Bipolar disorder is the name given to a group of mental health problems that cause fluctuations in mood and behavior. Everyone experiences variations in their mood but in bipolar the highs and lows are extreme and are beyond what would be considered normal for that person. The changes in mood can be extremely distressing: a recent review of the first-person accounts of people with bipolar disorder revealed profound experiences of loss, stigma, uncertainty, and despair [1]. Patients described how threatening it feels to receive a diagnosis of bipolar disorder, worry about relapsing, and the severe impacts bipolar disorder can have upon relationships and their ability to function [1]. Show
Figure 1: An illustration of manic, hypomanic, and depressive mood episodes in bipolar disorder. The highs of bipolar disorder are called ‘manic’ or ‘hypomanic’ episodes and the lows are called ‘depressive’ episodes. The term ‘bipolar’ just refers to the way that mood can change between the two extremes and different types of bipolar disorder are diagnosed depending upon which combination of mood states are experienced. People with bipolar disorder experience increased rates of mortality – the World Health Organisation estimates that they are 35-100% higher than the general population [2], and up to 15% of people with bipolar end their own lives [3]. One critical problem is that many individuals with bipolar disorder experience extremely long delays before receiving formal diagnosis and appropriate treatment. The average delay from first presentation to a medical professional until receiving a diagnosis of bipolar disorder is nine years [4]. It is therefore essential that clinicians feel confident in recognizing bipolar symptoms in order to minimize this delay.
Even expert clinicians experience difficulties in recognizing and treating bipolar disorder:
Given all of these complexities it is unsurprising that non-specialists struggle to recognize symptoms of bipolar disorder. Our goal is to help you to understand the important features of bipolar disorder and to overcome some of the common pitfalls that clinicians face when assessing clients who report symptoms of bipolar. The building blocks of bipolar disorderDiagnoses of bipolar and related disorders are made based on the presence of episodes of hypomania, mania, or depression. In order to confidently identify bipolar, it is essential that clinicians understand the ‘ingredients’ which comprise the different bipolar diagnoses. What is a ‘normal’ mood?It would be a mistake to think that ‘normal’ moods are steady. We all have moods that fluctuate – some days we feel motivated, energetic, and ready to engage with the world, and other days we just want to curl up and hide away. Many of these fluctuations happen in response to things that are happening in our lives, but our moods can fluctuate with the seasons, our health, or our hormonal cycle [11, 12] What is a manic episode?A manic episode is a period of ‘high’ mood. Someone having a manic episode might feel euphoric with a great sense of well-being, confident and adventurous, have an increase in sexual energy, and feel excited as though they can’t express ideas quickly enough. The way we feel affects the way we act, so when someone having a manic episode feels this way they are prone to behave in ways that are unusual for them such as being more outgoing or talkative, being much more active than normal, sleeping much less than before, being rude or aggressive, or even taking risks with their safety. What Is A Hypomanic Episode?A hypomanic episode is essentially a milder version of a manic episode. The mood and behavior changes seen in a hypomanic episode are not as extreme and they often do not last as long as a manic episode, although the emotional and behavioural changes are still definitely abnormal for the individual. Hypomanic episodes can feel more manageable than manic episodes and may not interfere so much with daily life, although other people may notice changes in the individual’s behavior. What Is A Depressive Episode?Everyone has periods of low mood and these are especially common when we experience losses or struggle with other challenges in our lives. According to formal diagnostic criteria, a depressive episode is more severe and persists for longer than normal downward fluctuations in our mood. A depressive episode is a two-week period where five or more of the following depressive symptoms are present: a depressed mood, diminished interest in activities, lack of energy or fatigue, sleep disturbances, suicidal thoughts or behavior, loss of confidence or feelings of worthlessness, or psychomotor agitation. What is a mixed episode?A mixed episode is a mixture of depressive and manic / hypomanic symptoms, or a rapid alternation between them. Individuals with bipolar often report that these are the most difficult episodes to cope with as they can be highly unpredictable and confusing for the individual to process.
Table 1: Symptoms of manic, hypomanic, and depressive episodes. Recognizing bipolar disorderDiagnoses of bipolar disorder are made by identifying different combinations of the ‘ingredients’ of manic, hypomanic, depressive, and mixed episodes. The DSM-5’s categorizations of ‘bipolar I’, ‘bipolar II’ and ‘cyclothymia’ form the most up-to-date diagnostic classification [12] with the ICD-10 using the alternative terminology of ‘bipolar affective disorder’ [14]. it is likely however that there will be more concordance between the two diagnostic systems with the publication of the ICD-11. Bipolar IA diagnosis of bipolar I requires one lifetime manic episode to have occurred. Only a minority (around 5-16%) of those with bipolar I exhibit ‘unipolar’ mania and a much more common presentation is manic episodes ‘bookended’ by depressive or hypomanic episodes [15]. Bipolar IIBipolar II requires at least one lifetime hypomanic episode and at least one major depressive episode to have occurred. The occurrence of a manic episode is an exclusion criterion for a diagnosis of bipolar II and some clients find that their diagnosis of bipolar II is changed to bipolar I during the course of their illness. Bipolar II is commonly misdiagnosed as unipolar depression since detection of a hypomanic episode can be more difficult than a manic episode due to its less severe impact on functioning [15, 6, 16]. Cyclothymic DisorderCyclothymic disorder, or cyclothymia, is a chronic fluctuating mood disorder with numerous periods of mild hypomanic and mild depressive symptoms that are distinct from one another. Diagnostic criteria require that the periods must never have been severe enough to meet the full criteria for a hypomanic, manic, or depressive episode thus making it more difficult to recognize than bipolar disorder. Because of this, cyclothymic disorder frequently goes undiagnosed [17]. Bipolar affective disorderInstead of bipolar I and bipolar II the ICD-10 recognizes ‘bipolar affective disorder’. For a diagnosis of bipolar affective disorder at least two lifetime episodes (manic, hypomanic, depressive, or mixed) must have occurred with at least one being manic or hypomanic. The diagnosis is typically sub-categorized according to the current affective episode the individual is experiencing. ComorbidityBipolar disorder is associated with significant comorbidity. In particular, there is substantial overlap between bipolar disorder and alcohol and substance misuse. Rate of alcohol and substance misuse have been reported to be as high as 69%, with average rates thought to be around 30%. Rates of anxiety, post-traumatic stress disorder (PTSD), and obsessive compulsive disorder (OCD) are also much higher than typical background levels [18]. Improving recognition of bipolar disorder in your clinical practice
Accurately diagnosing bipolar disorder in clinical practice can be difficult. Given the high rates of misdiagnosis it is incumbent upon clinicians to do all they can to familiarize themselves with the condition. Here are some practical steps you can take to help you to identify symptoms of bipolar disorder in your clients.
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