Recently, I read a journal editorial asserting
the overdiagnosis of bipolar disorder. The author presented a compelling case,
not that I needed further swaying, and raised several salient points that bear repeating…
Each criterion of mania has its own differential diagnosis, given the overlapping
symptoms of many psychiatric disorders. For example, grandiosity is a frequent
feature of narcissistic personality disorder. Moreover, insomnia and irritability
are as commonplace in mental health settings as are headaches and dizziness in primary care clinics.
Attempts to establish a history of mania or even hypomania based strictly on patients’
subjective reports can also lead to false positives. Patients may endorse
manic symptoms for any number of psychological reasons, such as denial of another problem; e.g., patients often minimize substance
use which may mimic manic symptoms. Additionally, some patients may use their
bipolar diagnosis to justify impulsive acts or offensive behavior.
Even though the DSM distinguishes between episodic illnesses such as bipolar
disorder and the enduring , stable patterns of aberrant behavior that are designated as personality disorders, many clinicians
in the current era of diagnosing by subjective checklists may be remiss in exploring these conditions in the differential. Mood lability and impulsivity are core criteria for personality disorders, and patients
whose life stories are written in these terms should be contrasted from those who have episodes of uncharacteristic and cyclical
behaviors as seen in bipolar disorder.
Treatment of bipolar disorder can be rewarding and simple, whereas treatment of
a personality disorder is usually agonizing and complicated. Such factors
might lead to an inadvertent collusion of doctor and patient to speak of bipolar disorder when a conversation about personality
traits and dysfunctional relationships may be more helpful and accurate, even if less desirable. Neglecting such discussion can result in misdiagnosis and lead to poor outcomes and, ultimately, a feeling
of defeat for both the patient and physician or therapist.
Lastly, some medications can ameliorate symptoms of both bipolar disorder and personality
disorders. Mood stabilizers and antipsychotics appear to reduce mood lability
and impulsivity regardless of diagnosis. However, to infer that a specific illness
is present simply because a particular medicine helped is to engage in faulty logic (post hoc ergo propter hoc). There have been a number of studies demonstrating that antipsychotics also reduce
aggressive behavior in conduct disorder. Surely, changing the diagnosis to schizophrenia
would not be justifiable for this reason alone.
Now, here’s a clinical anecdote that
I think illustrates the above considerations to a tee...Not along ago, I interviewed a young lady in her mid 20s, who presented
with a self-diagnosis of “bipolar disorder”, which she had surmised from internet research. She elaborated by describing symptoms of feeling sad, exhausted and unmotivated on most days, alternating
with shorter periods of being happy, wanting to play with her child, and cleaning excessively.
Upon further questioning, she reported experiencing early insomnia most of the time, in which she would lie in bed
for hours ruminating about all of the things that she needed to do. Fortunately,
she had a prior treatment history in childhood from our clinic which revealed problems with social and separation anxiety
(so intractable that she eventually required homebound education), as well as obsessional loathing of dirt associated with
compulsive handwashing and bathing. In discussing this history with me, she
tearfully admitted that her anxiety and cleanliness had not only persisted but worsened over the years, causing her to lose
several jobs and “keeping” her in an unhappy marriage due to her perceived dependency on her husband’s income
and resentment of him for not helping her more with their daughter, though she confessed to not being assertive in the marriage. She further admitted to trying to “put on a happy face for my daughter”,
on her “manic days”, but couldn’t sustain this faux countenance and optimism for more than a few
hours at a time.
Finally, she confided that she was “tired
and frustrated having OCD because I haven’t gotten any better after 12 years with it.” I suspect that the patient unconsciously thought that having bipolar disorder would provide her with renewed
hope. It is additionally worth noting that throughout the course of the session,
I observed her 2 ½ year old daughter enthusiastically cleaning her hands, the office furniture and blinds with disinfectant
wipes from her mother’s purse. When I asked her why she was being so busy,
she responded that she wanted “to be like my Mommy.” Diagnostically,
in addition to well-established OCD, the mother also appeared to be struggling with a previously unrecognized, mixed Cluster
C personality disorder, as well as secondary dysthymia, having developed a learned sense of helplessness and hopelessness
due to a string of failed drug trials.
The encouraging outcome of our interview
was that I determined this patient had really never received any appropriate psychotherapy to address her symptoms, neither
cognitive/behavioral therapy for her obsessive-compulsive symptoms, nor assertiveness training for her passive orientation
in relationships, nor supportive counseling to identify positive aspects of her character that had been obfuscated by her
chronically anxious and dispirited state. For example, it was clear during our
meeting that she had a nurturing disposition toward her daughter, and my merely bringing this to her attention (“Why
do you think your daughter wants to be like her mommy?”) was both comforting in terms of identifying value and meaning
to her life, and motivating as far as sparking some interest in counseling to develop healthier psychosocial skills for herself
and her daughter to model. This is not to say that her prognosis is good, as
she is still primarily focused on medication management, but perhaps more hopeful if she chooses to also pursue the proverbial
road less traveled. To paraphrase Robert Frost, it could make all the