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Bipolar Diagnosis on the Rise: Pros and Cons

Posted on May 2, 2008 by Dr. Fink

In a recent article in Westchester Magazine entitled “I’m Bipolar. He’s Bipolar. You’re Bipolar,” Carol Hall ponders the following: “Sometimes it may seem as if everyone is bipolar. Is this a real condition – or just a fashionable diagnosis?”

Although this question is likely to ruffle the feathers of anyone who’s had to deal with the often brutal reality of bipolar disorder, Hall explores this issue in detail and presents answers from various perspectives, including insights from both experts in the field (including myself) and patients who live with the disorder. (Visitors to the Bipolar Blog are already aware of what I see as the potential problems posed by over-diagnosing bipolar in children, as I discuss in “Bipolar Disorder Overdiagnosed in Children?“)

“Dr. Biederman’s stance is we diagnose young, so we can fix it early,” says Dr. Candida Fink, a New Rochelle-based child and adolescent psychiatrist. “But there are a lot of pre-pubertal children who are being diagnosed without presenting the full range of symptoms. People have gotten into labeling these kids ‘bipolar’ when many of them are not.” Dr. Gallager of Westchester Medical Center reports that his emergency room is seeing roughly the same percentage of bipolar adults but “about fifty percent more kids.”

From “I’m Bipolar. He’s Bipolar. You’re Bipolar,” by Carol Hall, first published in Westchester Magazine

The article does an excellent job of highlighting many of the factors that may be contributing to the rapid rise in the bipolar diagnosis over the past decade (a 40-fold increase in children and adolescents, and a two-fold increase in adults). Here are some of the most likely contributing factors (many, but not all, of these are mentioned in Hall’s article):

A greater awareness of bipolar disorder among doctors. The idea here is that many doctors simply did not recognize bipolar in the past, so they diagnosed it less.
A greater awareness of (and perhaps a greater acceptance of) bipolar disorder among consumers allows more people who really need help to feel more comfortable seeking it rather than just trying to deal with it on their own.
In the past, doctors often missed the bipolar diagnosis – patients often present with depressive episodes before full blown mania, so without careful diagnostic sleuthing, many people with bipolar were being diagnosed as depressed.
The professional criteria for diagnosing bipolar disorder have expanded with the publication of the 1994 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The addition of the Bipolar Disorder Not Otherwise Specified category opened up a much larger range of mood regulation difficulties to being diagnosed as a bipolar variant.
The highly influential 1994 article published by Joseph Biederman, MD from Massachusetts General Hospital formally introduced the idea that young children could have bipolar disorder and described many (1 out of 60) of his sickest patients with this label. Prior to the publication of this article, bipolar disorder was thought not to occur in pre-adolescent children.
Diagnosing children with mental illness has become more acceptable.
Diagnosing older people with mental illnesses has become more acceptable.
The proliferation of pharmaceuticals to treat both depression and mania have encouraged more doctors to make the diagnosis.
Health insurance companies tend to pressure doctors to work quickly, encouraging quick diagnostic labels and the quickest possible intervention. This often leads to medication rather than taking more time for a comprehensive assessment and recommending more complex and comprehensive treatment interventions that would include various types of therapy and supports in addition to medication. Reimbursement for non-medication interventions has typically been much more restricted than for “medical” treatments.
While it is just a speculation, it seems quite possible that as more and more anti-depressants (especially SSRI or Selective Serotonin Reuptake Inhibitor) are prescribed for treating depression, amphetamines (such as Adderall and Ritalin) are prescribed for treating ADHD, and other stimulants (including caffeine, nicotine, weight-loss drugs, and energy drinks) are used for various purposes, we’re seeing more emotional and behavioral side effects that can include agitation or sleep disturbances or even classically manic symptoms that may result in a premature bipolar diagnosis.

Wisely and appropriately, Hall is careful to point out that her report discusses trends, and that any question of whether bipolar disorder is over-diagnosed does not presume that bipolar is a phony diagnosis or that people (including children and adolescents) diagnosed with bipolar disorder have something else entirely. Her article contains reports from patients and parents who battle this devastating illness on a daily basis and who require medications and therapy to level out their mood fluctuations.

Her conclusion that bipolar disorder’s “newfound fame is helping its victims” is right on target. For those with this disorder, heightened awareness and improved understanding by the public – that this is an illness and not just “an excuse” or a moral failing – can only be positive. Shining a light on this most painful of illnesses is the only way to ensure that patients will be more able to seek help comfortably, and professionals will be more likely to make the diagnosis and provide help to those who are suffering.

Overall, I think this article is very well done, and I think you should certainly check it out.

Comments

6 Responses to “Bipolar Diagnosis on the Rise: Pros and Cons”

Larry Drain on May 21st, 2008 4:14 am

At our last support group meeting we had a psychiatrist by the name of David Snow as a guest speaker. Dr. Snow is evidently well acquainted with the psychiatrist who popularized the notion of bipolar 2 (He gave his name. I just forgot it. He has written over 140 of the 150 something articles on the subject). This psychiatrist is on the panel for the next revamping of the Dsm. He says that bipolar categories are going to multiply like crazy. All the way up to Bipolar 7. Part of the rationale evidently is that so many people are “biplolarly” but dont fit easily into one of the existing categories. Have you heard anything about this? If so what are your reactions? Do you know the name of the psychiatrist I am speaking of?
Dr. Fink on May 23rd, 2008 3:06 pm

Hi Larry –
I don’t know the name of the psychiatrist you are referring to off the top of my head – but I am aware of the literature that is looking at expanding bipolar disorder into more of a bipolar spectrum diagnosis. It is somewhat controversial actually – there are a number of people who are not sure that this is particularly helpful – at least not necessarily putting all of the mood regulation disorders into the category of bipolar. Bipolar has traditionally referred to a very specific set of symptoms – and expanding it into people who are reactive and dysregulated is a a big topic of discussion. I am hopeful that with time we will have more information on the underlying neuropathology – with imaging, biochemical and genetic data – that will take us from being solely descriptive in the DSM IV – and just trusting our instinct and general patterns – to being much more scientific about it.
So the answer I think is – stay tuned for lots more information to explode onto the scene in the next few years.
Take care -

Candida Fink MD
daisy rhodes on July 3rd, 2008 11:49 am

my sister was currently put on anti-depressants coz we suspect that she is bi-polar,do you think the condition will get worse?
Jim Dnn on July 3rd, 2008 11:53 am

Daisy i think your sister should be checked out by a physcian
—————————————–
Jim Dunn

http://www.dualdiagnosis.net/
Joe on July 7th, 2008 3:41 pm

I agree with Jim. If your sister does have bipolar disorder, taking an antidepressant without the protection of a mood stabilizer could trigger mania or make it worse. A doctor who has experience treating depression and mania is better qualified to tell whether your sister is experiencing unipolar or bipolar depression (or something else) before prescribing medications.

We posted a sample chapter from our book Bipolar Disorder For Dummies on the blog: Chapter 5, “Getting a Psychiatric Evaluation and Treatment Plan.” The information in this chapter could help ensure that your sister obtains an accurate diagnosis, which is key to obtaining the right treatment.
Jennifer on September 12th, 2009 10:26 am

Candida Fink says the following:

“The professional criteria for diagnosing bipolar disorder have expanded with the publication of the 1994 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The addition of the Bipolar Disorder Not Otherwise Specified category opened up a much larger range of mood regulation difficulties to being diagnosed as a bipolar variant.”

However, Bipolar Disorder Not Otherwise Specified existed already in DSM-III-R. With DSM-IV the diagnosis “Bipolar II” was added. I hope this information was helpful, Candida.

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