How does a psychiatrist diagnose bipolar disorder?

Diagnosing bipolar disorder is one of the specialties for psychiatrists in general. Every psychiatrist should know how to diagnose and treat bipolar disorder.

Why is that? A high percentage of people who come to a doctor to get their depression treated don’t have depression at all. If the doctor diagnoses depression and provides an antidepressant, it won’t work. Often when a patient has depression and comes to a doctor they have bipolar depression. This is about one in 20 people coming to see a doctor to get their depression treated, have a different form of depression that doesn’t respond to anti-depressants but mood stabilizers.

On average it takes at least 10 years and two providers trying four or more medicines, until finally someone with bipolar depression is correctly diagnosed and treated. Untreated bipolar disorder has a high risk for suicide so this is an important issue.

To help screen for bipolar disorder, there is the mood disorder questionnaire. This has a series of questions that asks if a person has had symptoms of mania. You can’t rely on a rating scale alone, however. People can endorse many of the symptoms of mania on this rating scale, but it could be because of anxiety, or they were withdrawing from alcohol, or they were using marijuana. So the rating scale is useful, but only in the context of working with a good mental health provider.

Bipolar disorder suggests that there are two poles, up and down, where the mood is swinging. The downswing is with depression. I have reviewed symptoms of depression elsewhere in this document.

The upswings include symptoms of mania. This is described as a distinct change from what has been normal for a person in their mood. They might have an elevated sense of well-being, which is quite subtle. On the other hand, they might be euphoric or extremely angry for no reason, which sometimes is visible to people around them but not to the person themselves.

Then the person with mania has other symptoms. There is often racing thoughts which is defined as, compared to what is normal for the person, there is an increased speed of thinking that the person can’t slow down on their own. The racing thoughts can lead to more impulsive behavior, such as spending sprees or driving recklessly or impulsively using street drugs or alcohol. Impulsivity can also include shoplifting and outbursts of anger or hitting people.

Other symptoms of mania can include a decreased need for sleep, such as three or four hours sleep at night, and not feeling tired the next day. They don’t take a nap to make up for it. There can also be an increase in goal directed activity. This could include you staying up until two in the morning cleaning their house, or working 10 to 12 hours a day and ignoring family or friends. It may simply be that a person is much more productive at work and works through their lunch hour, which can be subtle and easily missed.

Mania often just happens in a persons teenage years or twenties, then is rarely seen. In contrast, depression often starts in grade school or high school years and continues on into adulthood. So a person depressed in their thirties or forties, coming to see a doctor, might only have a vague recollection of the manic episodes in their teenage years.. This is why you want to work with a skilled clinician, who knows the questions to ask about mania. Sometimes, after several weeks of self reflection and the patient checking with friends and family, it is revealed that subtle manic mood swings did occur in a person’s teenage years. If there is one manic episode, then that means this is bipolar disorder, even if all the other mood swings for many years in the future are depression.

In one study, patients were interviewed five years after they had been admitted to an emergency room in Iowa, where a clear diagnosis of bipolar disorder was made with the present episode being manic. Fully one-third of the people could not recall ever being manic. Other people around them, including their doctor, observed the mania. What we learned from this study is it’s essential to have other people contribute information when there is a suspicion that perhaps a person has bipolar disorder.
Diagnosis drives treatment, so this is an important distinction to make.

Basically five symptoms mark mania, among a large number of possible manic symptoms: a change of mood from what is normal for that person to becoming euphoric or grandiose or angry, decreased need for sleep with 3 to 5 hours of sleep each night and not being tired the next day and not making up for it with nap, thoughts are racing, and there is a rapid pressured speech, and an increased drive for goal directed activity. There can also be trouble with attention or trouble with impulsivity. There can be a history of impulsivity with substance use, outbursts, inappropriate sexual activity, driving recklessly, and legal issues.

As with many other issues, there is often a limitation of self-awareness that these things are going on. They may have happened so many times that a person may regard them as “normal“ or a part of their personality. But people around them can see that they’re not acting like themselves. Often people with bipolar disorder are guarded about the diagnosis and don’t want other people to participate in helping the doctor clarify the diagnosis. Recognizing this, clinicians can ask at least for notes from other people, such as a parent or spouse, commenting on if there has ever been a manic episode.

A clear diagnosis of bipolar disorder is important. Untreated bipolar disorder has a high risk for trouble in school and work as well as financial issues and relationship issues. Untreated bipolar has a significant risk for suicide. As I show in my book, “Prescription For Positivity,” getting your bipolar disorder treated is a good thing, and it paves the way for more successes in that person’s life.

Many medications now exist to help in the treatment of bipolar disorder, as well as different counseling approaches. So, diagnosis and treatment of bipolar disorder is definitely a worthwhile experience. Often within several weeks to several months, the severe mood swings can calm down, and then a person can get control of their life again. Definitely, the treatment of bipolar disorder is an example of how advances in medical science have informed doctors how to get this difficult disorder under control. Most medications for bipolar treatment didn’t even exist twenty years ago.