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.
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