Bipolar Everywhere

Jill Littrell, Ph.D.

January 28, 2012

A recent dramatic rise in diagnoses of Bipolar has been documented (Moreno, Laje et al., 2007). Bipolar used to be a relatively rare event. When working at the state hospital during the 1970s, over a 7 year period, I recall only 4 or 5 patients with a bipolar diagnosis. Most of the patients at the state hospital were labeled schizophrenic. Now when I teach my classes on Substance Abuse or Psychopathology, at least two or three students in the class each semester announce, with enthusiasm, that they have been diagnosed with Bipolar.

Why the dramatic increase? Well, in 1994 with the publication of the DSM-IV, Bipolar II was added to the list of Bipolar Spectrum diagnoses. If you read the official rationale for the new diagnosis (see Dunner who headed the committee), the report will tell you that those meeting criteria for Bipolar II were midway between those with Major Depression and those with Bipolar I diagnoses on having relatives with the Bipolar I diagnoses. So even though others (Kupfer et al.) argued that those with Bipolar II were probably just depressed, the new Bipolar II diagnosis became legitimized.

While I have read no official explanation as to why a new diagnosis (Bipolar II) needed to be formulated, I can offer some speculation regarding what had changed in psychiatry that might have been the impetus for the new diagnosis. During the 1980s, prescriptions for antidepressants had taken off. The emergence of mania in people being treated with antidepressants was widely noted. There was speculation that only in those who were predisposed toward mania would antidepressants trigger mania. Perhaps, the new diagnosis was an attempt to identify persons meeting criteria for depression who should not be treated with antidepressants. The timing for the addition of Bipolar II to the 1994 publication of DSM-IV coincided with reports of mania emerging with antidepressant medications. Thus, the new diagnosis may have emerged not because there was a population that was problematic and suffering, but rather because established treatments caused disturbances.

So, how does one satisfy criteria for being Bipolar II? First, at some point in one’s life, one has to meet criteria for Major Depression. No problem, since community studies find that 24% of the population, at some point in their lives, have met criteria for Major Depression and studies conducted in Australia find that the percentage of persons experiencing a bout of depression may be as high as 40%. For Bipolar II, one must meet criteria for “hypomania”. For meeting criteria for an episode of hypomania, there must be a four day period during which the person was irritable or upbeat, talked rapidly, had rapid thoughts, had trouble sleeping, exhibited high self-esteem, was distractible, and engaged in pleasurable but risky behavior. Of course, if one experienced “significant” problems at home or at work during this four day period, then the episode is labeled as mania, and not hypomania. Not surprisingly, studies find that high percentages of the general population have met criteria for hypomania (Udachina & Mansell, 2007).

With the addition of Bipolar II to the manual, Akiskal, an expert on Bipolar, predicted the rise in the diagnosis. He suggested that half of those who are had been diagnosed as meeting criteria for depression would be relabeled as bipolar. His predictions appear to be correct. The diagnosis is now epidemic.

The problem with the term Bipolar II is that it implies that Bipolar II and Bipolar I share a common etiology. In fact, Coryell and colleagues tracked persons meeting criteria for Bipolar II. Those with Bipolar II were no more likely to experience mania than anyone else. Experts on Bipolar (Vieta & Suppes, 2008; Judd et al. 2003) acknowledge that the research on genes suggests that Bipolar II and Bipolar I don’t not share common predisposing genes variants. Finally, Judd and colleagues’ research suggests that tracked over time, the trajectories for Bipolar I and Bipolar II appear to vary. Thus, in terms of underlying causation, Bipolar I and Bipolar II have little in common. So, the common label is misleading.

The other puzzling finding, which seems to have caught the attention of the Mood Disorder Committee for the DSM-V, is that Bipolar previously was assumed to be manifested in bouts or episodes. In considering revisions for the DSM-V, the Mood Disorders Committee is suggesting that more emphasis will be placed on ensuring that the behavior manifested in an episode of hypomania is a marked contrast from the individual’s usual behavior. (I’m happy that the DSM-V is considering restricting the criteria for the diagnosis.) Presently, this caveat on episodic nature of mood events seems not to have been a big factor in rendering the diagnosis. Alloy and Abramson , researchers with government grants to study Bipolar II, find that those college students who meet criteria Bipolar II score high on the Behavioral Activation Scale. The Behavioral Activation System Scale, developed by Charles Carver, measures upbeat behavior. (Indeed, Richard Davidson, who developed the concept of the Behavioral Activation System, documents that persons scoring high on Behavioral Activation display resilience in the face of depressing events.) The Behavior Activation System scale is a trait measure. It asks about usual behavior. Thus, there is reason to believe that those currently being diagnosed as Bipolar II, exhibit hypomania most of the time. If the DSM-V suggestions are enacted, one wonders whether all the Bipolar IIs who exhibit hypomania most of the time, will be told that the diagnosis was wrong. So, quit taking lithium and atypical antipsychotics. The literature offers scant guidelines on how to detox individuals from psychotropic medications.

Of course, the consequences of being wrong in diagnosing a person as Bipolar are steep. The drugs for Bipolar have serious side effects. Lithium has been estimated to destroy kidneys in about 12% over a 20 year period (Presne et al., 2003). Atypical antipsychotics will shrink the cortex taken over a two year period (Ho et al., 2011). Anticonvulsants can cause damage to the liver and pancreas and induce depression (PDR). Then there is the issue of potential withdrawal symptoms when you discontinue the medications. These dangers are not trivial. The practice of diagnosing Bipolar is now epidemic. The label will probably shorten the lives of many people who would otherwise be resilient in the face of adversity.

Jill Littrell, Ph.D.

Life Style Can Change the Brain: A Clinical psychologist, Jill Littrell writes about research studies of psychiatric medications, and interventions to bolster natural resilience through talk therapy, proper diet, exercise, and support from your friends.

 

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16 thoughts on “Bipolar Everywhere

  1. “Of course, the consequences of being wrong in diagnosing a person as Bipolar are steep.”

    I’d say the consequences of diagnosing RIGHT OR WRONG is very steep…and it’s very questionable that regardless of accuracy in diagnosis that there is ever a good reason for long-term maintenance drugging.

    I”m so glad these arguments are being made in a venue where there are so many readers!

    I responded to some of what you talked about on Beyond Meds today. http://beyondmeds.com/2012/01/29/bipolarovertreated/

    I’m also a blogger here and it’s good to meet you!

  2. Bipolar Disorder is indeed rare,genetic,being almost invariably and obviously familial. Over decades in hospital, community,and academic practice in three Western countries, I have encountered few true cases. However, it has become diagnosed commonly,taking 25 years to do so,with the proliferation of supposedly specific drugs for it,which couples with the fact that anyone can be miserable, ask a doctor for help, agree he also sometimes is happy. Now,at last, the doctor has pills for that”bipolar” patient.

    • I probably won’t be providing many personal stories because that is not my strong suit. However, for the Bipolar issue, I have strong feelings based on witnessing a personal tragedy. Through a colleague, I met a person, the relative of my colleague, who probably fits the classical picture of Bipolar I. This individual had both a mother and grandmother who were hospitalized for hearing voices. This individual came from a family of high achievers. She graduated top in her class from medical school before she went “off the rails” with grand plans to capture various markets. Since that point, she has been taking psychiatric meds. When I first met her, she was extremely obese and did not have much of a life: few friends, never dated, not interested in her career. In the 20 years I have known her, her life has continued to deteriorate. Several years back, she had a kidney transplant. Her bones are quite deteriorated (probably from the valproate which is associated with osteoporosis); she is bent over and her body is twisted. Several years back, her cognitive deterioration became quite marked. We have long discussions on how to open a door with a key. Because she has been a good student throughout her life time, she always takes notes. She has recently retired from her job, much to her supervisor’s delight. She was in a recent car accident and has not driven since. The woman hired to help retrain her to drive, reports that it is too dangerous for her to drive. Mostly, my friend spends her time staring at the wall. Her neighbors are concerned because she wanders aimlessly around her apartment complex.

      It should be noted that on any measure of drug efficacy, my friend would look good. I have never seen her extremely distraught. Even when she has been about to be fired, her routine and mood did not change. Not much impacts her. Her reaction time and rate of speech is slow. I have also never seen her laugh.

      I know this lady’s family quite well. I have asked about what the mother was like. Despite being hospitalized for psychosis several times in her life, the mother refused medications. The family says the mother’s refusal to medicate told was ok, because the episodes were 20 years apart. Mother died the domineering matriarch of a family comprised of very competent individuals. The question in my head when I hear this is “perhaps my friend’s episodes also would have occurred at 20 year intervals. How do you know?” I never ask the question, because at this point, contemplating alternative realities could only bring pain. However, the 20 years of wellness between episodes of mania, fits well with the 1940 publication of Rennie in American Journal of Psychiatry who found that most episodes of mania were punctuated by long intervals of wellness.

      Although the trump card for psychiatrists to justify medications is always, “without medication the patient might suicide”, my rebuttal is ‘what about the danger of not having a life”.

      • Very interesting article; clear and compelling. I am shocked by how many of my “17 and under” counseling patients have been diagnosed by their psychiatrist as bi-polar. Seems a diagnosing epidemic for youngsters, too

    • Just wait until the DSM-V comes out there are some ineertsting changes in it. I’m a stickler for differential dx, to the chagrin of everyone I’ve taught/supervised. Major Depression v. Double Depression v. Dysthymia, etc. Fun fun!

  3. My last stint in a psych ward, I was surprised to find that about 80% of the patients had been diagnosed bipolar, often comorbid with a personality disorder. I myself carry diagnoses of bipolar II and borderline personality. I identify with these diagnoses to an extent. However, I think that the major factor in the increase of any psych Dx is the mental health industry’s tendency to pathologize human behavior. In other times and cultures (some, not all) we see a greater capacity to accept non-normative behavior, even to assign non-normative folks to places within society (though, admittedly, often on the fringes). Here, unruly children are given labels of ADHD and Conduct D/O, unruly adults are diagnosed bipolar if they display a little too much fire, schizophrenic if they sometimes see things they can’t explain out of the corners of their eyes. When I was a psychiatric nurse working with low-income communities, I saw more than one case where I recommended a reasonable, conservative diagnosis that did not indicate pharmaceutical treatment, but the psychiatrist in a rather knee-jerk fashion judged to be a true psychosis. Delusions and hallucinations after you’ve smoked several blunts a day for an extended period? I say substance-induced psychosis, stop smoking weed, Psychiatrist says paranoid schizophrenia, prescribes an atypical antipsychotic. Psychiatrists looking for disease will find it, because that’s what they’re trained (and paid) to do. Researchers looking for novel diagnoses or diagnostic criteria or pharmaceutical agents will find them, because that is what gets them published. The DSM is always problematic, as it is the product of politics internal to the mental health industry. Mental health consumers/clients/patients must be aware that diagnoses are at best approximations of truth, guidelines for them and their providers to engage in treatment. Psychiatry needs to be humbled, and then perhaps we’ll see a decrease in erroneous diagnoses and a greater acceptance of non-normative personalities and behaviors.

    Boy, that was rambling, wasn’t it?! Sorry!

  4. Also many women with premenstrual mood changes -often when they complain about irritability and increased libido- might be diagnosed bipolar an receive mood stabilizers and antipsychotics (at a childbearing age when so many pregnancy are not planified without becoming unwanted necessarily). A good gynaecologist might have solved or ease the complain with hormonal treatment and a psychiatrist should think of it.

    I went to a much needed conference “Hormones and Mood Disorders in Women” in London on the 26th of January 2012 organized jointly by the Royal College of Obstetricians and Gynaecologists and the RC of psychiatrists.

  5. Being misdiagnosed with major depressive disorder when one has bipolar II can be just as dangerous. Witness all the people who have had antidepressants and then had manic reactions to them. Right now, antidepressants are still the first line of attack against depression, so thousands of people are having these reactions.

    Even if Bipolars I and II are not aetiologically connected (surely there are two sides to that debate), if mood stabilizers help prevent depression and hypomania in bipolar II individuals, why is an aetiological connection even relevant? Are you suggesting that there is no evidence to support benefits from mood stabilizers for people who have been diagnosed bipolar II? We may just have two different illnesses here that can be treated by similar medications.

    • I am stating that the benefits of mood stabizers are eclipsed by the costs. See my reply on my friend with BPI. She has had no life. Now she is demented courtesy of atypicals. She had a kidney transplant 8 years ago courtesy of lithium. She has severe osteoporosis courtesy of valporate. She does not experience dispair,but then I’ve never seen her laugh.

      I have an article coming out in Ethical Human Psychiatry and Psychology on Bipolar research. There are no counter arguments supporting BP II. If you can find some research I missed, let me know.

      • This article in BJP is very interesting, as it suggested that many with treatment-resistant depression as missed cases of bipolar disorder: http://bit.ly/wMvNE2

        In one notable section it reads: “Our findings support the view that medication-resistant depression is the link between unipolar and bipolar disorders, especially bipolar II disorder.”
        Thoughts?

        There is also, as you yourself note, the possibility that schizophrenia was in previous decades massively overdiagnosed, and bipolar is just the diagnosis du jour. What, then, do you think people with Bipolar II ought to be diagnosed with?

        • With regard to the Bipolar Spectrum, as Tom Insel will tell you, the same genes for schizophrenia and Bipolar I keep coming up in the studies. Bipolar IIs do not share these genes. So, from the genetic perspective, the DSM does not “carve nature at its joints. I’m fine with looking for more genes. However, it is well to remember that if a genetic variation is stable in the population, the variation probably confers some advantage. Indeed, the frequently discussed short allele of the serotonin transporter, renders a person more responsive to the environment. If life is good, those with the short transporter will be happier. When life is bad, they’ll be more depressed. By the way, normal personality is determined by genetic variations too. Finding a gene does not imply “disorder.”

          Diagnoses are useful when they relate to effective treatments. Before focusing on biology, I studied social psychology. What people believe about themselves does relate to mood, goals, aspirations, and behavior. Labeling mood disturbances as problems in living (which all of us have) creates an expectation that problems are temporary and soluble. As the late Jay Haley, advised, “define the problem in such a way that it will have a solution.” Psychiatric diagnoses are life sentences and not soluble. Although psychiatrists will contend that their drugs are effective, if you read their long term studies (see Judd et al. 15 year follow-up), the outcomes for Bipolar I and II are dismal. On drugs, relapse rates for major depression are over 50% in a five year period. If psychiatrists believe their own literature, they know that the outcomes for all of the diagnoses in the DSM are bad news. Stick with them and you will be miserable. If they believe their own literature, they know that no one treated with their drugs will have a good life.

          In psychiatry, most of the treatments are ineffective and harmful. Perhaps, the exception is the anti-psychotics which do make the voices go away. However, the cost, long-term, is dementia. I’ll have more to say on the costs of anti-depressants in future posts. With regard to even short-term efficacy, I’m sure you know, the efficacy of anti-depressants is equivocal at best.

          If you look at the prevalence of major depression across time, before World War I, only 1% of the population was depressed. Now, we’re up to around 20% life-time prevalence. Certainly lack of exercise and high fat diet contribute through the inflammatory status route. Loss of human connections is probably contributing as well. However, since people have been coping with life problems since the time of Lucy, as a species, the numbers suggest we were better off before the DSM. If you define yourself as having a chemical imbalance and you believe it, the label becomes a self-fulfilling prophecy.

      • Research can’t show that benefits outweigh risks, because that would imply a single scale on which to weigh them. What you’re asking for can’t exist. Those with bipolar disorder need to weigh the risks against the benefits and make a decision.

  6. A small group of us had to attend a “med” education class while in the hospital. I witnessed some of the most amazing things I had ever seen in my entire life.

    The “nurse” sat in a chair with her back facing the wall. Most of the rest of us were sitting among the open space. But sitting to the right of the nurse, facing her directly, was a young man who captivated all of my attention.

    As I listened to the nurse speaking, I watched the man sitting next to her. He looked tranced and amazingly, was lip syncing her every word. I repeat: he was lip syncing her every word.

    That is no disease or disorder. His state of being was what I call “hyper-conscious”. He had been aligned to the nurse in such a way that he was in perfect unison with her.

    Watching him, I’d look over at the nurse and others to see if anyone else was noticing. Not one of them noticed.

    I think “bi-polar” is a gigantic load of crap. I think it’s only one term to describe a phenomenon that would be better known and understood if wise people broadened their minds to incorporate the spiritual, and also environmental and astronomical factors.

    I have a religious book that was published in the 80′s which states that humanity would go through decades of transformation as we experience the return of Christ consciousness. This book stated that there would be a great rise in “mental illness” and this would be the symptom of the great awakening and Christ consciousness. That was the 80′s.

    I believe that a “bi-polar diagnosis” cannot ever be made if a person had taken any psychiatric drug prior to the diagnosis. I know for a fact that these drugs CAUSE symptoms, and the symptoms are then re-diagnosed as a “disorder” or “disease”. I consider that to be severely unintelligent and grossly negligent.

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