Detecting classical bipolar disorder: A classic mistake?

Abstract

Awareness of mental illness, and mood disorders in particular, is arguably the highest it has ever been. And yet, the diagnosis of what appears to be a fairly common and self-evident illness, such as bipolar disorder, is often haphazard and can sometimes take years. Why is this so? The two reasons proffered most commonly are that firstly, bipolar disorder, which can only be diagnosed on the basis of mania, usually presents with depressive symptoms, and therefore there is a considerable period of time (months and years) during which a diagnosis of a depressive disorder is sometimes made, but in the absence of manic symptoms a conclusive diagnosis of bipolar disorder remains elusive.1 This reason, we will argue, is misleading and needs to be revised. The second reason most commonly raised to explain the delay in the diagnosis of bipolar disorder is that the symptoms that constitute bipolar disorder usually first emerge during adolescence and this makes them difficult to detect. This is because during adolescence there is dramatic physiological and psychosocial development involving neurobiological maturation, individuation and the transition to new roles. All this ‘growing up’ involves considerable change and this creates ‘pseudo-symptoms’ that can appear to be the same as those of emerging bipolar disorder. This makes it difficult to determine what, if anything, is abnormal (pathological). This reason we will argue is partly true but incomplete and that it is not only the ‘natural’ changes that accompany adolescence that obscure the symptoms of emerging bipolar disorder. It is important to note that these difficulties concerning the natural history and course of the illness and the complex and colourful background against which bipolar disorder often takes form, are genuine. But the explanation that bipolar disorder simply occurs at the wrong place (during adolescence when there is immense natural turmoil) and at the wrong time (depressive episodes usually precede the emergence of mania meaning that by definition bipolar disorder cannot be diagnosed earlier because of an inherent diagnostic limitation) feels inadequate and unsatisfactory because neither reason fully matches reality and can be readily rectified. Therefore, in this brief article we argue that these explanations are perhaps not the major reasons for the delay in diagnosis of bipolar disorder, and that in fact they may not even be the main problem. In the next section we offer some additional insights and introduce some alternative perspectives that perhaps better explain how and why this problem occurs.