Bipolar – misdiagnosed or missing diagnosis?


By David Joel Miller.

Diagnosing Bipolar Disorder

Why is it so hard for people with Bipolar Disorder to get diagnosed and treated? For mental and emotional problems, the sooner the diagnosis, the sooner the treatment begins, the less the suffering. The more entrenched the illness the longer and more difficult the recovery. We continue to have difficulty with Bipolar Disorder. Why?

Almost 70% of people with a Bipolar Diagnosis had another diagnosis first. On average they get four other diagnoses before the Bipolar one. Usually, somewhere along the line they are diagnosed with Major Depressive Disorder, given an anti-depressant. At this point, on an antidepressant, 40% of clients with Bipolar experience an episode of mania or hypomania. Antidepressants given to people with Bipolar disorder also increase the likelihood they will become rapid cyclers.

Our understanding of this condition has changed over the years. To be honest the mental health professions understanding of most illnesses has changed a lot over the years. We used to call Bipolar Disorder by another name – Manic Depressive disorder. Clients continue to come in to facilities and tell us that they have Manic Depressive Disorder and Bipolar, not understanding that both are the same thing, just a new name.

Currently there are two principle camps in this debate – those who think too many people are being diagnosed with Bipolar Disorder and those who think that professionals are missing a lot of Bipolar Disorder. The controversy goes back to the first efforts at classifying anything, the lumpers and the splitters. Some people would like a different name for every possible type of dog; other people are content to consider them all dogs, the same with mental illnesses. So what difference does it make? It could make a lot of difference.

Ira Glick, up at Stanford wrote an article a while back called Undiagnosed Bipolar Disorder: New Syndromes and New Treatments. This is not a really new article but it is important as we think about how diagnosis is likely to change in the next few years when the DSM-5 comes out. Glick suggests that the true rate of Bipolar may be as much more than what is being diagnosed. We used to expect Bipolar Disorder to run 1% to 2 % of the population; recently it has been diagnosed closer to 7%.

We are starting to think of this condition as a spectrum disorder. So there are a range of symptoms and the ones with less noticeable symptoms are not getting diagnosed.

Does it matter if some mild cases are getting missed and not treated? Yes it matters and the clients with the less prominent symptoms are not necessarily milder cases. Currently we separate cases into Bipolar I and Bipolar II.  People who have Bipolar II don’t have the pronounced episodes of mania. They do have other significant differences.

People with Bipolar II have way more unemployment. They get divorced more often; have more thoughts of suicide and more suicide attempts. This one disorder, according to Glick, accounts for more suicide attempts than any other mental illness, excluding personality disorders. This is big problem since Bipolar II looks like Major Depression until the mania or hypomania kicks in.

Many people who eventually get the Bipolar Diagnosis are first seen by their primary care physician. Primary care doctors treat more than half of all the depression and anxiety. There are a lot of medical problems that are especially problematic for people with Bipolar Disorder. People with bipolar disorder are more likely to have migraines, diabetes or obesity.

Medications for people with Bipolar are especially problematic. People with Bipolar II get antidepressants till they have a manic episode then they may get all sorts of meds. People with Bipolar I have the more pronounced psychosis and may get all kinds of heavy-duty antipsychotics. Sometimes people with depression have distorted thinking and we see psychosis. Sometimes the psychosis in Bipolar II looks a lot like Schizophrenia, Schizoaffective disorder and a lot of other things. 

We are also not sure how much of all this is a result of genetics and how much is learning. Some authors have talked about how personality traits, those supposed unchanging characteristic ways of behaving may be related to Bipolar Disorder.

In fact there is some question as to which mental health issues are district illnesses and which are symptoms. A cough is easy to notice but what causes the cough can vary a lot from person to person.

Despite all the issues with diagnosis, Bipolar disorder in all its forms causes a significant amount of suffering. It is also a difficult disorder to manage for the client and for the professional. If there is a chance you or someone you know has this disorder get professional evaluation. If you have Bipolar disorder become a knowledgeable client, and don’t give up hope, the treatment options continue to improve. 

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog there is also a Facebook authors page, in its infancy, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. Thanks to all who read this blog.

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16 thoughts on “Bipolar – misdiagnosed or missing diagnosis?

  1. This is a really great post. Though I would add one thing myself. I happen to be bipolar II. I think some of the issue is that we’re so stuck on our non-mental-health (“physical” isn’t quite right here) ideas about what medicine is and what options should be used.

    I’m not an expert of course, but I think it should be noted that any given mental illness may have many disparate causes since they are diagnosed behaviorally. I don’t think sharp demarcations will work quite the way we sometimes want them to.

    Perhaps I’ll do a post on behavioral diagnosis… but in any event, I liked your post. I like any post that gets information out into the public eye.

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