Study Highlights Diagnostic Challenges in Distinguishing Bipolar Disorder from Other Mental Health Conditions

Bipolar disorder is a disease that is still unclear in psychiatry. Chronic in nature, the disorder causes behavioral abnormalities in those affected. Alternating between states of mania, when patients are more agitated, and hypomania, periods in which depressive symptoms set in, sufferers often seek psychiatrists and specialists in cases of hypomania, making it difficult to differentiate the spectrums related to bipolar disorder. According to the Brazilian Association of Bipolar Disorder (ABTB), approximately 8 million Brazilians suffer from bipolarity. To better understand the subject, we spoke with Professor Doris Moreno, a psychiatrist who graduated from the Faculty of Medicine of the University of São Paulo (FMUSP) and is an expert on the subject. 

Characteristics of bipolarity

 “Bipolar disorder is a chronic and recurrent brain disease that begins around 18 to 22 years of age. It begins with the first symptoms in childhood, and develops clearly or more clearly in adolescence until the age of 25. By the age of 30, at the latest, most of those affected have already developed the problem fully. The characteristic of this disorder is phases, periods in which the person enters what we call mania or hypomania, which are alternating phases between depression and agitation,” he explains. 

According to the specialist, depression in cases of unipolarity tends to begin developing later, being characterized by continuous symptoms. “People who only have depression during their lives, according to studies in the general population, tend to start the problem ten years later. Therefore, the depressions characteristic of bipolar disorder tend to be much earlier, because the disease begins much earlier.” 

Bipolar disorder is divided into several variants, which can have different subtypes. Subtype 1, considered “classic bipolar disorder,” is characterized by frequent episodes of mania, periods in which the person becomes more irritable, aggressive, and agitated. “People become much more aggressive, irritable, faster, more talkative, and impulsive. They say what they think, they break down their filters, and they may engage in risky behaviors due to their high impulsivity. Whether it’s drinking, taking drugs, having sex, shopping, or adopting a more flashy look, it’s a predisposition to controversy in all spheres. This draws a lot of media attention and makes headlines. The milder counterpart, which is hypomania, doesn’t have as big an impact.” 

Subtype 2 is characterized by the prevalence of hypomania cases. According to the professor, these are the cases that generate the most concern regarding diagnosis and treatment. Because they have less striking symptoms and are more similar to those of unipolar depression, they often cause difficulties in identifying the correct condition.   

“It usually goes unnoticed and that is where the problem of differential diagnosis lies. Because people seek treatment when they are depressed. And depression, by itself, does not differentiate whether it is unipolar or bipolar. The doctor needs to be an expert in identifying in a person who is depressed, who often can barely realize how they are, whether the case is unipolar or bipolar. Depression slows down, leaves the person discouraged, without pleasure in things, very negative. It increases or creates problems and usually does not remember previous episodes in which they had hypomania or mania. And this is essentially what makes the diagnosis of bipolar disorder, the occurrence, during life, of periods of four days or repeatedly of one, two or three days, of both mania and hypomania. And, in general, what happens? People take around ten, 15 years, on average, to be diagnosed”, he warns. 

Bipolar genome

In addition to cases of hypomania and mania, the patient’s family history is also a determining factor for diagnosis. According to Doris Moreno, the disease is “eminently” and “mainly” determined by a complex genetic load, generating this vast range of symptoms and variants of the disorder’s manifestation. “In families, we can identify a so-called bipolar spectrum. There are dozens of genes that impact the manifestation of the disorder, generating different bipolarities in families, because several members in the family are usually affected by bipolar disorder, to a greater or lesser degree. This depends on the genetic load inherited from both the father and the mother. What causes the disease to appear is a sum of several of these genes that generate the predisposition for bipolar disorder. So, there is not a single gene responsible for the disorder, but rather a huge combination of small effects that add up,” she explains. 

“That’s why there are people in the same family who predominantly have periods of depression, people who are extremely agitated, who are predominantly accelerated, energetic, talkative. People who have a mix of everything, so they oscillate between everything; people with bipolar disorder type 1 and type 2, because they are being affected by different combinations,” he adds. 

Action in the brain

The brain affected by the disorder suffers from a series of changes in impulses that disrupt the normal functioning of the nervous system. “There is a failure, a change in the connection between several areas of the brain, mainly the area responsible for impulsivity and emotions, and the prefrontal cortex, which modulates behavior and emotions, which disinhibits or controls what is most impulsive in the person, or most negative or most energized. So there are different changes in communication between various regions of the brain, differences in both excitatory and inhibitory processes, linked to various neurotransmitters that act precisely by inhibiting impulses or stimulating impulses. That is why we have a complete disorganization between these various impulses that become contradictory,” he says.

“Another very important characteristic that has been the subject of study in recent years is a change in biological rhythms, in circadian rhythms, which constitutes an important area of ​​study. Because it is more objective, these are changes in sleep and energy that can be measured, for example, in actigraphy. This is another area of ​​study that also aims to assist, in the future, in the differential diagnosis between unipolar depression and bipolar disorder, because this increase in activity during many hours of the day will start to be measured objectively,” he adds. 

The professor also points out the strong stigma associated with bipolar disorder. Some other disorders have gained the status of “special” in the eyes of the public, while bipolar disorder remains a kind of “ugly duckling” that people tend to resist when they receive the diagnosis. “There is a huge prejudice against the diagnosis of bipolar disorder. It is much more fashionable to have ADHD, borderline personality disorder or be on the autism spectrum. Yes, this exists, we know it. When we tell the patient and confirm the diagnosis of bipolar disorder, they don’t like it, but they would love to receive the diagnosis of ADHD,” she concludes.