Bipolar disorder is a complex mental health condition characterized by extreme shifts in mood and energy levels. The main symptoms are alternating episodes of mania and depression. Bipolar is often misdiagnosed at first, with an estimated 69% of people with bipolar initially misdiagnosed. This article will explore some of the conditions that are commonly mistaken for bipolar disorder.
Depression
One of the most common misdiagnoses for bipolar disorder is unipolar depression. Bipolar disorder was formerly known as manic depression, which emphasizes the role of mania. However, bipolar equally involves periods of depression. Some experts estimate that up to 1/3 of people thought to have depression may actually have bipolar disorder. This is because the depressive episodes in bipolar can look similar to regular major depressive disorder. Some signs that depression may actually be bipolar include:
- Depression that began before age 25
- Periods of high energy, creativity, and productivity interrupting the depression
- Strong family history of bipolar disorder
- Depression that is treatment-resistant
- Psychosis during depressive episodes
People with bipolar depression may be misdiagnosed with major depressive disorder. Proper diagnosis is important because antidepressants alone can worsen the course of bipolar in some individuals. Mood stabilizers, atypical antipsychotics, and psychotherapy are first-line treatments.
Anxiety Disorders
Many people with bipolar disorder also have co-occurring anxiety disorders. In some cases, anxiety may be misdiagnosed as bipolar. Both conditions involve mood and energy changes. However, true bipolar mania causes impairment and psychosis when severe. Some examples of anxiety disorders that may mimic mania include:
- Generalized Anxiety Disorder: Restlessness, tension, and agitation may resemble hypomania.
- Panic Disorder: Periods of high arousal and energy during panic attacks can mimic mania.
- Social Anxiety: Rapid speech and discomfort in social situations exists in mania and social anxiety.
- PTSD: Irritability, insomnia, and emotional dysregulation may occur in PTSD or bipolar mood episodes.
Careful evaluation of symptoms over time is needed to distinguish anxiety from bipolar disorder. The two conditions commonly co-occur, so optimal treatment often includes approaches for both.
Borderline Personality Disorder
Borderline personality disorder (BPD) is characterized by a pattern of unstable relationships, emotions, sense of self, and impulsive behavior. BPD and bipolar disorder share some similar symptoms like mood swings and risky behavior during mood episodes. However, BPD mood changes arise due to interpersonal triggers rather than internal biological rhythms. Other differences include:
| Borderline Personality Disorder | Bipolar Disorder |
|---|---|
| Frequent angry outbursts | Manic episodes distinct from usual self |
| Chronic feelings of emptiness | Distinct periods of mania and depression |
| Self-harm behaviors | Risk-taking behaviors during mood episodes |
People with BPD often have unstable but intense personal relationships and fear of abandonment. Bipolar manic episodes are characterized by high energy and impulsiveness. Mood changes in BPD often last hours, while bipolar episodes persist for days to months. Dialectical behavior therapy is first-line for treating BPD.
Schizophrenia
There can also be confusion between bipolar disorder and schizophrenia. Schizophrenia is characterized by hallucinations, delusions, disorganized thinking, and breaks with reality. The psychotic symptoms of schizophrenia may resemble severe mania. However, mania involves very high energy and activity levels. Schizophrenia has prominent social withdrawal and flattened emotion and behavior. Differences include:
- Schizophrenia: Auditory hallucinations and fixed delusional beliefs
- Bipolar Disorder: Grandiose delusions about talent or abilities
- Schizophrenia: Emotionally “flat” and withdrawn
- Bipolar Disorder: Emotionally volatile
Medications like antipsychotics may be used to treat both conditions. But schizophrenia requires careful long-term management, while bipolar episodes can be stabilized with treatment.
ADHD
Attention deficit hyperactivity disorder (ADHD) involves ongoing issues with inattention, hyperactivity, and impulsivity. In children and teens, ADHD can be confused with early onset bipolar disorder. Both conditions include distractibility and restlessness. However, ADHD is fairly constant while bipolar fluctuates more. Hyperactivity in ADHD is more physical rather than mood-related. Impulsivity issues are also constant in ADHD but episodic in bipolar disorder. Stimulant and non-stimulant medications are first-line ADHD treatments.
Substance Use Disorders
Abusing drugs or alcohol can cause mood swings and unpredictable behavior. Someone with untreated bipolar disorder may also self-medicate with substances. The disinhibited behavior of substance abuse may resemble mania. Drug or alcohol withdrawal can include depressed mood as well. Features that point more to bipolar include:
- Manic symptoms that remain after withdrawal is complete
- Periods of depression despite abstinence from substances
- Family history of bipolar disorder
- Mania characteristics: euphoria, racing thoughts, grandiosity
Substance use disorders often occur alongside bipolar disorder. An accurate diagnosis requires ruling out intoxication or withdrawal effects.
Major Depressive Disorder with Psychotic Features
Psychosis can occur in severe major depression, characterized by delusions and hallucinations. If psychosis arises concurrently with extreme mania, it could indicate bipolar I disorder instead. Psychosis with mania includes symptoms like:
- Believing one has superhuman talents or powers
- Hearing voices or sounds that aren’t there
- Paranoia or delusional beliefs
- Disorganized, racing thoughts
- Severely disorganized or catatonic behavior
Psychotic depression more often involves delusions of guilt, persecution, disease, or ruin. Mood is depressed but energy is very low. Disentangling the two disorders relies on careful assessment of symptoms over time.
Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) features intrusive thoughts and repetitive behaviors. OCD compulsions are done to reduce anxiety and discomfort. In bipolar disorder, “manic compulsions” are motivated by racing thoughts or delusional beliefs. Unlike OCD, the behaviors in mania are not recognized as senseless or excessive by the individual. Other differences include:
- OCD Compulsions: Designed to reduce anxiety or prevent feared outcome
- Manic Compulsions: Grandiose life projects; impulsive gambling, spending, or sex
- OCD Obsessions: Unwanted, intrusive thoughts or fears
- Manic Thoughts: Creative and desired racing thoughts
Medications used in OCD treatment, like SSRIs, may worsen mania. Mood stabilizers are the foundational bipolar treatment instead.
Hypothyroidism
Hypothyroidism, or underactive thyroid, can involve symptoms like low energy, weight gain, and depression. Hyperthyroidism involves weight loss, rapid heart rate, and irritability that may mimic mania. However, thyroid hormone changes lack the characteristic cyclic episodes of bipolar. Thyroid disease also causes clear physical symptoms like goiter or bulging eyes. Bipolar treatment may improve thyroid function, making accurate diagnosis important.
Premenstrual Dysphoric Disorder
Severe mood changes are the main symptom of premenstrual dysphoric disorder (PMDD). PMDD may include irritability, depressed mood, anxiety, and emotional sensitivity during the premenstrual phase. These mood shifts may resemble bipolar cycling, but are connected to hormonal fluctuations. Key PMDD features:
- Symptoms begin after ovulation and resolve quickly with menstruation
- Symptoms do not meet criteria for mania/hypomania
- Does not involve psychosis
- Occurs only during luteal phase of menstrual cycle
Bipolar mood episodes persist for days or weeks, while PMDD resolves with the onset of menses. Lifestyle changes and antidepressants can improve PMDD. Bipolar treatments like lithium are not appropriate.
Borderline Personality Disorder
Borderline personality disorder (BPD) is characterized by a pattern of unstable relationships, emotions, sense of self, and impulsive behavior. BPD and bipolar disorder share some similar symptoms like mood swings and risky behavior during mood episodes. However, BPD mood changes arise due to interpersonal triggers rather than internal biological rhythms. Other differences include:
| Borderline Personality Disorder | Bipolar Disorder |
|---|---|
| Frequent angry outbursts | Manic episodes distinct from usual self |
| Chronic feelings of emptiness | Distinct periods of mania and depression |
| Self-harm behaviors | Risk-taking behaviors during mood episodes |
People with BPD often have unstable but intense personal relationships and fear of abandonment. Bipolar manic episodes are characterized by high energy and impulsiveness. Mood changes in BPD often last hours, while bipolar episodes persist for days to months. Dialectical behavior therapy is first-line for treating BPD.
Postpartum Depression
Women with bipolar disorder are at very high risk for severe postpartum depression. Postpartum mood changes may include hallmark bipolar symptoms like low energy, appetite changes, sleep disturbances, and suicidal thinking. However, postpartum hypomania or mania is also possible. True postpartum mania includes:
- Decreased need for sleep
- Racing thoughts
- Agitation
- Unusually elevated mood and energy
- Grandiose beliefs about abilities as a mother
Postpartum bipolar symptoms tend to begin within a few days to weeks after delivery. Treatment is vital for the safety of both the mother and baby.
Menopausal Mood Changes
Menopausal fluctuations in reproductive hormones can trigger significant mood changes. Women may experience depression, irritability, anxiety, and sleep disturbances. In some cases, apparent manic symptoms like euphoria, heightened energy, or impulsive behavior may also occur. True bipolar mania is distinguished by:
- Severe impairment in functioning
- Psychotic symptoms
- Mania onset not linked to menopausal transition
- Persistence of symptoms after hormone changes stabilize
Hormone replacement therapy may stabilize mood swings related to menopause. Bipolar requires more specialized medications and psychotherapy.
Adult ADHD
Inattentiveness, hyperactivity, and impulsivity can continue from childhood into adulthood in ADHD. Adult ADHD shares some characteristics of bipolar mania like pressured speech and distractibility. However, the mood changes in bipolar are separate episodes rather than everyday difficulties.
- Adult ADHD: Chronic ongoing issues paying attention
- Bipolar Mania: Periods of several days or weeks of euphoria and high energy
- Adult ADHD: Problems finishing tasks, following conversations
- Bipolar Mania: Taking on unrealistic goals that cannot be finished
ADHD does not involve distinct periods of mania and depression like bipolar. Stimulant medications used for ADHD may potentially worsen bipolar in some people.
Conversion Disorder
Conversion disorder causes neurological symptoms like seizures, paralysis, or blindness without a medical explanation. Mania very rarely includes movement issues like catatonia or muscle tension. However, conversion symptoms are not voluntary. Appropriate bipolar mania treatment will not improve conversion disorder. Key differences:
- Conversion Disorder: Physical symptoms not under conscious control
- Bipolar Mania: Excess energy and activity can be controlled
- Conversion: Often connected to psychological stress
- Bipolar Mania: Mood changes arise spontaneously
Conversion disorder requires psychotherapy rather than medication treatment. Careful assessment of all symptoms is needed to distinguish conversion and bipolar mania.
Conclusion
Bipolar disorder has complex and varying symptom presentation. Many other psychiatric conditions share common symptoms like mood instability, high energy, impulsivity, and even psychosis. Careful longitudinal assessment is key to accurate diagnosis. Some important considerations in identifying bipolar include:
- Sequence of mood episodes
- Triggers for mood changes
- Duration of symptoms
- Presence of mixed features
- Symptoms when not in an episode
- Response to previous treatment
- Family history
Ruling out other disorders and identifying patterns over time leads to appropriate treatment. While bipolar disorder is frequently misdiagnosed at first, an accurate diagnosis greatly improves long-term prognosis and quality of life.