Why is diagnosing Bipolar Disorder so tough?
Bipolar Disorders

Why is diagnosing Bipolar Disorder so tough?

Since its original description over 160 years ago, Bipolar Disorder has been a tough diagnosis to make accurately. At different times called “circular insanity,” “manic depressive psychosis,” and “manic depression,” Bipolar Disorder was not officially recognized as a standalone mental illness until 1980. Now we know that Bipolar Disorder is actually a group of four distinct illnesses with different severities and diagnostic criteria.

Despite this progress, over two-thirds of people with Bipolar Disorder wrongly receive a different diagnosis at first. One in three keep that initial, incorrect diagnosis for over 10 years before the error finally gets righted. People wait 5 to 7 years between when they first experience symptoms and when they finally are diagnosed with Bipolar Disorder. Because this disorder increases the risk of suicide by 20 times the national average, these frequent delays are potentially life-threatening.

Depression vs. Bipolar Disorder

Of the two sides of Bipolar Disorder (depression and mania/hypomania), the depressive episodes more commonly lead people to seek treatment. When people in the midst of a deep depression, it might feel like they have always felt that way and always will. Depression can be so powerful that people will not recall ever having felt manic or hypomanic. Many people who first experience mania or hypomania may not even recognize some of the symptoms as problematic, especially if they are more mild.

To add even more difficulty, there are no strong indicators of any difference between an episode of Major Depression and the depression that is part of Bipolar Disorder. When a doctor sees someone with depression, all they can use to tell the difference is the medical history the person gives. Usually, that’s not enough to know for sure if they have Bipolar Disorder. As a result, about 4 out of 10 people with Bipolar Disorder are initially diagnosed with Major Depressive Disorder instead.

Borderline Personality Disorder vs. Bipolar Disorder

Clinicians usually under-diagnose Bipolar Disorder in favor of a Major Depression. On the flip side, they often over-diagnose it instead of Borderline Personality Disorder. Half of people with Borderline PD are initially diagnosed with Bipolar Disorder. People with these disorders deal with wildly fluctuating moods. Both groups can be angry, irritable, and impulsive. People with Borderline PD typically struggle to maintain stable relationships, and similar issues are no stranger to those with Bipolar Disorder either. Most dangerous of all, suicide rates are unfortunately high for people with either disorder as well. All of this combines to make Borderline Personality Disorder one of the most misdiagnosed disorders of all.

Substance Use Disorders vs. Bipolar Disorder

Studies show that roughly 40-60% of people with Bipolar Disorder also deal with a Substance Use Disorder at some point in their lives, but drug use can make an accurate diagnosis of other disorders very difficult. The effects of stimulants like sleeplessness, racing thoughts, and grandiosity can mask or imitate mania/hypomania. This leads clinicians to either miss Bipolar Disorder or diagnose it in someone who doesn’t actually have it. Heavy use of alcohol can similarly confound a doctor’s ability to detect depression. This all means that, in order to make an accurate mental health diagnosis, people need to focus on getting sober first. Without sobriety, medications and therapy will likely act only as band-aids that don’t reach the underlying problem.

Anxiety vs. Bipolar Disorder

At least half of people with Bipolar Disorder suffer from some sort of anxiety disorder as well. This causes trouble when trying to make an accurate diagnosis, however, because anxiety can mask symptoms of mania/hypomania but not those of depression. People with mania, hypomania, or anxiety can have racing thoughts or trouble concentrating. Problems sleeping are another shared symptom that make the situation even more difficult to sort out. As a result, many end up with a dual diagnosis of anxiety and depression, instead of anxiety and Bipolar Disorder.

ADHD vs. Bipolar Disorder in children

Attention Deficit/Hyperactivity Disorder (ADHD) and Bipolar Disorder can be confused in children if clinicians aren’t careful. Symptoms such as irritability, trouble focusing, impulsiveness, and restlessness can appear in kids with either disorder (specifically during the manic or hypomanic episodes of Bipolar Disorder.) Mood symptoms are hard to identify accurately because children often give unreliable descriptions, and doctors have to rely on parents’ reports. The most accurate way to tell the difference is using the most extreme symptoms, such as suicidality, psychosis/delusions, or rapid cycling between moods, to identify Bipolar Disorder. When those aren’t present, the process of diagnosis is tough.

Consequences of misdiagnosis

When people receive the wrong diagnosis, be it Bipolar Disorder in place of something else or vice versa, it creates a dangerous and potentially life-threatening situation whose effects can last for years. There’s two sides to this problem. People with the wrong diagnosis end up getting treatment and taking medications that they don’t need, enduring the unnecessary side effects. As this is happening, their true disorder continues unchecked, creating havoc in their lives while they continue the treatment they think should help but never does.

People diagnosed with depression instead of Bipolar Disorder will continue to experience untreated manic/hypomanic episodes. Confusion between Borderline Personality Disorder and Bipolar Disorder can prevent people with Borderline from receiving the most potentially helpful treatment that exists for that disorder – Dialectical Behavioral Therapy. This leads to years of suffering and excessive risk of suicide.

Substance use disorders – misdiagnosed as Bipolar Disorder – continue to rage unabated, causing chaos throughout all areas of peoples’ lives. Medications and therapies for Bipolar Disorder won’t help this one bit, either. Drinking and drug use likely get worse without detox and a sobriety program. This is ultimately frustrating for everyone as people expect to feel better but continue to get worse. This pattern continues to hold true across the board when one disorder is mistaken for another. Manias confused as anxiety or ADHD go untreated, while depressive episodes occasionally get attention.

Getting it right

When seeing a doctor for the first time for a mental health evaluation, the more information available, the better. Most times, clinicians only have the individual’s personal report to go on, but the effects of Bipolar Disorder can distort perceptions and memories. Input from family, friends, and partners can be immensely helpful in identifying past episodes of mania/hypomania and providing family history. Doctors can also use a diagnostic tool called the Mood Disorder Questionnaire, which can help hone in on Bipolar Disorder.

Depressive episodes stand out while manias and hypomanias are usually missed. Taking extra time to make the diagnosis can help address this. Individuals can keep mood journals and bring them to subsequent meetings, giving a more accurate picture of the situation. All this additional information can help ensure doctors have what they need to make the best diagnosis.

References
  1. Singh, T., Rajput, M. (2021, October 11). Misdiagnosis of Bipolar Disorder. Matrix Medical Communications. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945875 on 10/11/21. [Citation in section Misdiagnosis of Bipolar Disorder, paragraph 2]
  2. Singh, T.,  Rajput, M. (2021, October 11). Misdiagnosis of Bipolar Disorder. Matrix Medical Communications. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945875 on 10/11/21. [Citation in section Introduction]
  3. Roy H. Perlis, M. D. (2020). Misdiagnosis of Bipolar Disorder. AJMC. Retrieved from https://www.ajmc.com/view/oct05-2151ps271 on 10/13/21. [Citation is on section Contributors, paragraph 1]
  4. Singh, T., Rajput, M. (2021, October 11). Misdiagnosis of Bipolar Disorder. Matrix Medical Communications. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945875 on 10/11/21. [Citation in section Misdiagnosis, paragraph 3]
  5. Ghouse, A. A., Sanches, M., Zunta-Soares, G., Swann, A. C., Soares, J. C. (2013). Overdiagnosis of Bipolar Disorder: A Critical Analysis of the Literature. Sci. World J., 2013, 297087. Retrieved from https://doi.org/10.1155/2013/297087 on 10/13/21. [Citation is on section 4, paragraph 2]
  6. Ruggero, C. J., Zimmerman, M., Chelminski, I., & Young, D. (2010). Borderline Personality Disorder and the Misdiagnosis of Bipolar Disorder. J. Psychiatr. Res., 44(6), 405. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2849890 on 10/13/21. [Citations are in Introduction, paragraph 2, and Discussion, paragraph 2]
  7. Ghouse, A. A., Sanches, M., Zunta-Soares, G., Swann, A. C., Soares, J. C. (2013). Overdiagnosis of Bipolar Disorder: A Critical Analysis of the Literature. Sci. World J., 2013, 297087. Retrieved from https://doi.org/10.1155/2013/297087 on 10/13/21. [Citation is in section 4.2]
  8. Roy H. Perlis, M. D. (2020). Misdiagnosis of Bipolar Disorder. AJMC. Retrieved from https://www.ajmc.com/view/oct05-2151ps271 on 10/13/21. [Citation is in section Contributors, paragraph 2]
  9. Ghouse, A. A., Sanches, M., Zunta-Soares, G., Swann, A. C.,  Soares, J. C. (2013). Overdiagnosis of Bipolar Disorder: A Critical Analysis of the Literature. Sci. World J., 2013, 297087. Retrieved from https://doi.org/10.1155/2013/297087 on 10/13/21. [Citation is in section 4.3]
  10. Marangoni, C., De Chiara, L., & Faedda, G. L. (2015). Bipolar Disorder and ADHD: Comorbidity and Diagnostic Distinctions. Curr. Psychiatry Rep., 17(8), 1–9. Retrieved from https://link.springer.com/article/10.1007/s11920-015-0604-y on 10/15/21. [Citation is on page 3, Clinical Features]