There are a number of challenges that the diagnosis of bipolar spectrum disorder can pose, which is precisely why the following information is so essential to mental health professionals as well as patients and their families. Bipolar spectrum disorders are clearly defined within the DSM-IV, or Diagnostic and Statistical Manual of Mental Disorders, and consist of:
- Bipolar I disorder: a manic depressive disorder that can exist both with and without psychotic episodes
- Bipolar II disorder: consists of depressive and manic episodes which alternate and are typically less severe and do not inhibit function
- Cyclothymic disorder: a cyclic disorder that causes brief episodes of hypomania and depression
These three conditions together affect approximately three to four percent of the population, although recent research and clinical observations seem to indicate that bipolar spectrum disorders may impact a larger percentage of the population to a lesser degree. These patients suffer from a sub-threshold bipolar disorder and are often less willing to receive medical therapies such as antidepressants.
Continued efforts are being made to properly subtype the bipolar spectrum, but those patients who have sub-threshold bipolar disorder are currently diagnosed with bipolar disorder NOS, or not otherwise specified. When these individuals are included in the total, the prevalence of bipolar disorder increases to around five to eight percent. This goes far beyond the mere one percent prevalence currently attributed to manic depressive disorders by major surveys and studies.
History of Bipolar Sub-typing
Bipolar disorder was first discussed by German neuropsychiatrist Emil Kraepelin in the late 1800s. He described it as manic depression and the current DSM-IV subtypes were included in his conceptualization as well as additional variations of episodic depression. Kraepelin’s view on bipolar disorder continued until the 60s when the first DSM was drafted and the creators proposed a different classification for manic-depressive illnesses. In later editions of the DSM, this morphed into what was known as the unipolar/bipolar dichotomy.
Types of Bipolar Defined by Dunner & Fieve
During the 1970s, Dunner and Fieve were responsible for differentiating between bipolar I and bipolar II disorder. In the early 80s, Gerald Klerman went even further by defining the following subtypes:
- Bipolar I: depression and mania
- Bipolar II: depression and hypomania
- Bipolar III: cyclothymia
- Bipolar IV: mania or hypomania caused by antidepressants
- Bipolar V: genetic bipolar disorder
- Bipolar VI: non-depressive mania
Today, the leader in the realm of bipolar disorder and subtyping is undoubtedly Hagop Akiskal, a clinical researcher with great respect for Kraepelin and his classification of the bipolar spectrum. His opinion on the subject differs greatly from Klerman, with Akiskal dividing bipolar disorder into six primary subtypes which include:
- Bipolar I: full mania
- Bipolar Ia: depression with hypomania
- Bipolar II: depression with episodes of hypomania
- Bipolar IIa: cyclothymia
- Bipolar III: antidepressant-caused hypomania
- Bipolar IIIa: depression and/or hypomania caused by substance use
- Bipolar IV: depression caused by hyperthymic attitude
- Bipolar V: recurrent depression and dysphoric hypomania episodes
- Bipolar VI: depression that progressives to a dementia-like disorder
Diagnoses that Go Beyond the DSM-IV
Any mental health professionals who have dealt with those with bipolar spectrum disorder will certainly agree that there are a number of patients who are suffering from anxiety, depression, and other symptoms that don’t exactly fall within the DSM classifications. In most cases, the symptoms experienced by individuals like these are more erratic and change over time. Both depression and anxiety symptoms are atypical and any present hypomania tends to be more dysphoric than is strictly defined in the DSM.
Many patients with these characteristics have been previously prescribed anxiolytic medications or antidepressants by their general practitioner or psychiatrist. They often don’t have the desired response to these drugs, with some only experiencing partial relief and others actually regressing into more intense episodes of depression and/or hypomania. Some patients visit a psychiatrist while already taking high-dose benzodiazepine, which often times is unable to relieve their anxiety.
All of these patients that seem to defy your typical bipolar diagnosis are lumped into a group that is known as “soft bipolars”. Until proper sub-typing of bipolar spectrum disorders is accepted and used across the board, psychiatrists who are aware of this none-too-rare subgroup are required to go outside of the DSM to diagnose these individuals.
There are a number of symptoms that can be attributed to soft bipolar disorder. These include the following:
- Episodes of Mood Instability
Patients will typically begin to demonstrate mood swings beginning around the time of adolescence. Individuals will alternate between brief periods of depression and euphoria. Paranoia, rage, intense anger, panic attacks, and phobias may also occur. This presence of multiple moods has led many professionals to believe that “multipolar” is a more accurate term for soft bipolar individuals.
- Episodes of Atypical Depression
Patients with soft bipolar disorders will often respond favorably to positive stimulus, but will often return to their overall depressed state within a period of hours to days. Additional symptoms might include binge eating, excessive sleeping, lethargy, as well as anxiety. Seasonal affective disorder, winter-triggered depression, pre- or post-menstrual dysphoric disorder, hysteroid dysphoria typically associated with romantic rejections, and abulic depression are other associated disorders that can go hand and hand with soft bipolar disorder.
Hypomania can be either dysphoric or euphoric. Hypomania in individuals with soft bipolar disorder can be either characterologic or episodic, although episodic dysphoria is certainly the most common. Dysphoric hypomania is characterized by irritability, impulsiveness, and poor judgement, while euphoric hypomania can often be pleasant for the individual, causing them to have a temporary boost in productivity and positive emotions.
Dysphoric symptoms can be quite damaging to relationships and can often be accompanied by a sense of desperation. Hypomania will often alternate with depression, making the mood of the individual highly unstable in virtually every case. The most common form of hypomania, namely dysphoric hypomania, can often be identified due to the bouts of paranoia, rage, and other emotions that the individual often experiences.
- Mixed Symptoms
Some individuals experience simultaneous hypomania and depression which is known as mixed bipolar disorder. Others have what is referred to as rapid cycling bipolar disorder which is characterized by frequent and often unpredictable switches between depression and hypomania. These two forms of bipolar disorder can often confuse the diagnostician and make identifying the problem different for even experienced mental health professionals. These types of symptoms are far more prevalent in women, especially in those who suffer from thyroid conditions, are unresponsive to lithium treatments, or are taking antidepressants that are worsening their symptoms.
Diagnosing these conditions in an outpatient setting ranges from difficult to downright impossible, even if a detailed medical history of the patient is obtained. In most cases, a diagnosis of mixed state disorder are only made after outpatient treatments have failed or only served to exacerbate the problem. Due to the issues commonly experienced during the diagnosis process, misdiagnosis of mixed state or rapid cycling bipolar disorder is all too common.
The Challenges Associated with Co-Morbidity
The definition of co-morbidity is the simultaneous presence of two or more conditions in one patient. Approximately 50 percent of individuals with bipolar disorders are co-morbid and are living with other psychiatric or medical conditions. Unfortunately, this can often make proper diagnosis and/or treatment more challenging. The following are some conditions that can impact the diagnosis and treatment of bipolar disorder:
- Thyroid conditions
Both hypothyroidism and hyperthyroidism can complicate bipolar disorders. Since the symptoms associated with hyperthyroidism can emulate those of hypomania, it can both make bipolar disorder difficult to diagnose and the symptoms more pronounced. On the other hand, hypothyroidism can often resemble depression and can make antidepressants ineffectual and worsen symptoms of the disorder. To make matters more complicated, lithium treatments can sometimes cause hypothyroidism which in turn can impact future treatment. Subclinical hypothyroidism has been linked to the development of rapid cycling and mixed bipolar disorders as well.
In order to properly treat the disorder, it’s necessary to address the thyroid problem first. In the vast majority of cases, the presence of a thyroid condition will interfere with the treatment of both depression and bipolar disorder.
- Substance abuse
Alcohol and drug abuse are both common among those with bipolar disorder. In fact, about 50 percent of patients with a bipolar spectrum disorder will struggle with significant substance abuse during their lifetime. This can be a big issue, as addictive and intoxicating substances will almost always worsen symptoms of the disorder. Not only do illicit substances and alcohol impact those with bipolar disorder, but nicotine and excessive caffeine have been known to do so as well.
Drugs and alcohol can mimic both hypomania and depression. However, they cannot cause bipolar disorder. However, substance abuse can make an existing illness more obvious, and bipolar disorder can make future alcohol and substance abuse more likely. It’s very common for those with bipolar disorder who have yet to be diagnosed and obtain proper treatment to attempt to self-medicate and find relief through a variety of substances, including amphetamines, cocaine, opiates, marijuana, and alcohol. When these individuals finally seek professional care, they often require treatment for two separate conditions that can exacerbate each other.
Treatment of bipolar disorder should typically not be begun until the patients have undergone a detox and rehab program and have been free of their substance use for a period of thirty or more days. The symptoms of bipolar disorder will rarely respond to treatment until all intoxicating substances have been eradicated from the body. Fortunately, in many cases, once the detox has occurred and the symptoms of bipolar disorder have been properly treated, the drive that led to the initial substance abuse will be largely dampened.
- Attention deficit hyperactivity disorder (ADHD)
While ADHD is typically associated with small children who struggle to pay proper attention in school, it should be noted that the symptoms of ADHD often carry on into adulthood and can merge with the symptoms typically associated with adults with bipolar spectrum disorder. Both ADHD and bipolar disorder have similar symptoms, such as impulsiveness, poor judgement, difficulty with focusing, restlessness, and hyperactivity. However, bipolar symptoms are rarely constant whereas symptoms of ADHD are almost always present in one form or another.
Both conditions can be present in the same person. However, no one yet knows the frequency of this co-morbidity. It’s important to identify the cause of the symptoms being experienced as many treatments used for ADHD, such as Ritalin (methphenindate), can make the symptoms of bipolar disorder far worse. When ADHD and bipolar disorder are present, tricyclic antidepressants can often be used to treat both conditions.
- Borderline personality disorder (BPD)
Patients with BPD often have symptoms of all of the different personality disorders discussed in the DSM-IV. This can make daily life difficult and unstable. These individuals are often dramatic and prone to feelings of sensitivity and abandonment. They also tend to put far too much pressure on loved ones and often have unrealistic demands for their families and friends. They tend to be self-destructive, and suicidal ideations are not uncommon.
It wasn’t long ago that those with BPD were believed to be the most challenging of all patients, and many psychiatrists have studied and written about the different methods of treatment. Recently, it has become quite apparent that BPD and bipolar disorder go hand in hand. This determination has been very helpful for patients as many are now able to receive the treatments they need to stabilize their moods and experience relief. The majority of patients successfully respond to treatment combinations that include SSRI antidepressants, antipsychotics, and mood stabilizers.
Once those with a co-morbidity of bipolar disorder and BPD are able to stabilize their emotions and moods, psychotherapy has been shown to be much more helpful. Those who accept treatment and are proactive with therapy have a very positive prognosis, especially when compared to the prognosis these same individuals experienced in years past.
- Other Personality disorders
During periods of disturbance, it’s common for those with bipolar disorder to experience symptoms of a number of different personality disorders. These can range from dependency, histrionic traits, paranoia, narcissism, hypochondria, passive aggressiveness, and antisocial characteristics. Typically, when the bipolar condition is treated, the symptoms of the various personality disorders will be alleviated as well. However, in cases where the symptoms are severe, treatment can become complicated.
Patients who have personality disorders can often be manipulative, self-destructive, and unwilling to seek out the proper treatment. Substance abuse is common, and psychotherapy and pharmacological approaches are often refused. While they understand that the treatment may be beneficial, they often put up barriers and neglect to take the proper proactive steps.
It should also be mentioned that bipolar disorders are quite common among those who are incarcerated.
There is rarely any confusion surrounding the diagnosis or bipolar I and II disorders as the DSM-IV criteria is quite straightforward. However, in cases where depression is the first recognized symptom, it’s common for clinicians to withhold diagnosis until a subsequent episode of hypomania or mania occurs. If the depression occurs in episodes and there is a history of bipolar disorder within the family, the clinician should look for other signs of bipolarity such as drug or alcohol abuse, uncontrolled rage, suicidal ideations, psychotic events, and the like.
While the first two forms of bipolar disorder are easier to diagnose, the situation becomes far more complex with bipolar spectrum disorders. This certainly should come as no surprise, especially considering the co-morbidities that were previously mentioned as well as the high number of bipolar subtypes.
When evaluating for mood disorders, the clinician should consider a number of items, including:
- symptom history in the patient
- history of episodes and the response of the patient to treatment
- family history of psychiatric conditions
- comprehensive medical history, including past physical examinations
- medications that the patient is currently taking, both psychotropic and non
- any noted positive or negative history with any medications past prescribed
The clinical interview should be as structured as possible in order to more effectively diagnose any present mood disorders. There are many established interview methods, many of which are specifically structured in order to detect bipolar disorder subtypes based on the presence of certain symptoms.
In some cases, laboratory tests can also prove helpful. For example, the TRH test assesses the presence of hypothyroidism and helps the clinician to determine whether the individual has bipolar or unipolar depression. Tests have also been shown to help delineate any changes in the brain that may indicate bipolar depression. CAT scans, MRIs, PET scans, quantitative EEGs, and SPECT scans are among the most useful tests and imaging techniques for bipolar disorder diagnosis. These tests are all quite costly and are occasionally unavailable to clinicians and psychiatrists. Even in cases where these scans and tests can be performed, the results are typically used primarily for research instead of for definitive diagnosis. However, this could easily change in the future.
In many cases, those who are suffering from bipolar spectrum disorder have failed to respond to standard treatment at one point or another. For those individuals who have not found relief from their symptoms using standard anxiolytic or antidepressant medications, an alternative can be found in an in-depth interview and assessment to better understand their anxiety and mood disorders. A catalog of all of their symptoms are recorded along with their severity. This, in conjunction with a quantitative EEG and TRH test can be quite helpful at determining whether an individual is in fact on the bipolar spectrum.
If the patient has previously been prescribed benzodiazepine or another medication that has not had the desired effect, the individual can be weaned off of the drug before another treatment begins. If the patient has a substance abuse problem, the individual will be required to get and stay sober for a period of at least thirty days to ensure more effective treatment. If a complicating illness exists, the patient is believed to have a mixed state bipolar disorder, or a high-dose benzodiazepine has been prescribed in the past, it may be beneficial for the patient to be stabilized in an inpatient, hospital setting that is dedicated to providing rapid detox.
During treatment, all patients will be closely counseled and informed of the importance of sticking with their medication instructions to the letter. They will also be told about the importance of long-term follow-ups and monitoring. Depending upon each individual’s needs and situation, group or individual psychotherapy might be necessary. However, this determination likely will not be made until the patient has been stabilized. In many cases, patients will need to be constantly reassured and encouraged to continue in their therapy, especially if they have been previously dependent on medications.
Those with bipolar spectrum disorder who are primarily plagued with depression and anxiety symptoms will likely be placed on SSRIs such as Zoloft, Lexapro, or Prozac. These medications are quite efficient in most cases at both alleviating depression and generally stabilizing the individual’s mood. Patients need to be closely monitored until they have been fully stabilized.
In cases where hypomania emerges during treatment, it may be necessary for a stabilizer such as Lamictal, Tegretol, or Topamax to be introduced as well. If no improvement is seen within a month or so or there are side effects that have made the medication dangerous or intolerable, a dual neurotransmitter option may be necessary. These include antidepressants such as Welbutrin and Cymbalta. Once a solution has been found and has been shown to be effective at managing the disorder, the clinician will likely recommend that the medication be maintained at the same dosage until some change necessitates an alteration in treatment.
Those individuals who seek treatment initially for dysphoric or euphoric hypomania or who have a history of violence or rage will almost certainly be placed on mood stabilizers before any other treatment can be begun. Once the uncontrollable anger and outbursts have been reined in, antidepressants can be added to their regimen.
Patients who have been diagnosed with rapid cycling or mixed state bipolar disorder or who have a history of recent substance abuse or addiction to anti-anxiety medications will almost always require treatment in a hospital setting. In cases like these, combination therapy that consists of antidepressants and mood stabilizers is often the most effective.
Patients who have co-morbid bipolar disorder and BPD will also typically require combination therapy with mood stabilizers, antidepressants, and anti-psychotics such as Geodon or Zyprexa. Once their mood disorder has been properly addressed, psychotherapy is far more likely to be effective. With long-term therapy and permanent medication, the prognosis is greatly improved.
Those with personality disorders pose a challenge as they are often hesitant or downright refuse to accept treatment. Some will follow procedure to please the clinician. However, this rarely lasts for the duration of the treatment, making it difficult to treat this group of patients.
Patients with bipolar spectrum disorder who also have a diagnosis of ADHD will typically be given both a mood stabilizer and a tricyclic antidepressant. In rare cases where this does not provide the desired results, a stimulant such as Ritalin or Adderall may be prescribed along with the mood stabilizer.
Those with substance or alcohol abuse issues will, as mentioned, be required to detox and be substance-free for a minimum of a month before treatment begins. Once free of drugs and properly treated for their bipolar spectrum symptoms, approximately 50 percent of individuals will remain free and clear of alcohol and drugs.
Individuals with other medical conditions often have a successful treatment as long as their medical issues are addressed first. Any problem of a metabolic nature, such as diabetes, fever, thyroid conditions, infection, or pain can disrupt the efficacy of mood stabilizers making a flare-up of bipolar disorder symptoms more common.
Occasionally, patients will not have the desired response to newer antidepressant medications. MAOI’s or monoamine oxidase inhibitors were developed in the 50s and were the first of their kind. Due to the hypertensive effects they were later shown to have among patients who consumed certain foods or took certain medications, they largely fell into disuse.
However, research later showed that patients suffering from atypical depression tended to be more responsive to MAOIs. Today, these medications remain available for cases where the individual is not responsive to more modern medications or has an adverse reaction to said drugs. MAOIs such as Marplan, Parnate, and Nardil are determined to be largely safe to use as long as the patient avoids certain foods and medications, and they have been shown to be quite effective in individuals who are diagnosed with anxiety or depression associated with bipolar spectrum disorder.
Antidepressants in Children and Adolescents: A Definite Dilemma
It’s no secret that children and adolescents can occasionally have a different and oftentimes negative reaction to antidepressant drugs, most especially serotonin re-uptake inhibitors or SSRIs. For this reason, packaging for these drugs now contains warnings indicating the potential dangers these medications can pose to depressed children.
It’s certainly disconcerting that many of those teenagers responsible for school shootings were in fact taking SSRIs at the time of the crimes. Without a doubt, these violent outbursts brought up the question of whether or not these medications might be doing more harm than good. In cases like these, it’s likely that the diagnosis of these troubled youths was where the issues began.
Ever since SSRIs were first created and marketed, clinicians have had to deal with the fallout of the occasional patient who not only didn’t respond correctly to the medication, but had intense, violent, and sometimes suicidal reactions to the drugs. In most cases, these problems were quickly resolved by stopping or altering the medication given. Suicide was uncommon in these cases, but there was no doubt that the drug did create an intense reaction in some younger patients. The presence of bipolar spectrum disorder in these individuals might indeed have been a contributing factor.
Psychiatrists who specialize in working with children and teenagers are beginning to take note that some of their patients, most especially those who appear exceptionally volatile, may indeed be suffering from a bipolar spectrum disorder. According to the data gathered by The Spectrum Project, it appears as though more than 50 percent of individuals diagnosed with depression will go on to develop symptoms of bipolar disorder as well. In cases like these, antidepressants may not be appropriate treatment and medications like these may indeed exacerbate the symptoms. This could certainly account for the violence, rage, and suicidal behavior of these individuals.
If there’s one thing that this research indicates, it’s that more studies must be conducted and more information collected about how to properly diagnose individuals, both young and old, who are living with bipolar disorders. The search must continue for objective parameters by which to properly diagnose the disorder and proper care must be given to train future clinicians in the subtleties of the condition.
Only a few years ago, soft bipolar spectrum disorders were only discussed in a handful of academic institutions and training programs. Fortunately, the understanding of these disorders continues to increase and the hope is that more and more mental health professionals will be able to correctly and effectively diagnose and treat those individuals who fall within this spectrum.