When You’re Not Really Bipolar After All: Anatomy of the Diagnosis of Bipolar Disorder

For the first few years after I arrived in the DC area, I took call at two local hospital emergency rooms as a way to gain more experience, and build my private practice. One evening I was paged to come into the Emergency Department to evaluate a man who hadn’t slept in 3 days. When I arrived, the ED staff had taken an initial history and reported to me that the man was full of energy, his thoughts were racing out of control, and that he had suffered from episodes of depression in the past. He was also exhibiting signs of grandiosity, with thoughts that were excessively ambitious. The ED staff suspected that this man was having a classic manic episode and asked for a consult to rule out bipolar disorder. But it turned out that after looking at his lab work and a urine sample, this patient was actually found to be intoxicated on cocaine, which mirrors symptoms of bipolar mania. Interestingly, cocaine withdrawal symptoms can produce a severe, but transient depression, that may also seemingly confirm an erroneous diagnosis of bipolar disorder. It was an example of how “checking the boxes” on a list of diagnostic criteria (similar to using an algorithm to solve a math problem) without looking at the patient in a broader context and ruling out other conditions, could lead healthcare professionals down the wrong path when diagnosing bipolar disorder.

Bipolar disorder is a distinct and specific mood illness

Bipolar disorder is a distinct, specific mood illness that requires a detailed history by clinicians who have had both experience treating the condition in an acute setting such as a psychiatric emergency department or an inpatient setting and in the outpatient psychiatric setting. Dr. Guillermo Portillo, who treats patients with bipolar disorder at our practice, finds that the condition is routinely misdiagnosed because of incomplete workups. “I’m bipolar” often is a catchall phrase for patients who may be suffering from a different psychological illness such as an addiction, a medical condition presenting with psychiatric symptoms, a personality disorder, unipolar depression or explosive anger problems. Many of our new patients have already been diagnosed with bipolar disorder by another physician before coming in, but after a thorough interview and careful review of their medical history, medical records, collateral information from friends and family, and psychological testing, we discover that there may be another explanation at play.

Concerned about a bipolar disorder diagnosis?

If you are concerned about your diagnosis, first ensure that you do your homework on your treating physician to determine his or her level of experience with treating bipolar disorder. Your doctor should try to rule out possible medical conditions that could be contributing to your symptoms. For example, if you have with an overactive thyroid it could look like mania, and alternatively an underactive thyroid could resemble depression; and certain vitamin deficiencies, especially the B vitamins (such as B9 which is folic acid) can also mimic some bipolar symptoms. Some patients presenting with delirium could in fact be suffering from a change in mental status caused by a medical condition like cancer, interactions among medications, an infection, or even an electrolyte imbalance. In other cases, substance abuse, seizures in the temporal lobe section of the brain or conditions like Wilson’s Disease (an inherited disorder that causes too much copper to accumulate in your liver, brain and other vital organs) could be contributing factors.

Ask about psychological testing to confirm diagnostic accuracy

Your doctor can use psychological testing to help make this “differential diagnosis,” which is the process of distinguishing one particular condition from others that present with similar symptoms. Two of the most common tests, the Minnesota Multiphasic Personality Inventory (MMPI), and Millon Clinical Multiaxial Inventory (MCMI) test, are tools designed to confirm diagnostic accuracy. The MCMI-IV, the fourth and latest edition, has 195 true-false questions and takes only about 25–30 minutes to complete.

It may sound odd, but when patients who have thought for years that they had bipolar disorder discover that they in fact do not, the news can be devastating at first because it has been a part of their identities for so long. But ultimately they begin to feel empowered with the knowledge of their misdiagnosis because they realize that there is a reason that they are not getting better, and look forward to starting a new treatment regimen. Billy Crystal, one of my favorite comedians, once said, “What’s so fascinating and frustrating and great about life is that you’re constantly starting over, all the time, and I love that.” Sometimes starting over is a good thing.

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