With close to 3 percent of the American adult population suffering from bipolar disorder, sample research indicates it may be both under- and overdiagnosed. For instance, one study showed an average of nearly 10 years between patients’ first experience of bipolar symptoms and their first treatment with a mood stabilizer. Conversely, another study reported that fewer than half of the patients interviewed actually had bipolar disorder, though they had been diagnosed with it.
Why is there so much difficulty diagnosing bipolar disorder, even for seasoned mental health professionals? There are several factors that can contribute to misdiagnosis.
Bipolar Disorder Has Symptoms that Overlap with Other Disorders
“Often, there are three diagnoses that are most confused with bipolar disorder, and sometimes they even coexist with bipolar,” says Janelle Bull, a licensed marriage and family therapist in Campbell, California. The three disorders that have overlapping symptoms are major depressive disorder, attention-deficit/hyperactivity disorder (ADHD) and personality disorders, particularly borderline personality disorder (BPD).
“ADHD symptoms can sometimes look like bipolar disorder because of that frantic, frenetic component,” Bull says. Indeed, the mood swings that those with ADHD tend to experience is often misdiagnosed as bipolar disorder, or vice versa. Additionally, the hyperactivity, impulsivity and inattention that people with ADHD exhibit can look a lot like bipolar mania or hypomania. The main difference between ADHD and bipolar symptoms is that while ADHD mood swings are a reaction to what’s happening in the patient’s life and are usually short-lived, bipolar symptoms take weeks or months to occur and aren’t brought on by external circumstances.
Borderline personality disorder also has the intense mood swings that are characteristic of bipolar disorder. One difference between the two is found in the tumultuous and extreme relationships that people with BPD have with others in their lives. BPD patients often present with similar euphoria to that found in the mania seen in bipolar disorder. “Then they crash, and it looks very much like bipolar disorder, but you have to look for the intensity of their relationships to sort it out,” says Bull. One study showed that close to 40 percent of patients with BPD were misdiagnosed with bipolar disorder instead. This may be partly due to the fact that some mental health professionals don’t have as much experience with BPD, and since the symptoms can be so similar, separating the two can be difficult.
Major depressive disorder, commonly known as depression, is usually the diagnosis people receive when they really have bipolar disorder. A little over 21 percent of people diagnosed with depression may actually have bipolar disorder, one recent study found. Two other studies showed that nearly 40 percent of people with bipolar disorder were diagnosed with depression first.
“Because of the overlapping symptoms, if someone does present with periods of low mood or loss of pleasure, the clinician may just pay more attention to diagnosing a depressive disorder and may not look for mania,” says Christina Villarreal, PhD, a clinical psychologist and adjunct faculty at UC Berkeley.
David Mahony, PhD, a clinical psychologist in Brooklyn, New York, agrees. “If a patient came in and started talking about the depressive side but not the bipolar or mania side, it could easily get misdiagnosed as just depression,” he says.
Patients Often Seek Treatment for Depressive Symptoms, but Not Bipolar Ones
The hallmark symptom of bipolar disorder is mania, found in Bipolar I, or hypomania, seen in Bipolar II. The problem is, many patients don’t seek treatment for the mania component. Instead, they seek help during the depressive episodes. “Clients tend to like the mania, it feels good, and so they don’t come to us when they feel good, they come to us when they feel bad,” Bull says. “They come in presenting with depression and neglect to tell us anything about the mania because to them, that’s not a problem.”
“Depressive symptoms are typically more likely to be reported because they are less tolerable to experience,” says Villarreal. “(Patients) may not bring attention to mania during their interview because they may not have noticed it or they may not be interrupted by it.”
There’s Less Face-to-Face Time for Clinicians to Diagnose Properly
Mahony has seen this phenomenon in his years of practice. “With psychologists, most sessions last about fifteen minutes and with psychiatrists, most patients tell me here in New York, they will only spend five to 15 minutes with a psychiatrist,” he says. “A lot of that is driven by the insurance companies…so mental health providers don’t have the time or the wherewithal to go into deep, long histories. They have to make a diagnosis very quickly.”
In Bull’s practice, this is common enough that the therapists there often go with their clients to appointments with their prescribing doctors so they can advocate on their clients’ behalves. “We see (our clients) every week and the doctors see them probably once every quarter, so we can go in and talk to the doctors about how the client is presenting week after week,” says Bull.
Patients May Not Report Their Use of Drugs and/or Alcohol
Research shows that substance use disorders often coexist with bipolar disorder. Unfortunately, the side effects of substances can look the same as symptoms of bipolar disorder, which can lead to a misdiagnosis.
Villarreal sees this with marijuana in particular. “As it wears off, it can create agitation and inability to sleep. People underreport it because they don’t think they’re using as much as they actually are,” she says. “The marijuana is contributing to their mood symptoms, so sometimes people come in and complain about their mood and they don’t necessarily want to link that experience with the quantity of marijuana they’ve used.”
What You Can Do
- Advocate for yourself. “Find out what the doctor you go to would most likely treat,” says Bull. “Do they mostly treat bipolar? Depression? I find that doctors that treat certain things lean heavily into those diagnoses.” Get a second opinion if you feel unsure about your diagnosis. If you see a therapist, get his or her input.
- Remember your mental health professional is only human. “Ask the really hard questions. How are they coming at this? Have they had other clients that have this diagnosis? How do they present? How do I know it’s nothing more? If my medication doesn’t work, what do we do next?” advises Bull. “Doctors are not gods and therapists don’t always have their acts together either.”
- Report all substance use. If you’re using drugs or alcohol, let your clinician know, even if you don’t think it’s significant. Something as innocuous as caffeine can affect your symptoms and make it hard to tell what’s a real symptom and what’s a result of the substance, according to Villarreal.
- Do the research. Check out the symptoms and treatments for bipolar disorder. “I find that patients are very uneducated about schools of medicine and psychopharmacology, so they don’t know there are differences. There’s not just one pill,” Bull says. “You can look up the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) online and read the criteria for any disorder,” notes Mahony. “A lot of times, the best thing is to go through it.”
- Keep a mood journal. The more details you can give your mental health professional about your moods, the easier it will be to get a correct diagnosis. Tracking your moods is a good habit to maintain because it can help you pinpoint patterns. What triggers your mood episodes? How long do they last? How intense are they?
- Find a doctor you’re comfortable with. “You want to make sure the person you’re working with is asking about all the symptoms you have,” Mahony says. “Make sure they’re not just handing you an antidepressant, but that they’re asking about other symptoms too.” This applies to your therapist too.
- Know your family history. “Have your symptoms been pervasive over a long period of time? Do any of your family members have this? Is there a family history of bipolar disorder?” says Bull. If anyone in your immediate family has bipolar disorder, your risk of developing the disorder is also higher.