Challenge #1: Manic symptoms can feel kinda good.
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.
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It can be really tricky
with bipolar disorder,
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because some of the symptoms of bipolar
disorder can feel really good, so
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people themselves might not
notice that there's a problem.
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To make a diagnosis
of bipolar disorder,
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you have to see either a manic or
a hypomanic episode.
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A manic episode is a period of one
week where a person needs less sleep
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in order to function during the day, more
outgoing, they tend to be more talkative.
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Most people report some
form of racing thoughts,
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there can be grandiosity where they
think that they are a God of some sort.
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They can tend to engage in risky
behaviors, like spending, or
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sex, or drugs, or alcohol.
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But you have to see a manic episode to
make a diagnosis of bipolar disorder.
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there's also hypomanic bipolar disorder,
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which is just, it's a sort of
lower level of a manic episode.
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But you need to see at least one of them
in order to make that kind of diagnosis.
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Because it's so tricky to diagnose and
because the symptoms
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can map on to other diagnostic conditions,
it's often misdiagnosed.
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Bipolar disorder is
a clinical diagnosis,
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as are all mental health
disorders pretty much.
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You would see your clinician, who would
ask about your family history to see if
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that's something to be concerned about,
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then would go over your symptoms with you,
particularly looking back at your history.
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So typically, what I see, is someone come
in, really presenting with depression, and
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thinking that they need
help with their depression.
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But what's very important is that your
clinician needs to look for any past
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episodes that could qualify as hypomania,
that you might have not realized, because
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that will really change how they decide
to treat you for this depressive episode.
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Sometimes it involves bringing a family
member in, because a person that is
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engaged in, or in the midst of a manic
episode, maybe not the best reporter,
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so you sometimes have to ask that person's
family members how they've been acting in
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order to really get a complete
picture of what's been going on.
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After my breakdown, and
the doctor had a sense,
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I guess, he asked me 20 minutes
worth of questions, and
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then asked my husband the same
questions to make sure I wasn't lying.
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He said, bipolar II disorder.
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In fact, people in hypomania
may be feeling really pretty good.
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I don't want to go in for treatment.
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I feel great.
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I don't know what you're talking about.
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So, it really is incumbent upon
others to note in family members or
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in friends something is going on,
and to help them to seek treatment.
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Awad AG, Rajagoopalan K, Bolge SC, McDonnell DD. Quality of life among bipolar disorder patients misdiagnosed with major depressive disorder. Prim Care Companion J Clin Psychiatry. 2007;9(3):195-202.
Bipolar disorder. Arlington, VA: National Alliance on Mental Illness. (Accessed on July 27, 2018 at https://www.nami.org/learn-more/mental-health-conditions/bipolar-disorder.)
Bipolar disorder. Bethesda, MD: National Institute of Mental Health. (Accessed on July 27, 2018 at https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml.)
Bipolar disorder. Washington, DC: U.S. National Library of Medicine. (Accessed on July 27, 2018 at https://medlineplus.gov/bipolardisorder.html.)