Being part of contemporary society can become extremely complicated. We continue to stretch ourselves thinner and thinner. Meanwhile, many of us pay little mind to our own mental health and instead take for granted that our minds are functioning optimally.
As a result, it’s not at all uncommon for a person to have some sort of mental or emotional issue that goes unnoticed. After all, developing a mental health disorder is not like contracting the flu where you know when you’re sick because of uncomfortable symptoms that interfere with your daily routine. By comparison, there are numerous mental health conditions of which the symptoms go unnoticed, or perhaps they’re masked by other, more noticeable symptoms, making it difficult to accurately determine their cause. Despite our technological and scientific advancements, the brain is still a very enigmatic organ, and the diagnosis and treatment of psychological afflictions remains a very tedious process.
One of the most notoriously difficult psychological diseases to detect and accurately diagnose has been bipolar disorder. When you consider that it’s actually a somewhat common condition with approximately five million Americans meeting the diagnostic criteria for bipolar disorder, it’s a little unsettling that its diagnosis remains such an elusive task. In fact, it’s estimated that almost seven in 10 bipolar patients are initially misdiagnosed and one-third of those individuals remain misdiagnosed for 10 or more years. As well, the consensus is that there’s not one, but two distinct types of bipolar disorder, so in the event that a person receives a diagnosis of bipolar disorder, there’s cause for doubt as to whether one has been diagnosed with the correct type.
What is it about bipolar disorder that makes it so hard to diagnose? Is there really such variation in the symptoms of bipolar disorder to warrant distinguishing between two types of the disease? Let’s start by looking at the broad strokes of bipolar disorder.
Bipolar Disorder: An Overview
The common perception of bipolar disorder is essentially that it involves sudden and inexplicable mood swings. Many people imagine someone crying one moment and in a violent rage the next. While extreme mood shifts are indeed characteristic of the illness, bipolar disorder, more specifically, is when a person shifts back and forth between mania and depression, which is why it was originally known as manic depression.3
To be clear, mania does not mean anger. Instead, a manic episode — the term used when a person is experiencing mania — is characterized by a marked elevation of one’s mood, typically coinciding with an increase in self-esteem, a sense of self-importance, distractibility, impulsivity, rapid speech, decreased need for sleep and racing thoughts.4 But symptoms of mania can vary as well, involving elation or aggression or irritability. In essence, mania tends to appear as an increase in energy and motivation, but with little rhyme or reason behind an individual’s impulsive behaviors. For these behaviors to be considered a manic episode, there must typically be a week of uninterrupted mania.
Therefore, a person with bipolar disorder will shift between periods of mania and periods of depression. The manic episodes often see people becoming extremely productive, albeit somewhat flighty, and sometimes entail risky or even dangerous behaviors due to the impulsivity. Depressive periods are often the most prominent and, consequently, tend to be why people with bipolar disorder initially seek help. While this alternation between mania and depression characterizes bipolar disorder as a whole, the disease can be more specifically broken down into two types: bipolar I disorder and bipolar II disorder.
Bipolar I Disorder vs. Bipolar II Disorder: What’s the Difference?
The overview above actually describes bipolar type I disorder, which is more well-known. With bipolar I disorder, the push-and-pull of the mania and depression is a more pronounced struggle with each of the two states essentially being opposite extremes. However, bipolar II disorder involves the alternation between depression and hypomania, a somewhat milder form of mania.
When a person is experiencing hypomania, he or she will exhibit many of the same behaviors that a person would exhibit during a manic episode — an increase in energy, decreased need for sleep, impulsivity, recklessness, distractibility and so on — but at a much lower intensity. Since the characteristics of hypomania are less pronounced than mania, hypomania is very difficult to detect and often goes unnoticed.5 After all, needing only a few hours of sleep, being impulsive, and experiencing inexplicable bursts of energy and good moods aren’t outside the realm of normal human behavior. By comparison, a person experiencing a mania will exhibit behaviors that are disruptive to his or her life and perhaps the lives of others.
Mania and hypomania also differ in other ways that show the difference between type I and type II of bipolar disorder. For instance, mania can progress to such a severity as to cause symptoms of psychosis, including hallucinations and delusions. It can also reach such an intensity as to prompt life-threatening behavior, making it common for people to become hospitalized until the symptoms of their bipolar I disorder are under control. There are a number of people who believe that, rather than being a separate type of bipolar disorder, bipolar II disorder is simply the earliest stage of bipolar disorder, representing the manifestation of symptoms before the hypomania reaches a level of severity consistent with mania. There have been a number of people with bipolar II disorder whose hypomania never reached the point of mania, but if left untreated and without the proper lifestyle adjustments it’s plausible that bipolar II could progress into bipolar I disorder.
Many people respond to the distinction between these two types of bipolar disorder by characterizing bipolar I disorder as the most severe and bipolar II disorder as the more manageable and less debilitating. While that would seem true on the surface, there’s been an unexpected phenomenon with regard to treatment compliance that puts both types of bipolar disorder into a gray area.6 Although type I is more severe, people who have bipolar I disorder — and, therefore, have likely experienced manic episodes that were truly disruptive to their lives — tend to more easily accept their diagnoses and embrace treatment so as to prevent further incidents in the future. Since bipolar type II is milder and less disruptive by comparison, patients tend to exhibit more frequent denial and greater resistance to treatment, increasing the level of disruption that the milder type II would otherwise have on their lives.
Why Is Bipolar Disorder So Difficult to Diagnose?
Now that we can distinguish between the two types of bipolar disorder, let’s address the question of why type I and type I bipolar disorders have proven so difficult to diagnose. Part of the difficulty is the complexity inherent in mood disorders as a whole, no matter where they exist on the spectrum. Moreover, since depression is the most well-known and identifiable mood disorder, it’s often depressive episodes that are most disruptive and cause bipolar patients to seek help. In fact, more than 40 percent of all bipolar patients are initially diagnosed with depression.7 In such instances, it’s not until later when a treatment provider observes signs of mania or hypomania that bipolar disorder can be detected.
More often than not, people with bipolar disorder experience an episode of depression first, followed by mania or hypomania. Since the depression occurs first, the mania or hypomania is frequently mistaken for a person simply returning to a more elevated mood state. With bipolar disorder, an accurate diagnosis requires observation of a person’s mood patterns over a period of time and it often takes quite a while for a treatment provider to observe the entire pattern, resulting in many incorrect initial diagnoses. However, it’s worth mentioning again that many people don’t recognize manic or hypomanic behaviors in themselves, instead seeing no connections or relationship between their manic-like behaviors. Frequently, it’s only when manic behavior results in dire consequences or becomes consistently disruptive to a person’s life that mania becomes more clear.