Bipolar What?

I have been seeing a ton of bipolar on the psych ward this week and last week. The director of our psych ward is a well seasoned psychiatrist with 30+ years of practice experience. He also sits on the board for the DSM which is the bible of diagnosing psychiatric illness and is a professor at one of the local medical schools and highly regarded in the field.  He is very interested in  bipolar disorder and has published many different papers and studies on the illness. What I am saying is this is the perfect guy to have as a mentor / teacher of  bipolar and everything else in psychiatry. 

What is bipolar and why is there so much confusion about this disorder? Why is there so much misdiagnosis in some populations and under diagnosis in other populations and finally over diagnosis in some populations? Oprah and the media have highlighted bipolar on their shows which has caused people to stream into their doctor's office thinking that they might have bipolar too. Today we had a big conference with the residents and attending physicians where we discussed bipolar as a psychiatric illness at great lengths. I will attempt to discuss the very basics here on the subject. 

You have Bipolar 1 and Bipolar 2. What are the differences? Bipolar 1 is a major manic episode with or without major depressive disorder. The patient with Bipolar 1 has to have had 1 episode of mania and that is it. It is irrelevant if he / she has depression. Now what is mania? Here is where all the confusion and debate comes in on the subject. The majority of psychiatrists believe that in order to classify an episode as true mania the patient has had to lose touch with reality and end up being hospitalized due to the mania. SO if I present a patient that sounds like mania yet it was not severe enough to land that person in the hospital they would tell me that it is not bipolar 1. Most patients with bipolar 1 are actually diagnosed when they end up in the hospital after their first real manic episode. The many bipolar 1 patients I have been working with on the psych floor are acutely manic and forced into the hospital. It is very apparent that they have lost touch with reality in many aspects of their life and suffer from various delusions. They claim to have jobs that they have never in fact had.  They really believe that they are the CEO of a major corporation or the head coach of a major league sports team. Every patient I have seen has been awake for nearly 1 week without sleep which is another sign of true mania. It is interesting to note that most patients do not recall their behavior or the events that took place during their manic episodes.  Most bipolar patients experience devastating consequences of their manic behavior including being arrested for violent behavior, losing their jobs, drug use, and extreme and risky hyper-sexual behavior like unprotected group sex.  These behaviors are indicative of bipolar 1 and and must be present in order to definitively diagnose bipolar 1.  

Now what is Bipolar 2? Bipolar 2 consists of at least 1 or more major depressive episodes and and at least 1 or more hypomanic episodes. If the patient has ever had a true manic episode then they can't be considered for bipolar 2. Simply put Bipolar 2 is major depression with hypomania. What is hypomania?  Basically hypomania is a dialed down version of true mania and does not end up with a psychiatric hospitalization. The patient has not lost touch with reality and not experiencing the delusions as seen in true mania. Nevertheless hypomania is not an episode of excitement that all people experience at different times in their lives. The episode is prolonged and much more intensified that the normal excitement we feel on a normal basis. Imagine the excitement you had as a kid around Christmas but now amplify this to the point where you have some seriously inappropriate social behaviors like grabbing your assistance behind in a hyper-sexual fashion  and then stretch this feeling out for 2 weeks straight and you start to get an idea of hypomania. Hypomania is not a mild situation and often lesser episodes or excitement are mistakenly called hypomania. The other confusing part of Bipolar 2 is that the patient must have experienced a major depressive episode as well. Again people confuse regular sadness or mild depression with major depression and then make an incorrect diagnosis.

Given this info it becomes clear how so many can be called bipolar when in fact they are not really at that level of disease. At the conference today, the doctor explained that true Bipolar is near, or on the same level, as schizophrenia. It is not a mild diagnosis. However in some populations it is a popular albeit incorrect diagnosis. For example you have a fairly regular patient who experiences anxiety and some mood changes with some inappropriate social behavior and some mild depression. Many diagnosis this as Bipolar when in fact the patient does not have a true mania or a true major depression. Most likely they have some generalized anxiety disorder with mild depression.

Now here is the kicker as explained to me today. Most psychiatrist know all of the aforementioned info inside and out yet many still make incorrect diagnosis of bipolar all the time. Why you ask? Answer = money. In order to get paid for certain medication management and clinical work, the patient must have a diagnosis that warrants aggressive medical management or the doctor will not get paid or will get paid much less. This happens in other fields of medicine all the time. In dermatology, in order to get paid for certain surgery a specific diagnosis of a condition must be made regardless of whether the condition actually exists. The insurance companies have created so many hurdles to get paid for your work and these misleading and incorrect diagnosis are unfortunately the result.

Who cares? Why make a big deal about all of this? Well the treatment of bipolar includes some heavy medications with serious long term side effects which a patient should not be exposed to if they do not need to. These are not minor side effects, and it can take time for the side effects to develop and may be irreversible.  In contrast, the treatment for generalized anxiety and milder forms of depression do not use these big gun mood stabilizers you see used in bipolar. Ironically a patient with generalized anxiety disorder and or mild depression will often see improvement while on these bipolar medications but unfortunately are exposed to levels of toxins that they do not need to be exposed to.  They can see the same level of improvement, if not better improvement, with other milder medications that target generalized anxiety disorder and or depression. I have not even brought up the social implications or stigma of being diagnosed with bipolar, and when it is an incorrect diagnosis a patient will needlessly suffer from these social issues as well.

Psychiatry is complicated. Unfortunately there are no blood tests for most of the psychiatric illnesses, and diagnosis can often be nebulous at best. A well versed psychiatrist can make nearly any disorder or syndrome sound like another or different syndrome if they so desire or take relatively normal behavior and stretch it to look like a disorder if there is some benefit in doing so.  At the same time, a truly gifted psychiatrist who follows his / her hippocratic oath can usually accurately make correct diagnosis for all of the psychiatric illnesses.  

The patient must be their own advocate or have a family member that can advocate for them, and 2nd and 3rd opinions are never a bad idea.