Final Report by Anouska Dias as part of the Neurowiki group "Bipolar Disorder"



Bipolar Disorder in most individuals.
Bipolar Disorder in most individuals.

Bipolar Disorder is a mood disorder that is shown through two types of behaviours: mania and depression. It usually appears in individuals during adolescence and early adulthood. Therefore, diagnosing this disorder has proven to be very important so that certain symptoms and behaviours can be kept under control[1] . There are a few ways to do the diagnosis and some include using screening tests and self-questionnaires. Some questionnaires include the Mood Disorder Questionnaire (MDQ) and Structured Clinical Interview based on DSM VI(SCID) which is an interview based screening[2] . However, these tests are not enough to diagnose a patient because it requires a thorough background check of the patients past mood swings[3] . After these tests are conducted, doctors can then categorize patients into the different types of bipolar disorder. These types include Bipolar Disorder 1, Bipolar Disorder 2 and more that will be talked about in this project. Bipolar Disorder 2 is the milder form of this mood disorder. There are also some difficulties that come along with diagnosing patients with bipolar disorder. This is mainly due to the fact that many individuals only see one form of the disorder- mania or depression[3]. Diagnosing this disorder takes time and involves looking at past episodes in order to diagnose the patient appropriately[4] .

Subtypes




As mentioned before, individuals that show signs and symptoms of bipolar disorder can fall into a few different categories: Bipolar Disorder 1, Bipolar Disorder 2 and Cyclothymia which fall under Bipolar Spectrum Disorder (BSD). Bipolar Disorder 1 and Bipolar Disorder 2 and the two main types of categories and are tested for differently. The main differences between the two is that Bipolar Disorder 2 is a more mild form of the condition and so if a patient with Bipolar Disorder 1 has manic episodes, then a patient with Bipolar Disorder 2 will have hypomanic episodes. This means that Bipolar Disorder 1 and 2 mainly differ in the severity of episodes. These moods have to be noticeably different from their normal behaviours.


Bipolar Disorder 1

Individuals with Bipolar Disorder 1 that have episodes of mania can also have psychotic symptoms which include delusions or hallucinations[5] ; Bipolar Disorder 2 individuals may also have these symptoms however it is more like to occur in Bipolar Disorder 1 individuals. Also, because their symptoms are so severe, Bipolar Disorder 1 individuals normal functioning can be hard to accomplish and individuals find that leading a normal life is far from possible
Bipolarity relationship among different mood disorders.
Bipolarity relationship among different mood disorders.

due to the fact that people around them can also be affected emotionally and maybe even physically. Sometimes the episodes can be so severe that close family and friends may not know what needs to be done. Patients then need to be taken into a hospital so that they can be calmed down and treated. In the article by Whitney and colleagues titled, "Information processing in adolescents with bipolar I disorder", it was found that adolescents with Bipolar Disorder 1 had memory bias which seemed to be a recurrent trait in adolescents and was not mood state dependent[5].

Bipolar Disorder 2

Individuals with Bipolar Disorder 2 have episodes of hypomania which can be seen if they do not require much sleep, talk more than usual and feel like they can’t stop, they are easily distracted or just overall hyper[6] . They also feel very confident in themselves and are always involved in activities around them[6]. These symptoms can interfere with daily life; however, many individuals don’t find that it can affect their social relationships of jobs[7] . The other extreme symptoms these individuals can face are depressive episodes. These symptoms are the opposite of hypomania: individuals could have insomnia, be tired all the time, crying, may have thoughts of death and overall have no interest in life[7].

Cyclothymia

Cyclothymia is another form of bipolar disorder that according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is, "a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms”[8] . Individuals with Cyclothymia have this disorder for longer periods of time and have episodes of hypomania that can be mild to severe but does not include psychotic features and can also have episodes of depression which can also be mild to severe but doesn’t include thoughts of death.

Questionnaires



Previously, overlooking the possibility of a patient having BSD led to a delay in diagnosis and an increased severity of symptoms. If not treated, these symptoms can get worse as a patient’s day-to-day life can be affected from relationships to work. Misdiagnosis can lead to more problems because patients may be treated with antidepressants which are serotonin reuptake inhibitors. This allows serotonin to linger around more and this may increase symptoms of mania/hypomania making those symptoms worse[9] . Some suggestions in order to increase proper diagnosis and recognition of the disorder is to screen for it using the MDQ that was talked about previously[9]. The MDQ was created by a panel of experts in the field of bipolar disorder in order to screen a patient’s history of episodes[9]. As previously mentioned, it is comprised of 13 yes/no question, another yes/no question talking about previous episodes and then functional impairment is also considered[9].


Difficulties




Diagnosing bipolar disorder can be extremely hard due to that fact that it requires extensive research of patients past episodes and it also takes time because both symptoms of mania and depression need to be seen in order to diagnose the disorder correctly. Most research in papers has been done on Bipolar Disorder 1 due to the fact that is holds the most severe symptoms and is easily seen in patients. In the paper by Hirschfeld and colleagues titled, "Screening for Bipolar Disorder in Patients Treated for Depression in a Family Medicine Clinic", they treated patients with antidepressants and conclude that many patients that are treated with antidepressants are misdiagnosed[1]. They believe that if doctors look at these patients more carefully they will be better able to identify bipolar disorder making the process a lot easier and efficient. This misdiagnosing mostly occurs in patients that are being treated with antidepressants because the depression side of the disorder is kept under control; however, it isn’t completely gone and this is why it is very important to diagnose patients with bipolar disorder correctly.

Diagnosing a patient requires detailed observation from the doctor allowing for a proper diagnosis.
Diagnosing a patient requires detailed observation from the doctor allowing for a proper diagnosis.
In order to diagnose bipolar disorder in another study done by Hirschfeld, a sample group was picked from the U.S. population and were mailed MDQs to their households. The MDQ consisted of 13 yes/no questions and other questions that asked about their mood, self-confidence, energy etc. and there were questions that asked if the symptoms happened at the same time or not[10] . If the questionnaires were not returned then a telephone survey of the households was carried out. After the study was finished, researchers found that bipolar disorder prevalence in the U.S. population may be more prevalent than was thought earlier[10]. It was also found that only 20% of the individuals that screened positive for bipolar disorder after the survey/ phone interview was actually diagnosed with the disorder and 31% or the individuals were diagnosed only for major depression. This shows that even through tests and surveys which are the only available diagnostic tools for bipolar disorder, it is not sufficient enough to get a proper bipolar diagnosis but instead receive a unipolar diagnosis[10]. A major depression diagnosis leads doctors to treat patients with antidepressants and this leads to untreated symptoms of mania/hypomania and this could prove to be worse for the patient. In this article it was suggested that repeated interviews should be conducted between doctors and patients in order to get a more clear understanding of the diagnosis patients should receive. It will also allow a more thorough research into the patient’s history of episodes making it easier to notice both symptoms of mania/hypomania and depression.

There are many difficulties associated with diagnosing an individual with bipolar disorder. As mentioned previously, diagnosing patients with bipolar disorder can be extremely hard because it requires time and extensive research into the patients past mania and depressive episodes. The prevalence of this disorder has increased recently due to more efficient surveying tools and more awareness of the disorder and the fact that it is misdiagnosed. In the article titled, Screening for bipolar disorder in the community, it was found that many individuals that screen positive for bipolar disorder are misdiagnosed by doctors and this was more prevalent in individuals aged 18-24[10]. It can also be hard to diagnose patient because individuals only notice their depressive states as being an issue and so only decide to go see the doctor during these states. They overlook their mania or hypomania symptoms and feel that it’s not a relevant enough issue to be looked into. When a patient comes to a doctor with depressive symptoms, many doctors fail to ask the patient about previous mood swings which may include mania episodes[9]. However, now doctors are more aware of this disorder since it is growing among the North American population and the cases of bipolar disorder has increased substantially.

Shows a child that may have bipolar disorder and may be misdiagnosed.
Shows a child that may have bipolar disorder and may be misdiagnosed.

Diagnosis in Children

Diagnosing children and adolescents with bipolar disorder was rarely done in the past; however, after the 1990s many researchers decided to look into bipolar disorder in these age groups and found that it was a possibility[11] . With children and adolescents, the problem lies in an over diagnosis of the disorder because it is seen different in them. They tend to have shorter mood episodes that occur more rapidly and so can be seen more clearly. However, these symptoms can also fall into other disorder such as ADHD and other behavioural disorders. In the paper titled, Treatment of Pediatric Bipolar Disorder: A Review, a diagnostic protocol for Pediatric bipolar disorder (PBD) was used which included 5 steps as seen in Table 1 below.




Table 1- Diagnostic Protocol for Pediatric Bipolar Disorder

Steps to diagnose PBD
Explanation
(1) Screening for mania using the Child Mania Rating Scale (CMRS)[11].
Standard test used to look for symptoms in child[11].
(2) Establishing an actuarial estimate of the likelihood of PBD[11].
This looked at family history for the disorder and was used to get a calculated likelihood of a recurring disorder in the child[11].
(3) Evaluating diagnostic criteria with high specificity to PBD[11].
This involves looking at specific symptoms to PBD that do not overlap with other disorders; these symptoms could include less need to sleep, no self-confidence, hypersexuality, elated mood, racing thought and a need to constantly speak and goal-directed activity[11].
(4) Obtaining evidence of episodes[11].
Need to look at current and past episodes[11].
(5) Extending the window of assessment[11].
Continuously asses the individual to be sure of the diagnosis[11].
Proper diagnosis of this disorder can be very beneficial to patients so that they do not continue to hurt themselves and their loved ones. It is important that doctors remember that BSD is a possible outcome if a patient approaches them with depressive symptoms. An MDQ should be completed and this allows for a clearer picture of what the individual is going through and what needs to be done in order to treat them. Also it is important to categorize the patient in the appropriate form of the disorder so that they can receive the appropriate treatment. The difficulties in diagnosing children, adolescents and adults were depicted in this paper. Diagnosing takes time and careful observation from the doctor’s point of view. If not diagnosed appropriately, it could lead to symptoms getting worse and more damage to the individual’s day-to-day life. Doctors need to keep in mind that if a patient approaches them with depressive symptoms, they should also be checked for manic episodes. Research still needs to be conducted in this area in order to get better diagnostic tools that are more efficient and to the point.
  1. ^ Hirschfeld, R. M. A., Cass, A. R., Holt, D. C. L. And Carlson, C. A. Screening for Bipolar Disorder in Patients Treated for Depression in a Family Medicine Clinic. J Am Board Fam Med July-August 2005 vol. 18 no. 4233-239.
  2. ^ Mitchell, A. J. Clinical utility of screening for clinical depression and bipolar disorder. Current Opinion in Psychiatry. Vol. 25 No. 24-31. January 2012.
  3. ^ Hirschfeld, R. M. A., Calabrese, J. R., Frye, M. A., Lavori, P. W., Sachs, G., Thase, M. E. And Wagner, K.D. Defining the Clinical Course of Bipolar Disorder: Response, Remission, Relapse, Recurrence, and Roughening. Psychopharmacology Bulletin. Vol 40 No.3-7. November 2007.
  4. ^ Joffe, R. T., Young, L. T. and MacQueen, G. M. (1999), A two-illness model of bipolar disorder . Bipolar Disorders, 1: 25–30.
  5. ^ Whitney, J., Joormann, J., Gotlib, I. H., Kelley, R. G., Acquaye, T., Howe, M., Chang, K. D. and Singh, M. K. (2012), Information processing in adolescents with bipolar I disorder. Journal of Child Psychology and Psychiatry.
  6. ^ Purse, Marcia. "What Is Hypomania? How Is It Diagnosed?". About.com. Medical Review Board, 29 12 2011. Web. 26 Mar 2012. <http://bipolar.about.com/od/maniahypomani1/a/what_is_hypomania.htm>.
  7. ^ Purse, Marcia. "What Is Bipolar 2 Disorder? ". About.com. Medical Review Board, 25 10 2011. Web. 26 Mar 2012. <http://bipolar.about.com/cs/faqs/f/faq_bp2.htm>.
  8. ^ "Psychiatric Disorder." AllPsych Online. AllPsych and Heffner Media Group, Inc., 29 11 2011. Web. 26 Mar 2012. <http://allpsych.com/disorders/dsm.html>.
  9. ^ Hirschfeld, Robert M A. Screening for bipolar disorder in the community. The journal of clinical psychiatry 64.1 Jan 2003: 53-9. Physicians Postgraduate Press Inc.
  10. ^ Hirschfeld, R M. Bipolar spectrum disorder: improving its recognition and diagnosis. The journal of clinical psychiatry 62 Suppl 14 2001: 5-9. Physicians Postgraduate Press Inc.
  11. ^ Washburn, Jason J. Treatment of Pediatric Bipolar Disorder: A Review. Minerva psichiatrica 52.1 Mar 2011: 21-35. Edizioni Minerva medica.