Numerous studies have show that the period of time between onset of bipolar symptoms and the point when the diagnosis is reliably established can take up to a full decade or more.
Reasons for this are numerous:
- Individuals' reluctance to seek mental health treatment
- Mental health professionals’ inadequate diagnostic training
- Comorbidity (coexistence) of other conditions that complicate the symptom picture
- Individuals’ denial or rejection of medical/psychiatric opinion
- Atypical presentation of bipolar symptoms
Any combination of these reasons can further delay the clear establishment of an accurate diagnosis. The fifth reason is probably responsible for the longest delays, even when an individual has been seen by psychiatric physicians. Sometimes bipolar symptoms just don't fit expectations with regard to typical bipolar symptomatology.
Think of someone with a hairline bone fracture who goes to a hospital emergency department and complains of limb pain with little to no swelling and no skin discoloration. The examining physician may fail to consider the possibility of a fracture due to the absence of swelling or discoloration. The diagnosis of bipolar disorder is not that different. The diagnostic process entails an assessment of the congruency of observed symptoms and gathered information with what might be reasonably expected in relation to symptoms accompanying a specific diagnosis.
Remember the famous words of the defense in the closing argument of the O.J. Simpson trial? "If [the glove] doesn't fit, you must acquit." With atypical bipolar symptoms, sometimes the glove simply doesn't fit, at least not like a glove.
How atypical bipolarity can manifest
Atypical bipolarity can manifest in multiple different ways. More often than not, an individual has sought treatment for many years from a range of different professionals without seeing any sustained treatment success. Additionally, numerous medications have been tried with little benefit or with even worsening mood instability. Understandably, the individual feels increasingly hopeless about finding help until a clinician recognizes the underlying bipolarity camouflaged by the atypical symptoms.
What are atypical symptoms? It’s difficult to categorize them. If we could, we’d have clear expectations about their presentation and we’d likely have a designated bipolar subset that they belonged to (i.e., bipolar III). What I can say is that there are some broad identifiable patterns that are often present:
- The full biphasic symptom picture fails to present with sufficient acuity to be easily identifiable as bipolar I or bipolar II disorder. In light of this, I also refer to atypical bipolarity as subthreshold bipolar disorder. The symptoms and patterns are present, but not sufficiently strong to meet the threshold for the bipolar diagnosis.
- There is evidence of repetitive patterns of mood instability. The symptom picture recurs over time.
- The patterns are discrete and phasic. They typically have a point of onset as well as a point where specific symptoms resolve.
- There is usually some shift (upward or downward) in energy and mood intensity associated with changing mood phases or episodes.
- The symptom set has yet to show any sustained positive response (lessening of symptom acuity and frequency) to psychiatric medications typically prescribed for non-bipolar disorders.
- Symptoms are not better explained by some other diagnosis.
The six points above still do not quite bring us closer to identifying specific symptoms, but they do address the broader gestalt observed when individuals are seeking help for mood-related distress that’s not been responsive to previous treatment endeavors.
Let’s get more concrete with regard to symptoms through four different examples of what atypical bipolarity can look like:
A 71-year-old retired male journalist with a long history of recurring depression: Much of the time his depressive episodes were not tied to external precipitants. His mood would drop sharply for no apparent reason. Often his depressed mood was alleviated by antidepressant medication, but invariably the prescriptions would lose their effectiveness. When not depressed he was generally feeling good. Occasionally he would have periods where his mood was very positive. As an oil-painting artist, he’d note heightened creative energy during these positive mood episodes. He would experience light and color as being more vivid and vibrant than usual. With the exception of his positive creative mood, there was nothing else about his behavior or mental processes that looked hypomanic.
A 45-year-old female physician with a 20-year history of occasional mood elevation without any accompanying depressive episodes: As a successful medical professional, her periods of high energy and high productivity did not appear to be any cause for concern. Instead, she was perceived by friends and colleagues as simply being highly ambitious in her work. In between her elevations, she was prone to periods of anxious irritability. She knew they would pass and she developed successful strategies for riding them out. Antidepressants increased her irritability. Anxiolytics caused her to feel affectively flattened and she didn't feel they provided any benefit.
A 68-year-old retired female educational administrator who has struggled with recurrent depression and irritability: Her depressions were fairly classic—very similar to what many people report when they're depressed: low mood and energy, low motivation, interpersonal withdrawal, fatigue, low self-esteem, etc. She nonetheless did her best to maintain functionality. In her job, she was good at creating administrative systems. Her difficulties reflected the reality when she became enthusiastic about a project, her enthusiasm often came along with obsessional thinking. She wasn't obsessional most of the time. But intermittently she'd find herself swept up in some endeavor and finding she couldn’t let go of obsessive planning and rumination pertaining to a work project. Others didn't note any observable changes in her behaviors, but she definitely experienced her internal process as being quite different and more intense whenever she became “swept up.”
A 39-year-old male real estate agent with frequent anxiety and irritability: He had a few depressive episodes in his teens and twenties, but hadn't been depressed in the last decade. He attributed his success in overcoming depression to being an avid cyclist, typically riding 50+ miles weekly. He viewed his exercise as being an effective functional antidepressant. His struggles are organized around recurrent irritability and insomnia. During the day, he wanted to bite people’s heads off, and at night, he’d lie awake ruminating about his irritability. It’s also noteworthy that this irritability was phasic. It had a beginning and an endpoint and it wasn’t necessarily tied to situational stressors. He had seen several therapists. He had tried yoga and meditation. Antidepressants worsened the irritability. He remained puzzled about what was going on.
As you can see, each of these brief vignettes provides a description of mood and behavior that lie at the edge of bipolarity. The journalist had depression plus positive mood and creativity. The physician had episodes of heightened work productivity, but alternating periods of anxious irritability and no episodes of typical depressive symptoms. The education administrator alternated between periods of depression and obsessional work productivity. The real estate agent had previous history of depression, now in remission, along with current frequent irritability and insomnia.
The retired journalist and educational administrator remained undiagnosed with bipolarity until approximately two years ago, which again points to the reality that low-end bipolar spectrum issues can elude accurate diagnosis for many years.
When I initially see these kinds of patients, the first task is to determine whether there’s any clear situational-environmental explanation for what’s happening with them. Are they in a bad marriage? Are they in a very unsatisfactory employment situation? Are they using substances excessively? Or, are there salient unresolved developmental/psychological issues that are contributing to the recurrent difficulties? Always consider whether there's a reasonable alternate (non-bipolar) diagnostic category that would provide a good explanation for what's happening with the individual.
If I can rule out those possibilities, the next step is to introduce the idea that their difficulties may lie on the bipolar spectrum and refer them for a second opinion to a psychiatrist who is skilled at the evaluation and treatment of bipolarity. If the psychiatrist also suspects the presence of bipolarity, mood-stabilizing medications are usually integrated into the medication treatment approach. Antidepressants may also be withdrawn to determine if they may be contributing to the unstable mood pattern.
The next step is to look closely at self-care, sleep hygiene, and overall lifestyle (diet, exercise, substance use, etc.) and identify and modify behaviors that impair healthy mood stability. Beyond that, the work with individuals who live with atypical bipolarity is similar to how we treat those in the bipolar population who meet criteria for BPI or BPII.
I do find that individuals on the hidden end—the subthreshold end—of the bipolar continuum face more complex difficulties in coming to terms with what’s happening to them. People who clearly fit bipolar diagnostic criteria, generally have an easier time identifying and understanding the reality of their bipolarity. Of course, there are exceptions—people who resist accepting the diagnosis. But for those who are not steeped in their resistance, the broad patterns of depression and mood elevation are identifiable. Hypomania can be trickier as distinctions between low-end hypomania and high-end normal mood can be fuzzy leaving much more room for uncertainty and resistance to the diagnosis.
When considering the realm of atypical or subthreshold bipolarity, identifying the bipolarity is even more difficult for those who live with it. If we consider the irritable real estate agent, what’s the difference between irritability that’s a normal part of life stress and irritability or anxiety that may be indicative of bipolar mood intensification? The same holds true for the strong positive mood of the journalist or the driven work intensity of the physician and education administrator. Gaining clarity on the presence of atypical bipolarity and integrating the diagnosis within one’s understanding of self is indeed one of the more difficult challenges of living on the mysterious end of the bipolar spectrum.