Bipolar Disorder - Term Paper Example

? The Subtle Forms of Bipolar Disorder The essay aims to address a two-fold objective to wit to identify the subtle forms of bipolar disorder; and (2) to provide factual information and empirical description of bipolar disorder and its subtle forms. The essay discussed bipolar disorders and its subtle forms through review of literatures and studies from 1983 to 2011. The subtle forms of bipolar disorder are difficult to diagnose, as they combine symptoms of both affective and psychiatric conditions. The current criteria confused medical practitioners, and misdiagnosis often occurred. Most of the reviewed sources suggest that revision must be made in the current diagnostic criteria used in order to draw clear boundaries between personality, affective, psychotic, and other comorbidity disorders. Majority of the studies also support the idea that there are subtle forms of bipolar disorder which should be diagnosed and treated accordingly, while a few do not support the idea that these subtle forms must be made distinct categories of bipolar disorder. The review of research literature also addressed the reasons why clinical staff misdiagnosed bipolar disorder. A brief description is provided, as well as the categories of bipolar disorder. The review of research literature suggests recommendations that would aid in drawing the clear boundaries of bipolar disorder and, thus, would reduce the number of misdiagnosis of the disorder. The Subtle Forms of Bipolar Disorder Bipolar disorder is a disease with subtle specificity and sensitivity (Quinn, 2007, 19). With the widening of the diagnostic criteria for bipolar disorder comes the loss of specificity and danger of overdiagnosis due to the increase in sensitivity of the subtle manifestations of bipolar disorder. As a result, overdiagnosis poses substantially greater potential for harm as desired treatment may not be appropriate and may lead to induction of hypomania, mixed states, rapid cycling, and worsening of preexisting agitation (Quinn, 2007, 19). Bipolar disorder is difficult to distinguish from other disorders because of mood variations in hormones, personality disturbances, personal stress, sleep problems, ingestion of drugs or alcohol and diseases of the brain, trouble in getting accurate histories because of difficulty in describing mood states to others, and inadequately trained professionals in the recognition of the subtle form of the disorder (Miklowitz, 2011, 43). These factors, together with the diagnostic criteria itself, create confusion in the diagnosis of bipolar disorder as certain symptoms can occur in other disorder. Clinicians, researchers, and allied health practitioners are challenged to prevent the over/misdiagnosis of bipolar disorder through different studies and literature, differentiating the subtle forms of bipolar disorder from the true bipolar disorder. Review of Literature Bipolar disorder and its subtle forms gained attention during 1983 when the American Psychiatric Association (APA) verified the existence of relatively mild and subtle spectrum of bipolar disorders (Grinspoon, 1983, 281). The subtle forms of bipolar disorder manifest psychomotor, interpersonal, and vocational dimension, rather than alterations in mood which is the core symptom of bipolar disorder. According to Grinspoon (1983), the subtle forms of bipolar disorder range between cyclothymic disorder and dysthymic disorder (281). Cyclothymic disorder starts during teenage or early adulthood years and may often be diagnosed as a personality disorder. Cycles are short and last for only a few days and may not meet the category for hypomania due to biphasic course. On the other hand, dysthymic disorders are subaffective and subtle hypomania is present. Onset is indeterminate and cardinal symptoms often occur at age 21. A full range of depressive symptoms occurs at subsyndromal level, and a patient is categorized in the subtle forms of bipolar disorder if patients do not have any diagnosable nonaffective disorder (Grinspoon, 1983, 282). The difficulty arises in the diagnosis of bipolar disorder when symptoms of personality disorders coincide with the symptoms of bipolar disorder. Misdiagnosis of bipolar disorder often occurs because the symptoms of bipolar disorder can also occur in other psychiatric conditions, such as panic disorder, obsessive-compulsive disorder, binge-eating disorder, and alcohol/substance abuse (Bipolar Clinic Staff, 2000, 10). In addition, subtle forms of bipolar disorder, such as rapid cycling, mixed states, and catatonic symptoms, may also be experienced by patients. It is not only similarities of bipolar disorder with personality disorders symptoms that complicates the diagnosis but comorbidities in anxiety and psychotic disorders as well. Most of the medical professionals believe that the subtle forms of bipolar disorder, such as rapid-cycling, mixed states, and hypomania must be distinct from the bipolar disorder (Jovinelly, 2001, 42). Doctors believe that the causality of these subtle forms might be attributed to the antidepressant medications patients are taking. Thus, distinctions must be made in terms of causality. Subtle forms of bipolar disorder or the bipolar spectrum disorders refer to patients who demonstrate symptoms of bipolar disorder but not indicative of bipolar I, bipolar II, or cyclothymia (Jovinelly, 2001, 42). Doctors usually refer to subtle forms of bipolar disorder as bipolar III or pseudo-unipolar depression (Jovinelly, 2001, 42). The diagnostic guide usually depends on the inclusion or exclusion of symptoms in the three categories of bipolar disorder. Vieta (2001) identified the two fundamental affective forms developed by Kraepelin, the unipolar and the bipolar disorder (257). Until a proposal came out in 1983, stating that the unipolar-bipolar dichotomy needed revision because of the broadness, complexity, and variability of the bipolar spectrum. Vieta (2001) stated that Akiskal’s clinical observations revealed that there are patients with dysthymia who became hypomanic or manic, patients with cyclothymia who fall into severe depressive episodes, and patients with unipolar depression who became hypomanic or manic (257-258). The clinical observation of Akiskal has led to the assumption that mood disorders cannot be simply categorized into unipolar or bipolar type but there are subtle forms of affective disorder that do not fall in either of the category. The comorbidity studies of Brieger (2004) do not support the idea that mixed states and rapid-cycling forms are distinct categories of bipolar disorder (175). The study illustrates the defect in the current diagnostic criteria, as patients with mixed bipolar disorders often show more anxiety and depression than manic states. In addition, those with rapid-cycling or mixed subtle forms comorbid with substance abuse and the causality remain unclear. Subtle differences occur in some researches demonstrating comorbidity of bipolar disorder to thyroid dysfunction and other psychiatric disorders. Therefore, the study found no evidence that would support the creation of distinction for subtle forms of bipolar disorder and thus, categories must be made in the closes comorbidity disorder. Goodwin & Jamison (2007) corroborated the finding that the premorbid impairment is a significant distinction between bipolar disorder and schizophrenia (n.p.). Authors added that patients with bipolar disorder are less premorbid impaired than schizophrenic patients and that a subtle premorbid cognitive dysfunction may exist in patients with bipolar disorder. The authors noted for further studies to elucidate the premorbid phenomenology of bipolar disorder in terms of psychotic and non-psychotic forms. Authors suggest that the premorbid impairment may be the key to accurately diagnose bipolar disorder and distinguish it from psychotic disorders. Duckworth (2008) described bipolar disorder as a complex medical illness of the brain withan irregular pattern of changes in mood, energy, and thinking which may be subtle or dramatic (2). The complexity and variability of bipolar disorder make it hard for individuals and families to provide an accurate history, as well as to provide an accurate diagnosis for the clinical providers. Duckworth (2008) enumerated the reasons of the Diagnostic and Statistical Manual (DSM-IV) why bipolar disorder is hard to diagnose, among of which are: depression are more frequent than mania or hypomania in most people with bipolar disorder; diagnosis is difficult or delayed if depression is the first episode, if there are subtle, infrequent, and brief episodes of mood elevation, if symptoms of other disorders are present, and use of professional words without provision of appropriate definition; non-mood symptoms are more prominent than mood episodes thus, confusion arises because bipolar disorder is classified as a mood disorder (2). Frameworks must be designed to address and categorized the subtle forms of bipolar disorder that have prominent non-mood symptoms. The study of Youngstrom, Freeman & Jenkins (2009) reviewed the diagnostic criteria for mood disorders in children and adults and found out that due to the dramatic changes and transitions of bipolar disorder into different episodes, diagnosis and diagnostic tools require complexity (354). The study also includes cyclothymic disorder as the most difficult disorder to distinguish from temperament that warrants clinical attention.Bipolar disorder is categorized into Bipolar I, Bipolar II, and Cyclothymia. Cyclothymia is the third form of bipolar disorder and differs in severity and symptoms. Cyclothymia has less intense cycles of both mania and depression and may be manifested for two years (Haycock, 2010, 14).The insufficient number of symptoms and the insufficient duration of the subtle forms of bipolar disorder make it hard for clinician to make an accurate diagnosis of the disorder in both children and adults (Youngstrom, Freeman & Jenkins, 2009, 356). Aside from that, clinicians are challenged to determine in every diagnosis that mood symptoms might probably due to schizophrenia, substance-abuse, or secondary effects of certain medications, all of which are comorbidities of bipolar disorder. The American Psychiatric Association (APA) (2010) focused on the amidst discussion of the accuracy of diagnostic criteria for bipolar disorder and recommends three actions that would clearly define the boundaries of bipolar disorder among other developmental spectrum: these includes clear operationalization of episodes by word revision of the criteria for manic and hypomanic episodes, addition of a new diagnosis Temper Dysregulation Disorder with Dysphoria (TDD) in the Mood Disorders Section of DSM-5, and addressing the nosological status of hypomanic episodes shorter than 4 days (1-8). Evidence from the review of research literature by Leboyer & Kupfer (2010) state that patient experience more subtle chronic course characterized by residual symptoms, emotional dysregulation, sleep and circadian rhythm disturbances, cognitive impairment, and increased risk for psychiatric and medical comorbidity in between mood episodes (1692). The study suggests that the development of more complex and comprehensive diagnostic tools and framework would aid in the accurate diagnosis of bipolar disorder among all ages. Underdiagnosis and overdiagnosis of bipolar disorder among children and adolescents remain a controversial issue. Contrary to other study, the study of Chilakamarri, Filkowski & Ghaemi (2011) in a community sample of children and adolescent found out that bipolar disorder is often undiagnosed, with 40-60% of children previously diagnosed with bipolar disorder but when systematically assessed, do not meet the criteria for bipolar disorder (28). Conclusion Review of the literature highlighted the main point: a revision of the current diagnostic tool/criteria must be made in order to clearly identify the boundaries of bipolar disorder to personality, psychotic, and other affective disorders. In addition, the review of literature addressed the most common mistake done by clinicians in diagnosing bipolar disorder which is under/overdiagnosis. The development of more complex and comprehensive diagnostic tools and framework would aid in the accurate diagnosis of bipolar disorder among all age groups and will reduce the incidence of misdiagnosis among patients. References American Psychiatric Association (APA). (2010). Issues Pertinent to a Developmental Approach to Bipolar Disorder in DSM-5. Retrieved December 25, 2011 from http://www.dsm5.org/Proposed%20Revision%20Attachments/APA%20Developmental%20Approaches%20to%20Bipolar%20Disorder.pdf Bipolar Clinic Staff. (2000). The Symptoms of Bipolar Disorder. Bipolar disorder: an information guide (p. 5-10). Ontario: Center for Addiction and Mental Health. Brieger, P. (2004). Do Comorbidity Studies Support the Idea that Mixed States and Rapid-Cycling Forms are Distinct Categories of Bipolar Disorders? Clinical Neuropsychiatry, Vol. 1(3): pp. 175-181. Chilakamarri, J. K., Filkowski, M. M. & Ghaemi, S. N. (2011). Misdiagnosis of bipolar disorder in children and adolescents: A comparison with ADHD and major depressive disorder. Annals of Clinical Psychiatry, Vol. 23(1): pp. 25-29. Duckworth, K. (2008). Understanding Bipolar Disorder and Recovery. National alliance on mental illness (p. 1-32). Virginia: National Alliance on Mental Illness. Goodwin, F. K. & Jamison, K. R. (2007). Manic-Depressive illness: bipolar disorders and recurrent depression (2nd ed.) (n.p.). New York: Oxford University Press. Grinspoon, L. (1983). The Bipolar Spectrum: New Concepts in Classification and Diagnosis. Psychiatry update: the American Psychiatric Association annual review (Vol. II) (p. 271-292). Washington: American Psychiatric Association. Haycock, D. A. (2010). The Basics of Bipolar Disorder. The everything health guide to adult bipolar disorder (2nd ed.) (p. 1-17). Massachusetts: F+W Media, Inc. Jovinelly, J. (2001). Bipolar Disorder. Coping with bipolar disorder and manic-depressive illness (p. 37-47). New York: The Rosen Publishing Group, Inc. Leboyer, M. & Kupfer, D. J. (2010). Bipolar Disorder: New Perspectives in Health Care and Prevention. The Journal of Clinical Psychiatry, Vol. 71(12): pp. 1689-1695. DOI: 10.4088/JCP.10m06347yel Miklowitz, D. J. (2011). Into the Doctor’s Court: Getting an Accurate Diagnosis. The bipolar disorder survival guide (2nd ed.) (p. 30-54). New York: The Guilford Press. Quinn, B. (2007). An Overview of Bipolar Disorder and Its Diagnosis. Wiley concise guides to mental health (p. 11-36). New Jersey: John Wiley & Sons, Inc. Vieta, E. (2001). Towards a New Classification of Bipolar Disorders. Bipolar disorders: clinical and therapeutic progress (p. 255-278). Madrid: Editorial Medica Panamericana, S.A. Youngstrom, E. A., Freeman. A. J. & Jenkins, M. M. (2009). The Assessment of Children and Adolescents with Bipolar Disorder. Child and Adolescent Psychiatric Clinics of North America,Vol. 18: pp. 353-390. doi:10.1016/j.chc.2008.12.002 Read More