Bipolar Disorder: Diagnostic Evaluation – Part 2 of 3
by David Mintz, MD, team leader and staff psychiatrist at the Austen Riggs Center
Treatment of bipolar disorder begins with careful diagnosis. Because bipolar disorder frequently presents first with depression, or because patients with manic or hypomanic states frequently do not recognize themselves as having a problem, accurate diagnosis is frequently delayed. Though historically under-diagnosed, recent research suggests that bipolar disorder is currently over-diagnosed almost half of the time. There are no laboratory tests for bipolar disorder. Diagnosis is made by a detailed appraisal of symptoms and of family history, and by ruling out other conditions that present in similar ways.
Bipolar disorder may be confused with a number of different psychiatric conditions, including major depressive disorder, schizophrenia, substance use disorders, borderline personality disorder, narcissistic personality disorders, and reliance on manic psychological defenses. Effective treatment for any and all of these conditions hinges on accurate diagnosis.
Major depressive disorder sometimes presents with irritable mood and prominent agitation, restlessness and sleeplessness, features that are also common in mania. However, in the presence of a depressed or intensely dysphoric mood, a diagnosis of bipolar disorder should not be made unless the patient meets other criteria of bipolar disorder (described above).
Patient with schizophrenia can also present with extreme agitation, difficulty sleeping, grandiosity, paranoia, and difficulty making accurate assessments about what is real. Like some patients with bipolar disorder, patients with schizophrenia often experience hallucinations and delusions. Patients in an acute schizophrenic decompensation or a severe manic episode may be impossible to differentiate. Often, it is the history of the illness that allows an accurate diagnosis. Some patients have features of both bipolar disorder and schizophrenia and are diagnosed with schizoaffective disorder.
Patients who use substances may also be confused with bipolar disorder, presenting with drug induced sleeplessness, agitation, irritability, impulsivity, and grandiosity. If apparently manic states have occurred exclusively in the context of substance abuse, it can be difficult to make an accurate diagnosis. It is especially complicated given that patients with bipolar disorder often have co-occurring substance abuse disorders.
Borderline personality disorder is also frequently mistaken for bipolar disorder. Patients with borderline personality disorder can also present with marked shifts in mood, difficulty making realistic appraisals of the current situation (particularly when under stress), irritability, and impulsive pursuit of pleasurable activities with a high likelihood of negative consequences. Sleep disorders are also common in this population. Patients may also have both conditions, complicating the treatment of either condition.
Like patients with borderline personality disorder, patients with narcissistic personality disorders can present with marked shifts in mood, but these patients also generally present with a façade of grandiosity, which serves to defend a deeply wounded sense of self-esteem. These patients may be irritable and may make unrealistic plans, similar to patients with bipolar disorder.
Some patients rely on manic defenses while not being, in actuality, manic. These “manic defenses” are psychological defensive operations, the intent of which is to ward off bad feelings. Patients who rely on manic defenses generally keep themselves extremely active, are often involved in various goal directed behaviors, and may be impulsive as well. One could say that these patients attempt to keep busy enough that they have few opportunities to think or, especially, feel. Manic defenses and mania are not mutually exclusive. Patients who have bipolar disorder may use manic defenses to ward off depressed feelings. Patients with bipolar disorder may also, consciously or unconsciously, do things to cause a manic episode (taking drugs, disrupting sleep, stopping medications), given that mania can feel preferable to a deep depression, or even a normal mood.