Think Bipolar Junior

"Think 'Bipolar Junior'"

By Steven A Weisblatt, M.D.

Many more people will suffer from milder forms of bipolar disorder (also known as “bipolar spectrum disorder”, “subthreshold bipolar disorder” or “soft bipolar disorder”) affecting their mental health than will have the disorder in its’ more commonly recognized or “classical” presentations. This milder form of the disorder – which will still meaningfully and negatively affect your life – is diagnosed when there are many of the symptoms of bipolar disorder, but not all the criteria fit the “textbook”. In fact, the prevalence of classical bipolar disorders in the general population is only approximately 2%, while the prevalence of bipolar spectrum disorders is upwards of 10%.

That’s a lot of people – and you could be one of them.

A historic study determined that patients suffering from classical bipolar were often misdiagnosed by multiple clinicians for many years. Given the problems with diagnosing and treating the classical, easier to recognize, forms of bipolar disorder, can you imagine what your likelihood is to be diagnosed and treated correctly if you have bipolar spectrum disorder?

One problem is that the criteria clinicians use to make diagnoses of mood disorders have evolved, haltingly, over many years. Although the trend has been to include those patients with less severe presentations, the current reference, DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) is now 15 years out-of-date. Yet the DSM is the “bible” that is used by most clinicians to determine if you have a mood disorder. Needless to say, this decreases your chance for an accurate diagnosis and that fact increases your chances for either getting no medication for a brain illness, or, even worse, medications that will make you more ill.

Another problem is that people think about bipolar disorders as requiring periods of days, weeks or months of “lows” followed intermittently by periods of “highs”. While this may be true for classical bipolar disorder, it is seldom seen in bipolar spectrum disorder. The more common presentation is of a patient who reports feeling depressed and who, unasked by the clinician and unspoken by the patient, also experiences some form of “amplified” or hypomanic state. When amplified states are under-recognized, you will almost always be diagnosed with depression and offered an antidepressant, which, if you have a bipolar spectrum disorder, is likely to make you feel worse in the long term. Given the tendency to miss the more subtle symptoms, it is helpful if you or a member of your support system can present to the clinician a comprehensive list of “target symptoms”. It is critical that symptoms of hypomania are presented early in the consultation.

Low grade hypomanic symptoms, such as amplified states of anxiety, irritability and panic, are likely to be subtle and may be confused as context-appropriate mood states – which they are not. For example, it is reasonable in life to get irritated (when cut off in traffic), but it may be a symptom of a mental health problem if you are irritable and people walk around you on eggshells. Notably, “amplification” may not necessarily be seen by others as people often try to suppress socially undesirable behavior (like heightened anxiety, irritability, hypersexuality or the inability to focus on what people are saying).

Other symptoms of amplification may include: increased anxiety or panic, sleep difficulties, increase in the range of your moods and/or quick shifts within your range, nervous energy and difficulty concentrating because of racing thoughts or thoughts you can’t get out of your head. In women, tell your clinician if you have a history of mood shift that is exacerbated pre-menstrually and/or if you have a history of post-partum mood shift. Although it is commonly thought that mood shifts pre-menstrually are “normal” for women, it is more likely that changes in hormones during that period exacerbate low-grade mood disorders.

Make sure you tell your clinician of any family history of mental health problems, hospitalizations and substance use or abuse - even if only in a grandparent and “back in the day”. This is critical as bipolar disorder is, of course, a genetically transmitted brain disease. Try to avoid any factors that can affect current symptoms as long as possible before the meeting with the clinician. Use of caffeine (including that in colas and energy drinks), alcohol, over the counter or prescribed sleep aids and herbal remedies can all confuse the clinical picture.

Sometimes, when the diagnosis is truly unclear, the only way to know if there is a partial syndrome is to do a “diagnostic” trial of an appropriate mood stabilizer. This means that if there is some evidence of a bipolar spectrum disorder, completing a course of appropriate medication treatment to see if “target symptoms” decrease can help establish diagnostic certainty. Of course, care has to be taken in choosing an appropriate medication, dosing it appropriately and treating for a sufficient length of time in order for the results of the trial to be helpful.

It is possible to treat most patients, both with classical bipolar disorder and bipolar spectrum disorders, to complete remission. As the more subtle presentations of bipolar spectrum disorder are quite challenging, you may be at a disadvantage when you seek diagnosis and treatment from clinicians who are often limited in time – and sometimes training. You can, though, put the odds of getting good treatment in your favor if you come to the interview well-prepared.

Dr. Weisblatt (www.drweisblatt.com) is a Former Assistant Professor of Psychiatry at S.U.N.Y. Downstate Medical Center and has private practices in New York and Pennsylvania. He has spoken and consulted widely about accurate diagnoses and effective treatments.