Using Symptoms in Diagnosing Bipolar Disorder

Why Is It So Difficult to Diagnose Bipolar Disorder With Symptoms?

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What are the symptoms used in diagnosing bipolar disorder and why does this make an accurate diagnosis so difficult?. Tara Moore/Taxi/Getty Images

Ask almost any individual with bipolar disorder about how they were diagnosed. You will probably hear of a long and difficult journey through many wrong turns and misdiagnoses based on their symptoms, numerous dead ends and new doctors. The path likely included abundant changes of direction and differing medications before arriving at the correct diagnosis of bipolar disorder.

Why is this so often the case? It's because the list of psychiatric conditions with symptoms similar to the symptoms of bipolar disorder is rather long. To further complicate the picture, most of these disorders can also occur with bipolar disorder.

And the overlap is not only with symptoms. Recent studies are finding a possible genetic basis responsible for some of this overlap, and even imaging studies of the brain show some remarkable similarities.

Psychiatric Conditions Which Overlap With Bipolar Disorder

There are distinct diagnostic criteria that have been proposed for bipolar disorder, but even with these criteria, the diagnosis is far from easy. Psychiatric conditions that can manifest symptoms similar to bipolar disorder include:

Attention Deficit Hyperactivity Disorder (ADHD)

Hyperactivity and distractibility are two of the hallmark symptoms of attention deficit hyperactivity disorder (ADHD.) However, they are also quite predominant in bipolar disorder, especially as it relates to children.

Many children diagnosed with ADHD are later diagnosed with bipolar disorder as well.

Alcohol/Substance Abuse

It is very common for those with bipolar disorder to struggle with alcohol and substance abuse issues. This is often an attempt, even on an unconscious level, to self-medicate. Additionally, the effects of these drugs (such as hallucinations or the inability to sleep) can be confused with the symptoms of bipolar disorder.

In addition to these concerns, alcohol may interact with the medications used for bipolar disorder.

Borderline Personality Disorder

The diagnostic criteria for borderline personality disorder include impulsivity, suicidal behavior, reactivity of mood, inappropriate anger, and paranoia. All of these are also associated with bipolar disorder. It is possible for an individual to be diagnosed with both of these disorders as well. (Learn more about the similarities and differences between bipolar disorder and borderline personality disorder.)

Delusional Disorder

The hallmark of delusional disorder is nonbizarre (the situations are possible) delusions. Mood episodes can be a symptom but they are brief in duration and are part of the delusion. If a doctor is not aware of the delusion, the mood may appear to be incongruent to current circumstances and therefore confused as bipolar disorder.


The one thing that distinguishes unipolar depression (clinical depression) from bipolar disorder is mania/hypomania. If a patient with depression swings into an episode of mania, the diagnosis becomes bipolar disorder. Many people who have undiagnosed bipolar disorder are found to have the disorder when medications such as some antidepressants are started and precipitate mania.

Eating Disorders

It is not uncommon for those with bipolar disorder to experience eating disorders. Moreover, depression, anxiety and irritability often result from eating disorders. Anorexia nervosa is an eating disorder characterized by an extreme fear of gaining weight or getting fat. Those with this disorder often have a body weight of less than 85 percent of that which is considered normal. Bulimia nervosa is typified by periods of binge eating followed by purging (purposely vomiting).

Panic Disorder

Panic disorder is characterized by recurrent, spontaneous panic attacks. In that these attacks are traumatic, they do create instability of mood which may be confused with the mood episodes of bipolar disorder.

Furthermore, panic attacks are also common in those with bipolar disorder.


Schizophrenia is a mental disorder that causes intense disturbances in both cognition (thinking) and emotions (feeling). It consists of two classifications of Symptoms—positive and negative. Positive symptoms include delusions, hallucinations, disorganized speech and thinking, disorganized behavior, catatonic behavior, and inappropriate moods. Negative symptoms are flattened emotions, lack of speech and a reduction in goal-directed behavior. The symptoms of schizophrenia are easily confused with those of bipolar disorder.

Schizoaffective Disorder

A diagnosis of schizoaffective disorder is given when the symptoms of both schizophrenia and bipolar disorder (predominantly mania) are both present—occurring simultaneously. If the symptoms alternate or are not present throughout an episode, a diagnosis of schizophrenia or bipolar disorder (perhaps with psychotic features) is more likely depending on the dominant symptoms. As you would expect, there is a great deal of confusion and controversy surrounding this disorder.

Bottom Line on Symptoms of Bipolar Disorder vs Other Mental Health Conditions

Even today, it's common for a person to not have a definitive diagnosis of bipolar disorder. Sometimes a few of these diagnoses are combined to describe a constellation of symptoms, such as with schizoaffective disorder. Other times doctors use the term "working diagnosis" to describe a situation in which a doctor and patient will work together under the presumption that they are treating a particular diagnosis, but without certainty that the diagnosis is correct. It's also common for people to have their mental health diagnosis change as more symptoms become apparent.

Living with a mental health disorder can be very frustrating, even when a diagnosis is finally made and is clear. One of the most important things you can do is find a therapist you trust—one who can work with you as you go through the sometimes painful trials and errors of finding the best treatment. Everyone is different, and a therapist who "fits" for one person may be different than a therapist who is right for another.

It's also important to be your own advocate and take a very active part in your care. Nobody is more motivated than you are to control your symptoms. Suicide among people with bipolar disorder is far too common, and everyone living with the disorder should have a plan in place if they find themselves feeling suicidal. If you haven't yet done so, take a moment right now to complete a suicide safety plan. It's difficult to cope with a diagnosis of bipolar disorder, but treatments are available which have helped many people live happy and satisfying lives. 


American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th Ed.). Washington, DC. 2013. Print.

Baryshnikov, I., Aaltonen, K., Koivisto, M. et al. Differences and Overlap in Self-Reported Symptoms of Bipolar Disorder and Borderline Personality Disorder. European Psychiatry. 2015. 30(8):914-9.

Betzler, F., Stover, L., Sterzer, P., and S. Kohler. Mixed States in Bipolar Disorder—Changes in DSM-5 and Current Treatment Recommendations. International Journal of Psychiatry in Clinical Practice. 2017 Apr 18. (Epub ahead of print).

Witt, S., Streit, F., Jungkunz, M. et al. Genome-Wide Association Study of Borderline Personality Disorder Reveals Genetic Overlap with Bipolar Disorder, Major Depression, and Schizophrenia. Translational Psychiatry. 2017. 7(6):e1155.