Challenges in Defining and Diagnosing Bipolar Due to Variations


All mental disorders have a range of symptoms and severity, but the most varying symptoms and severity may be with bipolar disorder. The range of mania and depressive episodes can make diagnosis a challenge for physicians and therapists.

Clinicians attempting to diagnose the disorder and experts attempting to define it both face difficulties. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the resource that provides diagnostic criteria for mental health disorders. The DSM attempts to capture the many variations and provide a list of criteria, including the cycling of manic and depressive symptoms. In a manic phase of the disorder, a patient may become extremely restless, irritable, unable to sleep and engage in risky pleasurable activities. In a depressive state of the disorder, the patient may experience deep feelings of hopelessness or sadness and a lack of motivation. Either phase can last for variations of time.

Some patients may experience a mixing of the two extremes. A patient can feel hopeless and sad while experiencing sleeplessness and a high level of irritability. Clinicians sometimes describe the two extremes as “onion symptoms” and “garlic symptoms.” Onion symptoms are the depressive symptoms, so-called because they tend to bother the patient long before they affect others. Garlic symptoms, on the manic end of the spectrum, tend to bother others before the patient notices them.

There are a variety of bipolar disorders. Bipolar I disorder is used to describe patients that are more extreme on the manic side of symptoms, while bipolar II is more heavily weighted with depression, with mania taking more of a side role. Cyclothymic disorder describes mood swings that occur in frequent shifts and never fully develop into depression or mania. Another is bipolar disorder “not otherwise specified,” which captures those patients that do not precisely fit into another category for diagnosis.

Bipolar II may appear milder than bipolar I, but it can be quite disabling, with the depression phase long-lasting, severely affecting the patient’s quality of life and ability to function.

Cyclothymia may also seem a milder version of bipolar disorder, but the patient’s stability is almost never intact, with stable periods lasting less than two months, and the patient not able to achieve goals or look forward to making any lasting plans.

With symptoms and severity so varying, the treatment for bipolar disorder can be challenging. Clinicians rarely see a patient with symptoms that fit neatly into the DSM description. The new fifth edition, or DSM-5, is the product of experts seeking to produce a definition that more closely resembles what clinicians see in practice. The team that developed the new criteria tried to address problems, such as the time lag between the onset of symptoms and an accurate diagnosis.

The DSM may never perfectly capture the variations seen by clinicians in practice, but the new criteria may help patients receive the diagnosis and treatment they need to reduce the severity of their symptoms and improve their quality of life.

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