Looking bipolar; DDx, anyone?

Someone came to me this week to discuss school, her career and her moods. She talked about how her father had been diagnosed years ago with bipolar disorder and toward the end of our conversation mentioned that a psychiatrist had diagnosed her with "bipolar lite" soon after she stopped using cocaine and ecstasy. I found it curious. She was not closed to the idea of having bipolar, but added that she stopped treatment because of the mood stablizing medications she was on just seemed to flatten her and numb her emotions. I went through the symptoms of mania -- rapid speech, racing thoughts, decreased need for sleep, hyper-sexuality, impulse-control, grandiosity and increased interest in goal-directed activities. She said "no" to virtually everyone of them, outside of the context of times when she was abusing substances. What about psychotic symptoms, which can occur in mania and deep depressions, and can lessen the likelihood of other disorders? Not a one of them, not even E.

No mania. No hypomania. But a bipolar diagnosis.

What was going on here? Did someone misplace their Diagnostic and Statistical Manual of Mental Disorders? It has felt, at times, lately, like being trapped in an episode of "House MD" where no one is doing the DDx -- the differential diagnosis.

News this week of a study that showed that bipolar disorder was being grossly over-diagnosed hardly came as a surprise. In a little more than a year, I have seen psychiatrists reverse the diagnosis of more than a half a dozen people in the support groups and of a client in clinical practice, and I have seen a growing number of people present with symptoms that convinced them or others that they had bipolar who have turned out to have one, often more than one, other disorder.

Researchers from the Brown University School of Medicine found in a recent study , published in the Journal of Clinical Psychiatry, 57 percent of a 145 adults who said they had been diagnosed with bipolar disorder turned out to not have the condition when given a comprehensive diagnostic interview. The follow-up showed that nearly half had major depression (some with recurrent, anxious, impulsive or hyperactive symptoms that contributed to the mis-diagnosis), borderline personality disorder, post-traumatic stress disorder and generalized anxiety disorder. Some other diagnostic possibilities seen at elevated rates among this group were social phobia, anti-social personality disorder and impulse-control disorder.

This woman had symptoms of anxiety and of depression, a recurrent type of depression that moved in waves that are not similar to those in bipolar disorder. Instead of the waves being between the poles of depression on one side, and hypomania or mania on the other side, this client seemed to swing from depression to not-so-depressed to good. Everything seemed to suggest major depressive disorder, recurrent type, and generalized anxiety disorder, so I sent her off to another psychiatrist to get a second opinion following the one she received from the psychiatrist she had spoken to earlier.

A little more than a year ago, several people in a bipolar support group in Northern Virginia who had been resistant to treatment with a wide variety of mood stabilizing, anti-depressant and anti-psychotic medications were re-diagnosed or diagnosed with a condition other than bipolar disorder. For one woman in her early 40s, the suggestion by her psychiatrist that she did not have bipolar disorder, and, instead had borderline personality disorder, shook her faith in treatment, her providers and, in some respects, her identity. Understanding herself and her actions had come within the framework of bipolar disorder. She had found strong support in groups with people with bipolar disorder. It all made sense. Or, did it?

The woman had been diagnosed with Bipolar II and had experienced mood swings, however, mostly on the depressive side. She could not remember every having a manic episode, although she described what seemed to be some symptoms of hypomania in her history. She had struggled, as many people with bipolar do, with interpersonal relationships, on her job and in other settings. What the woman did not realize was bipolar disorder shared certain characteristics with several other mental disorders, including borderline personality disorder, which also includes unstable moods, impulsive behavior and problems in maintaining relationships.

In my work with support groups, it has been often difficult to distinguish people with Bipolar II disorder and borderline personality disorder, particularly when it comes to men, who tend to be diagnosed with borderline personality disorder at much lower numbers than women, and who tend to be much less accepting of the diagnosis. The mood stabilizing medications for both disorders are similar, which helps, but the types of therapy and interventions that are deployed are often different. After some time, the woman we mentioned above came to accept and even see the benefit of the new diagnosis. After a hospitalization and years of falling in-and-out of executive-level positions, she has held down a stable position for more than a year. Things are on the upswing, perhaps, because of the new understanding of her illness.

This is not a criticism of psychiatrists, psychologists and others who diagnosis. It is often hard to tell the difference between disorders like Bipolar II and borderline personality disorder. Its often hard to tell the difference between many disorders, for example, where postraumatic stress disorder ends when it develops, as it is assumed by some that it often does, into borderline personality disorder (there are other routes to borderline personality disorder, as well, but trauma tends to be a prominent one).

Bipolar shares common traits with major depressive disorder, especially the recurrent type (where the mood swings up-and-down between depressed and normal, or below normal), borderline personality disorder (with its mood swings), generalized anxiety disorder, postraumatic stress disorder and others. Confusing matters is that individuals can have Bipolar disorder and some of these conditions (such as PTSD, generalized anxiety disorder or even borderline, at the same time). It gets even more difficult to tell the difference when a client, for example, has both recurrent major depressive disorder and generalized anxiety disorder at the same time -- a combination that can look a lot like bipolar without a good differential diagnosis. Another combination that can be difficult to differentiate from bipolar are combinations of attention deficit hyperactivity disorder and major depression.

The potential overdiagnosis of bipolar disorder has been attributed to drug company marketing and the fact that there are so many more Food and Drug Administration drugs approved for the treatment of bipolar disorder. The reality is probably more complicated. Even a clinician has a doubt between bipolar disorder and major depressive disorder, and little time or means to examine the difference, the safer course is to treat for bipolar disorder because mood stablizers and anti-psychotics used in bipolar treatment are unlikely to have serious negative effects in someone with major depression, while anti-depressants alone have a risk of causing mania. In addition, people tend to be more accepting of a bipolar diagnosis than a borderline diagnosis, and certainty more accepting of it than impulse-control disorders or antisocial personality disorder. At least, a bipolar diagnosis gives tangible hope of medical treatment.

Accurate diagnosis of bipolar disorder is important because of quality of life issues, medication and therapeutic approaches, side effect risks and a variety of other factors. In my experience with the support groups, family members who suspect their loved one has bipolar disorder often realize, when told about the symptoms, that it could just as likely be borderline personality disorder or anxiety with depression. There is no question in my mind, from the support groups and clinical experience, that "soft" bipolar, where people have bipolar disorder but have yet to have experienced full blown mania (just hypomania) exists. We would be worse off if these individuals were not diagnosed or there was no diagnostic criteria that they fit within, especially since many of these individuals eventually develop full-blown mania, especially without treatment.

Bipolar II -- or "soft bipolar" -- is real, but it is also a murky area where clinicians and clients should carefully tread. It's hard to miss mania, but hypomania can not only be missed, but it can be confused as something else. I recommend a careful reading of the symptoms, reviewing the experiences of others with Bipolar II and searching your history for symptoms of other disorders. I am lucky to work with clinicians who seem to take their time and wait until they have clarity until they make a firm diagnosis.

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