Bipolar Disorder: Screening Overview

This podcast provides general information, not a substitute for professional medical advice. Please consult your physician for personalized guidance. Hello, hello everyone. Welcome back to PsychRounds. We are going to be starting a very special series. It is going to be four parts. And this is going to be about bipolar disorder. So today we're going to be kicking off the very first episode. And what are we going to focus on? Well, it's going to be the basics of bipolar disorder and how to screen for it. We are joined by Dr. Larry Wing and Dr. Bradley Miller. So let's get into it. So I feel like this episode is important because bipolar disorder is one of the most commonly over diagnosed conditions in psychiatry. But it can also be one of the most frequently missed. So how should we conceptualize bipolar disorder overall? So Dr. Miller and I were actually talking about this the other day. And I think to think of bipolar disorder as a mood disorder may not be the most useful way to conceptualize it. So the pathophysiology of bipolar disorder actually appears to be heavily related to circadian rhythm and energy just as much as anything related to mood. And this can often get missed if you're just looking at DSM criteria. Yeah, and speaking of DSM criteria, let's go over those right now. So the symptoms of a manic or a hypomanic episode as defined by the DSM 5 TR can be remembered by the classic mnemonic that we have all used pretty much in medical school in residency dig fast. So what is that spell? So for students listening, do not forget that it will come in handy. So what is the D stand for the D stands for distract ability? The I stands for in discretion. The G for grandiosity or inflated self esteem. The F for flight of ideas, the A for increased goal directed activity, the S for decreased need for sleep and the T for talk it. Additionally, there is a time specifier of at least four days for hypomania and seven days for mania. So this is very important to remember. I'm going to go through it just for you all one more time very quick. So what I find kind of problematic about this is that a lot of these symptoms are non specific. So for example, if someone's more talkative than usual, distractable having flight ideas, you see a lot of these symptoms in anxious people. For example, one of our co-residents Jared when he was writing the pride exam this year, but at the same time it doesn't mean he was manic. So basically at the core of this illness, what it is basically is a period of elevated mood concurrent with a period of sustained decreased need for sleep. And when I say decreased need for sleep, I don't mean that you pull to all nighters while drinking caffeinated beverages that you bought from 7/11 all day before the pride exam. So manic patients often actually feel normal or sometimes even more energetic when not sleeping without the influence, of course, of any psychoactive substances. Just to jump in the most common mistake I see when it comes to screening for bipolar disorder is to ask the questions one out of time failing to specify that these are all occurring at the same time concurrently. If you ask someone if they've ever been more irritable than normal and then ask if they've ever been more talkative than normal, they may be referencing separate times in their memory rather than a particular episode. And everyone has been more irritable or related at some point. So especially if you're learning to do this screening, keep that in mind. Yeah, and I think those are both very good points Larry and Brad, you know, you talk about a Larry with focusing in on that period, especially with the sleep and Brad as well focusing in on that time frame of whether or not it's concurrent or not. Very important and distinguishing bipolar and diagnosing bipolar disorder. So with that, my next question is what is the relationship between bipolar one and bipolar two disorder? Because I know that bipolar two disorder is primarily slanted towards the depressed poll of an illness, but generally does not impair functioning to the same degree as patients who are hospitalized typically in bipolar one disorder. So is bipolar two disorder just a mild version of bipolar one? What are your thoughts on this guys? Yeah, it's important to specify that the less impairing of functioning is specifically referring to manic symptoms. So it's a common heuristic and it can sometimes be useful at times to think of bipolar two disorder in this way, but to think of it purely as diet bipolar one is aromias. It's on the same spectrum, but the presentation can be quite different. So for both versions of bipolar disorder, there is more time spent depressed to then elevated, but like doctor, he would said those with bipolar two disorder have more depression for dominant polarity. And bipolar two disorder may be less severe in terms of these manic symptoms, but overall it can be more chronic and malignant contributing to a high disease burden. Research appears to be going in the direction that bipolar two may have equivalent or even higher morbidity than bipolar one. When thinking about why this is, it can partially be due to the fact that bipolar two is easily missed. Average diagnostic delays about 11 years, resulting in significant period of suboptimal treatment. One of the issues is that many screening questions used for bipolar disorder just miss the mark when it comes to finding hypomania. Remember, these are episodes are good in the eyes of the patient. They may even be when they feel at their best and the most functional. So in particular, when thinking about hypomania, screening really should account for the fact that the patient has just increased self esteem rather than a delusional or exaggerated level of grandiosity. So one screening tool, the HDL32 has some good questions to use to point you in the right direction for this, such as asking if during this phase they feel more self confident or more creative rather than asking if they have superpowers or on top of the world. Yeah, I think that's a very good point there, Brad, talking about these different ways to try to tease out what the true diagnosis is because I think the theme with this episode in particular is that someone can present with that classic dig fast criteria that I just touched on in the beginning of this episode, but that doesn't necessarily mean they have bipolar disorder. So my question for you, Larry and Brad is since this condition is often over diagnosed and anxiety disorders can be one of those contributing factors to a mister over diagnosis. What about the common presentation of borderline personality disorder overlapping with bipolar disorder? I know for a fact that these patients, you know, if we talk about the classic, uh, bright exam or the step exam, right, these board exams, we take the patients in the question stems often present as younger females with self harm. Maybe they have broken up with their boyfriend, correct, have racing thoughts and falsivity and severe mood swings, right. If I take them through that dig fast criteria, it sure sounds a lot like bipolar disorder, right. Um, but with that a lot of the time I find that these types of patients actually want to be diagnosed with bipolar disorder and I don't want to make over generalizations here because that sure is not every patient, every patient is unique, right with their diagnosis and their journey. But that has been an anecdotal trend that I've seen. So why is this? Well, it could be attributable to that. It sounds better than telling your patient, you know, hey, you have a personality disorder, which they may often perceive to be their fault rather than attributing it to something like a manic episode that's a result of a true bipolar pathology. So any thoughts on these views, Larry or bread? Yeah, so I really like to emphasize the phasic versus the immediate or reactive distinction here in mood fluctuation as this is probably easiest to find and the most critical in terms of diagnostic clarity. So one question I might ask patients is does your mood switch more in the span of hours to a day or from days to weeks, obviously and borderline personality disorder, you're going to be seeing a lot more of this immediate reactivity in the span of, you know, one minute I'm on top of the world and then the next hour I'm depressed. and many of those switches per day. Another thing to look at is that the sleep patterns and energy patterns tend to be quite different. Like mentioned before by Dr. Wang, the underlying factor here is that in a manic episode, you have a prolonged period of abnormal energy. And this is not something that you'll see in such a prolonged way in borderline personality disorder. - Yeah, and I just wanna jump in and say that probably the best line I've ever heard on this differentiation was along the lines of bipolar disorder is a disorder of rhythm and energy while borderline personality is a disorder of forming secure attachments. So although some of the symptoms overlap, they're fundamentally different. Now, to be fair at the same time, sometimes you can have both. So looking at the data, it looks like about 10% of those with borderline personality have bipolar one disorder and another 10% of bipolar two disorder. And similarly, cyclothymia. So this is kind of a more mild form of the illness is more commonly seen in borderline personality than in the general population. Another confounding diagnosis that I often see is substance or medication-induced mania. So especially with things like cocaine and methamphetamine, so stimulant medications, the patient will often present like they have bipolar one disorder with psychotic features. And I find that unfortunately, some of these patients get slapped with a diagnosis of bipolar or a schizofective and this ends up staying in their medical record and they get put on medications, which I don't think they necessarily need long term. - Yeah, absolutely, Larry, I think that's a good point is, you know, these patients coming in, maybe they are under the influence of a substance and they are hitting all of the criteria, but the theme of this episode is kind of like pause, hit the breaks, dig into it, ask the right questions for your patient because some of these things can look like a bipolar diagnosis, but that might not be the true pathology. So one of the things though that I do need to mention is that substance use and bipolar can be co-morbid conditions. In fact, bipolar patients do use substances at a higher rate than the general population. So this is really where careful history taking is very important. So with both your patient and as always good collateral contacts. Now if the patient is only having manic like episodes in the contacts of substance use, then you can probably guess that it's not a true bipolar disorder. Now in addition to the DSM, there are other screening tools for bipolar disorder that we have in our toolbox. So the first and probably most common one is the mood disorder questionnaire. The acronym is MDQ. Now this is often seen in primary care physician offices. Now would you like to talk about this? Dr. Miller and kind of give our audience a rundown on what the MDQ is? - Yeah, so first of all, I'm glad we're going through this screening tools because even if you don't directly use one of these looking into them and getting an idea of the questions they ask and the symptoms they point to, can be a good way of supplementing your own diagnostic interview as well. But anyway, more to the point, the MDQ is honestly, I have more negative to say about it than I do good, but it's still a reasonable screening tool in the absence of nothing. This was developed in 2000 and it basically has a series of questions based on the diagnostic criteria. And sensitivity ranges depend on the population. So in psychiatric clinics, the sensitivity is about 0.73 and the primary care setting is about 0.58, but when applied to the general population, it had a sensitivity of around 0.28. And specificity is around 90% in several studies. So when looking at this, note the really low sensitivity and the MDQ relies on patients to identify that the mania is harmful to their life. And as we kind of hinted at before, this might not be the best requirement, especially because those in hypomania feel that it's the best version of themselves and so to with mania. There's a lot of lack of insight during those states as well. So it's not my favorite as a screening tool, but if it's positive, you may have some good evidence for bipolar disorder. - I mean, personally, I'm really surprised that the sensitivity is low and the specificity is high. So when I was doing my off-service rotations, I was in a family practice clinic and a lot of the patients who I thought for a cluster B personality would frequently score positive on this screening tool. So maybe I'm just a bad-dike nustition then or. - Yeah, Larry, I wouldn't say necessarily as likely that could be the demographic of the 10% false positives with that 0.9 specificity. I will say though, like Dr. Miller and you were going on that we do have some other screening scales. One of them that I have written down here is the bipolar spectrum diagnostic scale, acronym BSDS. So what about this one, Brad? - Yeah, so this one's pretty interesting. This was developed shortly after in around 2005 and the study I was looking at for this said sensitivity around 76% and specificity around 85%. So similar specificity, but the sensitivity was brought up a bit. So in my opinion, kind of an underrated one. It has a narrative sort of a format and it will describe what a typical man extent looks like and patients will indicate positive for statements that fit that they've encountered before in these states. It also has a unique benefit of distinguishing narratively what a uzi-mex state looks like as well and this existence of a uzi-mex state is even a point which I haven't seen in other bipolar rating scales. So granted sensitivity arguably is a bit better to look at than specificity here and in this way it seems to do a lot better than the MDQ screening for both bipolar one and bipolar two. And in my opinion, definitely beating MDQ or bipolar two is good. - All right, so that's two down. I think next we have the bipolarity index and just looking at this one quickly, I see the name Dr. Chris Aiken, who's from the Carlisle podcast and he was involved in the creation of this. So tell us more about this one. - Yeah, so like you said, this one, the bipolarity index was developed by Gary Sachs and Chris Aiken in around 2005, or sorry, excuse me, 2015. Sensitivity and specificity are both pretty high around 90%. One key difference is that this is a clinician rating scale rather than a questionnaire you give to patients. This makes it potentially more objective and avoids potential for patients with personality disorders to screen false positive very highly. But I personally feel that this has some drawbacks and it moves away from the position of an ideal screening tool. If you're already interviewing a patient and finding out this information, sure, this could be very useful to help objectively work through and confirm your suspicions or add as a diagnostic point for your suspicion of bipolar disorder. That said, in my opinion, the purpose of a screening tool is something a primary care doctor and outpatient physician can hand to a patient, check back in a few minutes and see if they need to examine further. This being provider given is less useful for that regard, but still the stats are very much in its favor. - So last but not least, we do have another screener available to us and this one actually is newer. This is called the Sydney bipolar screener. So let's talk about that to finish it off. - Yeah, so this one's very new, developed in 2021 to 2022-ish. And this one is interesting because they developed it with machine learning. Now my rudimentary understanding of this process is that they fed machine learning algorithm, a description of the symptoms of people who had self-reported their manic episodes. And it found commonalities that led to the highest sensitivity and specificity for these episodes. So looking at this, it's very interesting. It's a very short diagnostic scale, but it reportedly, in patients with a history of depression, had a 97% sensitivity and specificity cutoff. So that's quite remarkable. The only thing I'll add is that you can get a lot of these forms if you're looking to try to acquire them from we mentioned Chris Aiken, his website, www.treatmentcenter.com. - All right, well, thanks for going through those with us, Dr. Miller. We're gonna wrap it up here because I know we went a little over time on this episode, but before I close, I just wanna reiterate some of the very important points in themes of this episode. The first is going to be that you need to dig into the diagnostic process for the disorder. Once a patient, and has the diagnosis of bipolar disorder, it often will end up on their medical record for quite some time, maybe even their life, right? And they may additionally receive inappropriate treatments as well with an incorrect diagnosis. So take your time with making a bipolar diagnosis, right? Go through the process and roll out other presentations that can frequently look like bipolar disorder in a manic episode, but might actually not be, right? I will say that another theme of this episode is that bipolar disorder is a highly biological illness. It can be a disorder of circadian rhythm and energy, not necessarily the mood swings, which is what a lot of the population and our patient population quickly think it is, right? Now I will say that this brings our episode to an end. So thank you for listening as always everyone. We are going to continue on with our next episode of the bipolar series next week. We're gonna be doing a deeper dive into the circadian rhythm and energy, which I mentioned briefly. And we also will be looking at the pathophysiology of bipolar disorder. So thank you everyone. We will see you next time and have a great rest of the week and a great weekend. Thank you for tuning in.