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The overdiagnosis of bipolar disorder

Magical Realist Offline

"We’ve all become used to “that’s my OCD” when someone is double-checking; “she’s schizo” when a person is ambivalent; and “he’s so ADD” as a facetious diagnosis of anyone showing lack of attention. Now we hear “she’s bipolar,” meaning an individual’s moods change rapidly or are extreme.

Each of these incorrect usages grossly minimizes the struggles of actual sufferers while mischaracterizing the diagnoses. The misuse of bipolar disorder has surpassed these casual statements and is now commonly misapplied by actual mental health professionals. Patients assume that this diagnosis explains their troubles when the truth may be more complex or much simpler.

Throughout my career as a psychiatrist, aside from seeing patients, I have supervised many clinicians and reviewed many patient charts. Over the past 20 years or so, I have seen the diagnosis of bipolar disorder appear in charts and patient histories with implausible frequency. As a rule, I no longer accept these diagnoses until there is further proof. Unfortunately, my skepticism is usually borne out.

From the 1950s to the 1980s, American psychiatrists tended to underdiagnose bipolar disorder compared to our European colleagues. If someone was very sick and had a chronic course, we usually labeled them as having schizophrenia. Eventually, we understood that severe mood illness was common and corrected our ways.

However, from the 1990s into this century, things have changed. From 1996 to 2004, psychiatric hospitals showed a four-fold increase in the diagnosis of bipolar disorder for children and about 50 percent for adult in-patients. For out-patients during the same time period, we saw a previously unheard-of change. There had been up to a 40-fold increase in the diagnosis of bipolar disorder in children and a doubling in adults.

Although there has been some correction for children, in adults, the trend continues. A recent large study of adult patients found that since the year 2000, psychiatrists have tripled their billed visits for diagnosed bipolar patients, while their visits for schizophrenia patients remained the same. Just a few years earlier, these visits were roughly equal, which makes sense as the prevalence of the two disorders is also roughly equal.

The chief area of confusion in bipolar disorder is seeing moodiness or rapid mood changes (negative moods, anger outbursts, mood lability) along with impulsivity (e.g., spending a lot of money without forethought) as indicative of a bipolar disorder. While these might be important clues, they do not constitute the actual illness. In reality, they are common aspects of many problems, including depression, substance abuse, personality disorders, and even reactions to stress. By themselves, they serve only to invite more specific questions.

Normal depressions often produce labile moods, anger, tantrums, and a range of emotional responses. As a matter of frequency, these changes from regular depression are much more common than from bipolar disorder.

Bipolar disorder is a severe psychiatric disorder.

It consists of alternating depression and manias, which often lead to hospitalizations and a chronic course of illness. Patients’ lives can be chaotic with loss of jobs and relationships and associated problems like drug and alcohol abuse and cognitive impairment. There are exceptions, but many people who function well in their homes and careers do not have bipolar disorder.

The defining part of the illness is the existence of manias. These are episodes of several days to weeks (not minutes or hours) in which the person has very high energy, so high that they can go with little or no sleep for days without being tired (the patient will only stay in bed 1-4 hours, not all night tossing and turning). The high energy is reflected in behaviors such as rapid speech, excessive goal-directed activities (e.g., cleaning, doing repairs), and uncharacteristic conduct (spending, sexual, or grandiose in nature), as well as having a clearly high mood. High moods may be bright, expansive, grandiose, or very irritable. In cases that go untreated, the person may become fully psychotic with delusions and hallucinations.

In true mania, all these things appear together for a significant time period: several days to weeks, as mentioned. Parts of these symptoms for shorter periods are not mania. Examination usually finds another explanation, such as alcohol intoxication, drug use, or, commonly, depression manifesting as anger. There is something called “hypomania,” in which a person shows all the symptoms for the same periods, but not such that safety is a concern. This is still a type of bipolar disorder.

The manias alternate with depressions, which are just like other depressions. There is usually an interlude of normalcy between periods of manias and depressions. As the person has more and more episodes of illness, the time between them becomes shorter until there is no normal mood at all.

Despite these clear diagnostic criteria, patients who do not fit them are frequently diagnosed. It is true that some people have mood shifts and behaviors that are difficult to diagnose. Bipolar disorder may be an important consideration here, as the symptoms may be concealed by other issues. A thorough evaluation with a co-reporter (an important element that is often overlooked in serious and complex cases) usually reveals the bipolar diagnosis.

To make a point: spending too much money, having an affair, gambling, losing your temper, changing moods quickly, not sleeping well, feeling energetic, being grandiose, talking too fast, and having rapid thoughts are not, by themselves, bipolar disorder. All of these happen more frequently due to depression, substance abuse, personality disorders, and just being human than to bipolar disorder. Any of them may be a clue about a bipolar diagnosis. But bipolar disorder includes the full syndrome, as I described above.

Over-generalization of research and over-reliance on questionnaires play large roles here. In the case of research, studies about bipolar disorder done on patients in psychiatric hospitals do not tell us what happens with the much larger group of people in clinics and offices. The results of these studies are commonly applied to office patients and give a misleading picture of the risk for bipolar disorder. As for questionnaires, I commented on them in a previous post. Briefly, they work best for screening, not for diagnosis.

Another factor is newer medications. These medicines, called atypical antipsychotics (Risperdal™, Abilify™, and Seroquel ™ are common brand names), are effective in both bipolar disorder and common depression. Consequently, a clinician may not know which condition has improved when a patient feels better. If they assume the patient has bipolar disorder when she has only depression, over-medication with multiple medications will likely result.

Bipolar disorder is both common and serious. We should not make the diagnosis without evidence that conforms to diagnostic criteria, nor should we accept diagnoses that raise questions (such as the common case of a person labeled “bipolar” who has never taken mood stabilizers and has been without symptoms for years). This problem with diagnosis has gone on far too long. Clinicians of all stripes should review this important illness. As for patients, they should also read the criteria and discuss how they fit, or not, with their own clinician."
C C Offline
Few if any seem to address all the motives and reasons.
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Why is Bipolar Disorder Overdiagnosed?

EXCERPT: Based on my clinical experience, this is usually due to one or more of the following reasons:

Money: Clinicians can bill medical insurance for bipolar disorder. Some clinicians realize that a patient has borderline personality disorder or another diagnosis. However, many insurance companies will not reimburse for these diagnoses (or will heavily limit reimbursement). The companies will reimburse for bipolar disorder, so the doctor gives a bipolar diagnosis instead.

Clinician Inexperience: The majority of patients seeking diagnosis of and treatment for bipolar disorder are first seen by general practitioners or family doctors. These clinicians generally do not have advanced training in mental health and often have a high volume of patients they must see daily. [...] Sadly many clinicians do not realize a manic episode must last at least a week in order to qualify (unless the severity requires hospitalization or emergency treatment). For some clinicians, diagnosis is essentially left to guess-work.

Insufficient Resources: Some mental health professionals feel rushed, burned out, or are limited in resources (e.g., one person may have an overwhelming case-load). As a result, they spend very little time considering the diagnosis or examining information supporting other more appropriate diagnoses. If they see another clinician provided a diagnosis of bipolar in the past or the patient says they “feel bipolar,” the clinician may assign the diagnosis and quickly move on to the next case. Errors arise when a diagnosis is given without enough time or thought.

Favored Diagnosis: Some diagnoses go in or out of style in certain settings. Diagnoses such as eating disorders, dissociative identity disorder, and borderline personality disorder have each seen rapid increases during short periods of time. Then many diagnoses (also such as dissociative identity disorder) will suddenly decrease in prevalence as it loses support from the mental health community. In addition to favored diagnoses within the culture, certain clinicians will tend to have certain diagnoses they prefer. [...] Specialization and favoritism in one clinical area may blind clinicians to alternative hypotheses.

Diagnostic Overlap: A number of other diagnoses and presentations have symptoms and associated features which overlap with bipolar disorder. Generally, lay-people, physicians, and even mental health clinicians associate bipolar disorder with the manic symptoms of high energy and unstable mood. For many people (clinicians included), this is the full extent of their memorized knowledge of bipolar disorder diagnostic criteria. [...] I have seen many instances in which behavioral problems better categorized as oppositional defiant disorder or conduct disorder are diagnosed as bipolar disorder. The child/adolescent is very irritable, defiant, angry, violent, and aggressive. Because the patient’s mood fluctuates rapidly between anger and anything else, the clinician will think of bipolar disorder and provide the diagnosis without support for any additional diagnostic criteria...

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