1. CHALLENGES IN PRACTICE
AND ADDED VALUES OF
DIFFERENT ROLES IN A
MULTIDISCIPLINARY TEAM
IN THE DIAGNOSTIC
PROCESS OF BIPOLAR
DISORDER

2. 2
I N T E R N S H I P R E P O R T
Prepared for: Athena Institute, Amsterdam
Prepared by: BSc Tuğba Aydın, 2007991
Student: Master Management, Policy Analysis and Entrepreneurship in
Health and Life Sciences
Specialization: Management and entrepreneurship
Start date: October 2015
Version: Final version
Supervisors:
Dr. T.P. Groen
Faculty of Earth and Life Sciences, VU
De Boelelaan 1105 1081 HV Amsterdam
t.p.groen@vu.nl
MSc E.F. Maassen
Faculty of Earth and Life Sciences, VU
De Boelelaan 1105 1081 HV Amsterdam
eva.maassen@vu.nl

3. 3
Summary
Introduction: Bipolar disorder (BD), also called manic depression, is a mental disorder that is
characterized with severe mood swings and for example changes in energy level, cognition and
sleep. BD patients experience periods with a severe high mood state, which is called (hypo)mania,
alternating with severe depressed episodes, in which patient are likely to commit suicide. The
literature shows several difficulties in the diagnostic process of BD, which results in a high
misdiagnosis (for example with unipolar depression) that can lead to needless suffering and
medication use by the patient. This is a problem, because medication for unipolar depression can
trigger a mania and delays in the correct and accurate diagnosis can lead to personal, social, and
work-related problems. Due to the high rate of misdiagnosing, patients consult on average four
doctors and it takes at least 7 years before receiving the correct diagnosis for BD, meaning that
there are challenges in the diagnostic process of BD. The diagnostic process in mainly done in a
multidisciplinary team (MDT), in which several disciplines work together to ensure the quality of
the delivered care. MDT working has several benefits, it aims for example that all already
achievable knowledge and expertise within a diagnostic team is compiled and used in an efficient
manner, leading to a more accurate diagnostic process. However, achieving an efficient MDT,
and with that, an efficient diagnostic process needs some core concepts and enablers. One of the
important enabler is role clarification of the professionals involved in the diagnostics of BD.
Multidisciplinary collaboration requires according to literature recognition of complementary
roles in a team. In order to contribute to a more efficient diagnostic process, an insight of the
current daily practice role division and the added value of the roles of the professionals in the
MDT’s who are involved in the diagnostics seem to be necessary. Therefore, the aim of this study
is to set out the challenges that are faced in practice by professionals who are involved in the
diagnostic process of BD and besides that, to clarify the roles in the diagnostic process of BD of
these professionals.
Methodology: An explorative qualitative research method was used in this research, in order to get
more insight in the perspectives of professionals about the challenges in the diagnostic process of
BD and the added value of their and their colleagues’ role in the MDT. Interviews and focus
groups are held at different locations with members of specialist bipolar teams. The participants
are recruited based on pre-specified qualifications (professionals’ role in the diagnostic process)
and their experience in the diagnostic process of BD, focussing on three professionals who are
involved and experienced in the diagnostic process of BD: psychiatrists, psychologists and nurses.
In total five focus groups and four interviews are conducted. The data is transcribed and analysed
by a content analysis approach.
Results: Professionals mentioned many challenges during the focus groups or interviews. An
unreliable anamnesis can make the diagnostic process difficult. This can for example be caused by
the memory of the patient to memorize their possible hypomanic episodes in the past or the
choice to tell this to the professional. Besides, hetero-anamnesis seems also a challenging aspect,
due to for example the unavailability of the family members. Furthermore, determining the
difference between ‘what is normal for that particular patient’ and ‘what is hypomanic for that
particular patient’ is sometimes very challenging. Almost all professionals mentioned co morbidity
and symptom overlap as one of the most difficult aspects. Moreover, BD has aspecific symptoms
that do not always fit in the criteria as described in the DSM. The unawareness of professionals
outside the bipolar team can also lead to difficulties in an accurate diagnostic process of BD. Also,
practical issues with the health insurance were mentioned. One of the controversies and challenge

4. 4
in the diagnostic process is that BD can evolve and develop in time, but the time for the diagnostic
process is short.
Psychiatrists fulfil an essential role in the MDT, as they have a broad medical psychiatric view,
they are appointed to bear the final responsibility in the diagnostic process and formulate the
diagnosis, signal physical problems and have an eye for medicines related problems.
The nurses are almost at every location intakers. Furthermore, they are very practical, because of
their relatively low cost. Besides that, they have an important psychosocial role, wherein a low
threshold to the patient is an important aspect. Because of the longer and more personal contact
with the patient, nurses have a functional view, as they can estimate the feasibility of a certain
treatment and see the strengths of the patient.
A psychologist is skilled in using measuring instruments, in getting a deeper insight about the
personality of the patient for substantiated conclusions, is therapy oriented, pays special attention
for co morbidity and set out the developmental stages of the disorder.
Conclusion and discussion: This research aimed to get an insight in the challenges and role values of
different disciplines in a MDT in order to achieve a more efficient diagnostic process of BD. Some
challenges in practice endured by professionals can be mentioned: unreliable anamnesis,
difficulties with hetero-anamnesis, character of the patient, great co morbidity and symptom
overlap, vague DSM, course of disorder and time pressure and some practical issues. This
research also showed that the added value of the psychiatrists in the MDT is their broad medical
psychiatric view, their final responsibility, the knowledge about somatics and pharmacotherapy.
The added values of the nurses, which differs per location, are identified as: being intakers, having
an eye for the psychosocial aspect of the patient, having a functional view and being practical in
the diagnostic process. In teams where psychologists are always available, nurses fulfil a less
prominent role in the diagnostic process. The psychologists have an added value in using
measuring instruments, having an eye for co-morbidity and the developmental stages of the
disease, mapping personality of the patient, getting an overview and connecting all information
about the patient. A specialised look and research to the broad personality aspect is indicated as a
missing part, in case of no psychologist was available in the team. It is also remarkable that every
location has at least subtle differences in their way of diagnostics, which can influence the
perspective of team members about the added values of their selves and other disciplines. This
research also identified that many professionals have comparable skills, however the
responsibilities are different.

5. 5
Contents
1. INTRODUCTION ............................................................................................................................ 7
RESEARCH OBJECTIVE AND RESEARCH QUESTION .................................................................................. 8
2. CONTEXTUAL BACKGROUND ................................................................................................ 9
2.1. WHAT IS BIPOLAR DISORDER ................................................................................................................... 9
Aetiology of Bipolar disorder ...................................................................................................................................... 9
Bipolar disorder types .................................................................................................................................................. 9
Bipolar spectrum ....................................................................................................................................................... 10
2.2. CONSEQUENCES OF BIPOLAR DISORDER .......................................................................................... 11
Consequences of early onset ...................................................................................................................................... 11
Consequences of confusion and misdiagnosing ....................................................................................................... 11
2.3. DIAGNOSTICS OF BIPOLAR DISORDER ............................................................................................... 12
Screening instruments ............................................................................................................................................... 12
Challenges and perplexities in diagnosing .............................................................................................................. 13
Diagnostic opportunities ........................................................................................................................................... 13
2.4. TREATMENT OF BIPOLAR DISORDER ................................................................................................. 14
Long-term treatment ................................................................................................................................................. 14
(Non) compliance of Bipolar disorder patients ...................................................................................................... 14
2.5. DIAGNOSTIC TEAMS .................................................................................................................................. 15
3. THEORETICAL BACKGROUND ........................................................................................... 16
3.1. INTRODUCTION TO THE THEORETICAL FRAMEWORK ............................................................... 16
3.2. MULTIDISCIPLINARY COLLABORATION/TEAM .............................................................................. 16
Benefits of MDT working ....................................................................................................................................... 16
MDT, timely diagnostics and positive clinical outcome ....................................................................................... 17
Achieving an efficient MDT- phases ...................................................................................................................... 18
Achieving an efficient MDT- enablers ................................................................................................................... 19
3.3. ROLE CLARIFICATION IN THE MDT ................................................................................................... 20
3.4. THEORETICAL FRAMEWORK ................................................................................................................. 20
3.5. SUB-QUESTIONS .......................................................................................................................................... 21
4. METHODOLOGY ......................................................................................................................... 22
4.1. RESEARCH STRATEGY .............................................................................................................................. 22
Focus group and interview design ............................................................................................................................ 22
4.2. RESEARCH APPROACH ............................................................................................................................. 23
4.3. RESEARCH ANALYSIS ................................................................................................................................ 24
Validity ...................................................................................................................................................................... 24
Ethical consideration ................................................................................................................................................ 25
5. RESULTS .......................................................................................................................................... 26
5.1. CHALLENGES IN THE DIAGNOSTIC PROCESS ................................................................................... 26
Unreliable anamnesis ............................................................................................................................................... 26
Difficulties with hetero-anamnesis .......................................................................................................................... 27
Character of the patient ............................................................................................................................................ 27
Co morbidity and symptom overlap ........................................................................................................................ 29
DSM ......................................................................................................................................................................... 30
Practical issues .......................................................................................................................................................... 31
Course of disorder and time pressure ....................................................................................................................... 32
5.2. ROLES OF PSYCHIATRISTS ...................................................................................................................... 33
Broad medical psychiatric view and DSM ............................................................................................................ 33

6. 6
Final responsibility ................................................................................................................................................... 34
Somatics ..................................................................................................................................................................... 34
Pharmacotherapy ...................................................................................................................................................... 35
5.3. ROLES OF NURSES ...................................................................................................................................... 36
Intake ......................................................................................................................................................................... 36
Psychosocial aspect ................................................................................................................................................... 36
Practical .................................................................................................................................................................... 37
Functional view ........................................................................................................................................................ 38
5.4. ROLES OF PSYCHOLOGISTS .................................................................................................................... 39
Measuring instruments ............................................................................................................................................. 39
Co morbidity ............................................................................................................................................................. 39
Personality of the patient .......................................................................................................................................... 39
Therapy orientation .................................................................................................................................................. 40
Developmental stages ................................................................................................................................................ 41
Overview .................................................................................................................................................................... 41
6. CONCLUSION ............................................................................................................................... 42
6.1. CHALLENGES IN THE DIAGNOSTIC PROCESS OF BD ..................................................................... 42
6.2. ADDED VALUES OF PROFESSIONALS IN A MDT .............................................................................. 43
MDT functioning ..................................................................................................................................................... 43
7. DISCUSSION .................................................................................................................................. 45
7.1. REFLECTION ON THEORETICAL FRAMEWORK ............................................................................... 45
Psychiatrists .............................................................................................................................................................. 45
Nurses ........................................................................................................................................................................ 45
Psychologists .............................................................................................................................................................. 46
Challenges ................................................................................................................................................................. 46
7.2. MULTIDISCIPLINARY TEAM COMPOSITION AND CONSEQUENCES .......................................... 47
7.3. STRENGTHS AND LIMITATIONS ............................................................................................................ 47
Validity ...................................................................................................................................................................... 48
7.4. FUTURE RESEARCH ................................................................................................................................... 48
REFERENCES ..................................................................................................................................... 50
APPENDIX 1: FOCUS GROUP DESIGN ................................................................................... 55
APPENDIX 2: ROLES OF PROFESSIONALS .......................................................................... 57

7. 7
1. Introduction
Long before Kraepelin described ‘manic depressive insanity’ in the late 19th century, philosophers
like Aristoteles, Plato and Socrates had recognized mania and associated it with creativity and
ingenuity. Bipolar disorder (BD), also called manic depression, is a mental illness that brings severe
mood swings. BD can be separated from unipolar depression by the occasion of abnormally high
mood state, known as mania or hypomania, in combination with alternating depressed mood
(Anderson et al., 2012). Besides severe high and low moods, bipolar disorder also brings changes
in for instance energy, behaviour, cognition and sleep (Anderson et al., 2012).
According to World Health Organization (WHO), mood disorders like bipolar disorder are
relatively common in the Netherlands in comparison with other countries (Demyttenaere et al.,
2004). From the Dutch population aged between 18 and 65, it is estimated that 91.100 adults
suffers from BD (de Graaf et al., 2010), which can lead to high costs if accurate diagnosis is
missing due to for example faces difficulties by professionals during the diagnostic process.
Health professionals can face some difficulties in the diagnostic process of BD. First of all, the
symptoms of BD can be confused with other diseases, like ADHD or unipolar depression.
Hirschfeld describes in his research that 69% of BD patients were misdiagnosed with unipolar
depression. The percentage, which was incorrectly diagnosed, consulted on average four doctors
before receiving the correct diagnosis for BD. Many patients are mainly overlooked or
misdiagnosed by physicians (Anderson et al., 2012), resulting in needless suffering and medication
use by the patient. Besides the high percentage of misdiagnosis due to confusion of the symptoms
of BD with other diseases, the lack of knowledge of the causes of BD is also challenging. Namely,
BD has not a single cause. It appears that certain people are genetically predisposed to BD, yet
there is not one gene that shows significant development of this disorder. Researchers suggest that
many different genes are playing a complex role together with environmental factors (Muhleisen,
2014). Interestingly, a person with inherited vulnerability does not automatically develop the
disorder (Xu et al., 2014), indicating BD is a multi causal illness.
Hirschfeld and his colleagues reported in 2003 that patients with BD indicated that the disorder
manifests itself at a young age but that accurate diagnosis lacked. Approximately 30 per cent had
to wait 20 years or more for getting the accurate diagnosis, although they had reported manic
symptoms earlier. Therefore many patients indicated as reason for the delayed diagnosis the lack
of understanding of their physician about BD (Hirschfeld et al., 2003a). Indeed, according to
Brickman many physicians do not screen for BD routinely, even though the patient has a
depression history. A certain percentage of these people could meet the criteria for BD (Brickman
et al., 2002). Researchers emphasize the duration of at least 7 years before receiving the right
diagnosis, reproaching the poor screening (Mantere et al., 2004).
The confusion with depression and the failure to diagnose BD accurately could have serious
impact, since antidepressants without mood stabilizing drug may trigger mania (Ghaemi et al.,
2001), which is an abnormally elevated mood. BD can impair the patient more and more if it is
left undiagnosed and untreated, for example episodes could occur more severe or more frequent
over time. Also, delays in the correct and accurate diagnosis- and treatment- can lead to personal,
social, and work-related problems (Anderson et al., 2012). Therefore it is important that health

8. 8
professionals first of all diagnose BD correctly. The diagnostic of BD is done in a multidisciplinary
team (MDT) with several disciplines, like psychiatrists, psychologists and nurses. Since the
diagnosis of BD seems difficult, this research wants to get insight into the challenges in practice
and the roles of involved health professionals in the diagnostic process of BD. Understanding the
challenges and the added values of the roles can be used in practice for a more efficient
multidisciplinary collaboration between the professionals, since role clarification is an important
prerequisite of a well working multidisciplinary team, in which psychiatrists, psychologists and
nurses play a role (Orchard et al., 2005).
Research objective and research question
The aim of this study is to set out the challenges that are faced in practice by professionals who
are involved in the diagnostic process of BD and besides that, to clarify the roles in the diagnostic
process of BD of these professionals.
Hence, the research question is defined as:
What are the challenges in practice in the diagnostic process of BD faced by involved
professionals and what are the added values of the roles of these professionals in the diagnostic
process of BD?

9. 9
2. Contextual background
This chapter will provide more context information and in-depth knowledge about BD, the
consequences of it, the diagnostics and treatment of BD and the diagnostic teams.
2.1. What is Bipolar disorder
Aetiology of Bipolar disorder
As indicated in the introduction, BD has no single cause. The development of BD seems to be a
combination between nature and nurture. Some researches about brain imaging indicate physical
changes in the brains of people with the disorder (Strakowski et al., 2005; Lagopoulos et al., 2007)
while other studies steers to neurotransmitter imbalances as a cause. Also, a disturbed level of the
stress hormone cortisol (Cole et al., 2011), circadian rhythm disturbances (Harvey, 2008) and an
abnormal thyroid function (Kupka et al., 2002) are pointed as possible contributors to the
emergence of BD. At the same time, a collaborative genome wide study indicates that ion
channelopathies resulting from ANK3 and CACNA1C gene deficiencies are possibly involved in
the pathogenesis of BD (Ferreira et al., 2008).
The first signs of bipolar disorder is mainly seen in the teenage years, as first manic or depressive
episode usually occurs in that period. According to Hirschfeld (2003), especially young adults and
individuals with lower income are at higher risk for this disorder. Besides that, some studies have
pointed out the differences between older and younger manic-depressive patients (Depp and Jeste,
2004). For example, an association between aging and longer depressive or manic episodes was
found (Burt et al., 2000). It is also suggested that older patients with this disorder experienced a
shorter interval between the episodes, which makes the disorder less manageable and recurrences
more likely (Blazer and Koening, 1996)
Bipolar disorder types
Patients with BD are mainly diagnosed by using guidelines from the Diagnostic and Statistical
Manual of Mental Disorders (DSM-V, released in 2013). DSM is an American handbook that
serves as a standard in most countries in the psychiatric diagnosis processes. The DSM was
necessary to avoid international confusion about mental illnesses in the literature (Rockville,
2008). There are two types of assessment for diagnosing bipolar disorder: using retrospective self-
reports (Merikangas et al., 2007) and clinician rated assessments (Furukawa, 2010). According to
DSM-V, four basic types of BD can be distinguished: Bipolar I Disorder, Bipolar II Disorder,
Bipolar Disorder Not Otherwise Specified (BP-NOS) and Cyclothymic Disorder (APA, 2013).
Bipolar I Disorder last at least seven days with severe mixed or manic episodes. Depressive episodes
last at least two weeks. Bipolar II Disorder is observable by others, but not severe enough for
hospitalization. The primary symptom is depression alternating hypomanic episodes, which is less
severe than mania (See Figure 1). If the patient show the symptoms of the disorder but does not
meet the diagnostic criteria of neither Bipolar I disorder or Bipolar II disorder, the patient will be
diagnosed with BP-NOS. A mild form of BD is Cyclothymia, in which the patient shows episodes of
mild depression as well as hypomania for at least 2 years (APA, 2013).

10. 10
Figure 1: The difference between Bipolar I disorder and Bipolar II disorder in graphic (Anderson et al.,
2012).
Besides the basic types, another term about the severity of BD can be distinguished, namely Rapid-
cycling Bipolar Disorder. A person will be diagnosed with this severity within any type of BD when a
person has at least four episodes within a year of mania, mixed states, depression and hypomania.
Persons who experienced their first episode at a younger age are more likely to be diagnosed with
rapid cycling. Besides that, this type of BD may affect more woman than men (Voderholzer et al.,
2002).
Bipolar spectrum
Besides the four basic type of bipolar disorder, scientists iteratively suggested a bipolar spectrum
concept. According to Angst, the provision of more differentiated research for mood disorders
could be realized by the initiation and improvement of a validated bipolar spectrum concept
(Angst, 2007). This development may help reduce the underestimation and low recognition rate
of bipolar disorder.
To start with, a German scientist Kretschmer proposed a ranging concept (pathological to
normal) for schizophrenia (schizophrenic-schizoid-schizothymic) in 1921 and Bleurer indicated
the dimensional concept for affective disorder (manic-depressive disorder- cycloid `psychopathy'-
cyclothymic temperament) in 1922. Remarkably, the term `spectrum' was first used by Kety and
his colleagues in psychiatry for the schizophrenia spectrum (Kety et al, 1968). Thereafter, Akiskal
first described the cyclothymic- bipolar disorder in 1977and subsequently Klerman postulated a
mania spectrum in 1981.
Hence, the bipolar spectrum covers a severity range of BD. This dimensional concept for
classifying several mood disorders contributes to the alleviation of the problem in the under- and
misdiagnosing of BD. Some psychiatrists find the bipolar spectrum concept to be ‘a useful
framework for thinking about the driving force behind a wider range of mental health problems’

11. 11
(Akiskal et al., 1977), because the bipolar spectrum concept do not only refers to BD as
traditionally defined, but also to related mood disorders, see Figure 2 (Angst, 2007).
Figure 2: Several mood disorders in dimensional bipolar spectrum (Angst, 2007).
2.2. Consequences of Bipolar disorder
BD can have profound consequences according to Have and her colleagues. They show in their
research that BD has a more negative effect on the lives of the patient than people with other
mental disorder like anxiety disorder, substance use disorder and ‘other mood disorder’. People
with BD have periods of bed rest and are more likely to be absent because of their emotional
problems (Have et al., 2002). Besides that, BD patients are have more often attempted suicide in
their life, and experience impairments in their social functioning, emotional role and vitality and
thus a low quality of life. Emotional problems such as feeling depressed, nervous or less vital, can
lead to difficulties in daily life and at work. The severity of the problems varied for each patient,
however patients diagnosed with Bipolar I can experience more severe social and emotional
consequences in daily life (Have et al., 2002).
Consequences of early onset
Perlis and his co-workers investigated the early onset (<13 age) of the disease. In general, people
with early onset of the disease are associated with a more severe disease course, since Perlis
reports that they are more likely to have co morbidities and have more mood episodes. Besides
that, they endure more depressed days and have a high likeliness for suicide attempts (Perlis et al.,
2004), suggesting that these impairments have negative consequences for the quality of life of BD
patients.
Consequences of confusion and misdiagnosing
The confusion of BD with unipolar depression can also have consequences for the patient.
According to Kato who compared these two mood disorders in his article, is depression much
more dependent on environmental factors than on genetic factors in comparison with BD (Kato,
2007). The lifetime prevalence of depression is estimated on approximately 15%, while that for
BD is approximately 0.8-2.6% (Kato, 2007). Antidepressant drugs are common used in the
treatment of major depression, while mood stabilizer Lithium is marked as the most common in
the pharmacological treatment of BD (Ikeda and Kato, 2003).

12. 12
Due to the higher lifelong recurrence and higher rate of co morbidity with psychiatric disorders
like substance use and anxiety disorders could BD be a more distressful disorder than unipolar
depression (Angst, 2007). Besides that, BD is associated with serious other diseases, like
hypertension, Diabetes and cardiovascular disease (Weiner et al., 2011). This is related to the
mortality rates (and suicide risk) of patients with BD, which is higher in comparison with
depression (Osby et al., 2001). Therefore, an accurate diagnosis of BD is essential, as
unrecognised or misdiagnosed BD mainly lead to higher costs than major depression. However,
the cost can be reduced by early and correct diagnosis and the right treatment (McCombs et al.,
2006)
2.3. Diagnostics of Bipolar disorder
For the assessment of psychiatric disorders like BD, doctors mainly use five axes, which are
mentioned in the DSM. These axes refer each to an information domain that contributes to the
prognosis of treatment. The first three axes are relevant for the diagnosis, while the other two axes
are relevant for the assessment of the feasibility of a certain treatment. Axis I encrypts all
psychiatric disorders, except personality disorders and mental retardation. Axis II encodes the
personality disorders and mental retardation. Axis III encodes the clinically relevant, general
medical issues. Axis IV appoints clinically relevant psychosocial and environmental problems and
axis V set out general psychological, social and occupational functioning of the patient (APA,
2013). A manner for the diagnostics of BD is making use of screening instruments.
Screening instruments
Although BD cannot be diagnosed via a blood test or a brain scan, some screening instruments
are available. Hirschfeldand his co-workers described a self-rated screening instrument for bipolar
spectrum disorder, the Mood Disorder Questionnaire (Hirschfeld et al., 2000). It is based on
clinical experience of the writers and DSM-IV criteria and screens for (hypo) manic symptoms in
the lifetime history of the patient. Also researchers from Finland investigated the validity of the
Mood Disorder Questionnaire as a screening instrument for bipolarity in psychiatric field
(Isometsa et al., 2003), in which the questionnaire seems to be a practical method for the
recognition of BD. However, the article refers also to the considerable amount of unrecognised
Bipolar II disorder patients (Isometsa et al., 2013).
Furthermore, several other methods are used, such as the semi-structured interview called
Structure Clinical Interview for DSM-IV (SCID). The SCID consists of 10 different
modules:mood episodes, psychological and related symptoms, psychotic disorders, mood
disorders, substance use, anxiety disorders, somatoform disorders, eating disorders, adjustment
disorders and optional disorders (such as acute stress disorder or hypomanic episode). The
questions that relate to the criteria of the relevant clinical syndrome are scored from one to three
on the presence of the symptom or a question mark (?) for missing or unclear information. At the
end of the interview, the scores are counted for the final classification. It can be relatively time
consuming. Besides that, Depue has designed the General Behaviour Inventory (GBI), which
covers both the manic symptoms as the depressive symptoms in BD (Depue et al., 1981).
However, Akiskal described that the most valid (and reliable) way for obtaining a diagnosis of BD
is by using a structured interview by a trained clinician (Akiskal et al., 2002).

13. 13
Challenges and perplexities in diagnosing
Some researchers suggest that the variety of types within BD and subtle differences between them
may be an important reason of highly misdiagnosing this disorder (Anderson et al., 2012).
Subsequently, persons with this disorder do not react accurately and do not seek help when they
experience a hypomania or a mania, but mostly search for help when they are in a depressed
mood (Belmaker, 2004). Identifying BD is difficult; since it is highly based on self reported
symptoms of the patient (Merikangas et al., 2007). While depression is very perturbing and
relatively easy to diagnose, a hypomania is mainly perceived as the normal behaviour of the
person and will not be reported as much as the depression sides of BD. Therefore, identifying
hypomania and subsequently diagnosing Bipolar II Disorder is difficult. As a result of this,
unipolar depression in which hypomania or mania is absence, stays an uncertain diagnosing
(Angst et al., 2007).
Besides the confusion with unipolar depression, many other diseases have overlapping criteria
with BD. For example, the recognition of BD in youth could be complicated, since psychiatric co
morbidity and overlap of symptoms with more prevalent disorders are mainly seen. An example is
the attention deficit of patients, called the hyperactivity disorder (ADHD) and is very common in
youth (Birmaher et al., 2006). ADHD can be characterized with hyperactivity or distractibility,
which is also present in paediatric BD (Axelson et al., 2006; Birmaher et al., 2006). Mood
symptoms and severe irritability in ADHD are confusing factors, because they do not always meet
full criteria for BD (Hazell et al., 2003).
Other overlap of symptoms and co morbidities, such as anxiety has also been reported in youth
with bipolar disorder (Biederman et al., 2004). According to Krishnan’s literature study, also
alcohol and substance abuse can coexist with BD. Furthermore eating disorders and borderline
personality disorder is identified as common coexisting diseases with BD (Krishnan, 2005). The
symptom overlap with several diseases and possible co morbidities can delay the accurate
diagnosis and treatment of BD, leading to an uncertain diagnosis and consequences for the daily
life of the patient.
Diagnostic opportunities
Besides the issues in diagnosing, also some opportunities for diagnosing BD can be mentioned.
Some research has indicated that the prefrontal cortex is correlated with depression in BD (Ketter
et al., 2001). Reductions in prefrontal cortical metabolism (which is associated with controlling
impulsive behaviour) and an increase of Thalamus and Amygdala metabolism can be seen in
bipolar depression (Ketter et al., 2001). Malhi and his co-workers suggest that these patterns could
have potential diagnostic significance (Malhi et al., 2004).
Furthermore an article of McClure suggests that patients with BD are making more often
mistakes when they have to interpret the facial expressions of other people, at least in
experimental setting (McClure et al., 2005). This finding was also present in children, who were
not symptomatic during the study, suggesting that difficulties with the recognition of the
expression in the faces of people are not a symptom, but a part of BD. Interestingly, this difficulty
is even more negatively affected during mania (Altschuler et al., 2005)

14. 14
2.4. Treatment of Bipolar disorder
The treatment of BD often consists of a combination of medication, psycho-education,
psychosocial support and counselling and psychotherapy, and must be tailored as much as
possible for each patient. In the Netherlands, the outpatient treatment is mostly given by
psychiatrists, psychiatrists in training, social-psychiatric nurses and psychologists. Each of them
serves a specific part of the treatment, and often a patient is treated simultaneously by more than
one health professional. The treatment of Dutch psychiatric organizations is in general based on
the latest insights and guidelines, which are issued by Centre for Bipolar disorders (in Dutch:
Kennis centrum Bipolaire stoornissen) and organized according to the regional care program
mood disorders.
The main focus of the treatment is the stabilisation (euthymic mood) of the patient with
depression or mania. The goal for a prolonged time is for example the prevention of relapse, the
enhancement of occupational and social functioning and the minimization of sub threshold
symptoms. A big issue in the treatment of mania and depression in BD is the complexity of the
consequences. The same treatment that should alleviate the depression mood can cause
(hypo)mania or rapid cycling, while the treatments that should reduce (hypo)mania could cause
depressive episodes (Geddes and Miklowitz, 2013).
Long-term treatment
The best long-term treatment for BD seems Lithium, a metal that was first introduced by John
Cade in 1949. Although Lithium is in use for at least 50 years in clinical practice, Geddes and his
co-workers presented a convincing long-term efficacy evidence of this drug in 2004. They
performed a randomised clinical trial, in which Lithium was used as an active comparator
(Geddes et al., 2004). The trials in their article indicated that Lithium could reduce the risk of
depressive relapse with 28% and manic relapse even with 38%. Also, the risk of suicide is
decreased of more than 50% as an effect of Lithium, which is the only known anti suicidal
treatment with randomised evidence (Cipriani et al., 2005). Besides Lithium, antidepressants are
widespread used to stabilize the depressive mood in BD. However, the evidence for efficacy of
these medicines is scarce (Geddes and Miklowitz, 2013).
(Non) compliance of Bipolar disorder patients
Interestingly, some studies show that patients with BD often do not take their medication as
prescribed by their physician. An example is the 2-years study of Colom and his colleagues, in
which they show that approximately 40% of euthymic BD patients were not adherent to their
medication to some extent (Colom et al., 2000). Another study showed that 51% of the patients,
who were hospitalized for manic episodes, were thereafter not compliant to their
pharmacotherapy to some extent in a 1 year during follow up (Keck et al., 1997). There are
several reasons that are mentioned by patients for non-adherence to medication, but the most
common was denial of need. Others factors were associated with the feeling of that the mood is
controlled by medication and the feeling of being diagnosed with a chronic illness. Also, feeling
depressed and experiencing that taking medication regularly is a hassle were mentioned as
reasons for non-compliance (Pope and Scott, 2003).

15. 15
2.5. Diagnostic teams
There are two organizations that are important for this research, because the data is gathered
mostly from these organizations. Therefore, this paragraph explains the diagnostic teams at these
locations. GGZinGeest Bipolar and Altrecht Bipolar are both a specialised department of the
psychiatric organizations GGZinGeest and Altrecht in Utrecht. Both organizations provide
diagnostics, consultation and outpatient treatment to people with bipolar mood disorder. The
departments participate in the Centre for Bipolar Disorders (in Dutch: Kenniscentrum Bipolaire
Stoornissen). Patients are referred to these organizations if they are already diagnosed with BD or
if there is a presumption for BD. The diagnostic Bipolar team consists of psychiatrists, physicians
in training (to become psychiatrists), social-psychiatric nurses and psychologists. However, the
psychologists who are available have not much working hours in a week.
Altrecht Bipolar is a TOP-GGZ clinic, which is intended for patients with severe, complex
and/or rare diseases who have insufficient results from the normal second line treatment. TOP-
GGZ departments meet strict criteria in the areas of special diagnostics and treatment, scientific
research, innovation and knowledge and are assessed by an independent review committee. GGZ
inGeest clinics are an academic workplace for BD (in Dutch: Academische Werkplaats Bipolaire
Stoornissen (AWBS)), which integrates ambulatory patient care by research and education.
Besides regular second line care for the entire spectrum of patients with bipolar mood disorder, an
AWBS offers third line care for complex patients, also in the form of consultation and second
opinion. The diagnostic Bipolar team consists of psychiatrists, physicians in training (to become
psychiatrists), social-psychiatric nurses and psychologists.

16. 16
3. Theoretical background
For the deeper understanding of the scope of this research, this section presents necessary models
and theories. The concepts in the model play a central role in this research and therefore the
underlying theory and relevance in this research is described. Subsequently, these concepts are
linked to each other through a newly created theoretical framework. Hence, the sub-questions are
formulated from the theoretical framework.
3.1. Introduction to the theoretical framework
As earlier mentioned in the introduction, the correct diagnosis of BD lasts at least 7 years and the
disease is mainly confused with several other disorders, like unipolar depression or ADHD. The
diagnostic process of BD seems to face challenges. In order to contribute to a more efficient
diagnostic process, an insight of the current daily practice in role division of the professionals in
the multidisciplinary teams (MDT’s) who are involved in the diagnostics seems to be necessary.
All already achievable knowledge and expertise within a diagnostic team should be compiled and
used in an efficient manner, leading to a more accurate diagnostic process. This process cannot be
carried out by an individual but necessitates a multidisciplinary organizational level (Crossan et
al., 1999), wherein the roles of different disciplines involved in the diagnostic process of BD are
initially clarified and are known by each team member (Orchard et al., 2005).
3.2. Multidisciplinary collaboration/team
A MDT is a team of several professionals or health care providers, in which the perspectives and
the expertise of these professionals is recognized and valued. It enables ‘a partnership between a
team of health professionals and a client in a participatory, collaborative and coordinated
approach to share decision-making around health issues’ (Orchard and Curran, 2003), such as
diagnostics.
In recent years, various promoting models about health care teams are described by several
authors (Mickan & Rodger, 2005; D'Amour & Oandasan, 2004; Orchard et al., 2005). However,
there seems to be many challenging aspects in effectively implementing the suggested structures of
the teams. The key aspects of multidisciplinary collaboration are according to Silen-Lippenon and
co workers (2002): knowledge sharing, readiness to assume responsibility for outcomes of patient
care, joint intellectual planning of tasks and non-hierarchical team decision. However, Henneman
et al. (1995) indicated that collaboration is often lacking in the context of the team. Many
literatures suggest that fear of the loss of professional identity (Atkins, 1998), differing value
systems (Robinson & Cottrell, 2005), professional power imbalances (Orchard et al., 2005)
interdisciplinary fragmentation (Mechanic, 2000) and role confusion (Henneman et al. 1995;
Orchard et al., 2005), occurs within collaborative environments. For example, it is identified that
specialist nurses feel difficulties with the cultures of other disciplines, although they understand
very well patient knowledge and beliefs (Benner, 2001). Despite of the challenges in MDT
working, also many benefits can be mentioned.
Benefits of MDT working
A diverse composition of a team can increase the chance that each patient is offered the most
appropriate diagnosis and treatment plan. This is because the plans will be based on a range of
expert knowledge from the beginning, and all aspects that can influence the diagnosis and
treatment options will be considered (Ruhstaller et al., 2006). This approach is especially

17. 17
important and essential in more complex cases, especially when the timing and choice of different
diagnosis and treatment options is complicated, for example due to co morbidities. The open
nature of peer review at a multidisciplinary meeting could make teams more accessible for change
for delivering quality improvement initiatives (West et al., 2003).
Besides the improved clinical outcomes, MDT working could also improve the coordination of
services. Through regular meetings, team members will become more aware of avoidance of the
duplication of examinations and investigations, efficient ways of diagnostics and treatment
planning and simplification of referral processes between professionals (Ruhstaller et al., 2006). In
addition, MDT working could also result in more consistent information for the patient, because
each team member is aware of their own and other team members’ roles when they provide
information to patients (Carter et al., 2003). Healthcare professionals could benefit in several ways
too (Carter et al., 2003), for example, from a mutually supportive environment and reassurance
from corporate decision making. This is important in especially complex cases where an
appreciation of the specialist knowledge and different viewpoints of colleagues might be essential
(Edwards, 1998).
MDT, timely diagnostics and positive clinical outcome
Strong clinical consensus arising from the UK national survey supports the accumulating
evidence for benefits of MDT working. Taylor and Ramirez show in their study that at least 90%
of the participants assented that effective team working, such as a MDT, have improved clinical
decision-making. It also lead to more evidence based treatment decisions and thus improved
diagnostics and treatments, because an effective multidisciplinary team could deliver more
coordinated patient care (Taylor and Ramirez, 2009). Also Chang et al. shows evidence that
MDTs are linked with positive patient experience. He and his co-workers set out two
observational studies in breast cancer and these studies indicated that MDTs indeed lead to more
evidence based and timely diagnostics and treatment (Chang et al., 2001).
Junor and his co-workers (1994) stated that that care by a MDT has the potential to significantly
increase survival. Many other benefits can be mentioned from the literature, for example
increasing resection rate of lung cancers (Davison et al., 2004), improving the health outcome of
elderly inpatients after discharge (Caplan et al., 2004) and reducing medication variance (Sim and
Joyner, 2002). In a US study, the initial treatment recommendation for women with breast cancer
was changed following a second opinion of a multidisciplinary panel in 43% of the cases (Chang
et al., 2001). Pfeiffer and Naglieri acknowledged already in 1983 that the multidisciplinary
decision-making process is able to significantly reduce the wide variations in decisions made by
professionals who are acting independently (Pfeiffer and Naglieri, 1983).
Articles about multidisciplinary collaboration and teams in mental health care specifically are
scarce, however articles about MDTs in cancer and diabetic care show the importance of this
collaboration for positive patients outcome. Examples of cancer studies in which MDTs are linked
with positive outcomes are mainly from the last decade. Studies from the UK show that MDTs
can be associated with ameliorated five-years survival in colorectal cancer (Morris et al., 2006). It
is also linked with improved five-years survival in oesophageal cancer (Stephens et al., 2006).
Besides that Birchall showed an ameliorated two-years survival in head and neck cancer (Birchall
et al., 2004). Interestingly, the improvements were highest in for example breast, colorectal and

18. 18
lung cancer, which are cancers for which MDTs were more established, in comparison with
urological cancers where guides for MDT working was not published until 2002. Furthermore,
one article showed significant improvement in amputations rate due to diabetes through MDT
working and continuous audit (Krishnan et al., 2008).
Achieving an efficient MDT- phases
Working in a MDT seems to have several benefits for both patients as professionals, since the
professionals can experience for example an improved job satisfaction (Taylor and Ramirez,
2009). There are requirements that will lead to a successful collaboration, like the importance of a
common purpose, conflict management, methodology, flexibility in meeting goals, guaranteed
resources and leadership, communication processes and skills awareness (McPherson et al., 2001).
Orchard and his colleagues described the process and identified some core concepts of an efficient
MDT. He explains that achieving an efficient MDT needs different phases and enablers (see
Figure 3). The phases are the sensitization, exploration, implementation and evaluation phases. In the
sensitization phase of the process for establishing an efficient MDT power balances and varying values are
challenged (Glenn, 1987). This phase creates awareness of the current practice in the team, since
professionals explore the meaning of their roles and the daily decision-making process. This
means that it is needed that tacit unaware knowledge must evolve in explicit aware knowledge of
professionals about for example their added values of their roles. The process of creating explicit
knowledge can be realized by reflective learning and is also explained in the research approach in
the methodology section of this report. This ensues in the next phase; during the exploration phase
all professionals explore their roles and seek clarification of the value they each bring to the team
collaboration about for example the diagnostic process. Throughout the implementation phase, the
team work with the patients to gain an insight or understanding of how each member’s role can
be valued and how power can be shared in the team. In the last phase, evaluation, all professionals
assess the effectiveness of their collaboration multidisciplinary teamwork on patient’s satisfaction
with their participation. In this way, reflective learning can be realized and an MDT can be made
iteratively more efficient, resulting a better diagnostics of BD.
As indicated before, in the sensitization phase, some aspects or barriers are challenged. These
barriers for an efficient MDT are identified as: organizational structuralism, power imbalances and role
socialization. Organizational structuralism is about bureaucracy and requirements of authorities.
The MDT has to convert these aspects in a positive environment, where professionals are
supported in their work. Power imbalances can be caused by role conflict, like preconceptions that
professionals have of their own role, overlapping competencies and responsibilities and stereotypic
perceptions that professionals hold of members of their and other disciplines (Laschinger et al.,
2003). Bringing different cultures together in a MDT is also challenging and professionals have to
go through a socialization process (Clark, 1997). Therefore, health professionals must deal with the
fact that the boundaries of practice are blurred and must trust each other and members of other
disciplines in sharing the patient care (Clarke et al., 2002).

19. 19
Achieving an efficient MDT- enablers
Figure 3 shows also several enablers of a MDT, including trusting relationships, power sharing, role
clarification and role valuing. Orchard identified development of trusting relationships as where each
member trusts the decision-making capacity, the knowledge, and the sense of ethics of each group
member and power sharing where a willingness exists to facilitate joint power sharing within the
group (Orchard et al., 2005). The last suggest that decision-making power must be shared with
other members of the team. ‘Level of trust’ is described as a belief that other team members are
accessible, dependable and acting with moral intent (Lindeke and Block, 1998). Trust is an
important element in effective MDT and when it is lacking team effectiveness can be undermined
(Orchard et al., 2005). Developing trusting relationships among MDTs creates synergy and
tolerance of assertiveness, enhanced communication and shared decision-making about e.g.
diagnostics (Laschinger et al., 2003). Another important aspect of a MDT is the role clarification
of the involved professional, where this research focuses on.
One of the challenges of MDT working is achieving clear definitions of the professionals’ roles
and expectations with regard to shared care. This research’s scope is the allocation of roles within
the MDT, because clearly defining practitioner roles and responsibilities will enhance the positive
elements of the collaborative relations and reduce the possibility of ambiguity and
misunderstanding regarding procedures, protocols, authority and responsibility (Paquette-Warren
et al., 2004). Just as there is overlap in symptoms of BD and other disorders, there is much
overlap in the tasks of the involved professionals. A clear task division in the diagnostic process
could minimise misunderstandings between professionals and possible vagueness of roles within
the MDT (Jenkins et al., 2001).
Figure 3: the process of achieving an efficient MDT. (Orchard et al., 2005)

20. 20
3.3. Role clarification in the MDT
An important reason of focussing on role clarification in the MDT is explained by Orchard and
his co-workers. Namely, according to them role clarification and role valuing is one of the important
enablers of multidisciplinary collaboration between professionals. The better the multidisciplinary
collaboration, the more efficient the diagnostic process. The role clarification is defined as
‘gaining an understanding of both the roles assumed by each member of a group and their
requisite knowledge in exercising the same’, while role valuing is defined as ‘respect shown for
each other based on of each members knowledge and contribution to the team’ (Orchard et al.,
2005, p.3). When each member of the MDT develops a clear understanding of the added values
of each role and the contribution to the diagnostic process, respect will develop (Orchard et al.,
2005). In addition the valuing of the roles in the MDT by the professionals will facilitate new
ideas, sharing of responsibility and disagreement. A climate of respect and openness will be
created in which expression of feelings and opinions is guaranteed, if professionals can value the
contribution of each member in the MDT (Mariano, 1998).
This research focuses on the role clarification part in the model suggested by Orchard, since the
model suggests that role clarification comes at first in the exploration phase in order to go further
in the process of achieving an efficient MDT. In addition, collaboration that is a interdependent
relation, requires according to Makaram the recognition of complementary roles in a team
(Makaram, 1995), suggesting that role clarification are the core of a successful MDT. By
discussing the added values of the different professions and values and beliefs related to how the
professionals wish to work together, they can develop a shared vision for a good collaboration (in
order to get an more efficient team). An antecedent to formulating this shared vision is according
to Ingersoll and Schmitt (2004) the establishment of what professionals’ expectations will be from
each other and clarifying what each other’s roles and beliefs are about the MDT.
3.4. Theoretical framework
The relation between the concepts and the theory explained above are gathered together in a
theoretical framework as showed in Figure 4. The psychologists, psychiatrists and nurses collaborate in
the diagnostic process of BD and constitute a multidisciplinary team (see methodology section).
As summarized in the contextual background, several challenges are in the literature described as
challenging during the diagnostic process. It is important to investigate whether and which
challenges the professionals experience in practice. That is a good indication to have an insight in
the diagnostic process in practice, and eventually optimize the diagnostic process of BD. Besides
that, as mentioned before, one of the essential prerequisites of an effective multidisciplinary
collaboration between the professionals is the clarification of the different roles in the diagnostic
process of the members in the team. Thereby, it is essential that the professionals are aware of
each other’s added values of their roles in order to compile the already achievable knowledge and
expertise of the professionals. Clarifying the different roles in a MDT and creating explicit
knowledge can contribute in making the diagnostic process of BD more efficient.
The process at the left side of the model in Figure 4 is the process described by Orchard and his
co-workers for achieving an efficient MDT. According to this model, this process starts with the
awareness of the professionals of their roles, role clarification. Because of the importance of role
clarification in this model and according to other articles described above, all other boxes are

21. 21
given a grey colour. These grey boxes are meant for creating a better understanding of the ‘role
clarification’ concept and are not included in the research scope.
Figure 4: Theoretical framework (left part from Orchard et al., 2005)
3.5. Sub-questions
The sub-questions are derived from the theoretical framework and are as follows:
1. What are the challenges in practice endured by professionals during the diagnostic
process of BD?
2. What are the added values of the roles of the psychiatrists in order to get an efficient
MDT for an efficient diagnostic process of BD?
3. What are the added values of the roles of the nurses in order to get an efficient MDT for
an efficient diagnostic process of BD?
4. What are the added values of the roles of the psychologists in order to get an efficient
MDT for an efficient diagnostic process of BD?
Efficient
diagnostic
process
Efficient
multidisciplinary team
-Organizational
structuralism
-Power imbalances
-Role socialization
-Role
clarification
-Role valuing
-Trusting relationships
-Power sharing
-Team process
-Team member
satisfaction
-Client outcomes
Evaluation
Sensitization
Exploration
Implementation
Challenges in
practice in
diagnostics

22. 22
4. Methodology
This chapter describes the methods that are used for this research and is divided in three sections:
the research strategy, research approach and the research analysis.
4.1. Research strategy
This research aims to clarify the challenges in practice during the diagnostic process of BD and
the added values of the roles of professionals in the MDT who are involved in the diagnostic
process in order to make the multidisciplinary collaboration between them more efficient. For this
purpose, an explorative qualitative research method was used, in order to get more insight in the
perspectives of professionals. An exploratory research "seeks to find out how people get along in
the setting under question, what meanings they give to their actions, and what issues concern
them. The goal is to learn 'what is going on here?' and to investigate social phenomena without
explicit expectations." (Schutt, 2014, p5.).In this research two types of data gathering methods
were used: focus groups and interviews.
A focus group method is very suitable in this research, since it is a type of qualitative research, in
which the researcher obtains opinions of the group members (professionals) related to a specific
topic (BD). The group members of these groups are recruited based on pre-specified qualifications
(professionals’ role in the diagnostic process) and their experience in the diagnostic process of BD.
Therefore, this research focuses on three professionals who are involved and experienced in the
diagnostic process of BD: psychiatrists, psychologists and nurses.
A big advantage of conducting a focus group in this research is creating a discussion that can
produce insight that would be more difficult to generate without interaction in a group setting
(Lindlof and Taylor, 2002). The memories, experiences and ideas of the professionals can be
stimulated when they listen to each other’s verbalized explicit experiences and roles in diagnosing.
This is the group effect in which the focus group members show a kind of ‘chaining’ or ‘cascading’
effect (Lindlof and Taylor, 2002, p.182). If available and achievable, focus groups were preferred.
However, if the team consisted of just one professional with a specific profession, an interview was
planned. An accessory advantage of interviewing professionals was the anonymity of the
interviewee, whereby interviewees had the opportunity to be more on their ease.
Focus group and interview design
The focus groups were designed as homogenous groups, because homogenous groups generally
are more open and comfortable with each other and can create a higher degree of interaction and
valuable data (Lindlof and Taylor, 2002, p.182). Therefore the focus groups in this research are
designed with only one profession of the three professional types of nurses, psychologists and
psychiatrists.
Furthermore, almost all professionals are recruited from three locations: GGZ inGeest Bipolar
Hoofddorp, GGZ inGeest Bipolar Amsterdam and Altrecht Bipolar in Utrecht. The professionals
are an essential part of the bipolar team at these locations. Also two other organizations are
contacted, because the absence of psychologists in the team of GGZinGeest Hoofddorp and
Amsterdam. They are contacted via mailing and via previous connections and collaborations.
The meetings lasted for about an hour and are planned at the work location of the professionals.
The focus groups are planned in a time span of five months, September 2015 until January 2016.

23. 23
Figure 5 elaborates the gathered data within these five months. The nurses and the psychiatrists
are all interviewed in a focus group setting. All psychologists are interviewed, there was only one
focus group setting with two psychologists. In the end, a total of nine meetings with professionals
were arranged.
Figure 5: Elaboration of five focus groups and four interviews. The numbers in parentheses are the
amount of arranged meetings at the end of the data-gathering phase. Most interviews are held with
psychologists (at different locations), due to their absence at GGZinGeest Bipolar in Amsterdam and
Hoofddorp.
The focus group design can be found in the appendix. In this design, the challenging aspects of
diagnosing a patient with BD are investigated (for each discipline). Initially, it is important to get
an insight in the challenges of the diagnostic process of BD in practice. The literature shows us
many challenges, however for making this research complete and implementable in practice, the
challenges faced in practice by professionals of the MDT are included. To minimize these
challenges and to contribute to a more accurate diagnostic process of BD an effective MDT is
required. The professionals are asked to think about the challenges of diagnosing BD and to write
them down on post its. All post-its are discussed and related topics are stuck together on an A3
blanch poster. Furthermore, the opinions/perspectives of each discipline about the added value of
their discipline and the added value of their colleagues who are involved in the diagnostic process
of BD are questioned. For this exercise, forms that group members could fill out, were made and
printed beforehand.
4.2. Research approach
In order to clarify the added values of the different roles within the multidisciplinary teams of the
bipolar units of included locations, the reflective learning approach is used. Schön stated already
in 1983, that reflective learning is all about the capacity to engage in a process of continuous
learning and to reflect on actions or behaviour (Schön, 1983). According to Bolton (2010),
reflective learning involves critical attention paying to the practical theories and values. These
theories and values are about everyday actions. Paying critical attention to these everyday
practices, like roles of several professionals in the diagnostic process of BD, increases the
developmental insight (Bolton, 2010).
Furthermore, reflective practice can be an important tool in practice based professional learning
settings where people learn from their own professional experiences. It is also an important way to
bring together theory and practice; through reflection a person is able to see and label forms of
thought and theory within the context of his or each other’s work (McBrien, 2007). The act of
reflection is seen as a way of promoting the development of autonomous, qualified and self-
• Psychiatrists (2)
• Nurses (2)
• Psychologists (1)
Focusgroups (5)
• Psychiatrists (0)
• Nurses (1)
• Psychologists (3)
Interviews (4)

24. 24
directed professionals, as well as a way of developing more effective healthcare teams (Ghaye,
2005). Engaging in reflective practice is associated with improved quality of care, stimulating
personal and professional growth and closing the gap between theory and practice (Jasper, 2013)
Medical practitioners can combine reflective practice with checklists, like SCID, to reduce
diagnostic error (Graber et al., 2012)
As said, for a better diagnostic process of BD, a MDT is required in order to get all expertise that
are needed for the diagnostic process together. As this process is difficult due to several reasons
(e.g. co morbidity), a clarification of different roles within the team and subsequently a more
efficient collaboration between health professionals who are involved in the diagnostic process
seems to be a prerequisite for achieving better results in BD. Reflective practice promises, as
described above, several opportunities in order to minimise the diagnostic error in BD. In this
research, reflective learning is used as an approach, in which giving feedback and getting aware of
the added values of the roles of different disciplines important aspects. Especially focus groups
create a platform in which professionals can discuss their roles and get aware of their unconscious
(tacit) knowledge. In this research is tacit knowledge the roles in the MDT about the diagnostic
process of BD. Clarifying and valuing the roles and recognizing and appreciating the added
values of the colleagues will make this tacit knowledge explicit. This is important, because
awareness of the roles can be the first essential step to eventually redesign or change some
protocols in the multidisciplinary teams.
4.3. Research analysis
The analysis phase of the research aims to find patterns that emerge from the gathered data.
During the focus groups, a voice recorder was used to record all verbal data. All these data are
transcribed in a document. After this step, ‘adding comments’ function was used to add comments
in Word in the transcribed text about the themes, concepts or ideas that stand out. These themes
are arranged in an Excel table to oversee the related themes or categories. In this way, a
beginning of different themes or categories within the faced challenges in practices of the
professionals and the added values of each other’s roles was made. The next step comprised
sieving of the data by highlighting and sorting quotes. At this phase, the most important task is
reducing the data by contrasting and comparing data via the overview of the table in Excel and
rearranging similar quotes together and deleting unnecessary quotes.
The data were then ready for the last phase of analysing: interpreting the data. In this phase, it
was important to make sense of the individual quotes, but also to make an analytical translation to
see the relationships between the quotes and the themes. The stages described above are called
‘open coding’, in which the formulated concepts and key words are reduced to a concise
description (Strauss and Corbin, 1990). This is thus done by determining the key concepts and by
formulating the essence of the relations between the key concepts.
Validity
There are some artefacts that can affect a research design like maturation, sample selection and
researcher bias. The type of people included in the focus groups and invited for interviews, also
called the sample selection, is obviously very important. It is from high importance to ensure that
the participants are homogenous in several aspects. In this research, the professionals are divided
on their profession. The focus groups are arranged with only one profession in order to get a

25. 25
homogenous group, in which the focus group members are more likely to be comfortable with
each other. All professionals of the bipolar team at the locations are invited indiscriminately.
Maturation could be in focus groups when the respondents display signs of anxiety to be open or
boredom. The responses of the participants are in that case not legitimate. In this research, the
focus groups are conducted and guided by experienced researchers in order to minimize the
maturation bias by signalling possible problems and give everyone approximately the same
speaking time. Besides that, the interview setting gives the professionals the opportunity to be
more open.
Researcher bias can occur when the researcher (mostly unconsciously) influence the results of the
research by mistakes in for example data recording, questioning and interpretation. The focus
groups in this research are conducted or guided by experienced researchers. There are always
multiple researchers present, which could have increased the detection of this bias by giving each
other feedback.
Ethical consideration
The ethical consideration in this research consists of several aspects: privacy and anonymity,
confidentiality, data ownership and informed consent. The privacy and the anonymity of the
group members are considered, since no names are mentioned in the research report. The
meetings are recorded, after the researcher asked consent to all group members. The records are
treated as confidential and copies were deleted from the disk when it was transcribed, where the
original tapes are stored at a disk that requires personal codes. Only researchers who were
involved in this research had the data ownership. It was not needed to sign an informed consent,
since the participants are not asked to undergo a health care intervention.

26. 26
5. Results
This chapter of the report is divided in two sections in which it sets out the results of the gathered
data from focus groups and interviews with professionals. The first section presents the results
about the challenges in the diagnostic process of BD, where the second session presents the results
of the added values of the roles of several professionals who are involved in de the diagnostic
process. The professionals are: the nurses, psychiatrists and the psychologists. Each subsection
starts with a short summary in which the important aspects are underlined. These aspects are
explained later on with illustrating quotes.
5.1. Challenges in the diagnostic process
Professionals seem to face some difficulties in de diagnostic process, as the diagnosis of BD is not
always accurate. After the analysis of the gathered data, seven main themes about these difficulties
or challenges emerged: unreliable anamnesis, difficulties with hetero-anamnesis, character of the patient, co
morbidity and symptom overlap, DSM, practical issues and course of disorder and time.
Unreliable anamnesis
Some professionals mention the unreliable anamnesis as a big challenge. As reason for this, issues
with the choice made by the patient about what they tell to the professional and the memory of
the patient about the past episodes was mentioned. Also, patients can be familiar with the
terminology of the disease and are able to use this during the intake with the professionals, which
the professionals have to recognize and lance. Some patients are convinced that they have BD
and search for it on Internet. Besides that, it is mentioned that the conditions of the patient during
the intake can influence the anamnesis.
Coming back to the choice of the patient: in some cases patients do not have the desire to
mention their hypomania. That means that they choose deliberately to hide information for
several reasons. On the other hand, some patients are not able to mention their hypomanic
episodes even though they would like to report it. The memory of the patient leaves them in the
lurch. An example is:
‘Years ago, I had a man with recurrent depression. We asked him out, even his environment (family), we did not
note hypomania. But he felt better after Lithium was added to Notrilen. When I checked his dossier again, he simply
had BD. I discussed his old dossier with him. And then he said: 'Yes, I do not want to know that.’ He was acting,
and did his job well with the hypomania, he had the ability to learn everything by heart. He was very well focused,
but not derailed. This proves that even if someone says: 'No, I have not had hypomania,' you cannot be sure.’
(Psychiatrists).1
Another point that makes the anamnesis unreliable according to the respondents is the use of
terminology of the patient. Nowadays, patients can search the Web for diseases and have the
possibility to find out the terminology of BD and use this terminology during the consult, which
could be confusing for the professionals. Furthermore, the conditions (like emotions) of the patient
during the consultation can have a negative effect on the anamnesis, as some respondents noticed.
‘For example, what also can be an issue is that somebody is already convinced of the fact that he has a BD and uses
the terminology. That is also a difficulty.’ (Psychologists)2
1 Ik heb ooit, toen was ik nog in opleiding, had ik een man met recidiverende depressies. Er was goed gevraagd, ook trouwens bij de omgeving,
2Nou, weet je wat bijvoorbeeld ook meespeelt is dat als iemand zelf al wel overtuigd is van het feit dat hij een bipolaire stoornis heeft en iemand gaat ook
de taal gebruiken die erbij hoort. Dat is misschien ook een moeilijkheidheid (Amsterdam, psychologists).

27. 27
Difficulties with hetero-anamnesis
According to professionals, one of the important aspects of getting an overview of the (medical)
history of the patient is the heteroanamnesis3 , because this information is useful for the
formulation of a suitable diagnosis. The professionals pointed two main challenges about the
heteroanamnesis, first is the non-permission of the patient to consult the GP to gather information
about the (medical) history. This is important, because the GP can make a contribution to the
diagnostic process with the already gathered information about the medical history of the patient.
Another one is the unavailability of the family members or other people who know the patient,
examples of illustrating quotes are expounded below.
Professionals marked the importance of a good hetero-anamnesis. They mention that conducting
a good hetero-anamnesis will provide the professional with information, which can lack in a
conversation with the patient alone, but which is information that can be very essential in the
diagnostic process:
‘Especially with conditions such as hypomania, which is not mentioned by the patients themselves, a hetero-
anamnesis is very important. During hypomania, they feel fantastic. On the other hand, with a mania, you encounter
difficulties, but with a hypomania, they will never sign up themselves. Until the partner thinks there is something
abnormal.’ (Psychiatrists).4
Sometimes, patients don’t give permission for retrieving more information about the patient at
the GP or other related health professionals. This makes a good hetero-anamnesis challenging,
the respondents said.
‘Availability of hetero-anamnesis is important. It is difficult if it is not allowed..., if the patient does not want you to
contact the GP or other healthcare providers.’ (Psychiatrists)5
The second issue for conducting a good hetero-anamnesis according to the respondents was the
unavailability of family members or other relatives of the patient for a conversation. Besides, the
professionals do not always see the information from the heteroanamnesis about the patient in
practice with the patient. The reliability of the heteroanamnesis is being questioned.
‘Well, sometimes someone just comes alone. We don’t literally ask for a relative in the invitation. It lacks in the
invitation, but it also not possible later on. Because the partner is too busy with work, or because the patient doesn’t
want it. Or because of a new relation or the parents have already passed away. There are various reasons.’ (Nurses)6
Character of the patient
Unravelling the character traits of the patient is very important during the diagnosis. Since
hypomania can be applied differently to each patient, professionals mentioned several times that
determining the difference between ‘what is normal for that particular patient’ and ‘what is
hypomanic for that particular patient’ is sometimes very challenging. Because of this, bipolar type
3 A heteroanamnesis is information gained by the professional by asking specific questions to people who know the patient and can give important and
suitable information about the patient.
4Maar het is vooral de hypomanie die ze niet uit zich zelf melden, goede hetero anamnese daarom is heel belangrijk. Tijdens een hypomanie voelen ze
zich fantastisch. Kijk manisch, dan loop je tegen dingen aan, maar hypomanie zullen ze nooit aan zichzelf melden. Tot die partner denkt dat hij zich
anders gedraagt. (psychiatrists).
5Beschikbaarheid van heteroanamnese is belangrijk. Als het niet mag, als de patiënt het niet wil dat je met de huisarts zelf of met andere hulpverleners
contact opneemt (psychiatrists).
6Nou ja, soms dan komt iemand per definitie zomaar alleen. Het is niet zo dat in de uitnodiging staat van: ‘we willen graag dat u iemand die je goed kent
meeneemt.’ Dat staat niet in de uitnodiging, maar soms lukt het ook later niet omdat een partner werk voor wil laten gaan of dat de patiënt het zelf niet
wil of dat... of er is pas een nieuwe relatie en ouders zijn overleden, nou ja. Diverse redenen. (nurses)

28. 28
2 is harder to diagnose, the respondents find. Also, the ‘hypomanic-like mood’ can be a logical
result of the past events in the life of the patient. It is challenging but not less important that this
distinction can be made from the character of the patient. Besides that, the countertransference is
an aspect that needs attention during the diagnostic process. Illustrations are explained below.
Because of hypomania is sometimes a great feeling for the patients, they think that a hypomanic
episode is just like how they always strived to be in life. Therefore, many patients do not even
notice it and don’t mention it during the consultation. It is up to the professional to see the
difference between ‘what is normal’ and ‘what is abnormal’ for each patient, and that can be very
challenging sometimes, they point out:
‘It can be a part of the character. Besides, the patients don’t sign for a hypomania because they think it is a part of
them. How they always wanted themselves to be.’ (Nurses)7
Another illustrating quote of the consideration of the professionals whether a changed mood is a
logical result of events or whether it is abnormal for the patient:
‘Is it really silliness or is it a logical consequence? Because very often, positive experiences can increase that sort of
mood changes. Or just after a gloomy period, someone is recovering and feels free and fine, which is also quite normal
(Psychologists).8
Because of this constant deliberation of the professionals and the manifestation of hypomania is
not clear enough, especially bipolar type 2 is hard to diagnose, professionals said:
‘I think, especially bipolar type 2 is very hard to identify. Bipolar type 1 is often clear, because then, people become
that much disordered that they must be hospitalized (Nurses).’ 9
Even the patients themselves can sometimes have difficulty with the distinction between their
character and their hypomanic episode:
‘People find also themselves very troublesome when they have hypomanic symptoms. It is hard to make a distinction
between their normal states and their hypomanic states. (Nurses)10
Another interesting aspect in the diagnostic process is the so-called ‘countertransference’.
Countertransference is the influence of the patient on the unconscious feelings of the professional.
For example, the expectations of a narcissistic patient can confuse the professional in the
description of the right diagnosis. The professionals have to make a well-considered distinction
between the character of the patient and the applicable criteria of BD. A respondents explains this
as follows:
‘A narcissistic patient for example. Expectations of what you feel (from the patient), of what you need to do, or of
what you are deemed to make a clear statement (about the disease), while you think there’re more issues to investigate.
7Dat het zo dicht bij het karakter ook kan liggen. De patiënt vindt een hypomanie vaak niet erg en vindt dat het bij hunzelf hoort. Hoe ze altijd al hadden
willen zijn. (nurses)
8Is het nou echt gekkigheid of is het nou ja, een logisch gevolg? Want heel vaak zijn het natuurlijk ook positieve ervaringen die die stemmingen kunnen
verhogen. Of juist na een sombere periode dat iemand zich juist weer helemaal vrij en lekker voelt, wat ook heel normaal is (psychologists).
9Ik denk dat met name de bipolaire 2 heel moeilijk te stellen is. Bipolaire 1 is vaak wel duidelijk met... als mensen zo ontregeld raken dat ze opgenomen
moeten worden. (nurse)
10Mensen vinden het zelf ook heel lastig als ze bijvoorbeeld hypomane klachten krijgen dan vinden ze dat moeilijk los te koppelen, in mijn optiek, vaak
wat hun normale ik is en wat hun hypomane ik is (GGZinGeest Amsterdam, nurses).

29. 29
It makes you kind of uncertain, uncertain is not the right word, but the intake is more uncomfortable.’
(Psychiatrists)11
Co morbidity and symptom overlap
Almost all professionals mentioned co morbidity as one of the most challenging aspects in the
diagnostic process of BD. Besides that symptom overlap with different other diseases makes
diagnosing BD also very challenging. BD is a mental disorder, which is according to the
professionals very related with other disorders, like: borderline personality disorder, autism,
substance abuse (addiction) and ADHD. Professionals mention that these diseases can have
symptom overlap with BD, but also can coexist at the same time with BD (co morbidity). Some
professionals specifically mentioned Cluster B personality disorders, of which patients with BD
can also be related with. Cluster B is a categorization of personality disorders and includes
narcissism and borderline personality disorder. This category can either be co morbid with BD or
have strong symptom overlap.
Another confusion that makes diagnosis of BD challenging is according to many respondents that
BD is also commonly misdiagnosed with recurrent unipolar depression, due to the hardly
recognition and/or overlooking of hypomania (BD has great symptom overlap with unipolar
depression). Another reason why professionals can see BD as recurrent depression is the likeliness
that people only seek help when they are getting through a depression, while hypomania mainly
does not lead to big problems in daily life, professionals said. Alcohol abuse, substance abuse and
many more deficiencies can coexist with BD or have enormous symptom overlap with BD. It is
up to the professionals to make a distinction whether a symptom is resulted from a BD or another
disease, or whether it is both, professionals noted:
‘Alcohol and substance abuse, thus comorbid addiction, is a big problem. Because it has a lot of overlap in
symptoms. It can get worse in depressive episodes or manic episodes. If you look at addictions, it has a great overlap.
I think, that (co morbidity) is particularly the most challenging in diagnosing.’ (Psychiatrists).12
Distinguishing a particular disease or condition from others that have the same symptoms is also
called differential diagnosis, as one professional mentions the challenging aspect of it:
‘I think, especially the co morbidity and differential diagnosis can sometimes be quite difficult to clearly distinguish
from one another. So you count in symptom level, are the criteria for hypomania or mania met? If so, it is actually a
BD, but sometimes we are a bit puzzling like: 'yes, but is this not a result of another disorder?’. Such as autism,
such as personality disorders, such as ADHD’ (Psychologist).13
Making a distinction between symptom overlap and personality traits is very hard and is
mentioned several times during the focus groups, like:
11Een narcistische patiënt bijvoorbeeld. Verwachtingen wat je voelt, wat je moet doen, of geacht wordt een duidelijke uitspraak te doen, terwijl je denkt
volgens mij is er hier nog meer aan de hand. Waardoor je een soort van onzeker, onzeker is niet het goede woord, ongemakkelijker in de intake zit
(GGZinGeest Amsterdam, psychiatrists).
12Alcohol en substanceabuse, dus co morbide verslaving, dat is een groot probleem. Omdat dat ook veel overlap geeft in symptomen. Het kan indrinken
in depressieve episodes of manische episodes, als je naar verslaving kijkt, heeft dat een geweldige overlap (GGZinGeest Hoofddorp, psychiatrists).
13Ik denk vooral de co-morbiditeit en de differentiaal diagnostiek, die soms best wel lastig kan zijn om dat goed van elkaar te onderscheiden. Dus dat je
dan op symptoomniveau wel telt van, ja, is aan de criteria van een hypomanie of een manie voldaan? Najah, dan heb je dus eigenlijk een bipolaire
stoornis, maar dat soms wij een beetje zitten puzzelen van ‘ja maar komt dit eigenlijk niet voort vanuit een andere stoornis?’, zoals autisme, zoals
persoonlijkheidsproblematiek, zoals ADHD (psychologist).

30. 30
‘It is also difficult to diagnose if someone has also comparable personality traits. It can overlap. And other diseases
can manifest as well, which can coexist with the hypomania’ (Nurses).14
It is also mentioned that symptom overlap or the vague distinction between the character of the
patient and the disease symptom can lead to difficulties with the ability to make retrospective look
on the disease course:
And cluster B, which is really inconvenient, whereby mood swings also play a role. There’s often so much going on.
Therefore, you’re not always able to have a retrospective look: ‘was this a hypomania?’ or ‘was it a reaction to
anything else?’ (Psychologists)15
DSM
There are some challenging aspects about the DSM according to the respondents. Some
mentioned that the DSM gives a definition of BD, which is sometimes controversial with the
course of the disease. The professionals mentioned several times that despite of the essential role
of the DSM in the diagnostics; some problems can occur. First of all, it is several time marked that
the definition of BD is very vague and at the same time very strict, since a person with four days
(hypo)manic symptoms already fits in the criteria. Concurrently, BD has aspecific symptoms that
do not always fit in the criteria as described in the DSM, professionals said. They added that the
group of people who are potential BD patients, are mainly very heterogeneous. To summarize,
one professional used a metaphor and compared the DSM criteria with a baggy T-shirt, which
does not fit in many cases:
‘Well, the classification consists out of a description of several symptoms… and mainly people do not fit in the
description according to the ‘famous’ DSM classification. It is a little of this and also a little of that. It just does not
fit. Like a baggy T-shirt, you can say.’ (Nurses) 16
When a patient has a four days hypomanic episode, the criteria for BD is met according to
respondents, noting that the criteria are a difficult grey area. The difficulty of diagnosing BD
following vague criteria in the DSM in a short time, while BD is a disease that evolves in time, is
mentioned.
‘The diagnostic process is difficult, because according to the DSM, somebody has already BD when he had just four
days mania of manic symptoms. It is a grey area, but at the same time it is very definitive to diagnose somebody with
BD based on just a few days. Besides that, it is a disease that develops in time, so it a bit contradicting.’ (Nurses)17
Professionals find it sometimes difficult to put symptoms in a box of the DSM. This is according
to the professionals due to the great symptom overlap with other diseases and the aspecific
character of symptoms of BD. Despite of this the definition of BD in the DSM seems very clear, in
practice it is very vague as respondents noted. This can make the diagnostic process very
challenging.
14Wanneer het ook lastig is, vind ik, om een diagnose te stellen is als er iemand inderdaad persoonlijkheidstrekken doorheen heeft lopen. Dat overlapt
elkaar. Andere ziektebeelden die er doorheen lopen (nurses).
15En die cluster B die is wel echt lastig. Waarbij die affectwisselingen ook wel heel erg spelen. Er is gewoon zoveel aan de hand vaak. Dat je ook niet altijd
retrospectief echt kan aanwijzen ‘is het nou een hypomanie geweest’ of ‘was het een reactie op wat dan ook’? (psychologists)
16Nou ja, dat een classificatie, is een omschrijving van een aantal verschijnselen…en mensen passen eigenlijk heel vaak niet precies in de beschrijving
zoals wij die voor .... hè officieel via de DSM de beruchte, beroemde DSM moeten doen. Dus dat maakt het ... denk je ja, het is een beetje dit en ook een
beetje dat en het is ook wel dat en ja dan sta je beetje... Van ja, het past eigenlijk niet zo goed of het past net niet. Een beetje een ruim zittend T-shirt zal
ik maar zeggen. (nurses)
17Wat lastig is om een diagnose te stellen is dat volgens de DSM iemand al een bipolaire stoornis heeft als die 4 dagen manisch is of manische symptomen
heeft. Het kan nog een beetje grijs gebied zijn maar het is ook wel heel erg definitief gelijk hè, om iemand een diagnose bipolaire stoornis te geven op basis
van een aantal dagen. En het is eigenlijk een beloopziekte, dus ik vind dat een beetje elkaar tegenspreken. (nurses).

31. 31
‘The symptoms (of BD) are often aspecific and the group of BD patients are very heterogeneous. So, you never know
exactly which complaint is a consequence of which disease. In general it looks like BD is very clearly defined,
however in practice that is very disappointing. Sometimes you think it a symptom linked to BD, but later on it is
not.’ (Psychiatrists)18
Practical issues
Besides the challenges about the anamnesis, the character of the patient and co morbidity,
professionals mentioned also some practical issues, which professionals cannot influence. Firstly,
professionals saw their specialisation in BD also as a pitfall because they will relate some
symptoms too easily to BD, while the same symptoms may be induced by other disorders.
Secondly, before the patient is referred to the bipolar specialised department, he or she sees other
professionals like the GP, the professionals mentioned that the unawareness of professionals
outside the Bipolar specialised team can also lead to difficulties in an accurate diagnostic process
of BD. Additional to this, it is also noted that measuring instruments, like a MDQ could help in a
GP office. As third, the lack of a standard practice of measuring instruments is marked once as a
challenge, in a location without a psychologist in the team. Lastly, practical issues with the health
insurance were mentioned.
The respondents noticed the pitfall of professionals who are specialised in BD. Practically seen,
the professionals are skilled in screening for BD and will indeed relate symptoms more easily to
BD. This is mentioned as a pitfall, since there is a huge symptom overlap with other diseases and
a symptom does not relate necessary to BD:
‘That's actually a bit like compartmentalised thinking. The police look at everyone as a criminal and we see everyone
as someone with BD. So you're really going to look with those eyes and that's a huge pitfall of course. So we interpret
every symptom to that direction.’ (Nurses).19
Another practical challenge is the unawareness of professionals outside the specialist team. The
professionals in the specialist team do not have an influence on the colleagues outside the team.
Still, it can be challenging that the colleagues who refer the patient to the bipolar team have more
knowledge about the symptoms of BD. This could lead to more accurate diagnosis of BD, the
professionals marked.
‘The lack of knowledge of people outside the specialist team is sometimes a problem. Thus, for example the GPs who
don’t notice that a psychoses can be related with a mania or depression.’ (Nurses)20
One respondent answered that measuring instrument are underused in practice. This has to do
with the policy of the department, where professionals don’t have always influence on. For
example, a MDQ could be used in a GP practice to signal bipolar cases, but also at the specialist
bipolar team it is not standardly used.
‘No usage of measuring instruments like MDQ. It is an additional instrument, especially in clinics with mood
disorders, it is a good instrument. It is not used as a standard, only in anxiety disorders.’ (Psychiatrists) 21
18De symptomen zijn vaak aspecifiek en de groep van patiënten is vaak heel heterogeen. Dus je weet nooit precies welke klacht bij welke stoornis hoort
Nou ja, dat is eigenlijk in het algemeen dat bipolaire stoornis lijkt een vrij duidelijk gedefinieerde stoornis, maar in de praktijk valt dat reuze tegen
eigenlijk. Dat zit in die hoek van, dat is een symptoom en toch niet (psychiatrists).
19Dat is eigenlijk net zoiets als verkokerd denken. de politie ziet iedereen als misdadiger en wij zien iedereen als iemand met een bipolaire stoornis bij
wijze van spreken. Dus je gaat inderdaad met die ogen ook kijken en dat is gewoon een enorme valkuil natuurlijk. Dus dan gaan we alle symptomen die
richting in interpreteren (nurses).
20Maar het gebrek aan kennis buiten specialistische teams. Dus bijvoorbeeld huisartsen die niet helemaal in de gaten hebben dat een psychose
bijvoorbeeld uit een manie of uit een depressie kunnen komen. (nurses)