Why is Bipolar so hard to diagnose?

Bipolar is a relatively common yet debilitating mental health condition that affects over one-million people in the UK alone. While it affects everyone differently, it’s characterised by high, euphoric, or irritable periods called mania and low periods of depression that can lead to suicidal thoughts.

While there isn't currently a cure for bipolar, it can be successfully managed using the right treatment - if an accurate diagnosis is made. And here's where the real problem lies: of all the mental health disorders, bipolar is one of the most commonly misdiagnosed.

Almost 70 percent of people with bipolar disorder are incorrectly diagnosed initially, and more than one-third remained misdiagnosed for 10 years or more. This often leads to ineffective treatment and further distress for people with the condition.

Dr Simon Surguladze is a Consultant Psychiatrist with over 30 years of clinical experience that includes treating and diagnosing people with bipolar affective disorder. We spoke to Simon to find out why bipolar is often misdiagnosed and what people can do to help their clinicians accurately assess their symptoms.

Bipolar disorder is often confused with other mental health conditions

Several manic symptoms of bipolar disorder and ADHD resemble each other, often leading to misdiagnosis. The manic swings of bipolar can be mistaken for hyperactivity, while the low spells can look like inattention and lack of motivation, which are symptoms common in people with ADHD.

Two studies conducted in 1999 and 2000 respectively, concluded that almost 40 percent of bipolar disorder patients are initially diagnosed with unipolar depression. While the symptoms of depressive episodes of bipolar can look similar to unipolar depression, there are important differences between how each condition makes people feel and behave and differences in how they are supported through treatment.

Hypomania can go unnoticed

Bipolar is perhaps best understood as a spectrum disorder with a wealth of different levels of depression, mania and hypomania. One of the most challenging things for diagnosing individuals with bipolar is the difficulty in identifying hypomania, as Simon explains, "Hypomania refers to an elevation in mood that is less drastic than mania. Sometimes hypomania can be enjoyable due to the increased energy and confidence that often comes with it. However, it can still lead to impulsive, elevated and irritated behaviour with adverse consequences, such as overspending and damaging personal relationships. Due to the nuances in how it’s experienced, it’s harder to identify.”

Because it can be enjoyable, people often don’t seek treatment during a hypomanic episode and are more likely to seek treatment during a depressive episode. Furthermore, hypomania doesn't tend to end in hospitalisation, as mania sometimes does. For these reasons, hypomania is less likely to be recognised.

Clinicians don’t get enough information

Bipolar is often an overlooked condition, which can take years to diagnose - and more awareness is needed. One reason it can take so long to recognise is how challenging it is to obtain a full and accurate history of someone’s mental health, which is a key part of any psychiatric assessment. This can be for several reasons.

For a start, it can be hard for someone with Bipolar to accurately recall their moods and when they happened. Depressive and manic states make it hard to remember the detail of what you experienced. Anyone with a mental health illness will know how hard it is to verbalise their symptoms and experiences and therefore be able to clearly describe them to a clinician.

Simon also explains how people feeling unworthy, bad, or wrong can lead to them holding back when speaking to a clinician or even from seeking help at all, “It’s really important to be able to speak with the individual’s family, partner or close friend to understand another more objective view on the symptoms, but unfortunately this isn’t always possible. Sadly, people with Bipolar often feel shame or embarrassment with their symptoms, which becomes an additional barrier to diagnosis.”

Another condition can complicate diagnosis

If there is a more ‘pressing’ or immediate mental health condition, it could lead to bipolar going undiagnosed. For example, people with Autistic Spectrum Disorder (ASD) who also have bipolar disorder may not receive an accurate diagnosis because of what is called ‘diagnostic overshadowing.’ In this instance, symptoms of bipolar disorder are interpreted as autistic traits, and it may happen because there are overlaps in symptom presentation. 

Autistic people with bipolar disorder are also more likely to have mood states with mixed or atypical features, such as irritability and aggression, as opposed to euphoria, which can make an accurate diagnosis more difficult.

How can diagnosing Bipolar be improved?

There isn’t a quick fix for these challenges, but if you think you or a loved one has been misdiagnosed, it's always worth checking with your GP or seeking a second opinion from another health professional.

The following may help if you are considering a bipolar assessment:

1. Take notes of previous mood swings and try and describe how long they lasted, what the highs and lows felt like, and what the consequences were on your life (for instance, relationship pressures, spending sprees, suicidal thoughts). It’s often too difficult to remember these details in a consultation, so you could write bullet points, or draw a rough timeline and note the consequences alongside the periods to help the clinician see any patterns.
2. Ask someone close to you, friends or family to attend the consultation with you or, if this isn’t possible, to write the consultant a letter explaining their views on what has been happening. This might seem weird to you, but every bit of information can help. It's not about judging your condition or behaviour. It's about helping provide your clinician with a complete picture of your experiences and feelings.
3. Take a list of previous medications you have tried and how effective they were.
4. Read about the types of bipolar and note down anything that rings true for you – Bipolar isn’t just the ‘manic depression’ we hear about but can take on more subtle but just as devastating forms.

For more information about bipolar disorders, you can speak to someone at www.bipolaruk.org or your local GP. If you would like a private assessment for Bipolar, you can call 0203 326 9160 to speak to one of our experienced Assistant Psychologists who can talk you through your next steps.