How to get help and why it’s so tricky to diagnose. (Photo: Getty Images)
At age 23, Stephanie Joseph noticed she was having trouble concentrating at work – that is, when she actually made it into the office. Many days, she couldn’t get out of bed. She spent hours staring at the wall, crying at the drop of a hat. And although she’d only worked for nine months as a certified public accountant for a large accounting firm, she was already in danger of losing her job.
Joseph checked into a psychiatric hospital for several weeks, where she was diagnosed with what she and physicians then thought was major depressive disorder. The diagnosis made sense at the time; after all, Joseph had experienced mood dips throughout her teens. She was prescribed an antidepressant, found a psychiatrist and started talk therapy.
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It took 13 years and several doctors for Joseph, now 51, to realize she’d received the wrong diagnosis. After describing her agitated mood swings to a psychiatrist – episodes filled with anxiety, rage and impulsive shopping sprees, interspersed with prolonged periods of extreme sadness – she learned she had bipolar disorder, a psychiatric condition that affects an estimated 2.6 percent of the country’s adult population. More specifically, she had a subtype of the illness called bipolar II.
Like major depression, bipolar disorder is characterized by sadness, fatigue, a loss of enjoyment in everyday activities and disruptions in appetite and sleep patterns. But individuals with bipolar disorder differ from patients with major depressive disorder in that they experience what’s called mania or hypomania – emotional highs, bursts of extreme energy and severe irritability that ranges in intensity and duration.
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As Joseph’s case indicates, bipolar disorder is complex in presentation, and often extremely difficult to diagnose. Studies suggest it can take patients an average of 3.3 physician visits to get an accurate assessment of their condition, and 73 percent initially receive an incorrect diagnosis. Due to the illness’ broad nature, the latest iteration of the Diagnostic and Statistical Manual of Mental Disorders, DSM-V, divides bipolar disorder into several subtypes, but its symptoms often run on a spectrum, meaning there’s no one-size-fits-all diagnosis or treatment. And often, people who are initially diagnosed with depressiondevelop bipolar symptoms later in life.
According to the National Institute of Mental Health, bipolar disorder can result in a 9.2-year reduction in expected life span, and approximately 1 in 5 sufferers commit suicide. Clearly, it’s a serious diagnosis. But experts say patients who receive the right treatment and support can lead full, productive lives.
What Causes Bipolar Disorder?
The underlying causes of bipolar disorder are convoluted, experts say. Although the exact biological mechanisms are unknown, “it’s probably an interaction of genetic vulnerability with whatever happens in one’s life – so it’s a combination of nature vs. nurture,” says Terence Ketter, chief of the Bipolar Disorders Clinic at Stanford School of Medicine.
Research suggests bipolar disorder is 60 percent hereditary. Other factors that likely contribute include biological differences in the brain and an imbalance of chemicals called neurotransmitters and hormones. Life stressors such as emotional or physical trauma, a stressful relationship or a taxing career can also trigger the onset. While bipolar disorder typically rears its head in adolescence – at least half of cases occur before age 25 – it can also lie dormant and emerge later in a person’s life.
Bipolar disorder is equally prevalent in men and women, although studies indicate it might affect each both genders differently. For example, women tend to have more depressive features, while men experience more manic features.
Receiving a Bipolar Diagnosis
Francis Mondimore, director of the Mood Disorders Clinic at the Johns Hopkins Bayview Medical Center, says the main symptom of bipolar disorder is severe depression, which can last for weeks to months. There are physical signs – loss of energy, sleep and appetite changes – as well as a lower mood and alack of interest in life. Though there may be periods of another abnormal mood state, such as extreme euphoria or irritability, it’s often the lows that both patients and doctors first notice.
“Many people with bipolar disorder will present at treatment the very first time with depression symptoms,” Mondimore says. “The way we make a diagnosis of bipolar disorder in those people is to look at things like whether there’s a family history of bipolar disorder and a number of other indicators that suggest a period of depression might represent bipolar depression.”
These indicators, Mondimore says, vary. They include a young age of onset, since bipolar disorder often first presents in adolescence; having family members with the condition; or experiencing a first episode of depression after giving birth – a significant percentage of women who develop postpartum depression turn out to have bipolar disorder.
Additional red flags can include having tried antidepressants to no avail, or experiencing agitation or rushed, disorganized thoughts while on antidepressants. People who’ve undergone severe depressive episodes with psychotic symptoms, such as delusions or hallucinations, might also be at higher risk for bipolar disorder.
Diagnosis can further be complicated by having other chronic conditions. Sixty percent of patients with bipolar disorder also have substance abuse problems, Ketter says, making it difficult to determine if someone’s fluctuating moods are due to drugs or alcohol or something else. Attention deficit hyperactivity disorder is also common in patients with bipolar disorder, as as are anxiety and personality disorders, further exacerbating ease of diagnosis.
That’s why it often takes time for doctors to diagnose bipolar disorder, Mondimore says. “Sometimes people do walk in the clinic, show extremely classic symptoms and you can make a diagnosis in 15 to 20 minutes. But there are a lot more for whom there needs to be an assessment over a period of time.”
Forms of Bipolar Disorder
Igor Galynker, director of the division of biological psychiatry at Beth Israel Medical Center in New York, explains that there are several main subtypes of bipolar disorder. Patients who have bipolar I experience mania – an uncharacteristically elevated mood, accompanied by insomnia, over-activity and a tremendous sense of well-being. Patients often don’t need sleep, and they might become more talkative than usual. Manic episodes may be preceded – or followed – by a hypomanic or depressive episode.
In extreme cases, people with mania become impulsive and lose their inhibitions, leading to risky behaviors such as drugs, gambling and extravagant shopping sprees. Occasionally, they experience delusions and become psychotic. “They start believing they’re a prophet, or going to cure cancer or become a movie star or rock star,” Mondimore says.
A milder form of the disorder, bipolar II – the subtype Joseph was diagnosed with – is characterized by hypomania, or a very mild form of mania. While hypomania still causes elevated energy and over-activity, it’s not disabling. But that doesn’t mean it’s not serious. Often, those with hypomania make poor decisions; because their symptoms are subtler, however, they can be difficult to identify, increasing the likelihood that people could miss potentially destructive actions.
The illness’ third most common subtype, Galynker says, is mixed bipolar disorder – defined by symptoms of both mania and depression. Patients can feel agitated and energetic, but also extremely depressed. Mixed bipolar disorder often occurs later in life, and can be more difficult to treat.
While the DSM-V includes additional forms of bipolar disorder, including a mild type called cyclothymia, those listed above are seen most often.
Treating Bipolar Disorder
Ketter says bipolar disorder is typically treated with a mood stabilizer, such as lithium or Lamictal. These medicines help temper both mania and depression, and are occasionally used in conjunction with anantidepressant. However, doctors warn that antidepressants can nudge patients into full-blown manic episodes or cause rapid cycling, which describes fluctuations between mania, hypomania, depression and mixed states. Bipolar patients taking antidepressants should be carefully monitored.
Occasionally, patients are also prescribed second-generation antipsychotic medications, which help temper mania and depression. Many of these medications have side effects, so it’s important to discuss long-term risks with doctors.
Therapy is also helpful, experts say. Being diagnosed with bipolar is a life-changing event, and it’s helpful for patients to have support while dealing with a highly stigmatized mental illness. It can also help patients learn to cope with chronic psychological stressors that exacerbate symptoms.
Different patients might need different types of therapy. For example, patients with families might benefit from family-focused therapy, which aims to reduce stress and negative interactions within the family unit, support the patient and educate the family about the illness and how to work on encouraging medication compliance, Galynker says.
“What’s really important is what we call a psychoeducational component,” Mondimore says. “This is when we educate the patient about the disorder and what I call mood hygiene, or the lifestyle changes that are going to decrease the chances of relapse – avoiding sleep deprivation, avoiding intoxicating substances and adopting various lifestyle interventions.”
Sometimes, medication and therapy aren’t enough, however. A drastic life change, like a career switch, might be necessary to prevent triggers that worsen the illness. Support groups may also benefit patients, allowing them to meet others with the same diagnosis and develop a peer network.
Patients can achieve remission from symptoms, experts say – or at least enjoy stable lives. As for Joseph, after years of hardships, including multiple medication changes, filing for bankruptcy due to shopping spree-induced credit card debt and a suicide attempt, she has found that her illness can indeed be treated. Mood stabilizers and antidepressants, therapy and a structured daily routine have helped her immensely.
“I wouldn’t say it’s panacea,” she cautions. “I still have to be vigilant. I still have people in my life, like my therapist, who will let me know when they think I’m off. But you can live a full life with mental illness, especially the mental illness that I have. I just have to stay in therapy, and stay on medication. It’s in my brain. It’s not a character defect.”
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