mood episode.
✔ With catatonia: Catatonia is a state of minimal responsiveness to the environment and abnormal movement. Symptoms can include stupor, immobility, rigid muscles or movements, very slowed or very fast movements, repetitive movements or speech, mutism (not speaking at all), odd mannerisms or postures, staring, unusual muscle responses when someone moves her limbs, negativism (oppositional or no response to external stimuli), and echolalia and echopraxia (repeating other people’s language or movements). Catatonia can be present in many psychiatric conditions, and it can occur with either depressive or manic poles of bipolar disorder.
✔ With peripartum onset: This specifier is used when the onset of the bipolar mood episode is any time during pregnancy or in the four weeks after delivery, which is important because pregnancy and childbirth influence treatment decisions. (See Chapter 10 for details.)
✔ With seasonal pattern: This label indicates a well-established pattern of mood episodes that start and end at specific times of the year.
Distinguishing Bipolar from Conditions with Similar Symptoms
Before arriving at any medical diagnosis, doctors review a differential diagnosis to consider all the possible causes of the presenting symptoms. In bipolar disorder, the differential diagnosis often includes the following conditions that may involve symptoms similar to those of bipolar disorder:
✔ Unipolar depression: A major depressive episode without a history of mania or hypomania doesn’t qualify as bipolar disorder. However, if you experience depression and you have a history of bipolar disorder in any first-degree relatives (parent, sibling, or child), your doctor may want to monitor you closely if she starts treatment with an antidepressant, because of the increased risk that you may have bipolar disorder that hasn’t shown its manic pole yet. Additionally, the differentiation between unipolar and bipolar depression can be quite difficult. If a symptom such as agitation is present, it can be part of a mixed-mood episode of bipolar disorder, but it can also just be part of unipolar depression. Another difficult diagnostic situation is when during recovery from depression a person has periods of feeling particularly well. Are these periods symptomatic of hypomania or simply a strong recovery from a depressive episode?
✔ Anxiety: Anxiety may make you feel wired or tired with racing thoughts, poor sleep, and irritability, all of which overlap with symptoms characteristic of depression and mania. Many people with bipolar disorder also have an anxiety disorder, so they can happen together, but determining whether anxiety is the primary disorder rather than bipolar is important.
✔ Attention deficit hyperactivity disorder (ADHD): ADHD and mania are both characterized by impaired concentration and attention, impulsivity, high energy levels, and problems with organization and planning. However, for those with bipolar disorder, these symptoms are present only during a manic episode, not all the time. In addition, diagnostic criteria for hypomania or mania include an increase in goal-directed behavior, a decreased need for sleep, and grandiose thinking; ADHD doesn’t include any of these. The pattern of symptoms, especially the episodic nature of mood episodes, is a key way to distinguish bipolar disorder from ADHD.
✔ Schizophrenia and schizoaffective disorders: Schizophrenia and schizoaffective disorders are thought disorders characterized by psychosis – delusional thinking, paranoia, and auditory or visual hallucinations. Although psychosis may accompany mania and depression, the bipolar psychosis is present only during an acute mood episode and goes away during times of normal mood. In schizoaffective disorders, psychosis occurs for at least some period of time separate from the mood episodes. Schizophrenia and related disorders are persistent and severe disruptions of thinking and reality testing unrelated to mood episodes.
✔ Borderline personality disorder (BPD): BPD shares a few characteristics with bipolar. For instance, someone with BPD may be impulsive, irritable, and argumentative much like someone who’s experiencing a manic episode. However, BPD mood shifts are typically abrupt, short-lived, and in response to an external trigger, such as a conflict with another person; bipolar mood shifts are slower to develop, last longer, and may not appear to be in response to anything external. The rages that often characterize BPD aren’t equivalent to mania. BPD symptoms are chronic, representing the person’s baseline behaviors, whereas bipolar symptoms are episodic and different from the person’s usual behavior patterns.
✔ Other medical conditions: Many medical conditions – including brain tumors, meningitis, encephalitis, seizure disorders, brain injury, hormone imbalances, anxiety disorders, autism, and pervasive developmental disorder (PDD) – can produce symptoms similar to those of bipolar mania or depression.
✔ Mood instability caused by medications, alcohol, or drugs: A variety of prescription medications, alcohol, marijuana, and street drugs can affect moods. You and your doctor must rule out these possible causes before arriving at a diagnosis of bipolar disorder.
Considering Comorbidity: When Bipolar Coexists with Other Conditions
Bipolar disorder carries the distinction of having some of the highest rates of comorbidity with other psychiatric illnesses, which means that someone diagnosed with bipolar disorder is likely to have at least one other psychiatric diagnosis. Some researchers suspect that because bipolar disorder may actually be closely related to some of these illnesses, in terms of underlying brain changes – they may not really be separate disorders at all. Given how psychiatric illness is diagnosed at this point in time, we describe the disorders as separate entities and call them comorbidities, which we discuss in these sections.
Anxiety disorders occur very frequently with bipolar disorder. One study of a large community sample found that more than 90 percent of people with bipolar I disorder had a co-occurring anxiety disorder diagnosis. When all bipolar groups were considered, it was about 70 percent. Most studies have found rates of anxiety disorders to occur in somewhere between a third and slightly more than a half of people diagnosed with all types of bipolar disorder. Here are a few of the anxiety disorders commonly associated with bipolar:
✔ Panic disorder occurs in about 21 percent of people with a bipolar diagnosis. That’s more than 20 times the rate seen in the general population. Researchers suspect an underlying genetic relationship between the two disorders in some people and families.
✔ Generalized anxiety disorder seems to occur in nearly a third of all individuals with bipolar.
✔ Social anxiety seems to occur in about 50 percent of people with bipolar, in some studies.
✔ Obsessive compulsive disorder (OCD) has been found in about 21 percent of people with all types of bipolar disorder – about ten times the rate seen in the general population.
✔ Post-traumatic stress disorder (PTSD) has a high rate of occurrence in the general population, but an even higher rate in bipolar disorder. Women have higher rates than men with PTSD, both with and without bipolar disorder.
Treatment of anxiety disorders may complicate or complement the treatments of bipolar disorder, but reducing anxiety symptoms is an important part of managing bipolar disorder effectively.
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