Understanding Bipolar Disorder
Diagnosis can often be challenging.
Posted September 15, 2016
The piece below is adapted from a Q&A with Dr. Robert M.A. Hirschfeld that originally appeared in the Brain & Behavior Research Foundation's January 2016 Quarterly publication.
Dr. Robert M.A. Hirschfeld, professor of clinical psychiatry at Weill Cornell Medical College and founding member of the Foundation’s Scientific Council, is a world-renowned expert in the diagnosis and treatment of bipolar disorder and depression. In 2000, he developed the Mood Disorder Questionnaire (MDQ), the world’s most widely used screening instrument for bipolar disorder, and served as chair of the original and the revised American Psychiatric Association Guidelines for Treatment of Patients with Bipolar Disorders. Before joining Weill Cornell in 2015, he spent nearly 25 years as Professor and Chair of the Department of Psychiatry at the University of Texas Medical Branch in Galveston, and 18 years at the National Institute of Mental Health as Chief of the Mood, Anxiety, and Personality Disorders Research Branch.
There are many misconceptions about bipolar disorder, a lifelong disorder characterized by episodes of often persistent, highs, and often persistent, lows.
During manic phases, people may experience increased energy, less need to sleep, and sometimes delusions—some people who are manic actually believe they can fly or have other super powers. During this phase of the disorder, people often make rash decisions and do things that get them into trouble, such as spending too much money or being sexually promiscuous, which, in turn, can ruin lives and destroy relationships.
The other part of the illness involves depression, which manifests itself with decreased energy, sadness and feelings of emptiness. During these lows, people are pessimistic, negative and sometimes suicidal.
These ups and downs differ from those experienced by people who do not have bipolar disorder.
In the throes of mania, people who normally spend eight hours sleeping, may only sleep four hours and wake up energized; during the depressed phase, people may sleep for 12 hours and still have no energy.
There are two forms of bipolar disorder: Bipolar I, features at least one episode of mania and episodes of hypomania (less severe than mania), which does not require hospitalizations or include delusions. Bipolar II features at least one episode of hypomania. People with both forms of the disorder are at risk for depression and suicide.
Typically, people with bipolar disorder experience one or two episodes in a year, though some people experience rapid cycling—frequent episodes that may occur four or more times a year. Some people cycle even more rapidly, into three-day cycles, and some patients experience single-day cycles—hypomanic for one day and depressed the next.
Much can be done to help people manage their illness, and reduce or prevent manic and depressive episodes. However, people with bipolar disorder often go undiagnosed. Patients who see a health care provider for depression may not even remember they have experienced a hypomanic or manic episode. If the patient doesn’t bring it up, the family doesn’t say anything, and the health care provider doesn’t ask, the condition can be missed. In fact, approximately one in five depressions—20 percent—are caused by bipolar disorder.
The problem of self-awareness is real and one of the reasons the Mood Disorder Questionnaire (MDQ), a screening instrument with 13 “yes/no” questions about the symptoms of mania, was developed. The MDQ, which is available online, in many physician’s offices and through a variety of organizations, takes only five minutes to fill out, and can be self-scored or evaluated by a professional. A positive score calls for a thorough evaluation by a primary care provider or, better, a psychiatrist or another mental health professional.
Anyone who may be concerned that they, a loved one, or friend might have bipolar disorder may want to fill out the MDQ.
Sometimes parents and children disagree on symptoms, but it often turns out that the parents’ perception was the more accurate version. A recent study led by Dr. Karen Dineen Wagner addressed this issue. The study used three versions of the MDQ: one was filled out by the parent; one was filled out by the adolescent; and the third was also filled out by the adolescent, who was instructed to fill it out from the point of view of someone who knows them well. The study found that a MDQ filled out by the parent was, by far, the most accurate.
That is why it is important to have a family member come in with the patient on the first visit. They often bring very useful information with which the patient may be unaware.
In fact, the latest edition of the manual that doctors use to diagnose psychiatric disorders, the DSM-5, has made a major change in how we conceptualize and diagnose bipolar disorder. The current diagnosis is not based solely on mood disturbance, but considers disturbances in energy and activation. People who experience mood disturbances without changes in energy do not receive a diagnosis of bipolar disorder.