Bipolar disorder often misdiagnosed

By KRISTI EATON

VIEW ON HEALTH

Betty Smith has suffered from bipolar disorder since 1991.

Since that time she has been addicted to drugs, lost her children, had a nervous breakdown and was sent to a mental health rehabilitation center.

Anti-depressants, therapy and social groups have helped, she says, but she still suffers from mood swings.

Her 21-year-old daughter is also exhibiting signs of a mood disorder. She has depression and experiences panic attacks.

To this day, Smith says she tries to hide her diagnosis.

"I don't want everyone to know that I have a problem," says the Las Vegas resident. "Basically, I just go day by day. I put on a happy face. I don't show that I let things bother me like they do. I just let people see that I am not depressed -- that's what I show, but I actually am."

Smith is one of the 2.5 million Americans affected by bipolar disorder every year, according to the National Institute of Mental Health. The mental illness, marked by extreme changes in mood and behavior, is typically diagnosed before the age of 20, with more than two-thirds of patients having at least one close relative with the illness or with unipolar major depression. The disorder is found in all races, ethnic groups and social classes.

While both men and women are just as likely to develop the disorder, statistics and studies show there are gender biases in diagnosing it. According to a 2000 report from the Depression and Bipolar Support Alliance, women are far more likely to be misdiagnosed with depression and men are far more likely to be misdiagnosed with schizophrenia.

"Bipolar disorder and depression are two distinct disorders, however in some cases they may be difficult to distinguish," says Stacey Weiland, a board-certified internist from Evergreen, Colo.

Both diseases are defined by periodic depressive symptoms, she says, which include depressed mood for a large part of the day, nearly every day; diminished interest in daily activities; weight changes; sleep changes; fatigue and loss of energy; feelings of worthlessness or guilt; concentration problems; and thoughts of death.

Patients with bipolar disorder, she adds, experience episodes of mania, including impulsiveness, rapid speech, grandiose ideas and plans, and a decreased need for sleep. Manic episodes can lead people to engage in high-risk behaviors, such as promiscuity, spending sprees and drug use.

"Discerning whether or not a patient with seeming depression in fact has bipolar disorder can be very difficult," the doctor says. "In fact, it has been estimated that up to 30 percent of patients diagnosed with clinical depression are actually suffering from bipolar disorder."

Realizing the distinction is important because, Weiland says, medication for bipolar and depression vary greatly. In addition, treating a person who has bipolar with a common anti-depressant medication like an SSRI, or selective serotonin reuptake inhibitor, can actually bring about a major manic episode.

John Sharp, a psychiatrist on staff at the Beth-Israel Deaconess Medical Center in Boston, says a combination of medication and therapy is best for treatment.

"A mood stabilizer is necessary. I like interpersonal techniques that provide psycho-education, support and problem solving," says Sharp, who has written the book "The Emotional Calendar."

Social rhythm therapy, a behavioral therapy used to treat the disruption in circadian rhythms related to bipolar disorder, has a lot going for it, he says. "After stabilization, therapy helps with self-esteem issues, and prevents relapses."

'YOU FEEL TRAPPED'

Thelda Moyes was a teenager when she was first diagnosed with bipolar disorder.

Her biological father physically, sexually and mentally abused her from the time she was 2 months old to the age of 7, at which point she was taken out of the home. At that point, the Las Vegas woman was diagnosed as suffering from post-traumatic stress disorder due to the abuse. Less than a decade later, she was diagnosed as being bipolar. By the time she was in her 20s, she'd made 42 suicide attempts, she says.

"I quit going to the psychiatrist until I was about 24 or 25, when it started manifesting itself badly," Moyes says.

Moyes has since returned to counseling and sees a psychiatrist regularly. "Recently, I quite doing drugs and am learning a lot of coping skills ... I have learned a lot by getting down to the root of the problem," she says.

One of the biggest things she learned how to do was accept the fact that she has a mental illness. "I am learning how to deal with it and accept the fact that I have a mental diagnosis. That it is just an illness. It is not me," she says.

Along with regular therapy sessions, Moyes takes medication -- Seroquel and Celexa -- to deal with the mental illness, something that she has learned is crucial to her stability and health.

"I stay up on my meds. It is very important. Without them it can complicate things. Mostly I can function fine as long I take my meds," says Moyes, a mother of four adult children.

Like many people with a mental illness, Moyes says people often misunderstand her and her mental illness. "There is no reason to be afraid of a person with a mental illness," she says. "We are just like anybody else. We just have an illness."

She says people with mental illness turn to drugs to cope. It releases them from their pain, she says, and allows them to be free for a short time: "It keeps them from hearing the voices and the things that cause them to have the mental diagnosis. A lot of us turn to drugs because it helps quiet the voices or sets you free from the self-prison.

You feel trapped. It is like you are somebody else, but you are trapped. You want to be straight, but don't know how. "

CHANGES IN THE DSM

In May 2013, the fifth edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" will be published. A working group has proposed several changes to the diagnostic criteria of bipolar disorder.

Currently, under the DSM-IV, bipolar disorder is broken down into bipolar I disorder, bipolar II disorder, cyclothymia and dipolar disorder not otherwise specified. Bipolar I is further broken down based on the number and severity of various combinations of mania and depression.

"Proposed changes to the bipolar diagnoses for the as yet unpublished DSM-V make an attempt to clarify some confusing wording," says Weiland, adding, for example, "a distinct period" will be changed to "most of the day, nearly every day."

The proposed changes also create a new classification for children who may have otherwise been misdiagnosed with bipolar disorder. Temper Dysregulation Disorder with Dysphoria, or TDD, is characterized by severe recurrent temper outbursts in response to common stressors.

"The committee was very concerned about the over diagnosis of bipolar disorder in children," Stuart L. Kaplan, clinical professor of psychiatry at the Penn StatesCollege of Medicine, says of TDD. "It was well recognized that this was a disorder diagnosed in excess."

Before 1995, children were rarely diagnosed with bipolar disorder. Between 1994 and 2003, there was a 40-fold increase in the number of children being diagnosed with bipolar disorder -- from 20,000 to 800,000.

"In order to reduce the frequency of this diagnosis, they looked at data from several studies and they modified the criteria to give a different diagnosis that would better explain the critical picture than pediatric bipolar disorder," says Kaplan, whose book examining the subject, "Your Child Does Not Have Bipolar Disorder: How Bad Science and Good sPublic Relations Created the Diagnosis," is to be released in March.

Before DSM-V, chronic irritability was routinely being diagnosed as bipolar disorder, he says.

He says he recalls reading the studies and reports in 1995 about children with bipolar and thinking it was nonsense then. "It was ridiculous. These kids did not have bipolar disorder....DSM-V deserves a lot of credit putting a stop to it," he adds.

Under the new proposed criteria for TDD, a child must have severe temper tantrums, in excess of the provocation, that is not proportionate to their development. For example, an otherwise healthy 2 year old may have an extreme temper tantrum that is common for their age, but a 9 year old would not. The tantrums must occur three or more times per week, happen at home and one other setting, like school, and be on-going for at least 12 months. Also, children must be at least 6 years old to be diagnoses with TDD, but not usually older than 10, Kaplan says.

The Child and Adolescent Bipolar Foundation (CABF), a non-profit organization providing education, support and advocacy for families raising children with bipolar disorder and related conditions, has applauded the proposed changes for children. They believe it will lead to a more accurate diagnosis. They do, however, have a problem with the term "temper" in the new name.

"There is a strong negative connotation to the word 'temper,' conjuring images of inept mothers who cannot control their bratty kids. Instead of describing a serious brain illness, it implies bad behavior on the part of children and permissiveness on the part of parents," the organization says in a release.

Officials in the organization propose replacing "temper" with "mood" or "affect."