the way John is. He's always moody."

Or your friends or family may know some of the specific stressors you face and think that your symptoms reflect the way you are handling the situation. Others may have more psychological interpretations of your behavior. They may believe you are angry or irritable or anxious because of personality issues or psychological dynamics- "Joe always gets angry like that because he had a bad relationship with his father." Those things may be true, but the mood and behavior changes can still be symptoms. They are just getting expressed in this particular situation because of your life circumstances.

Because people with BSD have symptoms even when they are not manic or depressed, it can be particularly difficult to distinguish between symptoms and personality characteristics. There are two sets of symptoms, mood lability and interpersonal sensitivity, that are most likely to be interpreted as personality issues or stress responses. Some researchers have identified these symptoms as being closely associated with BSD, but they are not widely recognized and have not yet been included in the diagnostic manuals.

Mood lability means your mood is very changeable. You may be more sensitive to stress, more likely to cry or get irritable when you are stressed, and also more likely to have transitory moments of joy. When your mood is labile, you might be thinking that you are upset about some recent event or that this is just the way you are, a sensitive person. The people around you may come to accept this part of you, that you are a moody, sensitive person.

It is easier to recognize mood lability as a symptom when it is more severe. In these cases, moods change every few seconds and the facial expressions associated with the moods change rapidly and are very extreme. If you find that your "skin is very thin" (that you are very irritable or are reacting to things quickly and intensely), and that people are noticing it, you might want to consider the idea that you are having the symptom of mood lability.

Heightened interpersonal sensitivity is another symptom common to individuals with some types of BSD. Individuals with heightened interpersonal sensitivity feel very uncomfortable when they are interacting with other people or after they have had a conversation. If you have this symptom, you may feel as if you are hyper-self-aware watching and judging your own actions. You may feel very anxious or angry when you are interacting with others, on guard against criticism. You may find yourself ruminating about conversations that went awry. Sometimes it may seem easier to avoid a conversation than have to face the intense anxiety or agitation afterward. These symptoms can overlap with the symptoms of social anxiety, which can occur along with BSD.

BSD or a Mood Disorder from Substance Abuse?
Part of the difficulty with diagnosis in BSD is that up to 70 percent of BSD patients also have another psychiatric disorder. One of the most common co-occurring disorders is substance abuse. More than
60 percent of individuals with BSD also have difficulty with alcohol or other drugs, with almost half of all individuals with BSD reporting an alcohol abuse or dependence problem.

Alcohol or drug abuse or dependence can make it difficult to tell whether the symptoms you present are a function of drinking or drug use or of BSD. Like the cycles of BSD, alcohol initially disinhibits you, but then it depresses you. Your emotional reactions can become more intense. It can be very difficult to determine if you are having a problem with depression or mood lability or a problem with alcohol.

In some cases, people with BSD try to self-medicate with alcohol to reduce their symptoms of anxiety or agitation. But it isn't just self-medication. Underlying problems with mood stabilization can also make you more likely to abuse other dangerous drugs. Errors in the regulation of some neurotransmitters in different areas of the brain can make you more likely to pursue pleasurable or exciting activities with no ability to respond to signs of danger. So you may find yourself compelled to binge or to seek excitement, even when you know you are putting yourself in danger. The "danger" messages just don't carry the emotional weight that the "pleasure" messages do.

Very often psychiatrists will be unwilling to treat the BSD until the substance use stops. Although there are good arguments for this approach, it can be very difficult to tolerate the symptoms of BSD, especially if you have been used to self-medicating with drugs or alcohol. It can be helpful to seek out specialists in dual diagnoses (substance abuse and mood disorders). If these specialists are not available in your area, your doctor may be able to get some advice from other doctors through the Internet. You can work closely to contract with your doctor to get some help with your BSD symptoms as you participate actively in substance abuse treatment.

BSD or Anxiety Disorder?
Is it an anxiety disorder? Many individuals with BSD also have anxiety disorders, including panic disorder, agoraphobia, or obsessive-compulsive disorder (OCD). It's been found that many of the patients suffering BSD have anxiety disorders. And many patients suffering from OCD actually have BSD as well, even though that wasn't obvious from the beginning.

When you are more activated, as you can be during a mixed or manic episode, mild anxiety symptoms can get much worse. It is not uncommon to see patients engaged in nonstop obsessive thinking or compulsive rituals when they are in a mixed state. At any particular visit, this can make it very hard to tell if the symptoms are BSD or anxiety disorders or a combination of the two conditions. This is especially problematic because the treatments for anxiety conditions include antidepressants and other medications that can sometimes make BSD worse.

BSD or ADD?
People with BSD often have significant problems with memory, concentration, and attention. Many of patients say, "My memory is like a sieve; everything just flows right through my mind." They may make endless lists or put little sticky notes everywhere with details of the things they are supposed to remember. Some may develop a fear of trying anything new, because they are so afraid they won't be able to learn the information needed.

Is this attention deficit disorder? It might be. Studies of children suggest that up to 85 percent of children with BSD have attention deficit disorder as well. This creates a significant difficulty, because the medication used to control attention deficit disorder (ADD), like Ritalin or Adderal, can sometimes make the symptoms of BSD worse. New methods are being developed to distinguish these conditions using psychological tests, but more progress is needed.

Learning disabilities are also common among individuals diagnosed with BSD. Some of the difficulties with memory and attention may be a function of a preexisting learning disability.

But many of these difficulties with memory, attention, and concentration may also be a symptom of the working memory problems frequently seen in patients with BSD. Working memory is the memory you use to process information right at the moment to help you solve problems. Working memory is necessary to hold information "online" so we can evaluate the information and use it to make appropriate decisions. Problems with working memory will make it difficult to remember new information or to quickly make decisions based on new facts. As you get more stable, some of these difficulties will decrease.

Sources:

Akiskal, H. S., & Benazzi, F. (2005). Atypical depression: A variant of bipolar II or a bridge between unipolar and bipolar II? Journal of Affective Disorders, 84(2-3), 209-217.

Bauer, M. S., Altshuler, L., Evans, D. R., Beresford, T., Williford, W. O., & Hauger, R. (2005). Prevalence and distinct correlates of anxiety, substance, and combined comorbidity in a multi-site public sector sample with bipolar disorder. Journal of Affective Disorders, 85(3), 310-315.

Gollwitzer, P. M., & Bargh, J. A. (1996). The psychology of action: Linking cognition and motivation to behavior. New York: Guilford Press.