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The Long Road to a Bipolar Diagnosis: How Our Understanding Has Changed

The journey toward understanding Bipolar I Disorder is often long, but with accurate diagnosis, treatment, and support, recovery is possible.
The journey toward understanding Bipolar I Disorder is often long, but with accurate diagnosis, treatment, and support, recovery is possible.

The Long Road to a Bipolar Diagnosis


During my years in clinical practice, I've witnessed many changes in how bipolar disorder was recognized and treated.


People suffered because our understanding of Bipolar Disorder was limited and still developing. A combination of research and clinical knowledge has improved differential diagnosis and improved lives.


This article looks back at how our understanding has changed, what we've learned from people living with bipolar disorder, and why there is reason for more hope today.


Note: This article is educational and reflective. It is not intended as clinical advice or diagnosis. If you or a loved one is struggling with mood symptoms, please reach out to a qualified mental health provider. Crisis resources are listed at the end of this article.


Bipolar Disorder 1960 - 1980


In the 1960's until about 1980, bipolar disorder was categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM I - II) as "manic-depressive disorder". The cyclical nature of moods in Bipolar Disorder was beginning to be observed and recognized.


In 1980, with the iteration of DSM-III, the manic-depressive label was dropped and re-categorized as Bipolar Disorder. This deeper understanding of the cyclical nature of Bipolar Disorder led to refinement in diagnosis. Three categories were created: Bipolar I, characterized by full manic episodes; Bipolar II, characterized by hypomanic episodes and depression; and cyclothymia, characterized by cycling between high and low moods that are not as pronounced as in Bipolar I or II Disorder.


The research and clinical experiences observed in people with Bipolar Disorder led to the refinement of diagnostic categorization in DSM-III. However, in this era, practicing clinicians still primarily associated Bipolar Disorder with classic mania. Bipolar Disorder II, with hypomania, was not yet widely recognized. Mixed states were poorly understood. A clinician might perceive a unipolar diagnosis, such as depression or high anxiety, and may not have the clinical awareness to watch for signs of a Bipolar Disorder diagnosis.


As research advanced and clinicians gained experience, our understanding of bipolar disorder became more nuanced. Professional education improved, diagnostic criteria evolved, and clinicians became better equipped to recognize Bipolar Disorder in its many forms.


In addition, with better understanding of the Bipolar Disorder condition, public awareness about Bipolar Disorder has expanded. People who have suffered with Bipolar Disorder are more willing to speak out and share their story of suffering from a mental illness and share the stories of their eventual recovery and how they maintain stability.


Why So Many People Went Undiagnosed


Bipolar Disorder shows itself in many disguises, which confuses the diagnostic picture with multiple symptoms. It may show itself first as depression, or it may appear to be ADHD, OCD or high anxiety. The drive to self -medicate can lead to substance abuse. The highs of mania may be conflated with personality disorder traits. Diagnosis can be challenging as symptoms change over many years.


Today, clinicians have more training and awareness of the varied symptomology of Bipolar Disorder. However, the symptoms of Bipolar Disorder often reveal themselves over a long period of time...even over years, even spanning over a decade, from childhood to adolescence to adulthood.


Over the person's lifetime, most likely there were several changes in treating therapists. So, over the years, there's no one person seeing the entirety of the presenting symptoms in the individual.


An additional factor that confounds diagnosis, is that when a person is experiencing mania, they feel great. They don't think they need help. They feel productive, happy, motivated! Usually there are several episodes of mania until there is finally one that makes everyone realize there is definetly some sort of major problem. For example, one of my clients tried to remodel their kitchen counter with a chainsaw. They thought it was their best idea ever! Too bad they scared the heck out of their family and the family called the police.


How Treatment Has Changed Over the Years


Today Bipolar Disorder is understood to be a chronic brain-based mood disorder with a strong genetic and biological component. It affects thoughts, feelings, behavior, sleep, energy, and judgment.


Medications for Bipolar Disorder have evolved over years. In the 1980s, lithium was the main medication for Bipolar Disorder.


Today, there are more medications in different classes available, such as anticonvulsant mood stabilizers and atypical antipsychotics. These medications used to manage severe mental health symptoms, but they are not without side effects. This means that medication management is a component of managing Bipolar Disorder. In addition, in the 1980s. SSRIs were just emerging and could sometimes worsen bipolar symptoms if used without a mood stabilizer.


Bipolar Disorder requires a multidisciplinary approach, incoporating medication management, structured psychotherapy, social supports, and the individual's commitment to meticulous lifestyle management.


Real Lives Behind the Diagnosis


Below are the stories of three living human beings who suffer with Bipolar Disorder. Two are hopeful, one is unceasingly tragic, yet her life has quite sadly taught us the need for medication and lifestyle managememt.



Andy Behrman: A Story of Delayed Diagnosis


Andy Behrman's memoir Electroboy illustrates how bipolar disorder could remain unrecognized for years despite repeated contact with mental health professionals. His story follows the gradual escalation of manic episodes, depression, substance use, and risky behavior before he finally received an accurate diagnosis.


His experience reflects the reality that many people living in the 1980s and early 1990s faced—a mental health system that had fewer diagnostic tools and a more limited understanding of bipolar disorder.



Dyane Harwood: Bipolar Disorder After Childbirth


Dyane Harwood's memoir Birth of a New Brain tells a different story. Following the birth of her second daughter, she developed postpartum bipolar disorder and spent years searching for effective treatment. Her experience highlights how postpartum bipolar disorder was frequently mistaken for postpartum depression and how much the field has learned about perinatal mood disorders over the past several decades.



Andrea Yates: When Severe Illness Goes Unrecognized


Andrea Yates' story remains one of the most devastating examples of severe postpartum psychiatric illness. While every case is unique, her tragedy reminds us why early recognition, specialized psychiatric care, careful medication management, and strong family support are essential when psychosis emerges after childbirth.



What Helps Diagnosis Come Sooner


If Bipolar Disorder is going to be caught earlier and treated better, several things need to happen. They are things all of us can help move forward.


Careful mood history-taking. When someone presents with depression, screening for past hypomanic or manic episodes should be routine. The Mood Disorder Questionnaire (MDQ) is one of several tools clinicians can use.


Family history awareness. Bipolar disorder has one of the strongest genetic loadings of any psychiatric condition. A parent, grandparent, or sibling with bipolar, major depression, suicide history, or unexplained "moodiness" is meaningful information.


Postpartum vigilance. Any mother who becomes unusually elated, cannot sleep, feels flooded with energy or racing thoughts, or begins behaving very unlike herself in the days after giving birth needs an urgent psychiatric evaluation. This is a mental health emergency.


Reducing stigma. Every honest voice, every memoir like Andy Behrman's and Dyane Harwood's help others. Every public disclosure by artists and public figures, such as Catherine Zeta-Jones, Carrie Fisher, Ted Turner, Mariah Carey, al of whom have spoken frequently and publicly about their diagnosis helps make it easier for the next person to speak up and seek treatment.


A team approach to treatment. Bipolar disorder cannot be treated by talk therapy alone. It cannot be fixed by positive thinking.


It requires medication management by a skilled psychiatrist, supportive psychotherapy, lifestyle stabilization (sleep, structure, movement, minimal substance use), and sometimes, when needed, higher levels of care including electroconvulsive therapy (ECT). Mr. Behrman says that ECT saved his life, alhtough ECT treatment has a high level of stigma.


Skills for the daily work of living well. Once someone is diagnosed and stabilizing, the daily work of managing the disorder benefits enormously from tools like DBT — particularly the skills for emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness. These do not treat the illness. But they help a person live inside it with more skill, more self-compassion, and more agency.


Hope for a Life Worth Living


Today, clinicians have better diagnostic tools, more treatment options, greater awareness of Bipolar Disorder I and II and its mixed features, and a deeper understanding of postpartum psychiatric illness than they did several decades ago.


Although challenges remain, many people receive earlier diagnosis and more effective, individualized care than was possible in the past.


With earlier recognition of the illness, less shame about mental illness diagnoses, and better treatments, recovery and stability is possible.



Resources


If you or someone you love may be experiencing symptoms of bipolar disorder or is in crisis, please reach out:




Explore More


Understanding bipolar disorder is a lifelong journey—for individuals, families, and clinicians alike. These related resources explore recovery, emotional regulation, and compassionate mental health care.


Book Reviews


Learn More About Mental Health


Perinatal Mental Health



Sources


Miller, S., Dell'Osso, B., Ketter,T.A. (2014). The prevalence and burden of bipolar depression, Journal of Affective Disorders, V169(1), pp S3-S11


Ratheesh, A., Hett, D., Ramain, J., Wong, E., Berk, L., Conus, P., Fristad, M. A., Goldstein, T., Hillegers, M., Jauhar, S., Kessing, L. V., Miklowitz, D. J., Murray, G., Scott, J., Tohen, M., Yatham, L. N., Young, A. H., Berk, M., & Marwaha, S. (2023). A systematic review of interventions in the early course of bipolar disorder I or II: a report of the International Society for Bipolar Disorders Taskforce on early intervention. International journal of bipolar disorders, 11(1), 1. https://doi.org/10.1186/s40345-022-00275-3




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