How Doctors Diagnose Bipolar Disorder (and Why It’s So Tricky)

Challenge #1: Manic symptoms can feel kinda good.

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A “good mood” has its name for a reason: It feels good. You feel like you’ve been gifted a heavy dose of good luck, or maybe you feel unstoppably productive at work.

So perhaps it’s not surprising that people with bipolar disorder—a mood disorder that causes alternating episodes of depressive symptoms and manic symptoms—can be unaware or even resistant to the idea that they have a mental health condition.

The Criteria to Diagnose Bipolar Disorder

“Bipolar disorder is a clinical diagnosis, as are all mental health disorders,” says Gail Saltz, MD, psychiatrist at New York-Presbyterian Hospital, Weill Cornell Medicine. That means the doctor makes the diagnosis based on signs and symptoms instead of laboratory test results.

In addition to listening to your experience and symptoms, a clinician would examine your family history. Bipolar disorder tends to run in families, and carrying certain genes may increase the risk, according to National Institute of Mental Health (NIMH).

But the major thing the clinician is looking for is the presence of mania, either in the present or past. “To make a diagnosis of bipolar disorder, you have to see either a manic or a hypomanic episode,” says Ben Michaelis, PhD, a psychologist in New York City. These manic symptoms are ultimately what distinguishes bipolar disorder from unipolar depression.

During a manic episode, a person may need less sleep, be more chatty and outgoing, experience racing thoughts, feel special or grandiose, or engage in dangerous behaviors like excessive spending, risky sex, or drugs and alcohol, according to Dr. Michaelis. A manic episode can last at least a week.

“Sometimes it involves bringing a family member in,” says Dr. Michaelis. “Someone in the midst of a manic episode may be not the best reporter, so you sometimes have to ask that person’s family members how they’ve been acting in order to really get a complete picture.”

If manic episodes occur, the doctor may make a diagnosis of bipolar I or bipolar II disorder, depending on the nature and severity of the mania. Learn more about the types of bipolar disorder here.

The Challenges of Diagnosing Bipolar Disorder

The misdiagnosis of bipolar disorder continues to be a struggle for doctors and patients alike. In one study from the Journal of Clinical Psychiatry, 14.3 percent of over 1,000 participants diagnosed with major depressive disorder actually met the criteria for bipolar disorder.

And it’s important to make the right diagnosis to ensure proper treatment: Treating bipolar disorder is unique due to the extreme shifts in mood. It requires mood stabilizers and antipsychotics, as opposed to standard antidepressant drugs.

One of the first challenges in diagnosing bipolar disorder is that the patients themselves might not recognize the signs.

“Some of the symptoms of bipolar disorder can feel really good,” says Susan Samuels, MD, a psychiatrist at New York-Presbyterian Hospital, Weill Cornell Medicine.  “People themselves might not notice that there’s a problem.”

Consequently, when people with bipolar disorder *do* seek help, it’s often more likely to happen during a depressive state than a manic one, according to the NIMH. Plus, most people with bipolar disorder tend to present a depressive state first, and have them more frequently, than manic episodes.

“Typically, what I see is someone [will] come in, really presenting with depression, and thinking that they need help with their depression,” says Dr. Saltz. However, with targeted assessment, the clinician may find a history of hypomanic episodes, which are less severe and harder to recognize than a true manic episode.

Since hypomanic episodes feel “good” to the person having them, it might require a team effort to help the patient. “It really is incumbent upon others to note [that] something is going on, and to help them seek treatment,” says Dr. Saltz.