The Challenges of Diagnosing a Patient With Bipolar Disorder

In part 1 of this 2-part episode, W. Clay Jackson, MD, DipTH, speaks about diagnosing patients with bipolar disorder, other disorders commonly confused with bipolar disorder, and the risk factors and the prevalence of bipolar disorder. 

For more information on bipolar disorder, visit the Resource Center

Listen to part 2 of this episode here

W. Clay Jackson, MD, DipTh, is an assistant professor of clinical psychiatry and family medicine at the University of Tennessee College of Medicine (Memphis, TN).



Jessica Bard: Hello, everyone. And welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360, a multidisciplinary medical information network.

Nearly 3% of US adults had bipolar disorder in the past year, according to the National Institutes of Health. Dr Clay Jackson is here to speak with us today about bipolar disorder. Dr Jackson is an assistant professor of Clinical Psychiatry and Family Medicine at the University of Tennessee College of Medicine in Memphis, Tennessee.

Thank you for joining us today, Dr Jackson. Please describe mania, hypomania, and major depressive episode. And what are the differences between each?

Dr Clay Jackson: Wow. A short question with so many stems that we could sort of take off on and elaborate on. So let's start, actually with the last category question, which is a major depressive episode. This is what we learned in professional training, sort of the SIG E CAPS, S-I-G E C-A-P-S. Those are the traditional DSM or Diagnostic Statistical Manual criteria for diagnosing depression as far as a major depressive episode. And in order to be considered an MDE, or major depressive episode, a patient would need to advance, or demonstrate 5 out of 9 of those characteristics over a two-week period. It would need to be a change from their normal level of functioning. And those 5 of 9 criteria, 1 of them needs to be either a depressed mood or what we call anhedonia, a lack of pleasure, or a lack of desire for pleasurable activities. So that's a major depressive disorder episode or a major depressive episode.

Well, let's talk about then what is mania or hypomania. Now, when we think about mania and hypomania, some people think of elevated mood in terms of sort of grandiosity, or increased self-esteem, or euphoria in terms of a high in terms of mood. But it can also just be irritability as mood too. So, sometimes I think when explaining, we talk about increased energy of mood, not just an increase in the quality of the mood. But if we look at bipolar criteria, we're talking about basically seven diagnostic stems: increased grandiosity or self-esteem, a decreased need for sleep, rapid speaking, racing thoughts, easy distractibility, what we call psychomotor agitation or doing lots of activities at once, doing lots of tasks, maybe even purposeless movements, and then potentially harmful, impulsive activities, such as drug use, substance use, overspending, risky sexual behaviors, or dangerous driving.

And so, in order to be considered bipolar I or mania, then three of these need to be present for a week. And if it's just an irritable mood, and not an expansive mood in terms of euphoria, then four of those need to be present. And, obviously with bipolar I, we need to see in order for diagnostic specificity to be there a marked impairment, a need for hospitalization, or a significant impact on vocational, or relational activities.

For hypomania, it's the same criteria yet, they only had to be present for four days for it to qualify as bipolar II or hypomania. And there doesn't have to be marked impairment in vocational, or relational functioning. The patient would not need to be hospitalized. Also, any psychosis as part of a bipolar episode, no matter the duration, qualifies a person in terms of mania, or bipolar I. So that sort of gets us into bipolar I, bipolar II, and then major depressive disorder in terms of mania, hypomania, and a major depressive episode.

They're also, for those who want the bonus round, there's something called mixed state, or mixed features in which a patient might have a major depressive episode, but they could have three, or more of the symptoms of a manic episode present. Or a patient might have a manic episode on the other end of the mood spectrum. And they might have 3, or more of the 9 depressive criteria present. And we would call that manual with mixed features, or we'd call it major depressive episode with mixed features, depending on which end of the spectrum was diagnostic as a root cause. And then, the sort of additional symptoms.

And obviously mixed states, as one might assume, are sometimes a little difficult to treat. There's a filibuster answer to your short question you're probably afraid to ask any more questions, but a complex answer because these are complex patients and complex disorders.

Jessica Bard: Yeah, absolutely. So, we talked about the symptoms, but how is bipolar disorder diagnosed when we're talking about maybe physical examination?

Dr Clay Jackson: So, the key to most psychiatric diagnoses actually is the history. Certainly, a physical exam can help us. We can look at the patient's comportment. We can watch from movements. We can see, with our eyes, the patient's engagement, and how they look at us. We can listen to how they're speaking, and the expression of their thoughts, the organization, et cetera. And so, these are things that we can pick up on in physical space, or even through virtual, or telehealth. However, the history of the patient is sort of the sine qua non, or the key diagnostic feature.

The gold standard for diagnosis of bipolar disorder is a structured clinical interview, or so-called SCID. A structural clinical interview diagnostic. And that's a 30 minute interview with certain validated questions that are asked of the patient. However, in the lives of most busy clinicians, such a SCID interview is impractical, and is often not relied upon in the clinical setting so much as sort of shortcuts, or validated scales, or screeners that we might use to elucidate some of the patients.

Two of the screeners that I routinely use in my clinical practice are the rapid mood screener, and the mood disorder questionnaire. And these can sort of be shortcuts, if you will, or very quick instruments that are reported on by the patient. Take about three to five minutes to fill out. And they help clinicians to diagnose. They're not diagnostic in and of themselves, but they can help us screen for bipolar disorder.

The mood disorder questionnaire was developed by Robert Hirschfeld. And the rapid mood screener is a more recent screener that's developed. And I like it because it's shorter. It has fairly equal sensitivity, and specificity to the MDQ. So, we're talking 80, 90%. And then, it also takes into account some of the bipolar depression side of things, which the MDQ, or mood disorder questionnaire does not.

Now, importantly, there are not sort of smoking gun, or pathognomonic blood tests, or laboratory test that point us to bipolar disorder. This is a clinical diagnosis. And so, as we said, the history and, to some degree, the physical are the key elements in the clinician's diagnostic toolkit.

Jessica Bard: Are there other disorders that are commonly confused with bipolar disorder? What are they? And why would you say that is?

Dr Clay Jackson: Oh, wow. Yes, yes, yes, yes. There are many comorbid psychiatric disorders which can actually be present in the bipolar patient. And then, there are other disorders that are very similar that share symptomatology with bipolar disorder. And so, this can lead to significant diagnostic confusion.

Picture a set of circles kind of overlapping as a Venn diagram might with different symptoms in them that belong to different diagnostic clusters. And it looks like a flower with lots of different diagnoses that could be there. Certainly, substance use disorder can mimic the behaviors of patients who have had their cognition, their behavior, and their affect altered by illicit pharmacologic products. Drugs can certainly mimic bipolar disorder. In the absence of exogenous substances, patients with anxiety can often have some of the symptoms of bipolar disorder. The most common misdiagnosis is patients who have a depressive episode associated with bipolar disorder.

Remember it's two poles. And patients with bipolar disorder actually spend more time in the depressed phase than they do in the manic, or the hypomanic phase. And so, often they come to the clinician's office in a depressive episode. And if clinician doesn't take a careful history, then bipolar disorder might be missed. So, the most common misdiagnosis is major depressive disorder. Adult ADD, or attention to deficit disorder can often be misdiagnosed in patients who have bipolar disorder because impulsivity, and lack of concentration on task can be common between the two diagnoses in terms of the symptom cluster. So, again, MDD, ADD, and SUD, substance use disorder these are three common misdiagnoses for patients who have bipolar disorder.

Jessica Bard: When is bipolar disorder typically diagnosed?

Dr Clay Jackson: Too late. And I really don't mean that in a sarcastic fashion. I mean it as a call to action for those of us who are in the mental health space, and in the primary care space as clinicians. Even if a person's in a first responder space, such as an emergency department, or EMS, emergency medical services space, understanding and being aware of bipolar illness is so critical to picking it up. Because, as I mentioned, this can be a complex diagnosis. And, unfortunately, even in our current society with the positive peer pressure that we have for the de-stigmatization of mental illness, and mental health diagnoses bipolar patients, unfortunately, often suffer from their symptoms for a decade, or more before they receive a proper diagnosis. They may go through two or three clinicians, two or three pharmacologic treatment regimens before bipolar illness is accurately, properly diagnosed.

As you can imagine, this does a lot of damage to the body. This does a lot of damage to the brain. And, unfortunately, this does a lot of damage to the person's relationships, both vocational, and social before proper treatment might improve the symptomatology to the point that a patient could have improved functionality in both their personal and vocational lives.

In terms of the demographics of when patients get diagnosed, symptoms often present in the teen, or early 20s years. But patients typically get diagnosed, as I said, later. So, we're talking about the late 20s, mid-30s when many patients are diagnosed 'cause there's seriously approximately a 10-year lag from the onset of symptomatology to the onset of proper, nosology, or diagnostic precision.

Jessica Bard: What are the risk factors of bipolar disorder?

Dr Clay Jackson: Well, in terms of causality, that's a bit difficult to shake out. There are a number of genetic polymorphisms that offer some predilection for bipolar disorder. The environmental factors that may contribute are somewhat controversial but can be certainly contributory. The more that we learn about early life adversity, and how it sets up inflammation in the human brain we certainly see that correlation in major depressive disorder. And there are many who feel this has contributed toward bipolar disorder as well.

If we're talking about correlation, there are a number of factors that increase the chances that your patient who's having a mental health challenge may have bipolar disorder. That includes an early onset of depressive symptomatology, unpredictable or unexpected responses to antidepressant pharmacology for treatment of depression, a family history of bipolar disorder. Bipolar disorder is one of the most heritable mental health conditions that we know of. Patients who have frequent changes with domestic partnerships, with vocational aspirations. One classic phrase that's used often is tempestuous biography. Patients, who have a history of boundary transgression in ways that are a little bit beyond what their peers do, more experience. These can be predictive. In females who have a history of postpartum depression, again that points to an earlier age of onset, these can be indicators that a person might be experiencing bipolar symptoms rather than so-called unipolar, or straight major depressive disorder symptoms.

Jessica Bard: How about the prevalence? What is the prevalence of bipolar disorder?

Dr Clay Jackson:

Oh, that one's a hot one. It depends on with whom you're speaking.

In the old days, we used to think it was 1%, but typically an easy to monitor remember that? Is bipolar I is probably 1%. If we include bipolar II or bipolar not otherwise specified, or NOS, the so-called softer bipolar spectrum disorders, then we're probably up to about 3% in terms of cross prevalence for a given year, or looking back 12 months. And this sort of speaks to a real change in the research, and literature of the last two decades in which the prevalence of bipolar disorder in primary care populations has had a greater appreciation as a result of the research of some real clinical heroes like Sloan Manning, my mentor, Roger McIntyre, Michael [inaudible 00:14:05] and others.

Jessica Bard: Is there anything else that you'd like to add today Dr Jackson?

Dr Clay Jackson: These patients can be persons who suffer with complex symptoms. They can have clusters of expressions that are somewhat difficult to tease out in terms of what their proper diagnosis is. And then, treatment can be a challenge as well. However, it's incredibly satisfying, as a clinician, to lean into these patients' experiences, to listen to them, to learn from them what they're experiencing. And then, with the proper diagnosis and with treatment, these patients can do quite well. And the change that one sees in these patients' lives is remarkable. And it is one of the most satisfying clinical conditions in terms of treatment that I personally experience as a clinician.

So, I would just encourage my colleagues, don't be discouraged, don't be dismayed by the complexity of the illness. You can do this. You can offer good help to these patients. Just partner with them, collaborate with them in a non-judgmental, a non-pejorative way. Learn about their experiences. And you'll find this could be very rewarding as a treatment journey for you and the patient.

Jessica Bard: Well, thank you so much for your time today. We really appreciate you being on the podcast.

Dr Clay Jackson: Thank you so much. Enjoyed speaking with you today. And, hopefully, this is helpful for our colleagues. Thank you very much.