David Ayers, MS, LPC, NCC
Director of Clinical Services, American Day Treatment Center at Exton

Bipolar disorder has been receiving increased attention over the past several years, particularly as celebrities and public figures have increasingly made their illnesses public.  Recent, much-publicized examples include football players Alonzo Spellman and Barrett Robbins, Jim Carrey and Ted Turner.  While these examples have served to help raise awareness about Bipolar Disorders among the general public, it may also be contributing to an unintentional increase in the tendency to diagnose the disorder in patients who may be suffering from other issues or disorders.  This is especially concerning when the patients in question are adolescents.

To begin, it is important to understand how Bipolar Disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed, Text Revision (DSM-IV TR), a publication of the American Psychiatric Association.  Bipolar Disorder is a cycling between episodes of depressive and elated moods over a period of weeks, or even months.  The depressive episodes are often what prompt patients to seek treatment and are characterized by sad or low mood, lack of interest in or enjoyment of pleasurable activities, serious disruptions in sleeping and eating patterns, feelings of helplessness and/or hopelessness, lowered energy or motivation and, in extreme cases, thoughts of suicide.  These episodes are often preceded by episodes of elated mood or euphoria, lowered need for sleep, high levels of energy, agitation and irritability, poor judgment leading to unusual and often risky behaviors and exaggerated feelings of importance or power.  These episodes are referred to as "mania" or "manic episodes."  The transition from mania to depression is usually rather gradual and occurs over a period lasting from days to months.  The change can be stress-related but does not often have a clear trigger.  There are examples of patients who are considered to be "rapid-cycling" bipolars, who report much more frequent mood swings than the typical bipolar patient.  It must be understood, however, that true rapid-cycling bipolar patients are considered to be those who may cycle through four mood changes within a period of one year.  True depressive episodes are considered to last for at least weeks, if not months.  Patients who report cycling through moods multiple times during the day or even during a week are suffering from another illness or disorder.

What can happen is that family members and even providers get caught up in the simplistic factor of mood swings associated with Bipolar Disorder.  Patients may complain of depression, but then also report high reactivity to stress or conflict that results in sudden angry outbursts or crying spells and refer to these reactions as "mood swings."  If inadequate history of the patient's behaviors or moods is obtained, the provider may overlook important information and too quickly arrive at a diagnosis of Bipolar Disorder.  Also, family members may jump to conclusions about the patient's symptoms and make their own assumption that they are seeing Bipolar Disorder based upon their own inadequate information about the illness.  This can lead to seeking out providers who will validate this assumption and treat the patient in accordance with the patient's or family's wishes.  If the diagnosis is incorrect, the results can include delay of proper treatment, unnecessary use of medications with significant side effects, worsening of the patient's symptoms while awaiting proper treatment and labeling of the patient.  In particular, the labeling can be quite detrimental socially, as Bipolar Disorder is considered to be an illness that will require life-long treatment and such a label can significantly impact the patient's feelings about self and the reactions towards the patient by friends and family.

It is important to realize that natural parts of the adolescent developmental process are the development of higher reasoning skills and the formation of identity.  Often this process can lead to significant emotional distress and pronounced vulnerability to social pressures and criticism.  In turn, the adolescent will often be perceived as highly reactive and "moody."  However, these mood swings are not evidence of Bipolar Disorder and would not fit the criteria used to diagnose depressive or manic episodes simply because they are too brief and related to specific trigger events.  In addition, the mental and emotional changes that adolescents experience can also lead to oppositional attitudes, risky behaviors and poor decision-making as they attempt to form their individual identities separate from their parents.  While this process can sometimes be painful, even traumatic, these signs in and of themselves are no evidence of Bipolar Disorder.

Other things to consider before diagnosing a patient with Bipolar Disorder include carefully screening the patient for un- or under treated Attention Deficit Hyperactivity Disorder.  Any patients with ADHD will exhibit the agitation, poor impulse control, irritability and excessive energy that are common to mania. However, the difference will be found in that these patients will not report or exhibit elevated moods, unrealistically high sense of self-importance or the lack of need for sleep that the manic patient will experience.

Finally, those patients who report long-term rapid-cycling of moods are not considered to be Bipolar Disorder unless they truly meet all criteria for diagnosis of a manic episode.  These patients are more likely to be suffering from a personality disorder or some other disorder that has significantly impaired their ability to cope with stress and conflict.  Research and experience have shown that these patients will respond poorly to pharmacological treatment of their symptoms.

If you are concerned that a family member may have Bipolar Disorder, the best thing to do is seek the help of a skilled professional to assess the person and formulate a diagnosis.  In providing history to this provider, it is greatly helpful to look for a family history of similar illnesses as there is evidence that strongly suggests Bipolar Disorder is hereditary.  Having a family history can help in arriving at an accurate diagnosis.  Also, Bipolar Disorder is an illness that can require the help of the entire family to manage, so it is imperative that family members educate themselves about the treatment and management of the illness.  Everyone involved should bear in mind that the accurate diagnosis of Bipolar Disorder can be a long process, involving a long period of treatment, especially if there is minimal history of the patient upon which to base a diagnosis.  This may also mean that the patient may go through several medication trials in order to identify a medication regiment that works for that patient.  While this may sound intimidating, it is well worth it in the end as Bipolar Disorder, if left untreated, can become progressively worse as the patient gets older.  Patience and discipline can go a long way to minimizing the negative long-term effects of the illness on the patient.