Shrink Rap News

Rethinking Bipolarity


Back in the day, manic depressive illness was a diagnosis reserved for those who suffered from discrete episodes of depressed or elevated mood states. We know that people who suffer from this illness, in this way, do better over time if they are treated with mood stabilizers, and patients are often told to remain on medications for life.

Over the past two decades, the diagnosis has expanded to include those patients with hypomanic episodes and chronic mood lability. The diagnosis has become a catch-all category for some patients with impulsivity, irritability, and behavioral dyscontrol, even in the absence of discrete syndromic episodes or prominent mood symptoms. We now talk about bipolar disorder in terms of type I, 2, (or even 3), rapid cycling, mixed states, and we refer to it as a “spectrum” disorder where the lines between anxiety states, attentional problems, personality styles, substance abuse, adolescent turmoil, and sociopathy all blur. In children, the diagnostic criteria are even murkier.

So what’s the problem? Or is there even a problem?

From the perspective of psychiatrists, we’ve lost the ability to communicate about our work with one another and we’ve lost our credibility with the public. The word “bipolar” means something different to everyone, and it’s not uncommon for people to say that psychiatrists over-diagnose, and misdiagnose, and “call everyone bipolar.” Patients will insist they don’t have bipolar disorder because they aren’t doing the things a bipolar neighbor does. Or they may embrace the diagnosis in a way that both defines and explains all of who they are. It’s not uncommon to hear patients say, “I’m bipolar” rather than “I have bipolar disorder” and to offer it up as an explanation.

Many people with these difficulties seem to either feel or behave better if they are treated with medications. It wouldn’t be such a big deal if the diagnosis were not attached to a mandate – or at least a strong recommendation – for lifetime treatment with medications, and if it didn’t bring to mind images of dangerousness, volatility, unpredictability, and perpetual dysfunction.

The truth is that people come to psychiatrists when they are in states of distress, and their ways of suffering don’t always fit neatly into one of the 297 diagnostic categories that DSM-IV-TR identifies. Insurers demand diagnoses (only certain ones, at that) and the unwritten rules of good medicine say it’s not okay to prescribe for a patient based on sheer desperation, yet that is what we sometimes do. We diagnose because diagnosis justifies treatment. Often our interventions work and our patients get better.

The diagnosis of bipolar disorder has come to sound ominous. And yet, the course it will follow is hard to predict. One person may have three or four discrete episodes in as many decades and function quite well otherwise; classic bipolar disorder where we know that mood stabilizers are likely to decrease the number and severity of episodes. Another patient may live in the chaotic upheaval of underachievement, lost jobs, and marital struggle, while a third patient may have symptoms so entrenched with substance abuse and violence that the issue of actual “mood” gets lost in the mix. Consider the young child who throws temper tantrums and is too volatile to remain in a classroom, but who does so much better once he starts medications, or the moody teenager who requires intervention but later outgrows his difficulties. Are we sure these patients all have the same illness? Are we sure they all need lifetime treatment?

Perhaps they are all variants of the same disease and certainly the expansion of the bipolar diagnosis has allowed more patients to access treatment and get help. But we don’t know that all patients captured by the expanded range of bipolar spectrum disorders need the “medicine for the rest of your life,” nor do we know their prognosis – we simply don’t yet have the data to reach these conclusions.

Until we do have answers from long-term studies, perhaps we need to reassess how we think about bipolar disorder, its treatment, and the picture we paint of it to our patients and the public.

Over on our original Shrink Rap blog, I asked our readers to write about how they define bipolar disorder and the comments that came in are more poignant and revealing than anything I could ever write. Please do read them by clicking here and feel free to join in the discussion.

My thanks to Dean McKinnon, M.D., author of Trouble in Mind, who served as my mood disorders expert for this article.


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