Is Bipolar Disorder Overdiagnosed? Who Is At Risk Of Being Misdiagnosed With It?

To get the right treatment, you need the right diagnosis — this is one of the more obvious foundations of modern medicine. 

Bipolar disorder is, you may have heard, incredibly difficult to diagnose — it takes many patients years and years of mental health visits and cries for help before they finally get the right diagnosis. Many people who are actually bipolar are wrongly diagnosed with unipolar depression, because they're only in contact with mental health professionals during depressive phases. 

What conditions are most likely to be misdiagnosed as bipolar disorder, and why?

First, a refresher course: What is bipolar disorder?

"Bipolar disorder" isn't one thing. The fifth (and current) edition of the diagnostic and statistical manual of mental disorders, the DSM-5, has a whole chapter on "bipolar and related disorders", which covers a myriad of diagnoses:

• Bipolar I disorder
• Bipolar II disorder
• Cyclothymic disorder
• Substance- or medication-induced bipolar and related disorder
• Bipolar and related disorder due to another medical condition
• Other specified bipolar and related disor­der, and unspecified bipolar and related disorder

The DSM-5 chapter on bipolar and related disorders is sandwiched between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders to recognize the fact that these disorders feature aspects of both. 

You're probably familiar with the fact that bipolar disorders are characterized by extreme mood changes, or "mood episodes", and know that the two more extreme ones are mania and depression. 

• When someone with bipolar disorder suffers a depressive episode, they'll meet all the diagnostic criteria for major depressive disorder — which includes symptoms like feeling sad, empty, tearful, and hopeless, losing interest in important tasks and finding it hard to carry out their daily responsibilities, feeling hopeless, and — in some cases — having suicidal thoughts. 
• Mania is a "supercharged" mood episode during which someone feels incredibly energetic and "jumpy". Someone experiencing mania may feel euphoric or very irritated, but these mood episodes can be thrilling either way, and manic people may feel like they can do anything. They may lose touch with reality and engage in rather risky behaviors. 

Bipolar disorder — and the specifics will vary depending on the exact diagnosis — also comes with periods of remission ("typical mood") and other mood episodes, however. 

Hypomania is a less extreme form of mania during which someone is high-energy, has lots of racing ideas, is very talkative, and doesn't need much sleep. Though someone going through hypomania will have increased (and even grandiose) self-esteem, there are no psychotic features, no hospitalization is required, and the person can, with effort, keep up with the responsibilities of their daily lives. 

Some people also have mixed episodes, with features of depression and mania at the same time. 

Conditions that may be misdiagnosed as bipolar disorder

The conditions that may be misdiagnosed as bipolar disorder are, of course, the ones that have sone symptom overlap. This includes major depressive disorder (unipolar depression), of course (and we won't be covering that one in more detail because it's obvious how such a misdiagnosis can occur), but reaches far beyond it.

Borderline personality disorder, a condition characterized by volatile and intense interpersonal relationships, impulsive and reckless behaviors, fears that the person will be abandoned by loved-ones and efforts to prevent that, suicidal feelings, and — pay attention to this — highly changeable moods, has the potential to be misdiagnosed as bipolar disorder. 

People with attention deficit/hyperactivity disorder (ADHD) tend to be obviously fidgety and restless, and are easily distracted unless they're hyperfocusing on something meaningful to them. Their high-energy levels and impulsiveness may give the impression of hypomania. It is not hard to see why ADHD can be misdiagnosed as bipolar disorder (as well as vice versa, particularly in children), especially if someone with ADHD has been depressed already and a gradual return to their normal may be seen as signs of hypomania.

People on the autism spectrum, too, can be misdiagnosed with bipolar disorder. This is especially true for highly-verbal autistic people who would have previously qualified for an Asperger's diagnosis. The social and behavioral differences autistic people have may be falsely attributed to depression (as a person is intimidated by new or overwhelming environments) and mania or hypomania (as they are excited and display "racing thoughts"). Women, who are more likely to be overlooked for an autism diagnosis due to the false idea that males are much more likely to be autistic, might be particularly vulnerable to this kind of wrong diagnosis. 

Then, there's narcissistic personality disorder, the grandiose self-image, sense of entitlement, and feelings of "specialness" of which can resemble a manic episode in bipolar disorder rather a lot. 

A final word

As scientific research advances and we gain better and better insights into bipolar disorder and the brain in general, it's becoming clear that bipolar disorder is both underdiagnosed and overdiagnosed. That is, some people are being given diagnoses that they shouldn't have.

This can have far-reaching consequences, because though several conditions might have overlapping symptoms, that doesn't also mean they are managed or treated in the same way. Someone with major depression or ADHD won't best be served by mood stabilizers, for instance. 

It's important to take the fact that people can have more than one diagnosis at once into account as well. Some people weren't wrongly diagnosed, but simply weren't fully diagnosed — they may really have bipolar disorder, but also, for instance, ADHD. 

The right diagnosis remains the key to the best possible care, after all.