Diagnosing Bipolar Disorder in Adults

[erg923]

Do you find that the standard psychiatric exam/interview is enough in most cases? Or do you prefer something else (semi-structured/structured interviews, rating scales/questionnaires) as well? Testing of any kind?

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[wolfvgang22]

Do you find that the standard psychiatric exam/interview is enough in most cases? Or do you prefer something else (semi-structured/structured interviews, rating scales/questionnaires) as well? Testing of any kind?

Usually the psychiatric interview is enough. I usually don't get anything out of questionnaires because I ask the patient those questions anyway. Collateral information from family or friends and other clinicians is often very helpful also. I'm fortunate to work with some PhD psychologists who can also help with additional testing if there is any diagnostic confusion. Time is an issue and the psychologists have more of it in my practice setting.

 

[nitemagi]

I think a skilled clinical diagnostic interview is enough. IMO standardized questionnaires only do that -- standardize questions that should largely be in your clinical interview. For diagnosing bipolar though I've found that collateral is very very important. State dependent memory means a lot of people can't access accurately how sick they've been in the past, so it needs objective observers. While I think bipolar is largely overdiagnosed, I've "undiagnosed" it a couple times after digging into the self-report of symptoms, only to then have to shift back when I look at hospital records or talk with family members about the severe episodes.

 

[MBBSMOM]

In my opinion Bipolar, I is easy to diagnose. Especially when the pt presents manic to the unit. Bipolar II, on the other hand, I find hard to diagnose. If I suspect Bipolar II vs BPD I do order psychological tests.

 

[nexus73]

Is there a benefit to getting psychological testing? Does Mmpi have a bipolar response pattern?

 

[LadyHalcyon]

Is there a benefit to getting psychological testing? Does Mmpi have a bipolar response pattern?

Yes. It has a mania scale.

 

[clausewitz2]

Those more familiar with the MMPI can possibly answer this: is the mania scale something that has only been validated for people who are at that moment manic/hypomanic, or is it something that has some sensitivity for, say, a bipolar I diagnosis independent of current affective state? If the answer is the later that could be useful, but if the answer is the former I don't see the point.

I think anyone with decent psychiatric training should be able to do this with a careful clinical interview. Emphasis is on careful, though. I see the value of structured interviews and questionnaires to make sure that you are being thorough, but mostly as an aide memoire; at some point if you do it enough you will internalize this.

Agree very much that the most useful secondary assessment tool is picking up the phone and calling someone. The state-dependent memory thing is very, very real, although I think phenomenologicallyyou can see something similar with people who are better conceptualized as borderline PD, but that is more an apparent inability to reconstruct what one was feeling or why and often an incredulity at even being asked this because it's clearly a deeply unreasonable thing to ask of someone. My idea of the bipolar state-dependent memory is often much more about not being able to remember one's actions very clearly, so collateral is key; it is not rare for me to encounter people who say "yeah the doctors said I was bipolar but i don't think that's right" and then their good friend/aunt/whatever says "oh yes, so and so is normally an accountant but then a few years ago they stopped sleeping, bought three motorcycles, and punched a state trooper." You need to establish distinct episodic deviations from baseline, and baseline is not always easy to assess.

@erg923 I am very curious if you have instruments or testing in mind when you ask this question; I am not familiar with literature suggesting this is especially helpful but I am very willing to be educated!

 

[erg923]

@erg923 I am very curious if you have instruments or testing in mind when you ask this question; I am not familiar with literature suggesting this is especially helpful but I am very willing to be educated!

No. The question was just born out of the fact that patients are often not very good historians and sometimes collateral is either unavailable or not particularity reliable. Unless the patient is presenting as floridly manic, i just imagine it can be a tough call, especially with BP II?

@Justanothergrad researches the MMPI and its scales and is probably in a better position to describe the clinical sample used for scale 9 development.

 

[clausewitz2]

Yeah, BP II is a very tough call if it is hard to get a clear history, and I think in the absence of collateral it is a matter of evaluating other possible diagnoses and finding them wanting. This is definitely not ideal but it is what you are left with. Zimmerman et al. (2019) suggests two questions about affective instability that have a very high negative predictive value for BPD in people with mood disorders, but the specificity is garbage, so it only does a bit of work for you.

It is obviously bad from a medication perspective to miss a BP I diagnosis, but the data on switch rates wrt antidepressants in BP II is not that compelling, so it is a question of how depressed they are, are they responding to antidepressants, bad past rxns to antidepressants, their beliefs about antidepressants and their diangosis, etc. I like working with this population but I always feel the need to very carefully document my treatment rationales because I live in fear of passing them along to a less careful or thoughtful resident who will say "oh this borderline doesn't need all these medications, let's take them off" with predictable results.

At the end of the day if you can't get good history and you can't get good collateral I think you may be stuck with eliminating alternatives and attempting Jasperian verstehen, which is not especially satisfying from a psychometric (or insurance) perspective I'm sure.

 

[Armadillos]

Always found it interesting that bipolar 1 is often the easiest diagnosis to make in all of medicine, but bipolar 2 is quite tricky. I think must of us find it hard to be completely confident about the diagnosis in any pt with cluster B traits as well. I rarely make a bipolar 2 diagnosis based on one visit.

 

[Armadillos]

Yeah, BP II is a very tough call if it is hard to get a clear history, and I think in the absence of collateral it is a matter of evaluating other possible diagnoses and finding them wanting. This is definitely not ideal but it is what you are left with. Zimmerman et al. (2019) suggests two questions about affective instability that have a very high negative predictive value for BPD in people with mood disorders, but the specificity is garbage, so it only does a bit of work for you.

It is obviously bad from a medication perspective to miss a BP I diagnosis, but the data on switch rates wrt antidepressants in BP II is not that compelling, so it is a question of how depressed they are, are they responding to antidepressants, bad past rxns to antidepressants, their beliefs about antidepressants and their diangosis, etc. I like working with this population but I always feel the need to very carefully document my treatment rationales because I live in fear of passing them along to a less careful or thoughtful resident who will say "oh this borderline doesn't need all these medications, let's take them off" with predictable results.

At the end of the day if you can't get good history and you can't get good collateral I think you may be stuck with eliminating alternatives and attempting Jasperian verstehen, which is not especially satisfying from a psychometric (or insurance) perspective I'm sure.

What’s the full title of the Zimmerman paper you referenced? I thought remember skimming it somewhere but can’t find now

 

[clausewitz2]

What’s the full title of the Zimmerman paper you referenced? I thought remember skimming it somewhere but can’t find now

Zimmerman M, Balling C, Dalrymple K, et al. Screening for borderline personality disorder in psychiatric outpatients with major depressive disorder and bipolar disorder. J Clin Psychiatry. 2019;80(1):18m12257.

 

[st2205]

I think there are a few things to consider, the first being whether or not we are talking about bipolar I or also including II. For practical purposes, I’m concerned if they do or do not have bipolar I. Bipolar II is a separate discussion. If they’re bipolar I, I need to know because of risk of mania and hospitalization, and then to know because perhaps our management may change if they’re depressed. Again, bipolar II less so, but that’s a separate debate.

That being said, collateral is what I most value. Just guessing from my experience, I’d say half or more of people who have been manic will rationalize it another way, screen negative, or be completely insightless. Test that out next time you see a patient that the nurses report didn’t sleep at all over night. Ask them how they slept and at least 75% of the time they’ll say they slept pretty good. So collateral is the big one. I wouldn’t find testing useful at all, mostly because the state-dependent issues as mentioned above, but also because I don’t believe I’m making this more objective by determining if they match normative sample groups who have a clinical diagnosis of bipolar disorder.

If you’re questioning whether someone has bipolar disorder and simply said they didn’t in each case, you’d probably be right most of the time. You will certainly be wrong on some, and they’ll eventually prove that to you, which sounds irresponsible (and I’m not advocating that — just talking hypothetically), but I also find the overdiagnosis of bipolar disorder (and schizophrenia) and people on lithium and antipsychotics for years to be irresponsible.

 

[FlowRate]

I find that I trust answers to closed-ended symptom questions, regardless how carefully worded, much less than spontaneous symptom reports. Too many people with PD's, SUD's, insomnia, or trying hard to guess the "right answer" to get useful reliability out of many of the mania questions. Add to that all of the excellent points above about the truly manic folk not remembering/denying their symptoms and it becomes even more difficult to be convinced that the people screening-in for BPAD I (based in symptom history/interview) are the ones who actually have it...

 

[Sushirolls]

Here is a very quick news type article referencing a Zimmerman study about the over diagnosis of bipolar. Here is a more recent article on Pubmed that references some of the work by Zimmerman and others and the alarming rates of misdiagnosis.

I share in the assessment that BD is overly diagnosed. I often see ARNP level clinicians diagnosing based on irritability symptoms only. Or the diagnosis comes from a PCP who gave a bipolar form, or the patient self diagnosed because they have mood swings. Many of the diagnoses are actually Cluster B, or just depression, etc.

I'm always suspicious of new patients with diagnosis of bipolar, and proceed to take a more in depth history. I had positive feed back from one patient recently after a 4 year period that remembered the 'you have borderline PD and not bipolar' discussion and was grateful for the positive life direction since then. Enrolled in therapy and DBT, peeled back meds, improved social relationships. One of those things that reinforce the desire to spend the time with patients on their history and not just hit refill and continue the BD diagnosis.

 

[LadyHalcyon]

At one CMHC 90% of my caseload was diagnosed with either schizoaffective of Bipolar. During our initial meeting they would usually say they had "schizophrenic bipolar". I was carrying a caseload of probably 80 patients and I think maybe 5 were accurately diagnosed. I am very wary of close-ended questions and of using descriptors such as manic when assessing for Bipolar. I find I get much more useful information when I ask for examples. I also find it helpful to ask more contextual questions (i.e. What other stressors were you experiencing when you "couldn't sleep) etc. I haven't found assessments to be an essential component of diagnosing BP, as the mania scale of the MMPI can also pick up things like adhd or narcissm. That being said, the Harris-lingoes subscales of the mmpi can be useful to tease out certain things.

 

[st2205]

I’m also baffled by how many people entertain the possibility of bipolar or even schizophrenia when there’s stimulant use.

 

[Armadillos]

I’m also baffled by how many people entertain the possibility of bipolar or even schizophrenia when there’s stimulant use.

Obviously agree in context of ER settings trying to diagnose intoxicated pts with bipolar, but iirc about 40% of folks with bipolar have a comorbid use disorder of some sort, so I get frustrated with colleagues who refuse to treat obvious bipolar symptoms just because they have used substances in the past month.

 

[Ironspy]

We don't use a structured interview just a careful clinical interview. I have found that the majority (maybe 70%) of people I have seen diagnosed with bipolar I have something else:
1. if they were not manic prior to substance use its likely a SUD and I can't properly assess mood sx
2. if they are middle aged or older and have been "manic" "a bunch of times" but have never been hospitalized it was likely hypomania or substance use or PD or something else.
3. Ultra ultra rapid cycling bipolar is borderline PD until proven otherwise

Bipolar II is a more nuanced diagnosis and corroborative can help clarify both. Also the switch rate is lower for II so the stakes are lower in starting antidepressant monotherapy compared to bipolar I.

 

[st2205]

Obviously agree in context of ER settings trying to diagnose intoxicated pts with bipolar, but iirc about 40% of folks with bipolar have a comorbid use disorder of some sort, so I get frustrated with colleagues who refuse to treat obvious bipolar symptoms just because they have used substances in the past month.

I think it depends what is meant by bipolar symptoms and also what is meant by treatment. I’d agree BPI making people more prone to substance use, but I think SUD being misdiagnosed as BPD is one explanation for the inflated stats suggesting a larger comorbidity between the two than I really believe there is.

 

[nexus73]

CIDI 3 is a reasonable screening tool for bipolar. The Mood Disorder Questionairre is too sensitive and will indicate all your borderline patients have bipolar.

 

[nitemagi]

In my opinion Bipolar, I is easy to diagnose. Especially when the pt presents manic to the unit. Bipolar II, on the other hand, I find hard to diagnose. If I suspect Bipolar II vs BPD I do order psychological tests.

well... yeah. If they present manic it's kind of obvious IMPO. I was referring to diagnosing retrospectively in an outpatient setting, based on a self-report history, and its questionable accuracy.

 

[Attending1985]

A manic episode will leave some significant scars on your life social, legal, financial. BP 1 is easy to diagnose. BP two is also clinically obvious but I don’t see much of either. But they are rare disorders so that’s not surprising. I don’t diagnose bipolar spectrum which really any human being falls into with enough “thoughtful” questioning.

 

[Liquid8]

Diagnosing bipolar disorder and distinguishing it from its main differentials should be a bread and butter task for a competent psychiatrist. Careful history taking and clues in the presenting complaint and descriptions of phenomenology should lead one in the right direction, but this is something that tends to get easier with more experience. I find that there will usually be something in the presentation that will lead me to want to explore either bipolar or borderline symptoms in more depth as the first priority, although I’ll generally have to explore both as comorbidity is common.

Obviously agree in context of ER settings trying to diagnose intoxicated pts with bipolar, but iirc about 40% of folks with bipolar have a comorbid use disorder of some sort, so I get frustrated with colleagues who refuse to treat obvious bipolar symptoms just because they have used substances in the past month.

If we assume the clinician has explored past episodes of bipolar symptoms and has not found that any of these to have occurred during periods of sobriety, the likely justification for not treating someone who is actively using substances is that it’s preferable for them to cease them first, as if the mood symptoms resolve there is no need to put them on long term medication. We use the same principle for first episode psychosis patients who have been on drugs – it may be an emerging schizophrenia or drug induced. We would typically allow a brief period of observation without antipsychotics, and if it turns out to be the latter then you’ve avoided treating someone with antipsychotics who doesn’t actually need them. If it’s the former, the patient will probably need medication for the rest of their life so a day or two without them isn’t going to make a huge difference in the long term. Obviously these are only general guidelines and there will be situations where more active course of management is justified and a flexible approach is necessary.

 

[Armadillos]

Diagnosing bipolar disorder and distinguishing it from its main differentials should be a bread and butter task for a competent psychiatrist. Careful history taking and clues in the presenting complaint and descriptions of phenomenology should lead one in the right direction, but this is something that tends to get easier with more experience. I find that there will usually be something in the presentation that will lead me to want to explore either bipolar or borderline symptoms in more depth as the first priority, although I’ll generally have to explore both as comorbidity is common.



If we assume the clinician has explored past episodes of bipolar symptoms and has not found that any of these to have occurred during periods of sobriety, the likely justification for not treating someone who is actively using substances is that it’s preferable for them to cease them first, as if the mood symptoms resolve there is no need to put them on long term medication. We use the same principle for first episode psychosis patients who have been on drugs – it may be an emerging schizophrenia or drug induced. We would typically allow a brief period of observation without antipsychotics, and if it turns out to be the latter then you’ve avoided treating someone with antipsychotics who doesn’t actually need them. If it’s the former, the patient will probably need medication for the rest of their life so a day or two without them isn’t going to make a huge difference in the long term. Obviously these are only general guidelines and there will be situations where more active course of management is justified and a flexible approach is necessary.

Seems like several things mentioned in here are old-school folklore? My understanding is current recommendations are to treat mood symptoms even in presence of substance use as as it leads to better outcomes than the old approach of getting people sober first.

 

[clausewitz2]

A manic episode will leave some significant scars on your life social, legal, financial. BP 1 is easy to diagnose. BP two is also clinically obvious but I don’t see much of either. But they are rare disorders so that’s not surprising. I don’t diagnose bipolar spectrum which really any human being falls into with enough “thoughtful” questioning.

You have to be careful when reasoning from population statistics because the people you see in clinic are not a random sampling of the population at large. Borderline PD for instance has maybe a 1-3% prevalence in the general population but may represent more like 15% of people presenting to a psychiatric clinic and as high as 25% of inpatients in some studies. So things being, in general, rare does not mean that you are not seeing them all the time due to the filtering effect of them wanting to see a psychiatrist in the first place.

 

[Liquid8]

Seems like several things mentioned in here are old-school folklore? My understanding is current recommendations are to treat mood symptoms even in presence of substance use as as it leads to better outcomes than the old approach of getting people sober first.

I don't necessarily disagree, and I did think that a mere history of substance use in the past month was not a sufficient reason to not treat bipolar symptoms. Someone shows up who hasn't slept for days, pressured, talking at a 100mph and extremely irritable - drug induced or not they definitely need something to settle.

I think if you are seeing a patient that you can confidently make the diagnosis then I can't see a reason for delaying treatment. However, in patients where there are a lot of doubts and there is inconsistent or missing information, use of benzodiazepenes as a short term adjunct to manage florid psychosis/mania for sedation and to allow for a period of observation is common practice and definitely supported by our local first episode guidelines.

If a new patient presents to my rooms in an acutely manic state, I'd generally hit them hard and fast with a standard combination of regardless of recent substance use. It's not a common occurrence, but without the guaranteed backup of an inpatient admission option I have to err on the side of caution. OTOH if someone presents as depressed but they’ve got concurrent alcohol issues, I could add an antidepressant but it might take 3-4 weeks to kick in, which is ample time to organise a detox and reassess. If the patient started to suffer a lot of anxiety, you also wouldn’t be able to tell if it was due to the antidepressant or the withdrawal process. It's usually a lower risk presentation, so I can often put the options to the patient and family and have them decide.