Bipolar disorder is a mental problem that involves long-term interventions for treatment. Treatment of bipolar disorder problem involves different pharmaceutical companies’ steps to come up with the best medication that will assist in healing the individuals completely. According to Healy and his colleague, treatment of bipolar disorder involves Depakote, which has relative benefits when used to treat the manic stage of the disease as approved by the Food and Drug Administration (Healy and Le Noury, 2021). He continued to argue that the drug, when administered by qualified physicists, acts best for mood stabilization.
On the other hand, Frances argued that using mood stabilizers and antipsychotic drugs seems to have a wide acceptance to help patients with bipolar disorder. He viewed otherwise that the medicines work little on assisting patients to and later, the rate of bipolar disorders doubled among people (NPR Cookie Consent and Choices 2021). The main idea is that there is the fear of over-diagnosis and overtreatment of the condition. Miss-diagnosis leads to the wrong prescription of mood-stabilizing medications and a high cost of care. Frances further argued that putting the DSM diagnosis might worsen the conditions leading to over-diagnosis and overtreatment states. Healy argued that consequences associated with over-diagnosis and overtreatment of the disorder, such as the Illness, stay even though treatment might eradicate symptoms; therefore, the drugs are not effective (Healy and Le Noury, 2021). Another consequence is the doubling of the mortality rate among patients with the disorder.
Studies indicated that un-medicated patients do not have higher chances of committing suicide than medicated bipolar patients. Over-diagnosis has some negative impacts, such as improper psychoeducation and treatment, which leads to poor drug prescription due to exposure to medical risks. Bipolar condition is either over-diagnosed associated with false-positive outcomes and under-diagnosed, which is brings false negatives findings. Healy and colleagues were right in their discovery because they emphasized the hypomania disorder was found to be a bi-polar disorder, which was introduced as a new disorder to DSM-III in the round 1980s. They talked of various steps companies use in marketing medications for the condition, including literature and website materials to expound the knowledge of medicines on the disorder to multiple people. They came up with various drugs and patient guides to better tackle their conditions (Healy and Le Noury, 2021). The hypomanic states’ patients have borderline personality disorder with anger and irritable characters, making the disorder linked with the psychiatric syndrome.
The fact that hypomania, when used by DSM-IV criteria, does not bring social and functional impairment because of over-diagnosis, which failed to identify abstinent period for the patient with substance abuse disorder. The use of DSM-IV criteria brings a reasonable scientific boundary between normal distress and bipolar disorder because the DSM-IV concept helps to bring awareness to clinicians and researchers on the importance of caring about mood changes and general anxiety and stress. Both illicit drugs and prescribed psychiatric drugs can result in the creation of a hypomanic condition. The condition is addressed in the DSM-IV criteria but with challenges of over-diagnosis and under-diagnosis to persist (Aadil et al., 2017). Healy and his colleague claimed that those diagnosed with bipolar II would have sorted for other diagnoses over the past decades, indicating that early diagnosis may have assisted in early prevention after the medical condition of the patients proved the disorder’s existence. They claimed that early diagnosis from other diagnoses might have helped detect other disorders, which might primarily escalate to bipolar II conditions.
Aadil, M., Munir, A., Arshad, H., Tariq, F., Anwar, M. J., Amjad, N., & Akhlaq, A. (2017). Consanguinity Associated with Increased Prevalence and Severity of Bipolar Disorder in Pakistan: A Case Report Highlighting the Genetic Link. Cureus, 9(7).
NPR Cookie Consent and Choices. (2021). Retrieved 23 February 2021, from https://www.npr.org/2010/12/29/132407384/whats-a-mental-disorder-even-experts-cant-agree
PsychiatryLectures. (2014 March 26th). Manic-Depressive Illness- controversies. https://youtu.be/Qs8UKAf3ado
(2021). Retrieved 23 February 2021, from https://openexcellence.org/wp-content/uploads/2013/10/DHealy2007PediatricBipolarDisorderJRS419.pdf
Feb 25, 2021 at 9:06 AM
After reviewing and analyzing the material I have concluded that Bipolar disorder can be overdiagnosed and underdiagnosed in different situations. Due to the different disorders having so many overlapping symptoms, it can make it easy to misdiagnose patients (McIntyre et al, 2019, p. 3). Pharmaceutical companies, advertisements, and lack of research on the DSM can impact patients to be overdiagnosed. Authors Healy and Noury (2007), discuss the impact of patients being over-diagnosed. It has been noted that 30-40% is the undiagnosed rate. Psychiatrist Ghaemi analyses the reasons behind people getting undiagnosed due to clinicians being caught up with the disorder labels.
Psychiatrist Ghaemi discussed a study that was completed to analyze major depressive disorder and bipolar symptoms. The study found that about half of people with depressive symptoms also have manic symptoms. But their manic symptoms did not last that long, only 203 days at a time. Due to these patients not having longer time periods with manic symptoms they would go undiagnosed from having bipolar due to the DSM criteria (DSM-5, 2013). This can cause conflict and issues with mistreatment and issues with medication management. Ghaemi discussed how the DSM task force recommended hypo mania be lowered to 2 days for diagnoses, but the DSM leadership denied this (Ghaemi, 2014). This has serious implications for misdiagnoses.
The DSM stated that hypomania must not be severe enough to cause marked impairment in social or occupational functioning”. This can be concerning for clinicians that the DSM has a strict definition of hypomania because hypomania may present differently in different individuals. Hypomania can be tough to diagnose because it can be disguised as happy. Hypomania is when a person doesnt feel the need to sleep, energized, and can be a happy state for someone. But when it goes undiagnosed it can be untreated leading to a depressive state and could lead to suicidal ideation without the proper support and treatment. When diagnosing clients, it is important for the clinician to not overlook hypomania, and the DSM should be more general in its definition. I dont see the DSM-criteria as setting a reasonable scientific boundary between normal distress and bipolar II disorder because the criteria are very strict and overlap with other disorders making it challenging to pinpoint what a client is experiencing. Everyones definition of normal and baseline is different, so it is essential for the clinician to know the clients normal rather than grouping them into categories. Ghaemi stated that people will be diagnosed with a physical condition at least once in their lifetime, but why are we hesitant to diagnose people with mental health disorders. Everyone will go through chapters in their lives where they may need to seek mental health treatment and that should be normalized, like getting treated for a physical health condition (Ghaemi, 2014).
The DSM criteria state in the hypomania criteria The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment). This does address the concern that hypomania could be due to prescribed and unprescribed drugs but the DSM criteria do not go in-depth about how clinicians can differentiate between hypomania caused by drugs or hypomania caused by bipolar disorder or other mental health disorders (American Psychiatric Association, 2013). Researchers have been claiming patients being diagnosed with bipolar today, would have been diagnosed with other disorders in the past. Researchers are claiming the rise in advertisements and marketing is causing people to be diagnosed with bipolar more frequently (Healy & Noury, 2007).
In conclusion, I believe that in some situations people are being overdiagnosed with bipolar disorder and in other situations, people are being undiagnosed. I believe this because each clinician interprets and experiences the DSM differently, has different life experiences, and interprets the media differently. To solve the issues underdiagnosed and over-diagnosed, we need to be well educated on the topics and educate our clients, coworkers, and society.
American Psychiatric Association. (2013). Diagnostic and statistical manual or mental disorders (5th edition).
Ghaemi, N. ( 2014, March 25 ). Manic depressive illness controversies. Youtube.
Healy, D., & Noury, J. (2007). Pediatric bipolar disorder: an object of study in the creation of an
illness. International journal of risk and safety in medicine, 209-222.
Mcintrye, R., Zimmerman, M., Goldberg, J., & First, M. (2019). Differential diagnosis of major depressive disorder versus bipolar disorder: current status and best clinical practices. Psychiatrist,80 (3), 15-24.
Feb 25, 2021 at 1:29 PM
Bipolar disorder (BD) embodies the current understanding of the typical manic-depressive disorder or affective psychosis from earlier centuries (American Psychiatric Association [APA], 2013). Correctly diagnosing patients with BD has been problematic at times as several of its symptoms are shared by other conditions. This can lead to both views that BD could be both underdiagnosed and overdiagnosed. After reviewing all of the materials in this module, I generally believe BD is mostly overdiagnosed. This leads us back to the reliability of the DSM and the overwhelming concerns of proper diagnosing.
A contributing factor of possibly being misdiagnosed is a significant number of substances of abuse, prescribed medications, and numerous medical conditions that can be connected with manic-like symptoms (APA, 2013). In a study by Stewart and El-Mallakh (2007), the data represents that BD may be overdiagnosed in patients with substance abuse or dependency. Within the study, only forty-two point nine percent of the subjects were diagnosed with BD after being diagnosed previously. Leaving almost fifty-seven percent misdiagnosed. This study precisely validates that therapists may regularly misdiagnose individuals with substance abuse problems as having BD (Stewart & El-Mallakh, 2007). It is vital to recognize the high comorbidity rates among BD and substance use disorders which promote additional complications while diagnosing and distinguishing when substances may be inducing the patients current presenting symptoms.
Spiegel (2010) suggests the addition of BD to the Diagnostic and Statistical Manual of Mental Disorders (DSM) created alarming consequences. Once the updated version of BD was added to the DSM, the creators of the DSM made it easier to become diagnosed with BD, which lead to tremendous opportunities for drug companies (Spiegel, 2010). Drug companies took advantage of the new diagnosis of BD and how to treat it with mood stabilizers and antipsychotic drugs (Spiegel, 2010). In the mid-1990s, the drug company, Abbott, started marketing the mood-stabilizer Depakote. Before this development, mood stabilization did not exist (Lane, 2009). This created a fivefold increase in the development and use of antipsychotic drugs to treat BD in adults, teens, and children (Lane, 2009). As we have seen with other diagnoses, when the drug companies start advertising and marketing their products, there is a direct impact on how clients are labeled with the associated diagnosis. Spiegel (2010) reports that the diagnosis rates of BD have doubled since the development of these pharmaceutical treatments.
According to the DSM-5, hypomanic episodes do not create impairment (APA, 2013). The impairment usually is produced from the major depressive episodes or an endless array of erratic mood changes and unstable, unpredictable interpersonal or occupational functioning (APA, 2013). These episodes only have to last for four days, which creates the question of how a clinician can decipher between major depressive disorder and bipolar II disorder. I believe it is essential to realize clients may have an increased mood or energy for four days, which is entirely normal, ultimately affecting a diagnosis for a client and their appropriate treatment outcomes. I do not believe the DSM-5 sets a reasonable scientific boundary between normal distress and bipolar II disorder. The DSM-5 does not provide clarity concerning what is normal and not when evaluating a hypomanic state. Lacasse (2014) discusses the DSM-5 as vague and offers no clarity concerning the boundaries between what is normal and what is mentally disordered. The DSM-5 does define the criteria for various mental disorders, but it never identifies what strictly mental disorder is. This allows for interpretation from the clinician, hence why the DSM relatability continues to be an issue. If bipolar II disorder is not diagnosed correctly, it could cause drastic consequences as roughly one-third of individuals with bipolar II disorder report a long history of suicide attempts (APA, 2013).
Accurate identification of these disorders is essential to enhance treatment outcomes (Stewart & El-Mallakh, 2007). As discussed in this weeks module, if clinicians are incorporating a bio bio bio assessment instead of a biopsychosocial assessment, there will be an opportunity to misdiagnose individuals (Lacasse, 2021). Integrating a complete biopsychosocial assessment will allow for additional information to be obtained, like a possible traumatic event or substance abuse, or dependency. If we are solely focused on the DSM checklist, we will miss crucial factors that could be impacting the patient and how their symptoms are presenting.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.
Lacasse, J. (2021, February). Module 3 wrap-up with diagnostic exercises and more [Video]. Canvas. https://canvas.fsu.edu/courses/149317/pages/module-3-wrap-up-with-diagnostic-exercises-and-more?module_item_id=2847300
Lacasse, J. R. (2014). After DSM-5: A critical mental health research agenda for the 21stcentury. Research of Social Work Practice, 24(1), 5-10. http://doi:10.1177/1049731513510048
Lane, C. (2009, April 16). Bipolar disorder and its biomythology: An interview with David Healy. Psychology Today. https://www.psychologytoday.com/us/blog/side-effects/200904/bipolar-disorder-and-its-biomythology-interview-david-healy
Spiegel, A. (2010, December 29). Whats a mental disorder? Even experts cant agree. NPR. https://www.npr.org/2010/12/29/132407384/whats-a-mental-disorder-even-experts-cant-agree
Stewart C., & El-Mallakh, R. S. (2007). Is bipolar disorder overdiagnosed among patients with substance abuse? Bipolar Disorders, 9, 646-648. https://doi.org/10.1111/j.1399-5618.2007.00465.x
Feb 25, 2021 at 8:06 PM
Bipolar disorder is one that can be difficult to diagnose and can often be misdiagnosed (Stewart & El-Mallakh, 2007). Though Ghaemi argues it is underdiagnosed (2014), others suggest that bipolar disorder is overdiagnosed. In general, I do not believe there is a correct answer, as in certain populations it can be overdiagnosed, but in another population, it can be underdiagnosed. For example, Stewart and El-Mallakhs study found that in substance abuse clients, bipolar disorder is often overdiagnosed (2007). Symptoms of other disorders can easily mimic those of bipolar disorder, leading to overdiagnosing of bipolar when it could potentially be depression, anxiety, or even schizophrenia. I think that both overdiagnosing and underdiagnosing can have consequences, both being equally detrimental, but I believe overdiagnosing is the bigger problem if I had to choose.
Many symptoms overlap that are mistaken to be hypomania or mania, especially when a client has comorbidity of both major depression and bipolar disorder with other disorders. An example of an issue with hypomania is that a hypomanic episode could be mistaken for substance intoxication, which can cause a diagnosis of bipolar that may not be necessary (McIntyre et al., 2019). The definition of hypomania can be interpreted in a multitude of ways and is included in more diagnoses than just bipolar. For example, major depressive disorder (MDD) could consist of hypomanic symptoms that just dont rise to hypomania’s full criteria (American Psychiatric Association, 2013). But one can mistake the requirements to have been met and diagnose a patient with bipolar when in reality, it should have been MDD.
Hypomanias requirements in the DSM-5 include a minimum of four days experiencing an abnormal and persistent elevated mood, in addition to meeting at least three other symptoms like a decreased need for sleep, grandiosity, distractibility, or racing thoughts (APA, 2013). This criterion can easily be mistaken for other diagnoses, and a clinician working fast who is unable to determine the exact duration and number of symptoms can easily diagnose wrong (McIntyre et al., 2019). The DSM-5 also states that the episode cannot be severe enough to cause marked impairment in social or occupational functioning, which makes it challenging to find the boundary between normal behavior and an actual mental disorder. If this episode does not meet the severe enough levels, how are we considering it to be a bipolar disorder? The criteria to meet for hypomania needs to be more defined as to ensure misdiagnoses can be minimized.
The DSM-5 does include that medications and substances can cause hypomanic-like symptoms, and it is part of the six-step diagnosing process. Step two is meant to rule out that substances may be causing the symptoms before moving on and diagnosing. This step needs to be more thoroughly examined and researched before just quickly moving ahead onto a diagnosis. For example, in Stewart and El-Mallakhs study (2007), only 42.9% of patients who were previously diagnosed with bipolar disorder actually met the diagnostic criteria. This shows that their substance usage was overlooked when initially being diagnosed.
Healey talks about how the term bipolar that we use today has minimal relation to what was used historically. Before, this disorder, related to manic depression, would mean someone required hospitalization. But now, if you are experiencing certain elevated symptoms for a week, you are considered bipolar (Lane, 2009). I agree with him that this term is used more lightly now, whereas it wouldve been labeled anxiety or depression before. This change in how we use bipolar is a big reason we are often misdiagnosing bipolar disorder.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Ghaemi, N. (2014). Manic depressive illness controversies. Youtube. https://www.youtube.com/watch?app=desktop&v=Qs8UKAf3ado
Lane, C. (2009). Bipolar disorder and its biomythology: An interview with David Healy. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/side-effects/200904/bipolar-disorder-and-its-biomythology-interview-david-healy
McIntyre, R., Zimmerman, M., Goldberg, J. F., First, M. B. (2019). Differential diagnosis of major depressive disorder versus bipolar disorder: Current status and best clinical practices. J Clin Psychiatry, 80(3). doi:10.4088/JCP.ot18043ah2
Stewart C. & El-Mallakh, R. S. (2007). Is bipolar disorder overdiagnosed among patients with substance abuse? Bipolar Disorders, 9(6), 646-648. doi:10.1111/j.1399-5618.2007.00465.x
Feb 25, 2021 at 9:02 PM
There is much controversy surrounding the DSM-5 as a whole, and specifically the diagnostic criteria for Bipolar Disorder. The terminology Bipolar Disorder was added to the DSM-III in 1980 and replaced the term Manic Depressive Disorder. The criteria continued to evolve to the present-day diagnostic criteria set forth in the DSM-5, which is defined as a course of depressive episodes mixed with hypomania and/or mania (APA, 2013). According to the DSM-5, Bipolar Disorder hypomanic episodes are diagnosable if they extend for four days or more, while manic episodes are diagnosable if they last one week or more. Manic episodes are disruptive to what may be considered normal life, while hypomanic episodes are not disruptive.
According to Stewart and El-Mallakh (2007), Bipolar Disorder is hard to fully diagnose after a single one-hour session. They state that approximately 70% of patients are incorrectly diagnosed, most as having major depression upon first diagnosis. It actually took several years for the correct diagnosis to be given to many of these patients. With so many overlapping symptoms, misdiagnosis is bound to happen (McIntyre, Zimmerman, Goldberg, and First, 2019).
It is my opinion that Bipolar Disorder can be under-diagnosed and over-diagnosed given the situation. I believe that under-diagnosis is more problematic than over-diagnosis. The fact that medication is given too often to stabilize mood is not as terrifying to me as giving a person with Bipolar Disorder an SSRI (selective serotonin reuptake inhibitor) that may exacerbate the problems that they are already experiencing. I personally have been prescribed an anti-seizure medication that doubles as an off-label mood stabilizer (lamotrigine). This was after 21 years of being diagnosed with major depressive disorder, and taking medications that helped with the depressive episodes, but not with the hypomania that was becoming more of a problem. Admittedly, I now regret being prescribed the mood stabilizer, because I realized that the hypomanic episodes is where all of the magic happened. Over-diagnosis of Bipolar Disorder would be problematic if there were more unwelcome side effects from mood stabilizers like there are with SSRIs.
Comorbidities are one of the many reasons that over-diagnosis happens. It is not uncommon to have a patient present with the classic symptoms of Bipolar Disorder, only to find out later that the patient should have been diagnosed with Substance Use Disorder. It is very difficult to properly diagnose a patient within the first one-hour meeting. Reliance upon therapists with whom the patient visits weekly or otherwise on a regular basis should not be taken lightly.
In summary, it is my opinion that it is much more desirable to over-diagnose Bipolar Disorder than it is to under-diagnose the disorder. The reasons for this is that it seems less likely for the patient to suffer unwanted side effects such as suicidality from unnecessary SSRIs. Though not infallible, the diagnostic criteria in the DSM-5 should be followed carefully in order to not allow this to happen on a regular basis.
Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Arlington, VA: American Psychiatric Association.
McIntyre, Zimmerman, Goldberg, First (2019) Differential diagnosis of major depressive disorder versus bipolar disorder: current status and best clinical practices. J Clin Psychiatry. 80(3):ot18043ah2
Stewart, C., & El-Mallakh, R. S. (2007). Is bipolar disorder overdiagnosed among patients with substance abuse? Bipolar Disorders, 9(6), 646-648. doi:10.1111/j.1399-5618.2007.00465.x
Feb 25, 2021 at 10:50 PM
Over diagnosis or Under diagnosis
This module has expanded my perspective on bipolar disorder. I have realized that the criteria for bipolar disorder is not cut and dry, many factors contribute to inaccurate or misdiagnosis such as overlapping symptoms of conditions and comorbidity. What I have gleaned from this module is that the more I learn, the less I know. Over diagnosis and under diagnosis are both valid problems for bipolar disorder. Pharmaceutical advertisements and disease mongering are partially to blame for the overdiagnosis of bipolar disorder (Healy & Le Noury, 2007). The popularization of mood questionnaires and mood journals have contributed to the trend of neural typical people seeking medication or professional help for issues that do not rise to the level of clinical significance (2007). Another factor in over diagnosis is substance abuse. Because intoxication mimics many bipolar symptoms, clients who suffer from alcoholism or substance abuse are often misdiagnosed with bipolar disorder (Stewart & El-Mallakh, 2007). This is due to artificial highs and lows brought on by drug binges and/or withdraw symptoms. Although there is a clause in the DSM-5 that mentions that hypomanic or manic episodes should not be attributable to the psychological effects of substance abuse, many clients may not admit to using substances or they may have a comorbidity (American Psychiatric Association, 2013).
A reason for under diagnosis is because many clients who are suffering from bipolar disorder seek help when they are in a depressive episode (McIntyre, Zimmerman, Goldberg, & First, 2019). This causes clients to receive an inaccurate diagnosis of major depressive disorder. On the flip side, clients who are experiencing manic or hypomanic episodes may be misdiagnosed as having ADHD, borderline personality disorder or another condition with overlapping symptoms (2019). These instances of misdiagnosis can be extremely dangerous especially if inaccurate medications are prescribed. Certain medications, such as those used to treat ADHD, may exacerbate psychotic, manic or hyper manic symptoms in a person with bipolar disorder (2019). Another risk of under diagnosing or misdiagnosing bipolar disorder is death (Ghaemi, 2013).
Normal distress V.S Bipolar II
I think that the line between a hypomanic episode and normal functioning is quite fuzzy. Especially since hypomanic episodes are “not severe enough to cause marked impairment in social or occupational functioning.” The addition of bipolar II in the DSM-5 might lead to an overdiagnosis of bipolar disorder because the confines of the diagnostic criteria are easily met. After re-reading the criteria for bipolar II, it does not seem markedly strange that a client that has experienced a major depressive episode may have 4 consecutive days of an elevated mood and a burst of goal directed energy that does not necessarily effect social or occupational functioning. I am sure that if I tracked my moods with a journal, I could find a pattern that would qualify me to be diagnosed with bipolar II. I do not think that the DSM-5 sets a reasonable boundary between normal destress and a psychiatric syndrome. After completing this module, I have found that the conditions in the DSM-5 are clusters of symptoms that help clinicians categorize, define and understand human traits. I am not surprised when hearing about Healys claim that clients who are diagnosed as bipolar would have received a different diagnosis in the past. Society is constantly changing, and many factors including pharmaceutical companies and advertisement have a heavy influence on cultural norms.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Ghaemi, N. (2013, March 20). Manic-Depressive Illness- controversies. Lecture presented at Stockholm Psychiatry Lecture in Karolinska Institutet, Boston. Retrieved February 25, 2021, from https://www.youtube.com/watch?app=desktop&v=Qs8UKAf3ado
Healy, D., & Le Noury, J. (2007). Pediatric bipolar disorder: An object of study in the creation of an illness. International Journal of Risk & Safety in Medicine, 201-229.
McIntyre, R., Zimmerman, M., Goldberg, J., & First, M. (2019). Differential diagnosis of major depressive disorder versus bipolar disorder. The Journal of Clinical Psychiatry, 80(3). doi:10.4088/jcp.ot18043ah2
Stewart, C., & El-Mallakh, R. S. (2007). Is bipolar disorder overdiagnosed among patients with substance abuse? Bipolar Disorders, 9(6), 646-648. doi:10.1111/j.1399-5618.2007.00465.x
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