Bipolar Misdiagnosis: Signs, Impact & Next Steps to Take

Why Is Bipolar Disorder Often Misdiagnosed?

Bipolar disorder has been misunderstood and misdiagnosed for decades. The criteria for diagnosing bipolar can be complex, and many symptoms overlap with other disorders. The symptoms of bipolar can vary and may not always fit what is expected. Between bipolar I and bipolar II, bipolar II is found to be more often misdiagnosed due to the underreporting of hypomania.¹

Unfortunately, bipolar misdiagnosis is widespread. A large survey of individuals with bipolar disorder showed that 69% had been initially misdiagnosed, with an average of 3.5  misdiagnoses before being correctly diagnosed with bipolar.² Overdiagnosis is also common, especially for individuals with borderline personality disorder (BPD). Studies show that between 40-56% of people with BPD are misdiagnosed with bipolar disorder.³

Factors that contribute to a bipolar misdiagnosis include:

Age

There is a lack of agreement on how common it is for children with bipolar to be misdiagnosed due to inconsistent criteria and methods. Researchers disagree on how common bipolar is in children and even how to measure it.⁴ One thing we do know is that the younger the age when symptoms first appear, the more likely that the first symptom to appear will be depression, resulting in a misdiagnosis of depression.⁵

There are also issues around older and elderly adults with late-onset bipolar being misdiagnosed. As people with bipolar disorder age, mania is more likely to present as irritability or agitation. Medications used to treat low energy or medical concerns can trigger mania in undiagnosed older adults, as can the use of antidepressants. Even urinary tract disorders, common in the elderly, can trigger a manic episode.⁶

Gender

Gender can also contribute to bipolar misdiagnosis. Men with bipolar have been shown to have more manic symptoms and a higher risk of substance abuse. These manic symptoms are often underdiagnosed, and substance use can mask the underlying bipolar disorder.⁷ Boys are more likely to experience manic symptoms than depression, which may be interpreted as normal hyperactivity and high energy or attention-deficit/hyperactivity disorder (ADHD).⁸

Women and girls are shown to have more depressive episodes, a later onset of symptoms, and greater adherence to medication. This can result in the misdiagnosis of unipolar depression, which will likely result in a worsening of symptoms if treated with antidepressants. In addition, pregnancy and postpartum can trigger bipolar, which can make it difficult to distinguish bipolar from perinatal mood and anxiety disorders.

Diagnostic Criteria

The diagnostic criteria for bipolar disorder are complex. A person has to meet the criteria for depression for at least 2 weeks or mania for at least 1 week. There are many different possible symptoms that can meet these criteria, and they vary. Children are more likely to have mixed episodes or quick bipolar cycles, which can make the diagnosis even more difficult.⁹

Bipolar II disorder presents additional challenges for diagnosis. Instead of mania, a person must have depression with episodes of hypomania. Hypomania is similar to mania but lasts up to 4 days instead of a week and can be less severe. Following a depressive episode, someone may simply feel that they are feeling better, have more energy, and are in a good mood rather than recognizing a hypomanic episode.

Overlapping Symptoms

Bipolar disorder has symptoms that overlap with many other disorders. The hyperactivity and impulsivity that characterize mania can also appear in ADHD, post-traumatic stress disorder (PTSD), and anxiety. Depressive episodes share the same criteria as unipolar depression, with the only difference being the presence of manic episodes. Schizophrenia or schizoaffective disorder can look a lot like a manic episode or bipolar disorder with psychosis.

Misunderstanding Mania

The DSM describes mania as “A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed behavior or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).” This leaves a lot of room for interpretation and can make diagnosis difficult. Mania can look different for everyone and even vary across different episodes.¹⁰

The stereotypical example of a manic episode is when someone becomes hyperfocused on a goal, needs little to no sleep, or engages in risky behaviors like spending, gambling, or sex. While mania may look this way for some, for others, it can present as anxiety, irritability, overthinking, or agitation. Elderly adults are more likely to experience mania as agitation, while children are more likely to present with a depressive episode first.

Differences in Symptom Presentation

A diagnosis of bipolar disorder requires both depressive and manic episodes, and because of this, there can be a wide variety of symptoms that show up. One person may have a couple of weeks of fatigue, weight gain, and sleeping all of the time, followed by a week of working nonstop. Another person may have a period of crying every day, being unable to sleep, and loss of appetite, followed by a period of irritability and agitation.

Children with bipolar disorder often have more extreme highs and lows in mood and energy levels compared to their peers. They may have behavioral problems at home or school and struggle with schoolwork or be impulsive and take risks. They may also have times when they feel very low, sad, and isolated, and even have thoughts of self-harm.¹⁰

Lack of Awareness

Many people are simply not aware that their symptoms could be due to bipolar disorder. They may only be aware of their depression or may attribute mania to other conditions like ADHD. For this reason, people are less likely to talk to their provider about their hypomanic or manic episodes or the cyclical nature of their symptoms because they are simply not aware of it.

Parents may not realize that their child’s symptoms could be due to bipolar disorder, interpreting them instead as normal ups and downs. Children and teens can have moods that change rapidly, and bipolar mania in kids can mimic normal mood fluctuations and behavior.

Stigma

Bipolar disorder still carries a stigma. This can cause people to be reluctant to talk to their provider openly about their symptoms. For adults, this can result in a delay in treatment. Stigma may cause providers to attribute symptoms to other conditions and can also lead to reduced self-esteem. All of these factors can create a barrier to people getting the proper diagnosis and help they need.

In children, stigma can lead to parents and providers failing to consider bipolar as an option. They may attribute symptoms to other disorders or normal childhood behaviors. Fears about how a child will be perceived and potential challenges they may face from the diagnosis can make parents reluctant to seek treatment. This can also contribute to parents not following the provider’s treatment recommendations.

Signs of Bipolar Misdiagnosis

One of the first indications of a possible bipolar misdiagnosis is that treatment isn’t working. Medication may not work at all or make symptoms worse. A person may find that they are taking the advice of their therapist or psychiatrist and doing everything they can for their mental health, but symptoms continue to persist or worsen.

Sometimes, this lack of improvement with treatment is what alerts providers to take a look at the diagnosis. A person may have bipolar, and they were diagnosed with something else, or they may be incorrectly diagnosed with bipolar. Either way, the purpose of a correct diagnosis is to help the provider create the right treatment plan. The bottom line is that the goal of mental health treatment is to feel better, so if it isn’t working, talk to your provider.

What Conditions Mimic Bipolar?

Many different mental health disorders mimic bipolar symptoms, which contributes to bipolar misdiagnosis. Symptoms that impact energy levels, appetite, weight gain or loss, attention, and mood all overlap between bipolar disorder and other conditions. These can all contribute to making the process of diagnosing bipolar versus something else complex and difficult.

Conditions that mimic bipolar disorder include:¹⁰

Attention-Deficit Hyperactivity Disorder

ADHD and bipolar share many symptoms relating to energy, impulsivity, and attention, which can lead to ADHD being misdiagnosed as bipolar or vice versa. Mania can result in high energy, increased activity, and risk-taking, all of which are also symptoms of ADHD hyperactivity. Depressive episodes in bipolar disorder can cause difficulty concentrating or focusing, which are also symptoms of ADHD inattention.

Depression

Depression and bipolar share many symptoms, with the primary difference being the presence of manic episodes in bipolar. Depression is the most common misdiagnosis for people with bipolar disorder. This can occur when manic episodes go unrecognized or are simply seen as a break in depression. This misdiagnosis can be dangerous because antidepressants are not effective for bipolar and may make symptoms worse.

Anxiety

Anxiety and bipolar symptoms can also be similar, leading to misdiagnosis.  Generalized Anxiety Disorder is a  type of anxiety that results in anxious and worried thoughts about a lot of different things, which is similar to racing thoughts that appear with mania.  Both depressive and manic episodes in bipolar disorder can overlap with anxiety, with depression causing rumination on negative thoughts or feelings of dread and mania causing irritability and agitation.

Borderline Personality Disorder

BPD being mistaken for bipolar is extremely common, with 40% of patients with BPD reporting a previous misdiagnosis with bipolar. BPD symptoms include problems with mood regulation, unstable relationships, impulsive and often harmful behaviors, and risk of self-harm. All of these symptoms are also present in bipolar disorder which makes the distinction especially difficult.³

Schizophrenia

Schizophrenia and bipolar can share several symptoms when a person with bipolar also experiences psychosis. Psychosis is when someone loses touch with reality, sees or hears things that aren’t there or has delusional or paranoid thoughts. People with both schizophrenia and bipolar can appear to be agitated, disorganized, or anxious.

Insomnia

Bipolar disorder can cause insomnia during both depressed and manic episodes, with manic episodes resulting in a reduced need for sleep and depression resulting in an inability to sleep. While insomnia can often result from bipolar disorder, it can be caused by many other things as well. Finding the cause of insomnia can be another factor that contributes to bipolar misdiagnosis.

Post-Traumatic Stress Disorder

Both bipolar disorder and PTSD cause changes in mood and thought processes. Some people with PTSD may experience impulsive outbursts, lack of sleep, and an increase in risky behavior, which are also symptoms of mania in bipolar. PTSD can also cause isolation, loss of interest in activities, and thoughts of self-blame, all of which are also present in bipolar depression.

Impacts of Bipolar Misdiagnosis

A bipolar misdiagnosis can result in someone continuing to experience symptoms for a longer period of time than they otherwise would. In some cases, for example, when depression is diagnosed, and SSRIs are prescribed, medication can trigger a manic episode. This can result in unstable moods or impulsive actions and outbursts, which cause severe problems in relationships, work, and school.

Bipolar depressive episodes are different than the depressive episodes that occur with major depressive disorder, and SSRIs by themselves are generally not prescribed because they can trigger manic episodes. This leaves a person who has been misdiagnosed as having depression suffering from severe depression. On the other hand, if someone is diagnosed with bipolar who doesn’t have it, this leads to overmedication and a potential worsening of other disorders.¹¹

A bipolar disorder misdiagnosis may impact someone in the following ways: 

• Reduced self-esteem: A person who has been misdiagnosed may start to blame themselves and wonder if maybe they are the problem. This can result in low self-esteem and self-worth, which has a ripple effect on a person’s life.
• Unaddressed underlying conditions: If a person is misdiagnosed as having bipolar disorder when they actually have another condition, that condition continues to go untreated. This will cause the problems that brought them to treatment in the first place to persist or even worsen over time.
• Unnecessary medication: An incorrect diagnosis, whether a bipolar diagnosis is missed or made in error, can result in the prescribing of medications that will be ineffective and possibly even harmful.
• Worsening symptoms: When symptoms go untreated, they often become worse over time. In addition, medications like stimulants and antidepressants can trigger mania in someone with undiagnosed bipolar disorder.
• Lack of improvement: When a misdiagnosis occurs, it is very likely that no matter what else happens, symptoms will simply not improve. Treatment will be ineffective and result in more time and money spent before getting relief.
• Problems in relationships: Bipolar and many other conditions cause problems in relationships due to symptoms including mood instability, impulsive actions, irritability or isolation. A lack of proper diagnosis can allow these symptoms to persist, continuing the misdiagnosed bipolar to harm the relationship.
• Problems at work or school: Untreated or misdiagnosed bipolar or other mental conditions cause problems in daily functioning, which include conflicts, problems, and difficulty meeting expectations at work or school.

How to Prevent Misdiagnosis

Getting a thorough psychiatric evaluation with a provider experienced in diagnosing and treating bipolar disorder can help prevent misdiagnosis. It is important to provide them with as much information as you can about your symptoms as well as family history. It is helpful to track symptoms with a journal or app so that your provider can see the patterns over time.

Most mental health diagnosis is done through interview and assessment of reported symptoms based on the DSM V. Sometimes, additional assessment tools and questionnaires may be used as well. Unfortunately, a brain scan to check for mental illness is not a standard protocol at this time, as it is expensive and often not effective at identifying conditions like bipolar.¹²

What to Do if You Think You Have Been Misdiagnosed

If you think you have been misdiagnosed, it is likely that trust has been broken, and you may not know where to turn. A good place to start is by talking to your primary care provider or therapist, someone who is aware of your symptoms and your progress over time. This person can review your symptoms with you and help you identify the next steps.

Here are five steps to take if you think you have a bipolar misdiagnosis:

1. Contact Your Primary Care Provider

A primary care provider is the central point of contact in your healthcare. They have access to your medical and mental health history. This is a good person to start with because they can review your symptoms over time and are also aware of any medical factors that could be playing a role. They can also provide referrals to mental health providers they trust.

2. Contact Your Psychiatrist

If you are seeing a psychiatrist, it is likely that they were the provider who made the diagnosis in the first place. The most direct course of action would be to talk to them about how you are feeling and the symptoms that you are still noticing. It’s very common for a psychiatrist to review progress, medications, and diagnoses on a regular basis.

3. Get a Second Opinion

If symptoms are not improving or are getting worse, and you feel that you are not being taken seriously by your current providers, it’s important to seek a second opinion. A second opinion can provide additional information and clarity about the diagnosis and can help you feel confident that you are taking steps to take care of your mental health.

Here are examples of questions to ask when getting a second opinion:

• Can you confirm the diagnosis?
• What is the most effective way to monitor my symptoms?
• What treatments are available?
• What is your experience with diagnosing bipolar?
• What type of bipolar disorder do I have, I or II?

4. Talk to Your Therapist

If you feel that you’ve been misdiagnosed, talk to your therapist. Not only is this experience likely to cause you a great deal of stress, which you can work through in therapy, but your therapist is also aware of your history. They can help you review your symptoms and look at the diagnostic criteria to examine whether they fit.

5. Schedule a Complete Neuropsych Assessment

A neuropsych assessment is a series of tests, usually conducted by a psychologist. This can identify brain-based disorders like ADHD, autism spectrum disorders, or any other cognitive issues related to learning and development. This can be a very helpful tool for finding the correct diagnosis.

How to Talk to Your Primary Care Provider About Misdiagnosis

If you think you may have been misdiagnosed, talk to your provider openly and honestly. Providers are human and are only going on the best information they have access to at the time. Assessment is an ongoing process, and your provider is likely to take your concerns seriously and take another look at the diagnosis.

Here are some steps you can take to prepare for a conversation with your primary care provider:

• Keep a diary of your symptoms: Keeping a diary of symptoms is especially helpful with bipolar disorder because it can help identify whether there is a cyclical nature or pattern to the symptoms. Some helpful things to track include time of day, mood, symptom intensity, and whether there were any triggers or stressors.
• Communicate assertively: Assertive communication is expressing your thoughts and concerns in a clear and direct manner. This is different than aggressive communication because assertive communication is done in a respectful manner while still clearly communicating your needs.
• Consider bringing a loved one: It can be helpful to bring a loved one or good friend along to provide support, take notes, and help you remember important details.
• Ask for your medical records: You are entitled to receive a copy of your medical records. If you suspect a misdiagnosis, these records can give you a timeline of your diagnosis and treatment, which will be helpful if you end up seeking a second opinion.

How to Handle Medication During a Bipolar Misdiagnosis

If you suspect that you have been misdiagnosed, talk to your provider before discontinuing or changing any medications. They will come up with a plan for you to gradually taper off the old medications and transition to new ones. Many medications can cause withdrawal symptoms if stopped cold turkey, so this is not advised.

How to Emotionally Cope After a Bipolar Misdiagnosis

It’s understandable for someone experiencing a bipolar misdiagnosis to feel anger, fear, frustration, and sadness. It can be frustrating to have symptoms not improve in spite of treatment or to feel misunderstood. There may be a feeling of betrayal or lack of trust in providers. It is normal to have these feelings, but it’s important to not stay stuck in them.

Here are some tips for how to emotionally cope after a bipolar misdiagnosis:

• Allow yourself to grieve: You might find yourself grieving for many different reasons. You may experience a loss of trust in your provider or your treatment, and it is possible that your diagnosis has become a part of your identity. Whatever comes up for you, allow yourself to feel it and process it.
• Speak to a therapist: A therapist can help not only with ways to manage the symptoms you’re experiencing but also to work through your feelings about being misdiagnosed.
• Attend a support group: Bipolar misdiagnosis is common, and it is very likely that others in a support group have experienced the same. It can be helpful to talk with others who share the same experiences.
• Remember that you are not your diagnosis: A diagnosis is a set of symptoms that help providers plan your treatment. The symptoms are not who you are. Who you are does not change regardless of your diagnosis, your treatment, or any other outside source.
• Do something fun: It’s important to take a break from focusing on symptoms and have some fun. Call a friend who makes you laugh, play video games, go to a movie… Whatever is fun for you. Having fun can also give your brain a little dopamine boost, which helps you feel better.
• Get some movement in: Exercise has a big impact on mental health. Go out for a walk around the block, dance to your favorite song, or simply get up and stretch. Movement is one of the best ways to change your focus and help improve your mood.
• Lean on your support system: Call someone you trust and talk through your experience. Let them know whether you are looking for solutions or simply a listening ear so that they know how to best support you.

When to Seek Professional Support

If you are experiencing any negative effects on your life due to a misdiagnosis, it is important to seek professional help. It is likely that you are already linked with a medical provider or psychiatrist, or you may be seeking a second opinion. It is also important to talk to a therapist to process your experience and build new coping skills.

If you aren’t already linked with a therapist, an online therapist directory is a great tool for finding one. Look for a therapist with specific training and experience in working with bipolar disorder. An online therapy platform can be helpful for some individuals when it is easier to meet from home or work or if there are barriers to treatment like childcare or transportation.

In My Experience

Bipolar disorder has a complex set of symptoms that can be difficult to differentiate from other disorders. Many people first start to suspect misdiagnosis when they have been diagnosed with depression and find that their antidepressants do not work or trigger a manic episode. Others are diagnosed with bipolar and placed on mood stabilizers with no improvement.

I encourage anyone who suspects that they may have been misdiagnosed to talk openly with their provider. Mental health providers understand that diagnosis can be tricky and that many symptoms overlap. Their goal is to help you feel better, and they want to hear about your progress. Tell them specifically what symptoms you are still experiencing and that you would like to talk about your diagnosis.