Misdiagnosis of Bipolar Disorder
Getting the diagnosis right when symptoms are confusing
Posted February 13, 2014
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