Bipolar Disorder: Diagnosis

Diagnosis is based on the self-reported experiences of the patient as well as abnormalities in behavior reported by family members, friends or co-workers, followed by secondary signs observed by a psychiatrist, nurse, social worker, clinical psychologist or other clinician in a . There is a list of criteria that must be met for someone to be so diagnosed. These depend on both the presence and duration of certain signs and symptoms.

An initial assessment includes a comprehensive history and physical examination by a physician. Although there are no biological tests which confirm , tests are carried out to exclude which may rarely present with . These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and to rule out a metabolic disturbance, full blood count including ESR to rule out a or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions.[citation needed] There are several which may present with similar symptoms; these include schizophrenia,[19] , brief drug-induced psychosis, schizophreniform disorder and . Alternately, patients currently in a hypomanic or mixed affective episode may display symptoms resembling .[citation needed]

The last is important as both diagnoses involve symptoms commonly known as “”. In , the term refers to the cyclic episodes of elevated and which generally last weeks or months (notwithstanding Rapid Cycling variant of greater than four episodes a year). The term in borderline personality refers to the marked lability and reactivity of mood, known as , due to response to external psychosocial and intrapsychic stressors; these may arise or subside suddenly and dramatically and last for seconds, minutes, hours or days. A bipolar depression is generally more pervasive with sleep, appetite disturbance and nonreactive mood, whereas the mood in dysthymia of borderline personality remains markedly reactive and sleep disturbance not acute.[20]

The relationship between and has been debated; some hold that the latter represents a subthreshold form of affective disorder,[21][22] while others maintain the distinctness, though noting they often coexist.[23][24]

Investigations are not generally repeated for relapse unless there is a specific medical indication. These may include serum BSL if olanzapine has previously been prescribed, lithium or valproate level to check compliance or toxicity with those medications, renal or thyroid function if lithium has been previously prescribed and taken regularly. Assessment and treatment are usually done on an outpatient basis; admission to an inpatient facility is considered if there is a risk to self or others.[citation needed]

The most widely used criteria for diagnosing are from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the current version being DSM-IV-TR, and the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems, currently the ICD-10. The latter criteria are typically used in European countries while the DSM criteria are used in the USA or the rest of the world, as well as prevailing in research studies.

Recent studies by Dr. John Kelsoe have linked to genetic defects. “…[M]utations in the G protein receptorhinase (GRK3) gene—which regulates sensitivity to brain neurotransmitters such as dopamine…”[25] Dr. John Kelsoe is currently with the University of California in San Diego in the Department of Psychiatry[26] Kelsoe’s genetic discovery seeks to provide alternative treatments for those with bipolar disease. In 1997 a genome survey was completed and Dr. Kelsoe, along with his colleges reported that, “results support the presence of a susceptibility locus for on chromosome 22…These molecular data raise the possibility that common susceptibility genes may be involved.”[27] In February 2008, Dr. Kelsoe released an at-home bipolar test. The tests are sold over the internet to consumers for $399 through his company, La Jolla, Calif.-based Psynomics. This new form of diagnostics seeks to move away from diagnosing people based solely on their behavior. is derived from a combination of genetic factors and life experiences[28] Although Dr. Kelsoe is well-respected in his field of study, the test has become controversial and concerning to medical experts. To avoid misdiagnosis, the DNA results from the tests are sent only to the consumers’ doctors from Psynomics.

Diagnostic criteria and classification

There is no clear consensus as to how many types of exist.[29] In DSM-IV-TR and ICD-10, is conceptualized as a spectrum of disorders occurring on a continuum. The DSM-IV-TR lists four types of mood disorders which fit into the bipolar categories: Bipolar I, Bipolar II, Cyclothymia, and NOS (Not Otherwise Specified).

Bipolar I

In Bipolar I disorder, an individual has experienced one or more manic episodes with or without major depressive episodes. For a diagnosis of Bipolar I disorder according to the DSM-IV-TR, there requires one or more manic or mixed episodes. A depressive episode is not required for the diagnosis of Bipolar I disorder but it frequently occurs.

Bipolar II

Bipolar II disorder is characterized by hypomanic episodes as well as at least one major depressive episode. Hypomanic episodes do not go to the extremes of mania (i.e. do not cause social or occupational impairment, and without psychosis), and this can make Bipolar II more difficult to diagnose, since the hypomanic episodes may simply appear as a period of successful high productivity and is reported less frequently than a distressing depression. For both disorders, there are a number of specifiers that indicate the presentation and course of the disorder, including “chronic”, “rapid cycling”, “catatonic” and “melancholic”.

Cyclothymia

Cyclothymia involves a presence or history of hypomanic episodes with periods of depression that do not meet criteria for major depressive episodes. A diagnosis of Cyclothymic Disorder requires the presence of numerous hypomanic episodes, intermingled with depressive episodes that do not meet full criteria for major depressive episodes. The main idea here is that there is a low-grade cycling of mood which appears to the observer as a personality trait, but interferes with functioning.

Bipolar-NOS

Not Otherwise Specified is a catch-all diagnosis that is used to indicate bipolar illness that does not fit into the other diagnostic categories. If an individual clearly seems to be suffering from some type of but does not meet the criteria for one of the subtypes above, he or she receives a diagnosis of NOS (Not Otherwise Specified).

Although a patient will most likely be depressed when they first seek help,[citation needed] it is important to find out from the patient or the patient’s family or friends if a manic or hypomanic episode has ever occurred. This will prevent misdiagnosis of Depressive Disorder and avoids the use of an antidepressant which may trigger a “switch” to hypomania or mania or induce rapid cycling. Recent screening tools such as the Hypomanic Check List Questionnaire (HCL-32) have been developed to assist the quite often difficult detection of Bipolar II disorders.

Delay in diagnosis

The behavioral manifestations of are often not understood by patients nor recognized by mental health professionals, so diagnosis may sometimes be delayed for 10 years or more.[30] That treatment lag is apparently not decreasing, even though there is now increased public awareness of this mental health condition in popular magazines and health websites. Recent TV specials, for example the BBC’s The Secret Life of the Manic Depressive,[31] MTV’s True Life: I’m Bipolar, talk shows, and public radio shows, and the greater willingness of public figures to discuss their own , have focused on psychiatric conditions thereby further raising public awareness. Despite this increased focus, individuals are still commonly misdiagnosed.[32]

Children

Children with do not often meet the strict DSM-IV definition, tending to have rapid-cycling or mixed-cycling pattern.[33] The incidence in this age group has been traditionally held to be very rare.[citation needed] In September 2007, experts (from New York, Maryland and Madrid) found that the number of American children and adolescents treated for increased 40-fold from 1994 to 2003, and it was increasing ever since. They concluded that doctors had been more aggressively applying the diagnosis to children, and not that the incidence of the disorder had increased. The study calculated the number of visits which increased, from 20,000 in 1994 to 800,000 in 2003, or 1% of the population under age 20.[34][35]

Often other psychiatric conditions are diagnosed in bipolar children. These other diagnoses may be concurrent problems, or they may be misdiagnosed as . Depression, ADHD, ODD, schizophrenia, and Tourette syndrome are common comorbid conditions. Furthermore some children with histories of abuse or neglect may have Bipolar I Disorder.

Other theoretical models

Flux is the fundamental nature of .[36] Individuals with the illness have continual changes in energy, mood, thought, sleep, and activity. The diagnostic subtypes of are thus static descriptions — snapshots, perhaps — of an illness in continual flux, with a great diversity of symptoms and varying degrees of severity. Individuals may stay in one subtype, or change into another, over the course of their illness (Goodwin & Jamison, 1990). The DSM V, to be published in 2011, will likely include further and more accurate sub-typing (Akiskal and Ghaemi, 2006).

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June 5, 2008 | Filed Under Mental Disorders 

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