In the Spotlight: Psychodiagnostic Evaluations

by Dr. Alisha Brosse, Sutherland Bipolar Center Director

Given the dramatic portrayals of bipolar disorder in the media, you would think that bipolar disorder is easy to spot. Sometimes it is. But most of the time, it’s not. That’s why the Sutherland Bipolar Center offers extensive diagnostic interviews to people who wonder if they have bipolar disorder.

Why is bipolar disorder difficult to identify? First, many people with bipolar disorder experience depression as their first mood episode. If they seek help, they will be diagnosed with Major Depressive Disorder (MDD). There are no biomarkers (such as brain scans or genetic tests) to distinguish a depressive episode that’s part of unipolar depression from one that’s part of bipolar disorder. When they later develop symptoms of hypomania or mania, they may not report them to a treatment provider, so their diagnosis is not updated. Similarly, people with bipolar disorder tend to spend more time depressed than elevated. This means that depression is more salient to the individual and to his or her loved ones and treatment providers. It’s no wonder people with bipolar disorder are often diagnosed with MDD instead!

Second, media portrayals nearly always depict “classic” acute mania, in which the person is euphoric and maybe psychotic. This presentation is relatively easy to identify as bipolar disorder. But many people with bipolar disorder don’t experience euphoria. Instead, they are irritable or full of rage when manic. Many others with bipolar disorder have only mild escalations (“hypomania,” rather than mania). Although hypomania involves changes in the person’s usual behavior, the behaviors are still generally in line with social norms. So, a relative stranger – including new treatment providers – don’t realize that the person is more talkative, energetic, and active than usual.

These are some of the reasons bipolar disorder is frequently missed. But misdiagnosis also goes the other way: many people are diagnosed with bipolar disorder even though they don’t meet diagnostic criteria for the disorder. Why is this? One of the primary reasons is that professionals disagree on the boundaries of bipolar disorder. For example, some professionals will diagnosis someone with bipolar disorder if they report depression and anxiety, even in the absence of mania or hypomania. Another reason is substance use, which greatly complicates diagnosis. This is made even worse if the clinician doesn’t know the full extent of the person’s use of mood altering substances. We’ve also noticed a pattern of people with trauma histories being diagnosed with bipolar disorder even when their emotion dysregulation doesn’t fit the pattern of distinct mood episodes that defines bipolar disorder.

Proper diagnosis is essential. It guides treatment providers to the most effective interventions. It allows people to make sense of their experiences, and to access information about their condition and its management. When people with bipolar disorder first read about it, they often experience relief (“Oh, this explains so much!” or “Now I understand why I….”). When someone misdiagnosed with bipolar disorder reads about it, they often feel confused, misunderstood, or afraid that they must lack self-awareness since the descriptions don’t resonate.

The goal of providing psychodiagnostic evaluations at the Sutherland Bipolar Center is to give people clarity about their diagnoses, coupled with treatment recommendations specific to their unique needs. We use the same semi-structured clinic interview used in many research studies, and we assess not only mood symptoms but also other conditions that may be confused – or co-exist – with mood disorders (like anxiety, trauma, and substance use). The interview takes an average of four hours, split over 2-3 sessions; clients also complete questionnaires. When possible, the assessor also gets information from a family member or friend, past or current treatment providers, and/or hospital records.

We summarize the information gathered in a detailed letter to the client. We state clearly our diagnostic impressions and the evidence that supports them. We readily admit when we are unsure about a diagnosis. For example, we may suggest re-evaluation of symptoms after a period of sobriety from drugs or alcohol if the person’s mood symptoms have only been present during periods of drug use. Finally, we provide treatment recommendations, including referrals to specific providers or clinics. We review this report in a feedback session with the client (and family members, if desired).

Diagnostic labels enable people to access relevant information and proper treatment. But only if they are accurate. At the Sutherland Bipolar Center, we strive to help people find the right path to wellness.