This question is one that has come about due to my experience of having first no diagnosis, then a misdiagnosis, then finally a confirmed diagnosis of Bipolar Disorder living in the UK. For years leading up to my diagnosis I spent hours and hours researching bipolar disorder. For the majority of the information, it was based on the American DSM 4 and then 5 following its release. I then expected a sub diagnosis of Bipolar 1 or Bipolar 2 disorder, instead I was diagnosed with Bipolar Affective Disorder – the UK equivalent.
Why does this matter?
I will explain further below, but there is a seemingly huge emphasis among the USA to categorise bipolar’s into either BD1, BD2, Schizoaffective Bipolar Disorder, or Bipolar Disorder NOS. Treatment for each of these conditions, as well as their symptoms, are different and it is believed the correct diagnosis is required to find the correct treatment. So how then, in the UK without these sub-headings do we get the right diagnosis or the right treatment?
The DSM 4 Diagnostic Criteria for Bipolar Disorder
Under the DSM-4 Bipolar Disorder is diagnosed through experiencing mania or hypomania, and depression. Hypomania is differentiated from Mania as hypomania is defined as causing significant changes to behaviour that differ from the persons non-depressed mood, but not significant enough to cause impairment, require hospitalisation, or include psychotic features. I have explained the symptoms of mania in my post on Mixed Episodes here. This differentiation leads to the differentiation between the two main diagnosis’s of Bipolar 1 and Bipolar 2. The symptoms of depression match those of Major Depressive Disorder.
The DSM 5 Changes to the Diagnostic Criteria
The main change to the DSM 5 include the inclusion of mixed features within Bipolar 1 and Bipolar 2 disorder, instead of previously defined as a separate episode as explained here. This also includes the addition of psychotic features to Bipolar 2 disorder, which was previously only regarded as part of Bipolar 1 Mania. This change affected my diagnosis dramatically.
Bipolar 1 Disorder
As I said Bipolar 1 and Bipolar 2 are separate sub headings of bipolar disorder, and each poses their own symptoms and diagnostic criteria. For a diagnosis of Bipolar 1 you must experience symptoms of Mania for at least 1 week causing significant impairment to your normal functioning, this can often require hospitalisation. Sufferers of BD1 will experience depression although this is not required for diagnostic purposes, this is what Bipolar 1 disorder looks like under the DSM 5.
Treatment for Bipolar 1 disorder often includes mood stabilisers such as Lithium which manage mania, antipsychotics such as Aripiprazole to manage psychotic symptoms, it is not advisable to treat Bipolar 1 patients with an antidepressant as these can cause manic symptoms without the addition of mood stabilisers and is often only considered if all the available mood stabilisers do not manage the depression on their own.
Bipolar 2 Disorder
Bipolar Disorder is differentiated from Bipolar 1 through the absence of a manic episode, but where the sufferer experiences symptoms of hypomania for at least 4 days, and depression for at least 2 weeks. Under the DSM 5, Bipolar 2 can include mixed features. It is also noted that the depression within Bipolar 2 is often experienced for longer than and more frequently than in Bipolar 1.
Treatment for Bipolar 2 often includes mood stabilisers such as Lamotrigine which treat bipolar depression but do little for manic symptoms, and antidepressants such as Duloxetine.
Cyclothymia & Dysthymia
Among the Bipolar family is Cyclothymia, where hypomania and dysthymia are experienced.
Dysthymia is a lesser form of depression experienced over an extended period of months consistently.
This one I know significantly less about, but the main difference here is the experience of psychotic features outside of mania or depression.
The presence of bipolar symptoms that do not fit any of the above categories, but cannot be explained through another disorder such as BPD, could lead to a diagnosis of Bipolar Not Otherwise Specified.
Receiving A diagnosis in the UK – My Experience
Due to the difference in treatment I was curious to find out if I would he diagnosed Bipolar 1 or 2, what does this professional think of my mania? I had researched but was uncertain to which extent my behaviour would come into as the main symptoms of Mania had occurred whilst intoxicated, including the worst psychotic symptoms. Then, to my confusion, I was diagnosed with Bipolar Affective Disorder. It was explained to me that in the UK they do not use the DSM-5 or any version of this and therefore do not subcategorise the disorder further. So how then do you receive the diagnosis of bipolar disorder, how do you get treated, no wonder I was misdiagnosed!
My confusion was extended due to my experience when I was 19. I was experiencing at the time psychotic depression but didn’t know it, however was convinced for years before that I had Bipolar Disorder and was determined to seek treatment. I referred myself to my university’s mental health team and told them my experiences and they referred me to a mental health unit who assessed me but informed me that due to the time scales not fitting the criteria, I was not Bipolar. Where then did they get these from?
I understand now that my symptoms would probably indicate at this time bipolar 2 disorder with mixed features, which did not exist under the DSM-4 at the time, but if this is not used then I cannot understand why they did not listen to me then.
Misdiagnosis – Borderline Personality Disorder
Upon my second attempt at 24 I was referred by my GP to a mental health nurse who confirmed my suspicions that I could have Bipolar Disorder and referred me to a psychiatrist who diagnosed me with Borderline Personality Disorder. The 9 symptoms of Borderline Personality Disorder are
- Fear of abandonment. Borderlines have an intense fear of abandonment which often stems from childhood, it is also possible to experience this without having BPD due to experiences in your past, anxiety, ptsd, etc.
- Unstable relationships. Borderlines relationships go up and down along with their moods, something that can also be experienced through periods of mania and being overly sociable the life of the party, impulsive, destructive, and depression where socialising becomes too much to consider.
- Unclear or unstable self-image. Borderlines have an unstable sense of self, something I believe can also be experienced through being undiagnosed Bipolar. You are a different person when you are manic, when you are depressed, and when you are stable. You don’t have different names or memories but your perspectives and decision making among other behaviour is completely different, you think differently.
- Impulsive, self-destructive behaviours. Borderlines are impulsive and often destructive, this is also seen in Bipolar 1 Mania once it reaches a certain level. Mania is dangerous when it becomes destructive.
- Self-harm. This is only seen diagnostically speaking within BPD however many sufferers of depression, anxiety, bipolar, ptsd etc can suffer from self harming behaviours or ideologies that can be extremely painful to experience and can hinder recovery.
- Extreme emotional swings. The difference here between bipolar and borderline mood swings are the timescales, borderlines go up and down in a matter of hours whilst bipolar take days or weeks or even months. Except that is in mixed episodes, or when on the wrong medication, or when rapid cycling…
- Chronic feelings of emptiness. Borderlines feel lonely, empty. This is also experienced within depression.
- Explosive anger. Borderlines are known for having a temper they cannot control, they really cannot control it do not forget this if you know a borderline. So can bipolar’s when they are manic, or in a mixed episode, they experience anger, irritability, rage, impulsive outbursts etc.
- Feeling suspicious or out of touch with reality. Similar to Bipolar Disorder, psychotic features form a part of borderline, these mostly include disassociation and hallucinations. Both of which are seen among other disorders such as Bipolar, Dissociative Identity Disorder, and more.
As I noted the key difference is the timescales that these two disorders display their symptoms, borderline being much quicker than bipolar in most typical cases (not to include mixed features). So timescales play an important part between diagnosing Bipolar and borderline, yet there is just no information out there on these timescales specific to the UK.
Diagnosed as Bipolar
Finally upon my third attempt I was diagnosed as bipolar, due to experiencing ‘periods of elation and depression’ that were ‘not for like 10 minutes’ according to my psychiatrist. Again, timescales here mattered but he did not specify. Instead it appears to be a judgement call by the professional, no wonder it is common to be misdiagnosed on average of five times before receiving the diagnosis of Bipolar Disorder.
I was expecting to receive a specification, detailed understanding and treatment plan following my diagnosis. Instead my treatment has been a stab in the dark and an attempt to rectify damage done by BPD medication. I do not understand why this time was different to prior ones except for I went prepared with my whole story. I feel I could have so much more information to go on for my treatment and self care if I had a sub diagnosis.
When you research UK specifications it goes no further then your GP will refer you to a mental heath specialist who will ask you questions to determine if you have Bipolar Disorder. Useful.