Diagnosing Bipolar Disorder correctly from the beginning
Back to hypomania. It is quite unfortunate that many patients with bipolar disorder wait for many years fruitlessly seeing psychiatrists until the correct diagnosis is made. According to data collected by the Depression and Bipolar Support Alliance (DBSA) (www.dbsalliance.org)about 60% of patients ultimately diagnosed with bipolar disorder had the illness for at least 5 years before the correct diagnosis was made.
Typically these patients have been mistakenly diagnosed with major depression for several before it is recognized that the correct diagnosis is bipolar disorder.
There are several reasons for this error in diagnosis. Patients don’t typically come to the doctor complaining that they feel too good. In both hypomania and mania there is also a lack of insight into the illness. Additionally psychiatrists do always ask carefully enough about past bipolar symptoms in every patient they see who is depressed. They may simply ask one screening question for bipolar disorder and then fail to probe deeply enough. Nowadays the diagnosis of bipolar disorder is much easier.
A psychiatrist called Robert Hirschfield MD (Weill Cornell Department of Psychiatry) developed a screening instrument called the Mood Disorders Scale (MDQ) which is self-administered and available on the web site of the DBSA. This quickly gathers the information one needs to get a first impression of whether there possibly be bipolar disorder. One should remember though that is a screening instrument and not a diagnostic one. If the screen is positive the next step is to see a psychiatrist and have a thorough assessment to determine if bipolar disorder is present or not. The MDQ screen can be very suggestive but it doesn’t make the diagnosis by itself.
Bipolar disorder often develops early in life. The peak age of onset is in young people 15-30 years old. It can even occur earlier in late childhood. In teenage years the mood swings are more sustained and the depressions can be quite lengthy distinguishing it from normal ups and downs of teenage angst.
The earlier the diagnosis is made and proper treatment is started the better for the long-term prognosis. Therefore, any teenager with depression or who makes a suicide attempt needs to be screened carefully for bipolar disorder.
Identifying hypomania is important clinically for many reasons not least of which is that it is easy to miss and so miss or overlook the diagnosis of bipolar disorder. Patients will remember their depressions very clearly as the pain of them is not easily forgotten. However, hypomania wash over quickly and don’t have the same dramatic intensity as mania. By definition if one gets hospitalized with a disturbed and elevated mood state it must be mania. At that point it is too severe to still be called hypomania. Once hospitalized with mania the diagnosis now becomes BP-I disorder.
Hypomania on occasion can lurk insidiously in the background for a long time even though those close to the patient may know there is something wrong. But the patient lacks insights and usually refuses treatment. In this sense hypomania is insidious and can wreak a lot of havoc in one’s life before the diagnosis is made.