The chronic and disabling illness we know today as bipolar disorder was poetically named “la folie circulaire,” or “the circular insanity,” in 1854, for its characteristic shifting between high and low moods. It became known as “manic depression” a few years later. (1)
As recently as the 1950s, the United States Congress refused to acknowledge maniac depression as a legitimate illness. In wasn’t until the early 1970s that maniac depression was legally recognized, and laws enacted allowing patients suffering from it to receive Social Security benefits. (1) That term has since been replaced with “manic depression.”
In the 1980 edition of the DSM-IV, the illness was renamed “bipolar disorder” and classified into four types: bipolar I disorder, bipolar II disorder, cyclothymia, and bipolar disorder not otherwise specified, which is also known as bipolar disorder NOS. (2)
Bipolar disorder can be deadly, seemingly intent on the destruction of its host. A person caught in the orbit of la folie circulaire is 20 times more likely than the general population to attempt suicide. (2) Of those who do attempt suicide, 25 to 50 percent will succeed. (3)
The Danger of Misdiagnosis
What makes bipolar disorder particularly insidious is that it is notoriously difficult to diagnose. Bipolar patients usually seek help when depressed, since the mania or hypomania of bipolar disorder are rarely experienced by the patient as undesirable. For that reason, bipolar disorder is often misdiagnosed as simple unipolar depression.
The misdiagnosis of depression is dangerous. Monotherapy antidepressants such as SSRIs can induce rapid cycling and mania in a bipolar patient. (1) Rapid cycling occurs when a patient experiences four or more manic/hypomanic or depressive episodes in a year, drastically destabilizing their lives. (6)
Further complicating diagnosis is that the mania of bipolar disorder may present in one person as a decreased need for sleep and rapid-fire thoughts, in another as grandiosity and overspending, and in yet another as razor’s edge irritability with flashes of anger. Or mania may be comprised of any combination of the above. (4)
Getting It Right
Psychiatric Nurse Practitioner Shelley Berger Dooley agreed to speak with EmpowHer about the process of diagnosing bipolar disorder. I asked Dooley what she tries to ascertain during a first visit with a new, previously undiagnosed patient.
“First, I do a thorough psychiatric evaluation,” Dooley shared. “including what brings them into treatment at this time, current symptoms — mood, sleep, appetite, concentration, interest in activities, suicidal or homicidal thoughts or plans — family psychiatric history, and medical and social history.”
Dooley also performs a mental status evaluation which assesses memory, behavior, speech, thought processes and judgement.
I asked Dooley what signs can indicate that she might be dealing with bipolar disorder.
“I start to wonder about bipolar when there is lack of response or atypical response to antidepressants, significant mood shifts with or without situational triggers; history of postpartum depression, a family history of bipolar, chemical dependency, or mood instability.”
Not all who have postpartum issues are bipolar, but bipolar patients appear to have an increased risk and frequency of postpartum depression.
“Sometimes symptoms are not obviously associated with bi-polar and can be attributed to depression or anxiety,” Dooley noted, “but over time, the lack of a positive response to medication trials or manic behaviors like insomnia, severe anxiety or irritability, or racing thoughts are signals to reevaluate for the possibility of a mood disorder.”
Unearthing Bipolar II Disorder
Those suffering from bipolar II disorder have the swings of bipolar I disorder, but the highs are less expansive. The mania of bipolar II disorder, called hypomania, can present as a flight of ideas, increased energy and productivity, increased creativity or rapid, pressured speech. (5)
Few people seek a cure for an infectious, positive mood. But the pendulum of bipolar II disorder swings much further into symptoms similar to clinical depression. (5) Since the symptoms of bipolar ll disorder are less severe, it is frequently misdiagnosed as depression.
I asked Dooley how she distinguishes bipolar II disorder from depression. “Again, history is so important, as is the response to medication trials,” she said. “Usually, working with someone over time, a pattern of mood shifts become clear.”
She continued, “Since people generally do not see the hypomanic episodes as a problem, and do not always report them, family members can be a valuable resource. Family is often very aware of the mood shifts and can aid in the correct diagnosis and treatment.”
Sharing a Diagnosis of Bipolar Disorder With a Patient
I wondered how Dooley’s bipolar patients respond to being diagnosed with this serious — and potentially deadly — mental illness.
“That varies,” Dooley said. “Some patients are very relieved to finally understand what has been going on with them all these years. Many have been undiagnosed or misdiagnosed for years — many fear they will never feel better or ‘normal.’ So, a diagnosis provides information and hope for a future.”
Dooley affirmed that many people can and do live normal and productive lives once they find and maintain the right medication regimen and commit to a healthy lifestyle.
“Others are upset over the diagnosis and their perception of what it means. Education about the disorder, the various types and presentations, and the real possibility for improved quality of life and stable mood is very helpful.”
Once having reached a diagnosis, Dooley discusses medication options with the patient, including the risks and benefits, so they can agree upon a treatment plan.
Ensuring the Best Possible Outcome
Dooley emphasize the need for a treatment plan which includes lifestyle changes: restoring sleep, mindfulness training and cognitive behavioral therapy.
“Treatment consists not only of medication, but may also include stress management, cognitive therapy, social connectedness, adequate sleep and exercise,” she said.
“The lack of following through with positive lifestyle changes can result in poor response. People need to commit to follow treatment recommendations to achieve the best response.”
Non-compliance often occurs with patients who miss the manic highs of bipolar, or who feel that medications dull their creativity. Dooley cautions against stopping medication or changing doses without medical supervision, as this can be detrimental to recovery, and is potentially dangerous.
If a patient is unhappy with the effects of the medication, Dooley emphasized, it is essential to discuss this with his or her provider. Doctors can adjust or change medications to achieve the best possible response. That may mean rescheduling an appointment so that the adjustment can be made sooner.
Four points summarize Shelley Berger Dooley’s approach to managing bipolar disorder:
1) Talk with your provider if you are unhappy with the side effects of medication.
2) Monitor your mood and symptoms.
3) Take action early if you feel out of control, whether from mania or depression.
4) Commit to lifestyle changes that support recovery.
Dooley concluded, “I believe strongly in the ability of the patient to grow and change. I love what I do. It is an honor to assist people in their journey to a more satisfying life.”
If you suspect that you may have bipolar disorder, or if you have been diagnosed with unipolar depression and aren’t experiencing the healing you expect, please explore the possibility of bipolar I or II disorder with your health care provider.
May we all be well.
Shelley Berger Dooley PMHNP has been a Psychiatric Nurse Practitioner since 1996. She currently practices in Phoenix, Arizona, where she provides psychiatric evaluations, medication management and therapy. She is also a mindfulness educator offering 8-week courses in Mindfulness Based Cognitive Therapy. She can be reached at [email protected]
1) Misdiagnosis of Bipolar Disorder. NCBI.com. Retrieved January 25, 2016.
2) Bipolar Disorder Statistics. dbsalliance.org. Retrieved January 26, 2016.
3) Suicide and Bipolar. NIH.gov. Retrieved January 25, 2016.
4) Misdiagnosis of Bipolar Disorder. PsychologyToday.com. Retrieved January 26, 2016.
5) Bipolar II Disorder. WebMd.com. Retrieved January 26, 2016.
6) Antidepressants Risky for Bipolar II? WebMd.com. Retrieved January 28, 2016.
Reviewed January 28, 2016
by Michele Blacksberg RN
Edited by Jody Smith