There appear to be several reasons why it might take 10 or more years for someone to receive the correct diagnosis of Bipolar Disorder. One problem is that, unless someone has Bipolar I Disorder, and therefore experiences full-blown manic episodes, picking up on bi-polarity can be quite difficult. Patients with Bipolar II Disorder, who therefore experience hypomanic episodes rather than manic episodes, often don't report them unless specifically asked. This is because they commonly present when depressed and when depression symptoms at that time are preoccupying their attention. (See Mania and hypomania defined).
Bipolar depression is commonly a melancholic (or even at times a psychotic) type of depression, which has a serious impact on the individual's functioning, and is often noticed and commented on by others. It is often these symptoms which bring a person into the General Practitioner's surgery requesting help.
After experiencing recurrent periods of depression, having a hypomanic episode is often perceived as a pleasant relief from the miseries that have gone before. The increased drive, energy and need for less sleep can provide 'catch up' time for the person to pick up on activities which the depression made impossible. A hypomanic episode can therefore be seen as a time of relative 'wellness', not illness, without awareness it can impair insight. This can also make the acceptance of the diagnosis quite difficult for some people. Providing written information about Bipolar Disorder, website addresses and support group information at this time can be very useful in helping some accept the diagnosis and its treatment.
Apart from asking about mood swings and asking specific questions about the nature of these (see How to Tell; How to Differentiate Bipolar Disorder from Depression; Bipolar I and Bipolar II: what's the difference?), the factors below might help raise the Bipolar Red Flag .
As well as interviewing the patient directly, it can also be useful to talk (with the patient's permission of course) to their partner, a close family member or friend about what they notice when the person is 'high'. These informants can often give useful information that the patient may not recall or lack insight into.
If it is still not clear whether or not what the patient is experiencing when they talk about feeling 'high' is, in fact, a hypomanic episode then it can be helpful to ask them to come back to see you again when they feel 'high'. Patients will use different words to describe how they feel when 'high'. Often many people dislike the term 'high', so try to use their own terms when exploring these feelings.
There is increasing evidence that systematically asking about hypomanic symptoms significantly increases the rate of picking up Bipolar Disorder. One recent study showed that, of 168 patients originally diagnosed with 'Major Depressive Episode', 61% went on to be diagnosed with Bipolar II Disorder after a structured screening tool was used (Hadjipavlou G. et al). Many of these tools require specialist training and are often only used in specialist psychiatric research settings, however, some, such as those below, are also suitable for use in a general practice setting. Self-rated screening tools have also been shown to be effective in picking up hypomania which otherwise might go undetected.
The Mood Disorders Questionnaire (MDQ) is one such tool with a specificity of 90% and sensitivity of 73% when compared to formal semi-structured interviews and can either be provided as a self-rating tool to assist the GP in asking appropriate questions or used by the clinician as a prompt. (This tool was developed by Hirschfeld and colleagues and is accessible on PsychEducation's website.)
The Black Dog Institute research group has recently finished development of its own Bipolar Disorder Screening Tool, which again can be used as a self-rating tool that patients complete themselves or with a clinician. The screen can be undertaken online, or, if you prefer, you may download the tool, print it out and use it freely in your own clinical setting. Download the tool here. [PDF, 72KB]
In our development study, a score of 15 or more assigned most of the true Bipolar subjects (i.e. 86% sensitivity) and missed only 2% of the true Bipolar patients (98% specificity).
Making the diagnosis of Bipolar Disorder can sometimes be difficult because the person may be presenting with symptoms or signs of another problem, which then becomes the main focus of intervention. In saying that however, it is important to identify any co-morbid conditions and treat these separately to maximise the individual's stability. Drug and alcohol misuse (around 40% of patients with Bipolar Disorder) and abuse is common. Often these substances are taken initially as an attempt at 'self-medication' but can lead to physical and psychological dependence. Clearly excessive use of alcohol and illicit substances can produce mood symptoms in themselves but the risk of normalising these symptoms as only being part of the dependency problem will lead to a misdiagnosis and a missed opportunity for treatment. Concurrent anxiety disorders (social phobia, panic disorder, generalised anxiety and obsessive compulsive disorder) are also very common, occurring in around 50% of people with the illness.
Mood instability alone does not necessarily indicate Bipolar Disorder. A number of personality styles (e.g. borderline) are associated with considerable mood instability but alone do not make a diagnosis of a primary mood disorder. When trying to differentiate between these two options, obtaining a collaborative history can be invaluable, so can taking a detailed longitudinal history of the mood instability. Although childhood onset of Bipolar Disorder does occur, it is relatively uncommon. Therefore, having a clearly defined onset of mood swings in early adulthood would weigh towards a diagnosis of Bipolar Disorder. Long-standing mood instability associated with difficulties in forming friendships/relationships, and impulsive or antisocial behaviour not associated with elevated mood, would suggest the mood swings are more a result of the underlying personality style than of a Bipolar Disorder per se.
The impulsiveness and distractibility experienced by those with Bipolar Disorder can risk a false diagnosis of Attention Deficit Hyperactivity Disorder.
Page last updated: 26-Nov-2007
Depression and Bipolar Disorder Information Australia - Black Dog Institute.
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