Bipolar Disorder, Misdiagnosis and Related Factors
Although bipolar disorder and major depressive disorder are two separate mood disorders, bipolar disorder is often misdiagnosed as another psychological disorder, most often depression, which can lead to catastrophic consequences. The two diseases have similar symptoms when an individual suffering from bipolar disorder is experiencing a depressive episode. Confusion between the two disorders is further complicated because the onset of both is multi-factorial. This misdiagnosis is often a result of the application of various principles from different schools of psychology since there are many explanations for the onset of bipolar disorder. Proper diagnosis, understanding symptoms and related factors are all vital in order to get the best possible treatment.
Francis Mark Mondimore, M.D., author of Bipolar Disorder: A Guide for Patients and Families, wrote “A former professor of mine once told me, “When you can’t figure out what the patient has, he or she probably has bipolar disorder”. (Mondimore, 1999, pp. 1) Mondimore remembers thinking this to be absurd at the time, but later understanding exactly what her professor meant. Bipolar disorder includes symptoms associated with a variety of other psychiatric disorders. This often causes patients to be misdiagnosed with and treated for another disorder. There are many disorders that are more common, so naturally, when symptoms of such disorders are recognized, patients are often diagnosed as having the more common disorder. They continue to live their daily lives, unknowingly experiencing the scary and often dangerous symptoms of bipolar disorder.
Mood disorders are defined as a class of disorders marked by emotional disturbances of varied kinds that may spill over to disrupt physical, perceptual, social and thought processes”. (Weiton, 2005, pp. 400) Bipolar disorder is a type of mood disorder. Major depressive disorder is also a type of mood disorder and bipolar patients are often misdiagnosed as suffering from depression. This is understandable because, when an individual with bipolar disorder is experiencing a depressive episode, they exhibit symptoms and behaviors associated with depressive disorder.
The structuralist approach of psychology would say that in order to understand mood disorders, one must first understand what is meant by mood. This state of consciousness would be broken down into its individual parts. Mood is conscious state of mind or predominant feeling. Our mood includes our degree of happiness or sadness, state of optimism or pessimism, our feelings of content or of dissatisfaction, and even physical feelings. When people are in a good mood, it is easy for them to feel energetic, sleep well and feel physically well, but when one is in a bad or unwell mood, it affects everyday activities such as eating, getting dressed, socialization, going to the store, sleeping soundly or even getting out of bed in the morning. Functional psychologists would be interested in the brain’s functioning and how mood disorders affect the ability of the brain to adapt to its environment. One can become overwhelmed or distracted by their thoughts when suffering from a mood disorder..
Research suggests that there are a number of factors that play a part in the etiology of mood disorders. This involves an interaction between psychological and biological factors. These factors include genetic vulnerability, neurochemical factors, cognitive factors, interpersonal roots and precipitating stress.
Biological psychology suggests that the evidence supporting genetic vulnerability suggests heredity creates predisposition to mood disorders and environmental factors influence whether or not the predisposition develop into a disorder. There have been studies conducted on fraternal and identical twins and these studies concluded there were more identical twins than fraternal twins who both suffered from mood disorders. The evidence was also stronger for bipolar disorder than for unipolar disorder. According to “The Bipolar Disorder Survival Guide: What You and Your Family Need to Know”, “Your chances of passing the disorder on to your kids averages about 8% (20% if you include major depression). These probabilities are relatively low and are comparable to other psychiatric disorders. For example, if you have schizophrenia, your chances of passing it on to your children are about 13%”. (Miklowitz, 2002, pp. 85) Being genetically susceptible does mean one will necessarily suffer from the disorder.
Neurochemical factors in the etiology of mood disorders refer to the relationship between abnormal levels of neurotransmitters in the brain and mood disorders. Neurotransmitters are chemicals that send information from one neuron to another.
Norepinephrine and serotonin are two neurotransmitters found in the brain that are believed to affect mood. Norepinephrine contributes to the regulation of mood and arousal. It is understandable how depression could be associated with abnormal levels of norepinephrine because it cannot regulate mood if it is not regulated itself.
Serotonin helps regulate sleep and wakefulness, eating and aggression. Sleep is one of the most enjoyable activities one does and if you cannot get a normal amount of sleep or good quality sleep, it is understandable how one could become depressed. In the article “Sleep and Youth Suicidal Behavior: A Neglected Field”, the authors maintain that there is a relationship between increased adolescent suicide and insomnia. (Liu and Buysse, 2006, pp 288-293) This could be because sleep is vital to physical health and psychological well-being and when taken away, it can be miserable. An abnormal amount of the neurotransmitter responsible for sleep regulation in combination with problems an individual may be facing in their life prohibits the ability to get good quality sleep and increases insomnia. They lie awake at night thinking about these problems and becoming more depressed and more sleep deprived. This relationship between abnormal amounts of serotonin, sleep deprivation and depression makes sense.
Not getting a balanced diet could also interfere with one’s energy level which can lead to feelings of uneasiness. Also, poor diet fails to nourish the body and provide the essential vitamins and minerals needed. This could lead to feeling tired, uneasy and unhappy. When an individual is tired they tend to be more inactive because they do not feel up to doing anything productive or fun. Inactivity leads to lack of socialization and depression simply from lying around. Lack of socialization is associated with depression.
Cognitive psychology significantly helps explain thought patterns that contribute to bipolar disorder. Cognitive factors in the etiology of mood disorders refer to negative thinking that leads to depression. Learned helplessness is when one passively gives up because of exposure to unavoidable events. Individuals feel there is nothing they can do and they develop the “why bother?” mindset. Pessimistic explanatory style is related to high vulnerability to depression. People who demonstrate these thinking patterns tend to blame their personal flaws as opposed to situational factors. They jump to conclusions about their own inadequacies based on minor setbacks. Hopelessness theory builds on these thought patterns and incorporates a sense of hopelessness. It combines the pessimistic explanatory style with other factors that foster the sense of hopelessness.
Interpersonal psychology helps explain the sociology of bipolar disorder. Interpersonal roots refer to the factors in the etiology of mood disorders related to social skills. Researchers have found that poor social skills are related to depression. This makes since because when someone lacks social skills, they have a hard time making and keeping friends. Social rejection and lack of support can worsen or aggravate one’s depression. Depressed people have fewer sources of social support than people who are not depressed.
Precipitating stress is a factor in the etiology of mood disorders that suggests a correlation between stress and the onset of mood disorders. These factors attempt to explain the appearance of mood disorders in people living seemingly relaxed or normal lives. Research also suggests it is possible that stress affects how people respond to treatment of mood disorders and why some people experience a relapse of their condition. This makes since because individuals who are highly stressed become depressed by the demands of their lifestyle and long for more freedom. They may feel overburdened and feel their life is incomplete or missing something.
There is correlation between hormonal imbalances and mood disorders. The ancient Greeks believed the mind and body were kept in balance by four vital bodily fluids called humors. The word melancholia is derived from one of these humors. Depression is thought to be caused by an access of black bile and mania by an excess of yellow bile. The idea behind this is that physiology is disrupted by imbalances of bodily fluids or chemicals.
The hormone systems that are thought to be most important in relation to regulation of mood are the thyroid and adrenal hormones. Thyroid hormones help control the body’s metabolism. When the thyroid is hyperactive or hypoactive, it can lead to changes in mood and activity level. This can also make the body resistant to treatment of mood disorders. The adrenal glands are responsible for the secretion of cortisol and adrenaline which also play a role in the regulation of metabolism. Overabundance of cortisol can cause a change in fat distribution mainly leading to fat storage in the stomach area. This is thought to agitate depression and suicidal thinking. It can also lead to abnormalities in blood-pressure and blood-sugar. The hypothalamus helps regulate metabolism and physical responses to illness and stress by chemical signals to the thyroid adrenal gland. The hypothalamus has been linked to mood disorders, so the mechanisms and links between mind and body must play an important role in our physical experience of mood.
Hormonal imbalances make perfect sense when associated with the onset of mood disorders. Every hormone you can think of leads to some type of illness of disorder. Imbalances of insulin lead to diabetes when one has too little and hypoglycemia when one has too much. Imbalances of testosterone and estrogen can lead to sexual disorders or irregularities. Chemicals such as endorphins are also known to affect mood. When people exercise, it increases endorphins. Depressed people who lack the energy to exercise miss out on the opportunity to improve mood that endorphins can provide. The amount of endorphins they have in comparison with the average person is imbalanced. Adversely, people experiencing a manic episode are hyperactive and the amount of endorphins is also imbalanced.
Everyone experiences a normal amount of mood changes. This is normal because things are not always as one would like for them to be. Everyone has ups and downs that fall within a certain range. Individuals with bipolar disorder experience higher ups and deeper downs than permitted by the normal range. People who do not suffer from a mood disorder and go through some type of disappointment usually recover relatively quickly. Research suggests that mood changes associated with bipolar disorder are caused by the brains regulation of mood.
Bipolar disorder was formerly known as manic-depressive disorder. People suffering from this mood disorder experience both depressed and manic periods. Bipolar disorder is less common than unipolar or major depressive disorder. It affects 1-2% of the population and it is related to age, with the peak of vulnerability occurring most often between the ages of 20 and 29. It is found equally often in males and females, where depression is more common in females.
The DSM IV recognizes bipolar I and bipolar II as the two subtypes of bipolar disorder. Bipolar disorder I includes mania and depression. Bipolar II disorder includes depression and hypomania. There are also severities specifiers of mild, moderate and severe. Severity can also be specified by remission which can be full or partial. Full means there have been no episodes in the last two months. Partial means there have been only a few symptoms if the remission has been less than two months. Psychotic features can be added to the severity specifiers if the patient has delusions or hallucinations.
Special syndrome specifiers for bipolar disorder include catatonic, melancholic, or atypical features and postpartum onset. Catatonic features are added if the patient shows symptoms of catatonia which means the patient, lies, sits or stands motionless or stares into space for long periods of time. Melancholic features are added when the patient’s depressive episode is mainly characterized by presence of guilty feelings, mood fluctuation, loss of appetite and inability to experience joy or pleasure. Atypical depression is more common in depression patients than in bipolar disorder. This is characterized by a brightening of mood when positive things happen. When a mood change occurs within four weeks following childbirth, it is referred to as depression with postpartum onset.
Longitudinal course specifiers include with or without full inter-episode recovery, with seasonal patterns and with rapid cycling. With or without inter-episode recovery refers to whether or not patients are completely symptom-free between episodes. Seasonal effective disorder is when regular depressive episodes occur in winter and when hypomanic or manic episodes occur in summer. Rapid-cycling is having at least four episodes within a twelve month period.
Substance-induced mood disorder refers to when intoxication or medical conditions appear to be mania, hypomania or depressive episodes. In these cases, the medical condition or type of intoxication is specified. For example, a mood disorder triggered by hypoactive thyroid would be “mood disorder due to hypoactive thyroid” and mood disorder brought on by heroine use would be “heroine-induced mood disorder”.
There are emotional, cognitive and motor characteristics that distinguish manic episodes from depressive episodes. The emotional characteristics of a manic episode include sociability, euphoria, impatience and elation while depressive behavioral characteristics include irritability, gloominess, hopelessness, social withdrawal. Manic cognitive characteristics include desire for action, self-confidence, grand delusions, impulsiveness, talkativeness, racing thoughts and flight of ideas and depressive episodes include self-blame, negative self-image, indecisiveness, obsessive worrying, slow thought processes and delusions of guilt and disease. Motor characteristics of a manic episode include tirelessness, hyperactivity, increased sex drive, fluctuating appetite and requiring less sleep than usual and depressive episodes include inactivity, tiredness, difficulty sleeping, decreased sex drive and decreased appetite.
Manic periods are thought to be the most dangerous and dramatic of the abnormal mood states associated with bipolar disorder. Symptoms may be unnoticeable at first but gradually become more extreme. In the early stages, the individual is filled with pleasant feelings and then the feeling of self-confidence evolves into euphoria. The individual thinks they are thinking more clearly and rational than usual. Thoughts then begin to race and as the thought processes speed up, so does the speech. This is an attempt to express the thoughts that are spinning in their mind as fast as possible.
Feelings of self-confidence can lead to behavioral patterns typical of manic states. Some of the behaviors include, sexual promiscuity, shopping sprees and abuse of drugs and alcohol. Increased sexual feelings can lead to early engagements and infatuations. The shopping sprees can be extreme and lead to financial turmoil because at the time, the individual spends without regards for where the money will come from. Confidence levels lead to lack of inhibitions and sexual promiscuity. The article “Increases in Manic Symptoms After Life Events Involving Goal Attainment” found that manic symptoms tended to increase after patients attained a goal or made an achievement such as receiving a job promotion or getting married. (Johnson et al, 2000, pp. 721-727)
Thought patterns during the manic period race and can become delusional or unrealistic. The pleasant feelings of mania can sometimes be short-lived and become replaced by anger and irritability.
Mania episodes have been described and categorized in three stages. Stage I is said to be characterized by increased psychomotor activity with increased physical activity and rate of speech. Euphoria dominates and overconfidence, expansiveness and grandiosity are apparent. Increased spending, sexual preoccupations and excessive communication use such as telephone use and writing letters is typical. Many people are aware of the mood change they experience and describe it as a high. Individuals are not out of control at this point.
Stage II is characterized by further increased activity and pressure of speech. Mood is euphoric at certain times, but is characterized by increasing unpleasantness and depression. Irritability progresses to anger and hostility and racing thoughts progress to disorganization. Grandiosity and delusions become apparent.
Stage III is characterized by desperate and panic stricken behavior with frenzied activity. Thought processes are incoherent. Delusions are bizarre and hallucinations are often present. Some research suggests that this stage only occurs in a subgroup of bipolar patients.
In 1881 a psychologist named Mendel proposed a state of mania characterized by mild euphoria and hyperactivity that does not progress to full blown mania which he called hypomania. These individuals have the symptoms of stage I mania such as increased energy level, rapid thinking and talking and occasional irritability. They do not have the severe disorganization of mania and are not frenzied to the point of violence, but these individuals tend to engage in behavior with unpleasant consequences. Sometimes these individuals cannot be treated for their illness because they lack the criteria for involuntary treatment. This type of treatment usually requires dangerous or psychotic behavior. These individuals sometimes feel so good that they do not want to be treated.
The depressive episodes of bipolar disorder are similar and comparable with those associated with unipolar or major depressive disorder. These episodes are basically the “polar opposite” of mania. They shift from one extreme to another.
In major depressive disorder “people show persistent feelings of sadness and despair and a loss in interest in previous sources of pleasure. Negative emotions form the heart of the depressive syndrome, but many other symptoms may also appear”. (Weiton, 401) The average episode of depression lasts five months and most people (75-95%) experience more than one episode of depression over their lifetime. Onset of depression can occur at any time during an individual’s life span and severity varies greatly from one person to another.
Thoughts of worthlessness and inadequacy are common in major depressive disorder. Negative thought patterns dominate depressed individuals. Thoughts if sadness, loss, regret and hopelessness are common. These people feel they are to blame for their problems even when circumstances are beyond their control. Depressed individuals often suffer from insomnia or lack of sleep. It is also common for them to suffer from hypersomnia or overabundance of sleep. Hypersomnia is more common in bipolar disorder than in depression. Depressed people lack energy, have decreased appetite, talk slowly and feel anxiety and irritability.
Major depressive disorder is a very common disorder that affects 7-18% of Americans at some point in their lives. Depression is about twice as common in women as it is in men. Women are more likely than men to be poverty stricken, verbally abused, single-parents, physically and sexually abused, victims of harassment and to experience role constraints. Another possible explanation for this is that women have more issues with self-esteem and body image. Men are less burdened by the pressures of society to look a certain way and be within a given weight range. Everywhere women turn, their heads are filled with more images of how they should look and what is acceptable. Women are often attracted to partners for reasons other than the degree of attractiveness, but because of images seen every day, women tend to believe only certain looks are attractive. They engage in behaviors that are detrimental to their mental health. Women deny themselves desirable food, exercise excessively, maintain strict beauty regimens and wear clothes that are stylish, but uncomfortable. These are not enjoyable behaviors for most people. Women want to fit in and when they don’t there is increased tendency to become upset and depressed.
Aristotle said “No great genius has ever existed without some touch of madness”. Research has been conducted on the correlation between creativity and mood disorders. Many historically great individuals are thought to have suffered from bipolar disorder. Some of these include artist Vincent Van Gogh, poet Lord Byron, composer Robert Schumann, poet Sylvia Plath, author Virginia Woolfe and writer William Blake, among many others. The thought patterns of these creative geniuses are undoubtedly different from the average person. Perhaps there are completely different thought processes these people experience in comparison with the average person or maybe there brain structure is different. This also indicates that both bipolar disorder and unipolar or depression have been around for centuries. This eliminates any theories that insinuate these disorders are related to modern culture or environmental factors. The disorders could be influenced by these things, but depression and bipolar disorder have a history that is cross-cultural and has been around throughout the years.
Bipolar disorder was not always recognized as a mood disorder. In medieval times, behaviors associated with depression and bipolar disorder were often associated with witchcraft or demonic possession. Many mentally ill people were put to death. During the Renaissance, depression and bipolar disorder began to be recognized as disorders by physicians rather than problems to be dealt with by priests. However, early physicians believed mania and depression to be two separate conditions.
There are many common treatments for bipolar disorder. Mood-stabilizing medications are medications that have both antidepressant and antimanic effectiveness. Lithium is one of the most widely used mood-stabilizers. Lithium is an element and this means it is not chemically metabolized by the body. It is thought to effective treat acute depression and mania and to reduce the duration, frequency and severity of manic and depressive episodes. Side effects include nausea, diarrhea, weight gain, thirst, frequent urination, tremor, flare-up of dermatologic conditions and hypothyroidism. This supports the correlation between hormonal imbalances and mood disorders. Hormones adversely affect skin conditions and lithium is treating bipolar disorder, but lowering activity of the thyroid gland, causing hypothyroidism.
Antidepressant medications are very effective in treating the depression associated with bipolar disorder, but they can push a patient from the depressive state into the manic state. This can have catastrophic consequences because mania often includes psychotic factors and irrational thought. A person treated for depression long-term who actually has bipolar disorder could become irrational, dangerous, delusional, and hallucinogenic. Antipsychotic medications are effective in treating the psychotic features of mania. These include delusions and hallucinations. These medications are also calming, promote sleep and help decrease disorganization and agitation associated with manic episodes. The article “Current Treatments for Bipolar Disorder: A Review and Update for Psychologists” affirms that mood stabilizers tend to be more widely used than anti-psychotic medications because they treat the disorder overall as opposed to only the symptoms associated with mania. (Rivas-Vazquez et al, April 2002, pp. 212-223)
There are dietary supplements, hormones and other medications that are thought to aid in the treatment of bipolar disorder. Benzodiazepine medications treat insomnia and anxiety. They have been linked to serious conditions such as seizures. For acutely manic patients they can be used as a short-term tranquilizer and for seriously manic patients, they can aid the patient’s inability to sleep. Stimulants are thought to be helpful in treatment of depressive episodes because they boost the individual’s mood and energy level. St. John’s wort is a natural plant extract and is believed to have an antidepressant effect. It is mostly used for very mild depression and is not affective on severe depression.
As discussed earlier, treating patients for the wrong disorder can have catastrophic consequences. Individuals suffering from bipolar disorder are often misdiagnosed as suffering from depression. Treating an individual with antidepressants can cause onset of a manic episode. As discussed earlier, manic episodes are considered the most dangerous and dramatic of the abnormal mood states associated with bipolar disorder. Certain antidepressants are less likely to lead to mania, but it is never a risk that should be taken. One 24 year-old personal acquaintance was diagnosed as suffering from depression. This man was prescribed antidepressants and seemed to be normal. Suddenly, he became delusional and had an idea of creating an explosive within his apartment that would later be used if he should ever need some type of self-defense. The explosive went off in his apartment, causing property damage and landing him in a psychiatric hospital. Criminal charges were later brought against him and he is currently serving time in prison.
Misdiagnosis often occurs because the symptoms belong to another disorder. The excessive shopping associated with bipolar disorder’s manic episodes is also an indicator of obsessive-compulsive disorder. “Shopaholics” are often seen as having a compulsion to shop. Likewise, alcoholics are often seen as impulsive or obsessive drinkers. As mentioned earlier, drug use and substance abuse is recognized as common behaviors associated with manic episodes. The racing thoughts and rapid talking associated with mania could also be viewed as Attention Deficit Disorder (ADD) or Attention Deficit-Hyperactivity disorder (AD/HD). Anxiety is associated with the depressive episodes of bipolar disorder. The etiology of anxiety disorders is associated with some of the same factors as mood disorders. Cognitive factors and stress are associated with both anxiety disorders and mood disorders. Bipolar disorder could be mistaken for a sleep disorder such as insomnia. Restlessness is associated with both mania and depression. Phobias are unrealistic fears of things and situations that actually present no real danger. The psychotic tendencies of mania include delusions and hallucinations. Phobias could be described as delusional.
Irrational thoughts and hallucination that occur during mania are also associated with the irrational thought patterns and distorted perceptions common in schizophrenic patients. Schizophrenia also has a catatonic subtype and as discussed earlier, manic individuals can become catatonic. The etiology of schizophrenia is also associated with genetic vulnerability, neurochemical factors and precipitating stress.
One explanation for this is that people with bipolar disorder also suffer from a number of other psychological disorders. Another explanation is that bipolar disorder is all-inclusive. When it seems that a patient is suffering from numerous psychological disorders simultaneously, bipolar disorder may explain all of the symptoms and compress them into one diagnosis.
In conclusion, bipolar disorder is a mood disorder that affects 1-2% of the people, while depression is more common, affecting 7-18% of people. Bipolar disorder is multi0factorial and can be better understood by applying the various branches of psychology in order to understand the overall picture. Misdiagnosis often occurs because of similarities between bipolar disorder and other psychological disorders and because depression is more common. This can lead to dangerous and often catastrophic consequences. A likely explanation for is that the onset of bipolar disorder is multi-factorial and encompasses other separate psychological disorders. As research progresses, there is hope for individuals with bipolar disorders. The more psychology, medicine and psychiatry advance, the brighter the future becomes. There is help for individuals suffering from bipolar disorder. The key is being properly diagnosed and understanding symptoms and related factors in order to be better prepared and get the best treatment possible.
Do you or a family member suffer from either bipolar disorder or depression?
“The Bipolar Disorder Survival Guide: What You and Your Family Need to Know”. Miklowitz, David J, Ph.D. The Guilford Press. 2002.
“Current Treatments for Bipolar Disorder: A Review and Update for Psychologists”. Rivas-Vazquez, Rafael A.; Johnson, Sheri L.; Rey, Gustavo J. Professional Psychology: Research and Practice. Vol 33 (2). April 2002. pp. 212-223.
“Family Functioning and Mood Disorders: A Comparison Between Patients With Major Depressive Disorder and Bipolar I Disorder”. Weinstock, Lauren. Vol 74(6). Dec 2006. pp. 1192-1202.
“Increases in Manic Symptoms After Life Events Involving Goal Attainment”. Johnson, Sheri L.; Sandrow, David; Meyer, Björn. Journal of Abnormal Psychology. Vol. 109 (4). November 2000. pp. 721-727.
Mondimore, Francis Mark. Bipolar Disorder: A Guide for Patients and Families. 2nd Ed. The John Hopkins University Press. 1999.
“Sleep and Youth Suicidal Behavior: A Neglected Field”. Liu, Xianchen and Buysse, Daniel J. Current Opinion in Psychiatry. Vol 19 (3). May 2006. Pp. 288-293.
“Surviving Manic Depression: A Manual on Bipolar Disorder for Patients, Families and Providers”. Torrey, E Fuller, M.D. and Knable, Michael B., M.O. Basic Books. 2002.
Weiton, Wayne. Psychology: Themes and Variations. 6th Ed. Thomson Wadswirth. 2005.