There Are Too Many Bipolar Disorder Diagnoses
A supervising psychiatrist examines a problematic trend
Casual references to bipolar disorder are tossed around these days with alarming frequency.
We’ve all heard someone say “that’s my OCD” when double checking plans or details, or perhaps “he’s schizophrenic about that” to describe an ambivalent person. And of course “they’re so ADD” as a disdainful commentary of anyone showing lack of attention. Now we’ve added “she’s so bipolar” to the list of casual accusations, meaning someone’s moods change rapidly — without apparent reason.
As a psychiatrist, I am sensitive to each of these incorrect usages and consider them offensive — as they grossly minimize the struggles of actual people while mischaracterizing what is truly going on. Sadly, misapplying a bipolar diagnosis is a real problem. It is now commonly misapplied not just in casual conversation, but by mental health professionals as well. Countless patients I see are led to believe that a bipolar diagnosis explains their troubles when the truth may be more complex or, ironically, much simpler.
I supervise a small number of clinicians and review clinical charts. I see the diagnosis of bipolar disorder appearing in charts with an implausible frequency, as high as one in three patients. As a rule, I believe none of these bipolar diagnoses without proof. Unfortunately, my skepticism is usually born out.
This growing pattern among mental health professionals of diagnosing bipolar disorder, in lieu of clinical depression, is repeated across clinics and practitioners. My colleagues see the same pattern, which research has now confirmed. Sadly, with each mistaken diagnosis comes the risk of inappropriate treatment, overmedication, and years of unnecessary suffering.
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From the 1950s to the 1980s, American psychiatrists tended to under-diagnose bipolar disorder compared to their European colleagues. If someone was very sick and had a chronic course, mental health professionals usually deemed them schizophrenic. Eventually, we came to understand that severe mood illness was common and corrected our ways.
Large studies conducted in the 1980s and 1990s have shown the incidence of bipolar disorder to be 2% to 3% of any population. By contrast, estimates of major depression are between 7% and 11% . It was studies such as these that initially prompted psychiatrists in the 1980s to look more carefully at the mood component of a patient’s illness. This led to a large corrective shift in how American psychiatrists diagnosed sicker patients.
Countless patients I see are led to believe that a bipolar diagnosis explains their troubles when the truth may be more complex or, ironically, much simpler.
However, from the 1990s into this century, things have changed. For people admitted to psychiatric hospitals, there was a fourfold increase in the diagnosis for children and about 50% for adults. For outpatients, there was a 40-fold increase in the diagnosis of bipolar disorder in children and a doubling in adults.
Due to the extremely large increases in childhood diagnosis of bipolar disorder, research was conducted to narrow the diagnostic criteria. In adults, the trend continues in spite of already clear diagnostic criteria. A recent large study of adult patients found that since 2000, psychiatrists have tripled their scheduled visits for diagnosed bipolar patients, while their visits for schizophrenic patients remained the same. Just a few years earlier these visit numbers were roughly equal.
Cause for confusion
The chief area of confusion in bipolar disorder misdiagnosis is considering moodiness and rapid mood changes (negative moods, anger outbursts, mood lability) along with impulsivity (for example, spending a lot of money without thought for the consequences) to be indicative of the disorder. While these clues might point toward a bipolar diagnosis, they alone are not evidence of the actual illness. These behaviors are common aspects of many mental health problems including depression, substance abuse, personality disorders, and even stress. By themselves, they serve only to invite more specific questions of the patient.
What bipolar really looks like
Bipolar disorder is a severe psychiatric disorder. It consists of alternating depressions and manias, which often lead to hospitalizations and a chronic course of illness. Chronicity in this case consists of constant abnormal moods, cognitive problems, and poor ability to function in basic life roles such as parent or employee. Patients’ lives are chaotic — often marked by loss of jobs and relationships, and many associated problems like drug and alcohol abuse and cognitive impairment. There are, of course, exceptions — but it is widely understood within psychiatry that people who function well in their homes and careers usually do not have bipolar disorder.
The key aspect to the illness is the pattern of manias. These are episodes of several days to weeks (not minutes or hours) in which the person has very high energy, so high that they can go with little or no sleep for days without being tired; very high levels of activity such as rapid speech, excessive goal-directed activities; uncharacteristic behaviors (financial, sexual, or grandiose in nature); and a clearly high mood. The quality of the high may be bright, expansive, and grandiose, or very irritable. In cases that go untreated, the person may become fully psychotic with delusions and hallucinations.
In true mania, all of these things appear for a significant time period — several days to weeks. Parts of this aspect, or acting like this for shorter periods, does not constitute mania. A thorough examination usually finds another clear explanation such as drunkenness, drug use, or (commonly) depression manifesting as anger. There is something called “hypomania,” in which a person shows all the symptoms of mania, for the same periods of time. The difference between hypomania and mania is that in the case of hypomania, the patient never behaves in ways which are considered dangerous or impairing. In a true bipolar situation, manias alternate with depressions. There is usually an interlude of normalcy between periods of mania and depression. As the person has more and more episodes of illness, the time between mania and depression becomes shorter until there is no normal mood at all.
In spite of a clear description of the diagnosis, patients who do not remotely fit within it are being diagnosed with bipolar disorder. The misunderstanding among clinicians is the belief that changes in mood, energy, or behavior of any worrisome nature must be bipolar disorder. They are not. Normal depressions often produce labile moods, anger, mood tantrums, and a range of emotional responses. As a matter of frequency, these shifts within the normal course of clinical depression are common — and should not be attributed to bipolar disorder.
Spending too much money, having an affair, gambling, losing your temper, changing moods quickly, not sleeping, feeling energetic, being grandiose, talking too fast, having rapid thoughts does not serve as evidence of bipolar disorder. All of these things happen more frequently in people who struggle with depression, substance abuse, and personality disorders.
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There have been several converging elements within clinical practice that have led to the current situation of misdiagnosis. Outdated teaching and over-reliance on questionnaires used in office practice play large roles here. Newer medications may also be a factor. These medicines, called atypical antipsychotics, offer broader activity against mood diseases than previous treatments.
Patients are commonly prescribed medications which help them in part, but not completely. Usually some aspect of their mood improves — causing the provider to conclude that the bipolar disorder is better, perhaps because the anger outbursts have stopped. But in reality all the clinician has done is to partially treat the depression. What many clinicians do not know is that if you treat depression, the accompanying irritability and lability go away. There is no need for separate treatment, and one medicine may suffice for two or three.
The criteria for bipolar disorder you find in a book like the psychiatric DSM-5 are not the be all, end all. But they are the basis of common diagnoses. If you or your clinician want to know if there is reason to suspect bipolar disorder in you, start there.