Misdiagnosing Bipolar Disorder

Bipolar Disorder is a widely recognized and legitimate mood disorder that affects approximately 6.4 percent of the general population and, depending on severity, can affect an individual’s ability to work, socialize, and/or care for them self and others. There is growing public concern, however that similar to more than one million cases of ADHD, the subjective diagnostic criteria, interpretation, application, and motivations of both patient and mental health professionals result in a large amount of misdiagnosis. With that in mind, we will explore common processes, contributing factors, and circumstances that result in the diagnosis and possible misdiagnosis of bipolar disorder and its effects.

The general procedure for diagnosing bipolar disorder, previously termed manic-depression until 1980, includes a physical examination, interview/mental health evaluation(s), and lab tests performed by medical and mental health professional(s). Upon ruling out ailments and traumas that can result in symptoms similar to a mental disorder, a mental health professional may conduct additional interviews of family, friends, and people close to the patient as well as detailed documentation of the heredity and history of related symptoms. The resultant findings are then applied to the widely accepted standards of criteria set forth by the Diagnostic and Statistical Manual of Mental Disorders version Four Text Revision (DSM-IV-TR) and a diagnosis is made, typically by committee.

As with any science the application and methodology can be flawed by various human elements and psychiatry, in particular it relies heavily on many intangible and less concrete observations for definition, diagnosis, and confirmation. The DSM itself is not entirely clear regarding the diagnostic criteria for bipolar and similar mood disorders. The DSM wording utilizes non specific and arbitrary language, unclear time references, and contradictory symptoms that indicate the same diagnosis. Additionally, the inclusion of bipolar not otherwise specified (NOS), which acts as a ‘catch-all’ diagnosis if the defined criteria cannot be met or properly evaluated and opens the door even wider for mental health professionals to categorize virtually any abnormal mood related behavior as bipolar. The future revision of the DSM, expected sometime in 2012, will likely expand on the already vaguely defined criteria by including the more severe Rapid Cycling Bipolar Disorder and the broader Severe Mood Dysregulation (SMD) and Temper Dysregulation Disorder with Dysphoria (TDD). Furthermore, it is expected to formally introduce the concept of the bipolar spectrum, which allows more room for diagnoses that do not clearly meet specific criteria.

While a diagnosis of any mental health disorder does not in itself specify a list of characteristics shared by all patients, its intent is to identify a starting point for effective treatment and recovery. The addition of several external factors, however greatly affects the diagnostic process and can result in additional complications as a result of misdiagnosis. Mental health providers are under intense pressure from insurance companies to provide speedy diagnoses, which can result in unclear and/or biased histories of the condition(s) and contributing factors. Further, in recognizing the validity and severity of mental health disorders, insurance companies, employers, and society may inadvertently offer incentives for individuals with such a diagnosis. Examples of this include the potential for long term disability, medical severance, priority employment status, etc. Adding to that is the lack of clarity in the identification of situational or ‘normal’ mood changes versus an ‘abnormal’ change in mood and behavior. With both patient and mental health professionals sufficiently motivated for a positive diagnosis in a muddied field of study, how can a truly unbiased and effective treatment plan begin?

Common treatments for bipolar disorder include medication, psychotherapy, and in some cases Electroconvulsive Therapy (ECT). The medications used to treat bipolar disorder typically alter the brain’s chemistry and pathways with regard to how an individual’s mood is controlled. The resultant use of mood stabilizers, anti-depressants, anti-psychotics, and focused chemical inhibitors cause highly subjective reactions and many times a laundry list of new or aggravated mental and physical side effects. Frequently a patient will undergo multiple medication changes until an acceptable balance of intended treatment versus inhibiting side effect is found. There exists also a high risk of dependency, toxicity, increased tolerance, and rebound from many commonly prescribed medications for the treatment of mood disorders. Cognitive Behavioral Therapy (CBT), Family-focused Therapy, Interpersonal and social rhythm therapy, and Psychoeducation are some recommended examples of psychotherapeutic treatment options that are intended for application in conjunction with medications (NIHM Handbook). Further, the inclusion of a well defined support network, daily journaling, and establishment of routine is a highly recommended common practice. For extreme unresponsive cases the use of ECT, previously referred to as electro-shock treatment, may be applied with a varying degree of positive results and even more subjective and intense side-effects, the most common being short term memory loss.

In conclusion, the tendency for the misdiagnosis of bipolar and other mental health disorders can result in drastic effects on an individual’s already deteriorated quality of life. Although some moderate successes in genetic testing can shorten the trial and error period of medicinal treatments, many medical insurance companies will not approve of the expensive procedures. Also, while the intention of the DSM is simply to provide diagnostic criteria for mental health professionals, the possible necessity of amplifying information regarding the standardization of the procedures used to diagnose, could help minimize the potential for misdiagnosis. From the patient and family perspective a quick diagnosis of a mental health disorder and resulting intrusive treatment options should include some elements of caution and extensive psychoeducation should be a large part of initial and continued treatment even in immediate cases. Lastly, however unlikely, something should be done with respect to the commonly encountered division of psychological therapy and psycho-pharmaceutical dispensaries (prescription writers). Whatever the end solution(s), the growing trend of a psycho-medicated population is approaching critical mass. There doesn’t seem to be enough psychiatric professionals to go around and the sarcastically referred to ‘religion’ of psychiatry continues to grow in size and public favor.