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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 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 difference.  

Scott Zentner

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