Patients with bipolar disorder often present as a volatile mix of anxiety, depression, temperamental instability, which sometimes leads to a mistaken diagnosis of borderline personality, histrionic personality, or even psychopathy. What are some other historical and familial factors that act as clinical pointers to bipolar disorder? I have found all the following to be of assistance. Age of onset is important. Anyone meeting criteria for a major depression who is not yet 25 year old is considered bipolar until proven otherwise. Other clinical pointers are a high rate of recurrence, five or more episodes; each episode develops quickly and resolves quickly; depressions in the postpartum period especially if severe or psychotic; marked seasonality of episodes; atypical depressive presentation which includes hypersomnia, overeating and weight gain, tremendous fatigue, and interpersonal rejection sensitivity; hostile and labile mood as well as mixity which means hypomanic symptoms during depression; cycling with antidepressants; failure to respond to three antidepressants in sufficient doses from three different classes; bipolar family history; and family history of mood disorder in three generations. Also, the phenomena of tachyphylaxis is common. This refers to antidepressants loosing their effectiveness after a positive response.
Some studies have shown that there is a lag of almost 10 years between a bipolar patient presenting in a psychiatrist office and an accurate diagnosis of bipolar disorder is made. The most common mistaken diagnoses are major depression, panic disorder, anxiety disorder, and sometimes PTSD. Given the evolving data linking bipolarity and suicidality as well as episode progression, it is important to make the correct diagnosis and institute the appropriate treatment early in course of the illness. Viewing bipolar disorder as a mix of anxiety, depression, and temperamental instability and using the above clinical pointers to augment and add weight to this view is useful.