Bipolar disorder tough to diagnose

Originally published in The Ottawa Citizen October 29, 2003
Original Title: Polar Opposites

Mr. S. was visibly upset about his wife’s behaviour and mood swings. Her “gambling addiction” playing the slots accumulated $40,000 in debt. Mrs. S. admitted gambling was a problem but continued to do so because of the exhilaration of knowing she would win the big prize. There were other notable behaviours.

She would lock all the doors within the house 15 times per day and awake at night to ensure they remained locked. Her screams at night that demons were under the bed terrified her family. She would talk about one subject and rapidly switch to another in mid-sentence. She experienced bursts of energy lasting several days. She would obsessively clean the entire house and cook a month’s worth of food.

Then her mood would crash. She would socially isolate herself for weeks on end. With the prospect of a marriage breakdown, bankruptcy, loss of their home and 30 years of mood instability she had hit bottom.

Mrs. S. has Bipolar Disorder (previously termed manic-depressive disorder). Bipolar disorder is an under-diagnosed and under-recognized condition. Indeed, an average of eight to ten years passes from the time of initial symptoms to diagnosis and treatment. It usually appears between the ages of 18 to 24 but can appear at earlier and later stages of life.

Bipolar disorder is an inheritable illness that leads to extreme mood swings. One study revealed a 13 percent risk of bipolar disorder among children of biological parents with the disorder. Indeed, Mrs. S.’s alcoholic father had similar mood swings problems.

About one in 100 Canadians suffer from this condition over their lifetime. The World Health Organization identified it as the sixth leading causes disability-adjusted life years in the world among 15 to 44 year-olds.

Drug and alcohol abuse usually accompanies this condition. Twenty-five to 50 per cent of people with bipolar disorder attempt suicide and 15 per cent will die. Ninety per cent will be admitted to hospital for at least one psychiatric assessment and treatment and two-thirds will have two or more hospitalizations in their lifetime

The characteristics of mania, a psychotic condition, include feelings of inflated self-esteem, grandiosity, invincibility and irritability. The manic person may think they are Jesus Christ or other famous person or deity capable of fantastic powers and brilliant ideas. They speak rapidly often changing the content of their discussion in mid stride and are easily distracted. Physical activity increases and the need for sleep decreases. They may exhibit hypersexuality and act impulsively (e.g. go on extravagant spending sprees) without reflecting upon the consequences of their actions. They have poor judgment and do not recognize their condition.

People with hypomania are not psychotic. Their behaviours are similar to mania but without the psychotic traits, poor judgment and impulsivity. They tend to be more irritable and impatient but are able to function without impairment. Indeed, they may function at a superior level in the short-term.

There are several types of bipolar disorder distinguished by whether there is true mania (Bipolar I) or hypomania (bipolar II) in conjunction with bouts of major depression. The Bipolar II person experiences frequent periods of severe depression interspersed with hypomania.

Diagnosing bipolar disorder is problematic. Most patients will come to see their doctor only when they are in the depressed phase of the illness. They rarely come in when they are manic or hypomanic because they feel good. Indeed, when they are depressed they do not report instances of feeling well or view these fleeting short episodes as inconsequential since their focus is on their depressed mood.

This situation leads to the diagnosis Major Depressive Disorder instead of Bipolar Disorder.

Further compounding the problem is the initial dramatic improvement in symptoms in the first two weeks after starting an anti-depressant medication. However, by week four they revert to their depressed state. Increasing the medication dose or changing it to another product may not result in any improvement. Indeed, a “clinically depressed patient” who does not respond to three different anti-depressants should arouse suspicion they have bipolar disorder.

The Mood Disorders Questionnaire ( is a tool available to patients and physicians that helps differentiate between bipolar disorder and depression. It contains a series of statements that checks for characteristics inherent in bipolarity and the degree of impairment experienced by the patient. A positive screen for bipolar disorder is accurate nine out of ten times.

If you know of a family member or friend who is irritable or angry, thinks and talks so fast that others cannot follow them, sleeps excessively or not at all, feels very powerful and important, has trouble concentrating, has thoughts of suicide or death, spends too much money, abuses alcohol and drugs, is obsessed with sexual activity and suffers from severe mood swings, they should be evaluated for bipolar disorder.

A month after beginning treatment, Mrs. S. no longer had any desire to gamble. Her mood swings resolved. She functions well at work, her marriage is stronger, the debt is consolidated and her life is back to normal. Thirty years of suffering has ended.

For more information: The Mood Disorders Society of Canada

© Dr. Barry Dworkin 2003

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