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‘I want to be bipolar’…a new phenomenon

  • Diana Chan (a1) and Lester Sireling (a2)
Summary

There has been renewed interest in the concept and diagnosis of bipolar affective disorder in recent years. Previous epidemiological studies have reported the prevalence of the disorder in the USA at 1–2% but further studies have shown that the disorder is underdiagnosed and the true prevalence may be as high as 11%. Despite the stigma attached to mental illness, we have noticed in our clinical practice a new and unusual phenomenon, where patients present to psychiatrists with self-diagnosed bipolar disorder. Here, we explore the background to this phenomenon, the diagnostic challenges and the implications for our patients and practice.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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References
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1 Santosa, CM, Strong, CM, Nowakowska, C, Wang, PW, Rennicke, CM, Ketter, TA. Enhanced creativity in bipolar disorder patients: a controlled study. J Affect Disord 2007; 100: 31–9.
2 Michalak, EE, Yatham, LN, Kolesar, S, Lam, RW. Bipolar disorder and quality of life: a patient-centered perspective. Qual Life Res 2006; 15: 2537.
3 Angermeyer, MC, Matschinger, H. The stigma of mental illness: effects of labelling on public attitudes towards people with mental disorder. Acta Psychiatr Scand 2003; 108: 304–9.
4 Wolkenstein, L, Meyer, TD. Attitudes of young people towards depression and mania. Psychol Psychother 2008; 81: 1531.
5 Kelly, CM, Jorm, AF. Stigma and mood disorders. Curr Opin Psychiatry 2007; 20: 13–6.
6 Kraepelin, E. Manic-Depressive Insanity and Paranoia. E & S Livingstone, 1921.
7 Leonhard, K. Aufteilung der endogenen Psychosen. Akademie, 1957.
8 Jamison, KR. An Unquiet Mind: A Memoir of Moods and Madness. Picador, 1996.
9 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV). APA, 2000.
10 World Health Organization. The ICD–10 Classification of Mental and Behavioural Disorders. WHO, 1992.
11 Angst, J, Gamma, A, Benazzi, F, Ajdacic, V, Eich, D, Rossler, W. Toward a redefinition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 2003; 73: 133–46.
12 Hirschfeld, RM. Bipolar spectrum disorder: improving its recognition and diagnosis. J Clin Psychiatry 2001; 62 (suppl 14): 59.
13 Hirschfeld, RM, Lewis, L, Vornik, LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the National Depressive and Manic-Depressive Association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry 2003; 64: 161–74.
14 McElroy, SL, Altshuler, LL, Suppes, T, Keck, PE Jr, Frye, MA, Denicoff, KD, et al. Axis I psychiatric comorbidity and its relationship to historical illness variables in 288 patients with bipolar disorder. Am J Psychiatry 2001; 158: 420–6.
15 Angst, J. The bipolar spectrum. Br J Psychiatry 2007; 190: 189–91.
16 Benazzi, F. Bipolar II disorder, epidemiology, diagnosis and management. CNS Drugs 2007; 21: 727–40.
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BJPsych Bulletin
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‘I want to be bipolar’…a new phenomenon

  • Diana Chan (a1) and Lester Sireling (a2)
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eLetters

Self-diagnosis should not be a barrier to services

In their response to Chan and Sireling “I want to be bipolar” (1) Sharma and Kumar present data about the proportion of people presenting with a self-made diagnosis of bipolar disorder. They argue that their finding that none of the 46 people seen were “given” a diagnosis suggests that clinicians should beware of making the diagnosis of bipolar disorder in this group. However, their data could equally be used to demonstrate a problem with under-diagnosis or misdiagnosis in their service given the fact that so many of them reported core symptoms of the disorder.

Bipolar disorder is a serious mental disorder with serious consequences in terms of treatment with potentially toxic drugs. It is therefore important, as it is with all presentations, to adopt a rigorous approach to diagnosis However, the data provided does not justify special treatment of people who self-diagnose.

Reference:

1. Chan C, Sireling L. ‘I want to be bipolar’… a new phenomenon. The Psychiatrist. 2010; 34: 103-105.

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Conflict of interest: A.M. provides psychiatric assessments to members of the public, many of whom have diagnosed themselves.

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A review of referrals seeking a diagnosis of bipolar disorder

Avneet Sharma, Psychiatrist
24 November 2014

It is not uncommon in psychiatry to receive referrals for patients who believe they have bipolar affective disorder. This has been explained partly by a trend of celebrities openly talking about beingbipolar along with an explosion of information about bipolar illness on the internet (1).

We analysed the records of 46 cases who requested referral to aCMHT over a three year period seeking a diagnosis of bipolar illness. The patients were predominantly young women (mean age 32 yrs, female:male 31:15). Clinically they presented with problems of anxiety and low mood with a history of mood swings (90%); racing thoughts (70%); impulsivity (100%) and over-activity (60%).

All patients had visited a website offering self assessment for bipolar illness and reported scores being highly suggestive of a bipolar illness- this had influenced their decision to seek referral. Around 25% of patients reported seeing a TV programme featuring a celebrity talking about their bipolar illness. Five patients had joined the local Manic Depressive Fellowship of their own accord before the assessment.

None of the patients were given the diagnosis of bipolar illness at initial assessment. All were given formulations about their problems in terms of mood swings, coping and lifestyle issues. The ICD10 diagnostic categories were as follows: N=20 mixed anxiety depression/adjustment disorder/dysthymia; N=10 emotionally unstable personality disorder; N=5 alcoholism/ alcohol abuse; N=11 no psychiatric diagnosis. Around 33%, after going through the history taking, readily agreed that they were not suffering from a bipolar illness at the end of first meeting. Five patients asked for a second opinion- all were experiencing relationship problems.

Our experience attempts to highlight the issues while assessing patients who may actively seek diagnosis of bipolar illness. There is merit in taking the patient into confidence about the confusion around diagnosing bipolar illness and the risks associated with medical treatment. Also while trying to arrive at a diagnosis it may be best to look for classical or severe bipolar illness and if the evidence is not strongly suggestive then the diagnosis should be avoided or deferred till one obtains conclusive evidence.

References:

1.Chan Diana; Sirelng L. 'I want to be bipolar'...a new phenomenon.The Psychiatrist (2010) 34,103-105.



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Conflict of interest: None declared

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The suggested obligation to declare mental health issues to employer

clive h morgan, occupational physician
23 March 2010

I enjoyed this article considerably although must write in response to the comments about "obligatory declarations of mental health to employers."

Whilst there is little doubt that in most cases employers need to be aware of a bi-polar affective condition in employees that is not always appropriate. Indeed best practice requires employers to require submission of pre employment forms not to themselves but to an occupational health professional. Those with a bi-polar condition should almost always be invited to a review with an occupational physician.

At that point - and that point only - is it appropriate for there to be discussion as to what is share with the employer. At the very least such a

consultation is likely to head in the direction of advice to an employer that the employee has a condition which may require adjustment under the Disability Discrimination Act 1995 and 2005. What an occupational physician tells an employer is however subject to both his or her own professional judgement and indeed ultimately down to what the employee feels is appropriate.

Occupational medicine is a small specialty although a valuable one not least for psychiatric patients - for whom we can do a great deal.

Yours sincerely,

Dr Clive Morgan
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Conflict of interest: None Declared

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The importance of early and accurate diagnosis

Nick Craddock, Professor of Psychiatry
23 March 2010

The excellent article by Chan and Sireling (1) about the recent increase in public awareness of bipolar disorder mirrors our own experience in research and practice and highlights important issues for health services.

This article is very timely because there is ongoing debate about theextent to which bipolar disorder may be over- (2), or under-diagnosed (3).It is also possible, and we think very likely, both over- and under-diagnosis occur and are problematic. Some people may be inappropriately labelled while others who would benefit from the diagnosis are missed. Optimal treatment of depression is different in bipolar and unipolar disorders. This is one of many examples in psychiatry where making an early and correct diagnosis is highly likely to have a very direct and important effect on the quality of care offered to, and quality of life experienced by, a patient (4).

Chan and Sireling highlight new cases of bipolar disorder from the primary care setting. Preliminary data from our ongoing studies of primary care depressed patients suggest that bipolar (ie.manic/hypomanic) features are relatively common in this group (unpublished data). In our wider research in individuals with both bipolar and unipolar mood disorders we have found that those with a diagnosis of recurrent unipolar depression who have a history of mild manic symptoms tend to respond less well to antidepressants (5).

Inevitably, increasing awareness of any medical illness has the potential to lead to over-diagnosis, and this could cause problems for thepatient as well as for services. Thus, a balance must always be struck between the need to increase awareness appropriately amongst patients, public and clinicians, whilst not causing a tsunami of uncritical over-diagnosis and self-labelling (Smith, D.J., Thapar, A., Simpson, S. Bipolarspectrum disorders in primary care: optimising diagnosis and treatment. British Journal of General Practice, In press). As psychiatrists we must ensure we are pragmatic and put the patient’s well-being at the centre of decision making. This will require us to have knowledge of the developing evidence base, make a comprehensive diagnosis based on a detailed lifetimehistory of both depressed and manic mood (including asking an informant) and have an awareness of the boundaries of clinically-relevant symptomatology.

Nick Craddock* PhD, FRCPsych, Ian Jones PhD, MRCPsych, Daniel J. Smith MD, MRCpsych

Department of Psychological Medicine and Neurology, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN, United Kingdom

*Correspondence: Nick Craddock, Department of Psychological Medicine and Neurology, Henry Wellcome Building, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN, United Kingdom. (Email: craddockn@cardiff.ac.uk)

Declaration of interest: The authors declare no competing interests.

References

1) Chan C, Sireling L. ‘I want to be bipolar’… a new phenomenon. ThePsychiatrist. 2010; 34: 103-105.

2) Mark ZimmermanIs underdiagnosis the main pitfall in diagnosing bipolar disorder? NoBMJ 2010;340:c855

3) Daniel J Smith and Nassir GhaemiIs underdiagnosis the main pitfall when diagnosing bipolar disorder? YesBMJ 2010;340:c854

4) Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A, Cowen P,Craddock B, Eagles J, Ebmeier K, Farmer A, Fazel S, Ferrier N, Geddes J, Goodwin G, Harrison P, Hawton K, Hunter S, Jacoby R, Jones I, Keedwell P,Kerr M, Mackin P, McGuffin P, Macintyre DJ, McConville P, Mountain D, O'Donovan MC, Owen MJ, Oyebode F, Phillips M, Price J, Shah P, Smith DJ, Walters J, Woodruff P, Young A, Zammit S. Wake-up call for British psychiatry. Br J Psychiatry. 2008 Jul;193(1):6-9.

5) Smith DJ, Forty L, Russell E, Caesar S, Walters J, Cooper C, JonesI, Jones L,Craddock N. Sub-threshold manic symptoms in recurrent major depressive disorderare a marker for poor outcome. Acta Psychiatr Scand. 2009 Apr;119(4):325-9.
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Conflict of interest: None Declared

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