Suddenly, it seems that everybody and their cousin is asking us if they have bipolar disorder. A few years ago, bipolar disorder was the ignored orphan diagnosis in psychiatry. However, now that various patented molecules have been proven effective, industry money is flying into efforts to publicize the diagnosis, and it's clearly working.

We are getting many more referrals from both therapists and primary care physicians for evaluations of possible bipolar disorder. Patients are often brandishing web-based diagnostic check-lists during their initial visits.

Unfortunately, the impression in the psychiatric front-line is that many patients are labeled "bipolar" when they are not responding well to treatment, are having insomnia, are "hyper," or are simply too annoying for someone else (ie, a spouse, an internist) to tolerate.

The “lumpers” claim a 10% bipolar prevalence; the “splitters” are happy with 1%.

Identifying possible bipolar suspects is no longer the issue; distinguishing true positives from false positives is the real challenge. Researchers in the field have made things confusing by becoming polarized into two camps: the "lumpers," who believe in a "bipolar spectrum" disorder that would end up encompassing about 10% of all humans, and the "splitters," who like the specificity of DSM-IV criteria and prefer the traditional 1% prevalence figure for bipolar disorder. As usual, the truth lies somewhere in between.

Here are TCR's top five diagnostic quandaries in bipolar disorder, with suggestions for how to approach them:

1. History of Mania in a Depressive Presentation. Unless you happen to be running a Bipolar Disorders Clinic at a tertiary care center, most bipolar patients will come to their first visit undiagnosed and appearing depressed or anxious. Epidemiological studies tell us that about 10-20% of depressed patients are actually bipolar, though they may not proclaim themselves diagnostically as such for several years. So your job is to probe relentlessly for a history of manic or hypomanic episodes in all depressed patients. Begin with an all-purpose question like, "Have you ever had a period of at least a week when you were manic-that is, overtalkative, overactive, too energetic, and not needing any sleep, as though you drank too much coffee or took speed?" Once a candidate period is identified, refer to it as you ask the usual DIGFAST questions (see box).

DIGFAST Mnemonic for DSM-IV Bipolar Disorder

D: Distractibility
I: Indiscretion
G: Grandiosity
F: Flight of ideas
A: Activity increase
S: Sleep deficit
T: Talkativeness
For bipolar disorder diagnosis
3/7 + expansive mood or
4/7 + irritable mood

2. Irritable Mania vs. Depressive Irritability. Up to half of all bipolar patients are irritable rather than euphoric when manic. In case you haven't noticed, this fact makes our job much harder. The problem here is that irritability is also a common feature of unipolar depression, anxiety disorders, adjustment disorders, etc…. So what makes manic irritability special? A few things. It co-occurs with at least 4 of the DIGFAST criteria during a given week. It is vastly out of proportion to the provoking situation (obviously, this is a judgement call on your part). It is often directed toward strangers in addition to family members/spouses. For example, the patient who says he flew into a rage because the grocery store clerk used paper instead of plastic has graduated from a "bad mood" into something diagnostic. If in doubt, bring family members into the appointment; they will be more likely to give you the straight scoop.


3. Mixed Mania vs. Agitated Depression. Patients with mixed mania suffer both manic symptoms (either euphoric or irritable) and depressive symptoms, all in the same day. The diagnostic confusion is embodied in the following scenario: a depressed patient reports racing, ruminative thoughts, excessive, "nervous" energy, distractibility, and poor sleep. This patient meets criteria for both agitated depression and mixed mania. As a psychiatrist, you are definitely under the gun, since you have to decide whether to use an antidepressant or a mood stabilizer/atypical antipsychotic. There are no easy answers here. Ask about clues to bipolarity, such as a positive family history and prior poor response to antidepressants.


4. Hypomania vs. Normal Happiness. It is most unsatisfying to give someone a psychiatric diagnosis for simply being very happy. And this is essentially what hypomania is: exhuberant, energetic, productive happiness in the absence of social or occupational dysfunction, lasting at least 4 days. But patients with Bipolar II have recurrent depressions between such halcion days, and are generally pretty miserable by the time they land in your office. Some European researchers believe that almost half of patients we now label "depressed" actually meet criteria for bipolar II if you root around in their history long enough (1). But this view is controversial. To diagnose it, you start out with the same type of screening question as for Bipolar I, but you only have to document that the elevated or irritable mood and associated behaviors occurred for 4 days.


5. Cyclothymia vs. Borderline Personality Disorder. Think of cyclothymia as the "dysthymia" of bipolar disorder. The patient reports numerous periods of subsyndromal depression alternating with hypomanic episodes. It lasts at least 2 years, and if there is any full-blown depression or mania during the first two years of the disorder, the patient loses the cyclothymia tag and converts to some version of bipolar disorder. Cyclothymia can be confused with borderline personality disorder, because in both, there can be chronic mood lability, impulsivity, irritability, up and down relationships, etc….Treatment-wise, it's not clear how useful a diagnosis this is, since there are no clear treatment guidelines for cyclothymia, and many clinicians resort to treating it as they would bipolar disorder (see this month's Anecdotes from the Field).

TCR VERDICT: How to Diagnose Bipolar? Very Carefully!

_{1. Hantouche EG, Akiskal HS, Lancrenon S, et al. Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EDIDEP). J Affect. Disord. 1998;50:163-173.}