Bipolar spectrum disorder is best described as a longitudinal diagnosis that requires longer-term observation of mood swings, and other associated symptoms (Hirschfield, 2001). The abnormal mood swings associated with bipolar disorder include major depressive episodes, intermingled with manic and/or hypomanic states. Complicating the diagnostic process with this disorder, are several associated factors. In addition to the presence of six subtypes, the need for an observed presence of cyclical manic-depressive mood states, further complicates matters (Hirschfield, 2001). Finally, without a clear pathophysiological etiology, the diagnostic process rests largely on clinical judgment (Hirschfield, 2001).
With all these factors in mind, it is interesting to note the epidemiological increase in occurrence of bipolar disorder within both adult and child populations (Kaplan, 2007). For example, while previously viewed as “virtually nonexistent” (Harris, 2005) in the child and adolescent population, recent years have shown a sudden rise in prevalence. One resource for this paper, states this risen in prevalence as a “40-fold increase in the diagnosis of bipolar disorder in youth” (Xu, et al, 2007, 1). One can’t help but wonder how this may correlate with the conceptual broadening of this diagnostic category since the DSM-IV-TR was taken into effect. In the following sections, we outline the proposed causes of this “epidemic rise” (Bauer, 2005) with suggestions to improve the assessment and diagnosis for this population.
“As depressive episodes often precede the first clear-cut mania, it is almost inevitable that major depressive disorder (MDD) is by far the most frequent diagnosis…Of course, to some extent, the misdiagnosis of bipolar depression is unavoidable, because technically, the diagnosis cannot be made until an episode of mania or hypomania has occurred….There is at least a 10% chance that someone experiencing a first lifetime episode of depression actually will develop bipolar disorder. “ (Thase, 2005, 258).
One common reason, proposed for the increased rate of misdiagnosis for this population is the nature of the presenting complaints. Individuals suffering from bipolar diagnosis commonly seek help for treatment of symptoms of depression (Thase, 2005). Additionally, when help is sought to manage symptoms of mania or hypomania, it is commonly not the patient’s who do so but their family and/or legal system (Thase, 2005). When you add to this, the additional problem of a lack of continuity in care – an accurate diagnosis is frequently delayed (Kaplan, 2007).
Without a prior knowledge of the client’s history of mood swings, and the ability to engage in a longitudinal observation, a misclassification is common. Since the symptoms associated with a bipolar diagnosis overlap with other psychiatric disorders, this further complicates matters (Bauer, 2005). In fact, several resources lag time between symptom onset and accurate diagnosis, at somewhere between 7-10 years (Stensland, 2010, p 39; Thase, 2005).
A second key reason for increase prevalence and misdiagnosis of this disorder is the lack of a clearly understood pathophysiological etiology associated with this disorder (Kaplan, 2007). In fact without a clearly defined biological marker associated with this diagnosis, the process is a matter of clinical judgment (Xu, et al, 2007). With this in mind, the degree of imprecision associated with the diagnostic criteria for this disorder warrants close examination (Xu, et al, 2007, 246).
Juvenile Bipolar Diagnosis
Another key issue associated with the increase prevalence of bipolar diagnosis, is the lack of developmentally-based symptomatology (Harris, 2005). With a lack of universally acceptable criteria from an age-specific perspective, room for diagnostic misinterpretation exists (Harris. 2005). In fact, one resource for this paper poses the following question: “Are juvenile and adult bipolar disorder, the same disorder” (Harris, 2005, 529). In providing support for this possibility is the fact that symptoms present differently across the life span. What’s more, research has shown that a good majority of juveniles with bipolar disorder do not go on to exhibit the adult variety (Harris, 2005, 529).
Further complicating matters, are the associated pressures that can influence the diagnostic process (Harris, 2005, 531). For example, telling parents a child has a mental illness takes away the need to closely examine family interactions. Additionally, the government and insurance industry exert their own financial pressure that also influences diagnostic processes.
The perceived worthiness of the recipient may play a hidden role in the policy development. For instance, it is often easier for a child to get special educational services if the diagnosis is presumed to have a more biological basis. In many state programs, a child qualifies for services if the diagnosis is bipolar disorder but not if it is PTSD or disruptive behavior disorder. (Harris, 2005, 532)
Conceptual broadening of the bipolar spectrum disorders, is the most-cited reason underlying the increased prevalence of this diagnosis (Harris, 2005; Kaplan, 2007; Thase, 2005). In fact, it appears that further research to clearly understand the underlying etiology, and a refinement of diagnostic criteria are two key solutions to the issue of increase prevalence.
In a paper titled “The Road to DSM-V” is a discussion of the needed changes to the bipolar spectrum disorder description. The authors of this article provide the following assessment of the potential revisions to this category of disorders:
Useful Categorical Descriptors.
According to Colom & Vieta, three key descriptors of bipolar diagnosis remain quite useful. These key symptoms include, catatonic features; rapid mood cycling and depression with atypical features (Colom, et al, 2009). In fact, this article appears to call for further research to better understanding the nature of catatonia within bipolar disorder. Additionally, education to help medical professional’s understand how to better differentiate bipolar and unipolar depression is key (Colom, et al, 2009).
Areas of Revision.
While a more in depth discussion of suggested revisionary changes is beyond the scope of this paper, what follows is a brief listing of suggestions. These suggestions also come from the article titled “The Road to DSM-V” by Colom & Vieta:
Modification of seasonal pattern descriptor in bipolar diagnosis is warranted as research has proven this associated symptom to be inconclusively associated with the disorder itself. (Colom, et al, 2009).
Modifying and expounding upon levels of severity and/or degrees of remission would help provide further diagnostic clarity. While this resources states that a description of severity stages hasn’t been utilized in the field of psychiatry, it would be very helpful (Colom, et al, 2009).
Suggestion Descriptive Additions
Finally, two suggested additions are provide by Colom & Vieta, including addressing the juvenile variety of disorder, as well as varied degrees predominant polarities seen within patients.
Discussing the early onset forms of bipolar disorder, would involve a developmental age-related descriptor of symptomatologies across the life span. (Colom, et al, 2009).
Addressing the issue of predominant polarities, can provide clarity to research which reports high degrees in symptomatic presentation between predominantly hypomanic versus depressive patents (Colom, et al, 2009).