I have a confession to make. I don’t know what “bipolar disorder” is. And as a psychiatrist, I’ll admit that’s sort of embarrassing.
Okay, maybe I’m exaggerating when I say that I don’t know what bipolar disorder is. Actually, if you asked me to define it, I’d give you an answer that would probably sound pretty accurate. I’ve read the DSM-IV, had years of training, took my Boards, treated people in the midst of manic episodes, and so on. The problem for me is not the “idea” of bipolar disorder. It’s what we mean when we use that term.
I recognized this problem only recently—in fact, just last month, as I was putting together the July/August issue of the Carlat Psychiatry Report (now available to subscribers here). This month’s issue is devoted to the topic of “Bipolar Disorder,” and two contributors, faculty members at prestigious psychiatry departments, made contradictory—yet perfectly valid—observations. One argued that it’s overdiagnosed; the other advocated for broadening our definition of bipolar disorder—in particular, “bipolar depression.” The discrepancy was also noted in several comments from our Editorial Board.
Disagreements in science and medicine aren’t necessarily a bad thing. In fact, when two authorities interpret a phenomenon differently, it creates the opportunity for further experimentation and investigation. In time, the “truth” can be uncovered. But in this case, as with much in psychiatry, “truth” seems to depend on whom you ask.
Consider this question. What exactly is “bipolar depression”? It seems quite simple: it’s when a person with bipolar disorder experiences a depressive episode. But what about when a person comes in with depression but has not had a manic episode or been diagnosed with bipolar disorder? How about when a person with depression becomes “manic” after taking an antidepressant? Could those be bipolar depression, too? I suppose so. But who says so? One set of criteria was introduced by Jules Angst, a researcher in Switzerland, and was featured prominently in the BRIDGE study, published in 2011. His criteria for bipolarity include agitation, irritability, hypomanic symptoms for as short as one day, and a family history of mania. Other experts argue for a “spectrum” of bipolar illness.
(For a critique of the BRIDGE study, see this letter to the editor of the Archives of General Psychiatry, and this detailed—and entertaining—account in David Allen’s blog.)
The end result is rather shocking, when you think about it: here we have this phenomenon called “bipolar disorder,” which may affect 4% of all Americans, and different experts define it differently. With the right tweaking, nearly anyone who comes to the attention of a psychiatrist could be considered to have some features suggestive of someone’s definition of bipolar disorder. (Think I’m kidding? Check out the questionnaire in the appendix of Angst’s 2003 article.)
Such differences of opinion lead to some absurd situations, particularly when someone is asked to speak authoritatively about this disorder. At this year’s APA Annual Meeting for example, David Kupfer (DSM-IV Task Force Chair) gave a keynote address on “Rethinking Bipolar Disorder,” which included recommendations for screening adolescents and the use of preventive measures (including drugs) to prevent early stages of the illness. Why was it absurd? Because as Kupfer spoke confidently about this disease entity, I looked around the packed auditorium and realized that each person may very well have has his or her own definition of bipolar disorder. But did anyone say anything? No, we all nodded in agreement, deferring to the expert.
This problem exists throughout psychiatry. The criteria for each diagnosis in the DSM-IV can easily be applied in a very general way. This is due partly to fatigue, partly to the fact that insurance companies require that we give a diagnosis as early as the first visit, partly because we’re so reluctant (even when it’s appropriate) to tell patients that they’re actually healthy and may not even have a diagnosis, and partly because different factions of psychiatrists use their experience to create their own criteria. It’s no wonder that as criteria are loosened, diagnoses are misapplied, and the ranks of the “mentally ill” continue to grow.
As editor of a newsletter, I’m faced with another challenge I didn’t quite expect. I can’t come out and say that bipolar disorder doesn’t exist (which wouldn’t be true anyway—I have actually seen cases of “classic,” textbook-style mania which do respond to medications as our guidelines would predict). But I also can’t say that several definitions of “bipolar” exist. That may be perceived as being too equivocal for a respectable publication and, as a result, some readers may have difficulty taking me seriously.
At the risk of sounding grandiose, I may be experiencing what our field’s leadership must experience on a regular basis. Academic psychiatrists make their living by conducting research, publishing their findings, and, in most cases, specializing in a given clinical area. It’s in their best interest to assume that the subjects of their research actually exist. Furthermore, when experts see patients, they do so in a specialty clinic or clinical trial, which reinforces their definitions of disease.
This can become a problem to those of us seeing the complicated “real world” patients on the front lines, especially when we look to the experts for answers to such questions as whether we should use antipsychotics to treat acute mania, or whether antidepressants are helpful for bipolar depression. If their interpretations of the diagnoses simply don’t pertain to the people in our offices, all bets are off. Yet this, I fear, is what happens in psychiatry every day.
In the end, I can’t say whether my definition of bipolar disorder is right or not, because even the experts can’t seem to agree on what it is. As for the newsletter, we decided to publish both articles, in the interest of maintaining a dialogue. Readers will simply have to use their own definition of “bipolar disorder” and “bipolar depression” (or eschew them altogether)—hopefully in ways that help their patients. But it has been an eye-opening experience in the futility (and humility) of trying to speak with authority about something we’re still trying desperately to understand.
From a patient’s perspective, this can make coming to grips with one’s illness difficult. If the parameters o r extent or aspects of the illness are so . . . differently defined, even if only loosely, by such a wide variety of practitioners in psychiatry, then facing the challenges bipolar causes, fighting them, and knowing where one stands as well as what areas need extra “bracing” in mental, emotional etc. terms in order to try to function . . . these things and more are a bit problematic with such flexible definitions, descriptions, etc. of the disorder.
For example, with OCD, you may read a recommended book called Brain Lock; this book has you fight your OCD impulses in part, by having you tell yourself that, “It’s the OCD, not me.”
I have found that when fighting a certain type of urge that I only have when manic, that it helps to tell myself, “This isn’t me, it’s the mania.” That really helps, and with the blurry view of bipolar that all these overlapping perspectives on bipolar can result in, on the patient’s part, I know I need to look to myself and my specific problems and my specific issues, symptoms, etcetera.
However, for some things that are a bit less clear, or even for the example mentioned just above, where it took me a number of years to come to such clarity about that urge and mania, it would help the patient to not feel so unsure of what bipolar encompasses, for them.
Everyone is individual, and individuals tend to have some differences in symptoms, effects, etc. of any illness that other people may have. However, many or most of the symptoms can be seen to me similar across the board, or you wouldn’t be able to define or diagnose the disease. This last is where the large variety of perspectives on bipolar again, makes being a patient who struggles with the illness, feel less as if they have a solid foundation to fight the disease, and more like one is standing on shifting sand. This is not conducive to effectively fighting the illness, but one does what one can, and I continue to explore how I am affected and in what ways, figuring out what areas of my life, mood, thinking, and behavior that the illness may be specifically effecting me, and then work on trying to fight that. It would be at least an order of magnitude less difficult if the bipolar illness was less ill-defined . . . but this doesn’t take into account the view that one of the speakers you mention that proposes a broader view of bipolar.
Sorry this is so long! The issue touches on alot of big things of me. Not the least of which being a variety of views as to how responsible one is for one’s actions when at the extremes of mania or bipolar depression, which subject upon which I discuss, here. http://sarebear.typepad.com/blog/2012/07/bipolar-extremes-responsible-or-not.html
Thanks for posting this, Steve. With DSM 5 just around the corner this issue is likely to be pretty flamable.
My two beefs are 1) diagnostic criteria and treatment protocols being driven so forcibly by Pharma; and 2) does anyone consider affective symptoms when making a Bipolar diagnosis any more? It seems to have become exclusively a mood disorder. This leads to the big debates regarding PBD vs Bipolar and ‘ultradian’ cycling.
I once tried looking up how frequently people with “unipolar” depression develop (hypo)mania after antidepressant treatment and it seemed really rare. (The real statistics proved impossible to come by seeing as I’m not a shrink and don’t subscribe to the Journals). If it really is rare then why do the DSM complicate the issue by insisting that a person who does get all hyper on antidepressants cannot be diagnosed bipolar? And may have to wait years until they’re able to synchronize (hypo)mania with a doctor’s appointment..? I had this problem for years and of course when you take an antidepressant you’re expecting your mood to change. So I really remembered these times. What I didn’t realize was that I was going hypomanic not on antidepressants.. well it’s all a great mess and eventually I went psychotic and manic, and then the dr ended up saying I was NOT bipolar but schizoaffective. I was REALLY PISSED OFF with that.
Are you REALLY a psychiatrist? Most of the blogging psychiatrists I come across seem decidedly fishy. Like they’re normal people, who wish they were a shink, but are too thick and couldn’t be bothered anyway contributing the near-decade required for full training… Know what I mean..? 😉
PS while I have your attention what about all the cowshit about bipolar being UNDER diagnosed, when it’s pretty evident that type 2, at least is massively OVERdiagnosed. Eg you hear about hypomania that people can barely recognize “without proper training” (when hypomania is a blaringly obvious condition, in fact mania is the only psychiatric condition a non-doctor can pretty accurately spot, once they know what’s involved)
take the example of this article:
which talks about increased attention span. To have better than usual attention the hypomania has to be really really fucking weak because a scattered mind is pretty much an inherent part of a manically elevated mood.
Such a load of bullshit is spoken about the whole issue nowadays. Eg that “Bipolar is not crazy”. Didn’t Kay Jamison say psychotic mania was “as crazy as it gets”..? If you read the really old psychiatric texts eg by Emil Kraepelin, you see pretty quickly that many people diagnosed bipolar 2 today would have been labelled cyclothymic 100 years ago.
And why do people take use DSM criteria as shorthand descriptions of the illness. They were never meant to “describe” any condition. Merely to ensure that fully trained doctors, with years of experience gave matching labels to patients with similar symptoms. Those diagnostic criteria are so unhelpful to sufferers. When I had been in depression for months I obviously started to normalize my experiences. I googled depression several times, came up with those God-forsaken diagnostic criteria and convinced myself nothing was wrong time and again. My psychiatrist just nodded sagely when I told him of this, years after the fact. I don’t think he likes the DSM. And being as I’m in London they have no “power” over us here ha ha harr! 🙂
PS I don’t know why I’m ranting like this. I must be manic ho ho. 🙂
Your post is wonderful, should be copied and handed to every patient who presents with an affective disorder. Patients decide whether or not they have bipolar disorder, not doctors. A doctor is free not to treat a disease a patient thinks she has when the doctor thinks the patient is wrong.
I firmly believe there is a lot of under-diagnosis of bipolar disorder. I believe that my life was very seriously affected by this. But from what I have read above, Kupfer is profoundly dangerous. I am a bipolar imperialist but Kupfer is no ally of mine.
Bipolar disorder is not perfectly well defined, but neither is democracy or pornography. I am simply concerned that there are many seriously troubled people who would do well on a simple mood stabilizer and a lot of abstinence from alcohol and illicit drugs. The experiment is cheap, and not dangerous.
Steve: “Why was it absurd? Because as Kupfer spoke confidently about this disease entity…”
It is absurd because the treatment recommended is likely to be dangerously worse than the disease even if the disease exists, and I believe that it does.
Is this what Kupfer wants to do: “I am going to help your mood some by giving you a drug that seriously affects the way your body delivers glucose to your cells—that’s what keeps you alive—but trust me.”
At the end of your post, before the “like this”, “share this”, and “comment”, is an advertisement for Visa. The ad begins with a shot of gymnastic parallel bars and once clicked on, is Nadia Comenici’s famous 1976 Olympic routine where she recieved the only perfect “10”.
As one diagnosed with bipolar (or whatever, don’t care what it is called anymore, my MD and I agree to meds when needed and the less evil meds for stability). I find the analogy of parallel bars most fitting. The leap of faith the brilliant gymnast mastered as she maneuvered the two bars at parallel levels is an ideal visual representation of the disorder.
As always, thanks for your enlightened posts, and in a strange comforting way, it is good to know that even MDs have trouble defining it. I sure do! It is a most personal battle for those afflicted and am gratedul that my MD and I don’t sweat the small stuff. Best, Clare
“Readers [meaning doctors] will simply have to use their own definition of “bipolar disorder” and “bipolar depression.” Oh, Dr. Steve, you know perfectly well where that goes!
I don’t see why you can’t define bipolar disorder in a classic way. David Allen does it, again entertainingly, here http://tinyurl.com/c37hlyk
As for patients suffering from adverse effects of antidepressants being saddled with with a diagnosis of bipolar disorder, this happens far, far too often. They are then treated with God-knows-what drug cocktails, thus gratuitously escalating their condition to a serious mental illness further complicated by iatrogenisis.
As adverse effects of antidepressants cause nervous system destabilization that may come in waves, these phenomena added to the mythology of ever-shorter bipolar cycling in bipolar [x+1] diagnoses (Allen calls these bipolar MA — “my *ss”).
Yes, adverse effect of antidepressants come in waves. It’s the nervous system wobbling under the chemical assault. I’ve got the case histories to prove that here http://tinyurl.com/3o4k3j5
In these cases, common sense would dictate STOP THE ANTIDEPRESSANT and allow symptoms to resolve but since when does psychiatry respond to common sense?
I’ve even had correspondence with otherwise sensible doctors who know they’re seeing adverse effects of antidepressants but give a diagnosis of bipolar [x+1] disorder anyway just to give the insurance companies a code.
Furthermore, adverse effects of antidepressants may respond to “mood stabilizers” such as lamotrigine because THOSE DRUGS REDUCE NERVOUS SYSTEM REACTIVITY, not because the patient is bipolar. Reasoning to a diagnosis backward from the effect of a drug — way to go, psychiatry.
We may be on the same page, or at least reading the same book—it’s all about excitation and glutamate.
More than half of all bipolars drink alcohol and suffer GABA death and glutamate resurection.
Maybe bipolar in some folks is just a bad trip after alcohol, too bad, I love the stuff and our Colonial Forefathers really loved it.
@Alto: I am surprised you posted a link Allen’s thoughts, because that is exactly what I was thinking when I read this. And it was the same article too. What I remembered was him pointing out that, in Bipolar Disorder, you are either Jekyll or Hyde and you are not both at the same time. Not sure where he said this, but he also talked about agitated depression being lumped in with Bipolar Disorder and it’s because tacking on a mood stabilizer often helps people with agitated depression…but does that make it Bipolar Disorder? I like how The Last Psychiatrist put it a long time ago. If he had a patient who presented in every way with depression, no bipolar in sight, and the patient responded to seroquel, he wouldn’t think that meant the patient was bipolar.
It seems like part of this issue is that people may be put on risky meds that they don’t need. But then apparently pdocs have been tacking on a mood stabilizer for depression for years. It’s just a matter of whether we want to call that kind of depression bipolar disorder or not. If you have MDD and respond to Seroquel does that make you Bipolar? What if you have Bipolar Disorder and respond to Zoloft? Does that mean you really had MDD?
Labels are tough. I actually do have a friend with Bipolar Type 2. The PDoc prescribed Zoloft…and he’s fine. That surprised me, but he’s been fine for years now with no mood stabilizer and only the Zoloft so I don’t know…
DrSteve: Once again, you are right on the mark!
Human nature, and psychiatry in particular, seems to be addicted to automatically labeling and classifying (at least, what APPEARS to seem) a “pattern”… even if the label—–ooops! I meant “diagnosis” doesn’t exactly fit the DSM protocol description, well now, no real problemo… simply attach “NOS” to the diagnostic term, and VOILA! a label, thus, MADE to fit neatly!
Another issue I have is the way another human being’s “observation” is taken to be the gospel Truth, when the very nature of observation itself is (at best) shaky. What a person sees (or rather “sees”) is based upwards of 80% on their own preconceptions and assumtions of said patient and/or their label… and yet the frightenign thing is, even “porfessionals” observations can be, and MANY tuimes ARE WRONG!!! And if the patient thmselves do not catch it or another professional who actually KNOWS the consumer, NO one EVER thinks teven challnge it for the sake of rigid science and fairness or just plain, ol’ good practice!
And human bias is rooted out as much as humnaly possible via the jury system and the tough protocol of clinical research through committees and the double-blind method, yet day after day, NO one seems to routinely double-check the psych nurse’s or pdoc’s “unbiased observations” of the consumer, w/ disastrous results.
Truly, truly frightening.
Another great article on the complexities of psychiatric diagnosis. One minor correction though: David Kupfer is the chair of the DSM-5 taskforce, not the DSM-IV taskforce.
I don’t know why people think they do or should know what “Bipolar Disorder” actually is. It is defined descriptively based on experiencing particular symptoms in contexts for periods of time that are impairing/distressing to someone. Many people who show present differently may meet criteria. This descriptive definition gives no information about etiology or physical pathology, or indicates that there is or should be anything singularly “Bipolar Disorder.”
I suppose many think that DSM diagnoses are meant to be indicators of a particular neuropathology, but there is no actual reason or evidence to make that jump. Why not just be ok with saying certain symptom experiences are classified as bipolar, ask about how much these symptoms are distressing/impairing, and support people if they want in reducing the distressing symptoms (without creating new ones ie. major drug side effects.)
There is no inherent validity to nearly all DSM diagnostic categories. Pretending that they are only seem to make doctors and patients seem pressured to have definitive answers to things that they don’t and can’t have, waste lots of money in research and treatment that pretends to focus on an actual pathology, and from this post this belief that DSM diagnoses should/do have validity make doctors pridefully try to look smart to each other by not questioning poor claims by “experts.” This isn’t good for medicine, science, or people who are in distress.
If uncomfortable with the fact that there is such little validity in psychiatric diagnosing, just don’t diagnose. If you do, recognize that diagnoses aren’t more than co-occuring symptoms for which many different presentations (with countless more “etiologies” be they medical, psychological, societal, economic, political, etc.) can be lumped under one descriptive category. If there are treatments that have been shown to reduce severity of symptoms and/or distress/impairment linked with them that people are willing to try after full consent, then I’m all for that. I am not for having to pretend to know why someone showing symptoms has a brain problem and then lying to a patient in order to give them drugs that treat that pretend brain problem.
The reason promiscuous diagnosis of bipolar disorder is dangerous is that it gives doctors carte blanche to throw antipsychotics and creative drug cocktails at the patient, as the literature is all over the map for treatment of bipolar disorder. (Not surprisingly, as it can be defined as just about anything.)
You point to the specious link i’m trying to highlight between descriptive diagnosis (not based a valid test for a valid pathology) and the apparent belief that somehow descriptive diagnosis indicative of a pathology. It takes believing that our diagnostic system can detect brain pathology with known mechanisms that can be treated by drugs with known mechanisms to maintain what is happening. What actually is happening is that people have distressing symtpoms and are given drugs that without selectivity have psychoactive effects, where some people like those effects better than what they were experiencing, some people don’t experience much benefit but do experience all sorts of new feelings/changes that can be bad, and some deteriorate, get addicted, etc. This is because drugs don’t actually treat a pathology, just very bluntly chemically alter complex brains, to variable and non-specific effect.
taken further. I think then a more humble psychiatry would admit this, better study outcomes of treatments beyond just intended effects (which have been shown to be pretty weak anyway), to provide more accurate information to people who experience distress about the expectations of drug therapy, how they don’t know how it exactly works, some people experiences changes they perceive as beneficial and some people don’t or experience worsening or new symptoms. Also that it is difficult to withdraw for a lot of people, and nervous system changes caused by use can last a long time. If doctors are ethical and reasonable, they probably wouldn’t recommend such a treatment unless less risky or more likely to more specifically help treatments had been tried.
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Manic depressive illness has been consistently described for hundreds of years. It responds to certain medications like lithium but not to others. Patient in manic or depressed states look nothing at all they do all the rest of their time. They look highly similar to one another, with mostly the same symptoms and presentation. The disorder also has a specific epidemiology.
To say that a disease does not exist because we don’t know the cause is specious. They didn’t know what caused plague in the middle ages (some thought it was a Jewish plot), but they sure as hell knew it was a disease.
The wiring of the brain is so complex that a lot could be wrong with it that wouldn’t show up using current technology. Parkinson’s disease fits that bill. Are you saying that isn’t a real disease? Dopamine depletion in the basal ganglia? Doctors say the almost the exact same thing (in a different area of the brain) about schizophrenia.
Believe me, I totally agree that many DSM diagnosis are HIGHLY dubious and fit the ridiculously loose definitions people are discussing here, but to say that ALL of them are like that shows appalling ignorance. If you worked in a state hospital for a day you would immediately know what I am talking about.
Get off your train. You know we are talking about bipolar 2 here and you don’t believe in that. I believe in Bipolar 2 as a consequence of an insanely effective response to lithium monotherapy, persisting for years and years.
You are responding to that old French aphorism when you talk about bipolar 2, “It’s no good, it works in practice but not in theory.”
I am always disheartened when I read that a practicing psychiatrist clings to the now tattered myth that lithium is a specific and effective antidote/prophylactic for “bipolar disorder”. The only remedy for ignorance is knowledge: I would encourage you to read Chapters 11 (“The Idea of Special
Drugs for Bipolar Disorder”) and 12 (“Evidence on the Action of Lithium and “Mood Stabilizers”) in Joanna Moncrieff’s book, “The Myth of the Chemical Cure”. If you have already read Dr. Moncrieff’s book and believe that she has “spun” the data or “cherry-picked”, then I challenge you to produce a longitudinal study (5 yrs. or more) that demonstrates a benefit for lithium therapy. As you well know, there are various harms associated with lithium therapy – impaired cognition,renal and thyroid problems, and the high risk of a severe discontinuation syndrome known as manic rebound.
Sorry, but tattered myth? Hardly. You mean there”s no study where where a couple of hundred patients come back every three or four weeks for five years to get a serum lithium level to see if it’s adequate and to be sure that they are compliant with meds? And who are willing to be followed that long? Got about 20 million dollars to do it?
There are ZERO studies that show that appendectomies prevent deaths from ruptured appendices and peritonitis. I bet you’d have one.
I’ve followed scores and scores of patients who were stable on lithium for years without a recurrence of mania, and saw scores more in the residents’ clinic and in other doc’s practices. Lithium is less effective at preventing bipolar depression, but does prevent patients from flipping into mania if they take antidepressants.
Thyroid side effects are reversible, and we check patients yearly for kidney function. Haven’t had to take a patient off lithium because of kidney problems yet, by the way, but I might just be lucky.
Of course lithium doesn’t work for “bipolar II,” because it is one of the nonsensical diagnoses being discussed in this post. People who carry that diagnosis NEVER meet the DSM criteria if you follow them closely. Studies show that patients with personality problems get the (mis)diagnosis, and when I see them, they ALL have severe family issues even if they deny it at first.
Dr. Allen: I find that I agree w/ most of what you state about people being misdiagnosed.
I myself was misdiagnosed—- knowingly! The person who did it was a fresh psych RESIDENT (not even a full, real “doctor” yet) and gave HER OWN diagnosis of me in a psych e.r. setting (uhhhh… uncomfortable, cramped dimly-lit, unnatural, scary, locked setting, may just MAY cause odd symptoms, right!),I was NOT violent or suicidal (I just needed someone to talk to!) OVER that of my OWN psychiatrist who knew me (at said time ) for almost 20 years! And did NOT, I repeat NOT even GO the psych e.r. unit (VOLUNTARILY, I might add!) for ANY sort of “diagnosis” at all!
The resident gal labeled me “schizotypal” when, in fact, I have Asperger’s—— even AFTER being thus informed by my own doctor, whom they called from there.
When my won psychiatrist found out, let’s just say that calling her angry at the presumptuous young resident gal (yes, I realize that this is “highly disrespectful to your peers and field”, but I feel it’s justified for the highly disrespectful and poor care I got, and her incompetence and presumption, to me, do NOT entitle her to the august title of “doctor”!)
I may seem to “digress” a bit, but necessarily for you and the rest of the readers here to get a full grasp of my sickening experience w/ emergency psychiatry: power-hungry, uneducated, sadistic male security guards allowed to have “access” to female patients in a way that they would NOT on the medical unit, deliberately taunting the patients in order to actually instigate the “fun” of restraining a female in a “take-down” (uhhhhh, I OVERHEARD them SAY this; they seem to think because a patient is a psych patient, we don’t have ears somehow, or our overhearing their sometimes bawdy conversations doesn’t matter)…
Needless to say… I would NEVER EVER in this lifetime or in the known Universe EVER voluntarily go back to such a hellhole again, and common sense should dictate that such experiences CAUSE the anti-psychiatry backlash that you guys are wondering about so much!
Please see my other, more calmer comments on this subject comment board about how easily misdiagnoses are routinely made, and how nothing usually gets done about it.
Psych ER’s vary widely from state to state, and with private and public hospitals. Unfortunately, a lot of what you describe does go on in some places. Especially if a private, voluntary patient is going to be admitted to a psych hospital, sometimes the diagnosis is “tailored” to make sure that the hospital days will be covered by insurance, whether the patient has the diagnosis or not! “Borderline personality disorder” allegedly won’t be covered, although I question that.
I’d be curious to know which residency program the resident you encountered came from. I ran a residency program for 16 years, and, if what you say is accurate (and I have no reason to think it isn’t), I would have seriously questioned her diagnostic acumen.
The psych ER at the public hospital we were involved with was originally so bad it was nicknamed “the Punk” and patients were literally chained to the walls! That was before I was in Memphis, thankfully. By then a psychologist friend of mine had cleaned up the place and it became very well run – until our own practice group sold us out. The hospital then closed the psych ER and just merged it with the regular ER. It had been a great teaching venue for the residents when it was in our hands.
There have, in fact, been a handful of longitudinal studies on individuals diagnosed with “bipolar disorder”, and one of these was conducted by Mr. Lithium himself (Mario Maj) in which he and co-authors studied the 5 year outcomes for patients treated with lithium, lithium plus an antipsychotic or antipsychotic alone, and patients who refused all medications. The outcomes for the lithium treated patients were similar to those patients who refused all medications. The addition of an antipsychotic medication was associated with uniformly worse outcomes. The fact that you have seen scores of patients apparently stable on lithium for years suggests to me that these patients didn’t have bipolar disorder to begin with, although I’ll bet if they abruptly terminate their lithium, they’ll quickly find themselves hospitalized with rebound mania.
I would agree that for an individual suffering from acute appendicitis, an appendectomy alone (without antibiotics) may not be sufficient to save the patient’s life. Back in the “old pre-antibiotic days”, a surgeon who carefully isolated an inflamed appendix might have given the patient an improved chance of survival. An appendectomy will permanently cure chronic appendicitis, and a prophylactic appendectomy may be performed on individuals who will be removed from medical care for prolonged periods of time (South Pole scientists, space station inhabitants, etc).
It is interesting that you mention personality disorders: I would agree with you that many of the “bipolars” have been recruited from the ranks of the “personality disordered” – all it takes is one adverse reaction to an antidepressant (as you know, depression is a frequent complaint with Axis II disorders) and presto! – the patient has a bipolar disorder in addition to his/her personality disorder! Volatile moods or emotional lability are another characteristic of Axis II disorders, and a treating physician may be tempted to “try lithium”. Now, to the extent that lithium produces a mental dulling and/or cognitive impairment (even in normal controls), the patient may be satisfied (psychologically) with this treatment, but if the patient becomes disgruntled or upset about a social setback and subsequently stops the lithium, well, rebound mania may arrive in short order. I’m going to end my remarks by stating that I have no desire to offend or blame the “personality disordered”: we all have personality issues, what matters is the degree to which these issues interfere with “getting on with life”.
If having an acute onset of grandiose delusions, out of character impulsiveness, and all of the other sx of classic mania without any drug abuse isn’t mania, then I don’t know what is.
I’d have to look at this study you quote, but every one I’ve seen didn’t do blood levels nearly as often as needed, and when they did they accepted patients with subtherapeutic levels. And they did highly incomplete diagnostic evaluations, so I would strongly question whether the patients really met DSM criteria. They really almost never do personality disorder evaluations.
So the studies out there are highly unreliable, as critics of psychiatry love to point out except when a study says what they want it to say (and with no analysis of widespread clinical experience by good clinicians, which they just dismiss for no rational reason)
I do agree that most true bipolar patients don’t need an antipsychotic, because lithium alone does the trick. So they WILL do worse! And lithium at proper blood levels only causes cognitive impairment in a tiny minority of patients (if it isn’t one of the OTHER meds). Just ask Ted Turner. If it does cause intolerable side effects, we use something else.
I have the impression that Ted Turner made all his significant contributions/achievements BEFORE he was “diagnosed” as “cyclothymic”. Since then, he’s ventured nothing/accomplished nothing. And you say he’s on lithium? Hmm. What was that I said about cognitive impairment, emotional dulling?
I’m not arguing with your definition of mania, but I do question the etiology of said mania and I do question your use of the term “drug abuse”. Are you including prescription medications? And who is the abuser?
Not that this matters a dang in this debate, but Ted Turner claims to have been misdiagnosed and went off lithium after a few years. The true poop from Hollywood Reporter: http://www.hollywoodreporter.com/news/ted-turner-jane-fonda-cnn-time-warner-295773
Lithium has effects that might be construed as beneficial in people who are not anywhere near bipolar, not to mention the placebo effect. One absolutely cannot reason backward from a positive response to lithium to a diagnosis of any kind of bipolar disorder, any more than a response to an SSRI determines a diagnosis of serotonin deficiency.
Lithium is incredibly toxic, especially in the dosage used by psychiatrists! Don’t take my word for it. Go to FDA MedWatch, keyword Lithium and read the thousands od reports!
Lithium Aspertate works for some at very low levels, or even spring water with trace amounts (Crazy Water can be found at Whole Foods)..
Psychiatry is a dangerous profession… ironically, with a “manic” approach when it comes to human suffering!
spelling – lithium aspartate
available online in 5mg
best to be used with support from naturopath, or a medical doctor (md) in functional or holistic medicine
psychiatry only thinks it has a monopoly
Crazy Water (with trace amts of Lithium) –
Jane – all drugs, the patient.
Alto – true dat last part.
It’s seems clear that you belong to the “blame the victim” camp, and I will confess that I’m only one step behind you, BUT I’m nevertheless troubled by physicians who prescribe a medication with the full knowledge that noncompliance may result in a catastrophic consequence for the patient. First, do no harm.
Jane – Just so you know, the idea that a going off of lithium leads to “rapid cycling” or worsening of bipolar disorder is another one of those PhARMA-propagated myths that has been debunked: http://davidmallenmd.blogspot.com/2011/12/ultra-rapid-cycling-bipolar-disorder.html. And I blame psychiatrists for not knowing this crap, not their patients!
You’re makin’ some great points, but David ain’t listenin’.
David Allen has shut down…
Closed his mind on anything new that would challenge his “expertise”.
He is afterall, a psychiatrist.
So, no big surprise here.
Lithium is frequently used in tandem with an antidepressant, because lithium causes dull affect for the vast majority… The antidepresant can cause a manic episode!
And cominf off any drug that temporarily numbs can cause a similar “manic episode”, especially the neuroleptics (antipsychoyics) that are used as “adjuncts”!
Psychiatrists are just brilliant!
Wait, you mean Ted Turner didn’t tell the truth to Hollywood Reporter? Inquiring minds want to know.
I have never stated that rapid cessation of lithium leads to a “worsening” of “bipolar disorder”, although as early as 1981, at least one publication pointed out that noncompliance with a lithium regimen did “more harm than good”. I cited the rebound mania phenomenon as a catastrophic “harm” that attaches to lithium therapy. As pointed out by Whitaker, “rapid cycling” appears to be a purely iatrogenic illness.
Jane, just how exactly do you know whether an episode mania is rebound or just a re-occurence of an untreated disease? When most patients go off lithium, nothing at all happens at first – nothing maybe for months or years – since they don’t have manic episodes all that often to begin with.
Non-compliance is rampant, so if you were right you’d think bipolar patients would be having more episodes since they go off the drug frequently. They’re not. Sorry, I’ve been prescribing the drug and following patients closely since 1974. I just couldn’t be that lucky. (Rapid cycling, btw, is defined as 4 episodes a year – a very small percentage of cases overall). Feel free to have the last word.
Provisionally, I use the same reasoning to distinguish “relapse” from antidepressant withdrawal syndrome. The drugs cause such pervasive changes in the nervous system, my guess is true relapse soon after withdrawal probably doesn’t occur very often.
Wouldn’t it be a hoot if, in all the research on antidepressants, just about every incidence of “relapse” after discontinuation recorded was actually withdrawal syndrome?
In other words, as Warner et al 2006 suggested, after discontinuation, withdrawal syndrome is the horse and relapse is the zebra.
You kept you short-fuse temper in check through this exchange. Good for you, better for us!
Dr. Allen, I was wondering your thoughts on both my own thoughts, experiences, and insight into the murky area of “emergency psychiatry”. I was awaiting your comments on it, as I have noticed you, like Dr. Steve, aren’t afraid to say what you think, and call an ace an ace. Mine is dated August 9, 4:40pm.
Re: “Bipolar Disorder”
The key is to first look for any underlying physical conditions –
And to provide tools and resources that lead to recovery –
Re: “Bipolar Disorder”
The key is to first search for any underlying physical conditions –
And to offer tools and resources for full recovery –
“People who carry that diagnosis NEVER meet the DSM criteria if you follow them closely. Studies show that patients with personality problems get the (mis)diagnosis, and when I see them, they ALL have severe family issues even if they deny it at first.”
Then in my experience lithium is a miracle drug for personality disorders–driven, successful high achievers, who eventually burn out, way, way out. They are never really right anyway and live in what I think of as mixed states.
I don’t care how you treat your patients, just tell them there is this idea called bipolar 2 and you think it’s a pile of trash but a lot of smart people don’t. Informed consent requires you to do it.
I have always wanted to say this to you—people with mental diseases come from bad families in part, and I emphasize in part, that won’t be enough of a caveat for you, because their mentally ill parents abuse them.
Finally, my personal observation is pf remission after a level of exposure to anti depressants that amounts to abuse. So in fact Alto everything you say is consistent with my experience.
Finally, finally many bipolar patients of whatever stripe are getting themselves stoned and messing up any possible treatment—often getting stoned on anti depressants.
Thanks, I guess, hawkeye. Are you saying your “bipolar 2” was a result of adverse effects from antidepressants, and lithium helped that? I wouldn’t call that bipolar 2, I’d call it damage from antidepressant adverse effects. Good for you that lithium helped.
I am not talking about my direct experience or that of my immediate family.
I speculate that this whole issue is about something you said: a diagnosis of bipolar gives doctors license to do dangerous poly-pharmacy. This is done, over and over. Dangerously and destructively.
There is no such moral license conferred, it is assumed. Treatment irresponsibility is at least a serious factor in the general suspicion of bipolar 2.
Jesse Jackson Jr. and “unmasking” of bipolar II by weight-loss surgery (????!!!!) http://www.medpagetoday.com/Psychiatry/BipolarDisorder/34217
Really??? And what other systemic changes could rapid weight loss and malabsorption of nutrients cause? I hope these are being treated, too, and not just arbitrary psychiatric drugs thrown at the poor guy.
Not to mention — he needs a narrative of recovery to sustain a political career after whatever erratic behavior he displayed. (Wonder what that was!) The propaganda serves everyone’s purposes.
I don’t think any of the docs in the article thought the surgery caused bipolar disorder. Only one thought it was possible that Jesse was already bipolar and the strain from surgery could have pushed him over the edge. A lot of things can induce mania in susceptible individuals, right? Even lack of sleep can do it.
If Jesse Jackson Jr. developed a mood disorder following biariatric surgery, wouldn’t that be considered an iatrogenic condition and not “Bipolar II”?
You would think. But not in the alternative universe of psychiatric diagnosis, where iatrogenic problems are routinely considered to be “pre-existing” mental disorders and treated as such.
Re: Jesse Jackson, Jr.
Poor absorption and lack of nutrients could certainly be the reason. If psychiatrsis were *real* doctors, they would look for these underlying physical conditions *first*. But the vast majority know *nothing* about natural approaches to healing. –
I called each of his three offices and alerted them of the dangers of psychiatric treatment, and gave them some links for alternative care – asked that they pass the info in to Rep, Jackson…Sent the Congressman a card in the mail…
I do not share his political views, but since hearing the news he’s been in my prayers every day… He is a *brother*… any person who has been subjected to psychiatric mis-labeling and mis-treatment (which is what psychiatry is all about) is forever a brother or sister.
Many of us (a growing number) feel this way. And many of us have had enough! And we’re not going away! We’re in this for this for the long-haul…until the present system is abolished and replaced,,,Conventional psychiatry ain’t seen nothin’ yet…
We’re just getting warmed-up!
At-ease, David Allen.
“Bipolar Disorder” diagnosis is a lot like the Rorschach Ink Blot test. The diagnosis is, unfortunately, what I say it is.
In “Lessons from the DSM-IV Past and Cautions for the DSM-5 Future” Allen J.Frances and Thomas Widiger make a number of points relevant to this discussion. Dr. Frances One of their most interesting points is regarding over diagnosis. We seem to have abandoned the goals of DSM-III (revised in 1980 to clarify diagnostic clarity and reliability) The broadening of criteria moving forward from DSM-III has most certainly reduced reliability–the degree to which independent examiners agree. Without diagnostic reliability checks, I’m free to diagnose whatever I want. We generally don’t have lab tests in psychiatry as reliability checks. I personally ask for patients to do personality testing and other psychological tests.. not so much as a reading of the “true diagnosis,” but rather to get another source of information, and to generate hypotheses for future discussion with the patient.
When I was trained, I got a job as an interviewer for a research project (using the Research Diagnostic Criteria– a forerunner of DSM-III), we were given specific questions to ask, and our interviews were videotaped and a subset of patients were interviewed by someone else, and our diagnoses were compared. I can tell you that achieving diagnostic reliability is not trivial, nor is it easy. We disagreed a fair amount. I’m not at all confident that we can make these diagnoses reliably in clinical practice. No reliability=no validity. Also, I think we tend to over diagnose conditions. Not intentionally, but subtly. A patient comes to you, they are distressed, antidepressants of various types haven’t worked, etc. Its very tempting to start asking questions about irritability, sleep, poor judgment and so on, which can subtly lead you and the patient to a bipolar spectrum diagnosis, because we have medications to treat it. In some ways, we have treatments in search of a disorder, rather than the other way around.
To quote Frances and Widiger:
“We depend heavily on expert recommendations on how to change the diagnostic system, but we must not follow the recommendations blindly, without a careful consideration of the many risks that may be outside the expert’s expertise and experience… Most importantly, experts tend to be biased in the same direction. They always worry them¬selves greatly about false negatives—the missed diagnosis or patient who doesn’t fit neatly into the existing criterion sets. In contrast, experts are relatively indifferent to the much more se¬rious problem of false positive patients who receive unnecessary diagnosis, treatment, and stigma and incur needless expense.”
And don’t forget the health risks of unnecessary diagnosis and treatment — they can be considerable. Psychiatry likes to pretend they’re negligible.
Thanks. I get a little wound up about this, because the reliability problem and over diagnosis are a potential embarrassment for psychiatry… which BTW is very hard to practice well, people are often critical no matter what you do, and most practitioners want to do what’s right. If psychiatry is to be a branch of medicine (which I think it is), there needs to be a relentless focus on the scientific underpinnings.
Although I am not a subscriber, I think the Carlat website and letter is fantastic. Thanks for the interesting post!
I don’t believe it’s a potential embarrassment for psychiatry, I think it’s an actual embarrassment. Every patient who realizes he or she has been misdiagnosed and overtreated loses respect, justifiably, for the profession, and tells their friends and relatives.
That is why there is so much very public criticism of psychiatry. Lots and lots of injured patients, lots and lots of negative word of mouth. Psychiatry badly needs to clean its own house to survive.
I enjoy this blog so much I am trying to give it up—maybe for Lent.
Let me propose that there are two ways unconscionable and life destroying damage can be done in the treatment of affective disorders,—giving anti depressants patients with bipolar disorder on a long term basis and giving atypicals to anyone on a long term basis.
I believe quite firmly that bipolar disorder, when it expresses itself as a disorder, is very much a matter of hyper-reactivity to stimuli. Take the isolation out of American life and you might see some real improvement in the outcomes of affective disorders.
[…] and keep her job, her family, and her life. But there are many flavors of mental illness (i.e., not everything called “bipolar disorder” is bipolar disorder), and different people have different needs. That’s the essence of psychiatry: […]
[…] and keep her job, her family, and her life. But there are many flavors of mental illness (i.e., not everything called “bipolar disorder” is bipolar disorder), and different people have different needs. That’s the essence of psychiatry: understanding […]
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