For most of my life I’ve experienced fatigue and headaches. It wasn’t until relatively recently though that it occurred to me that my fatigue might be related to having migraines. In 2009 after reading about the connection between mood disorders and migraines I convinced my GP to let me try Valproate to prevent migraines. During that time though I experienced a psychotic reaction and the focus on treating the migraines was some how lost. I also tried Propanolol but it had such a sedating effect I couldn’t tolerate it for long. I felt like I was about to pass out the entire time I was on it. Continue reading
Is there such a thing as a “bipolar spectrum”? I am undecided on this question and welcome any new perspective. Joel Paris, a personality disorder expert, had written a book on the topic in 2012 and tried to make the case that much of what falls in the “bipolar spectrum” is really a problem with “emotional dysregulation”( borderline personality disorder). He also tries to make the case that Bipolar I,Bipolar II and melancholic depression are diseases despite the lack of any physical tests or genetic evidence.
Its crucial to remember that that the bipolar spectrum is an unproven concept. The alchemy that turns depression, impulsive disorders, childhood behavioral disorders, and personality disorders into bipolarity depends on entirely superficial resemblances between observable behavioral symptom patterns. Its not based on any basic understanding of the disease process.
For the most part the book was a logical and interesting critique of the “bipolar spectrum” concept however I had the feeling that, given the fact that Paris was a personality disorder expert, he might be jealous of all the money that goes to fund bipolar spectrum research and would like to divert some of those resources.
I have been diagnosed with Dysthymia and Psychotic depression and might, according to this book, be labeled with Borderline disorder. To label everyone with mood instability as Borderline or another personality disorder seems just as unreasonable as labeling everyone as bipolar given the fact that personality disorders aren’t defined much better than Bipolar disorder. In my case the instability could be explained by PMS and an extreme diurnal mood variation. According to Paris my personality disorder should have abated by middle age however I don’t think my condition has improved much since it began.
Finally, affective instability has a different outcome from bipolar disorder. It gets better with time, but never completely disappears. It remains the chief complaint of patients with personality disorders who are followed into middle age.
Patients with unstable mood experience daily life differently than bipolar patients according to Paris.
They describe their life as on an “emotional roller coaster.” they wake up feeling normal but get rapidly upset by each and every life event . In the course of the day, they feel sad and hopeless, angry to the point of uncontrollable rage, or happy enough to briefly feel slightly “high”. Each mood lasts for a few hours. These emotional reactions are intense, and can take some time to “come down” from them.
He seems to believe that the only true diseases in the DSM are melancholic depression(severe depression) and Bipolar I/II. One could still argue that the previously mentioned categories are still quite arbitrary and vague in comparison to many other diseases. Further more the definition of severe depression varies between different researchers and “severe” depressives only fared slightly better on antidepressants according to some experts(Moncrieff) who have written critiques of antidepressant research.
CBT is a therapy based on the belief that one’s negative illogical thoughts can cause depression and correcting them can treat the depression. CBT therapy is usually performed with a therapist however now computer programs are being created to help depressed individuals. While CBT therapy is endorsed by psychiatry it has a number of problems.
Depression is known to cause distorted thinking so what comes first the depression or the distorted thinking? CBT doesn’t clarify this issue. It just says that correcting illogical thinking treats the disorder.
CBT therapy has been shown to be as effective as antidepressant therapy and prevents relapses better than drugs. The problem with this is that antidepressant therapy isn’t all that effective. Antidepressants are, in reality, only slightly more effective than a placebo. Additionally, since major depression is cyclical how does one know for sure if the treatment was actually helping. Many experiments are performed over rather short periods of time and a certain percentage of people will have spontaneous remissions. This of course could be the same issue for antidepressant trials.
Experiments involving CBT vs antidepressants are not double blind which is considered essential for the highest level of objectivity. If the researchers and the patients know what type of therapy is being performed objectivity is diminished.
A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in
Researchers say that brain scans show that CBT “works” and yet brain scans are not considered a reliable way to diagnose mental illness. People with mental illness often have more than problem such as depression and ADD. This confounds diagnosing a mental disorder or saying confidently that an individual is in remission. This excerpt from Scientific American explains the problem.
During testing, the system analyzed the shapes of brain regions in each test scan and assigned it to the group it most resembled. The scientists checked its work by comparing the new labels on the test scans with the original clinical diagnoses. They repeated the procedure several times with different randomly generated sets. When the system chose between two disorders or one ailment and a clean bill of health, its accuracy was nearly perfect. When deciding among three alternatives, it did much worse.
The basis of CBT doesn’t explain how people with a rapid cycling form of bipolar disorder cycle between depression and mania. Do they start off having negative thoughts during a depressive episode which eventually cycles with mania and the mania consequently produces delusional thinking? CBT has not been shown to be effective for preventing depressive episodes in bipolar disorder.
CBT has given no biological explanation for how it works and yet implies that possibly negative thoughts might exacerbate stress which in turn precipitates a depressive episode. Even though stress has long been thought to cause depression stress(HPA activation) is not distinctive to just depression. Stress is implicated in numerous health problems in a rather vague manner. To further complicated matters what is stressful to one person isn’t stressful to another. Consequently it is complicated to study stress.
In the end CBT emphasizes that depressed people are responsible for their depression which is still questionable in the eyes of science.
One person in a Facebook group asked why is it popular to have bipolar disorder and other mental disorders among the young today? One possible answer is that bipolar disorder has been associated with an unusual amount of creativity,intelligence and wealth. Kay Jamison is partly responsible for this romantic notion. Other studies on the topic seem to support the theory regarding creativity and upward mobility but not so much intelligence. I think most people would rather be diagnosed with a disorder that is associated with excess productivity,creativity and wealth than depression or schizophrenia which hasn’t been associated with any of these attributes. Here is an excerpt from one article regarding the topic:
We examined clinical features in 877 in- and outpatients affected by depression who were enrolled in psychopharmacological trials, subdivided according to Hollingshead’s method into five social classes. The results showed that social class correlated significantly with the subtypes of mood disorders, with bipolar disorder being more frequent amongst the upper than the lower social classes. Furthermore, as already reported in other countries, social class appeared to influence the psychopathological pattern of depressive symptoms: somatization and anxiety were more frequent amongst the lower social classes, while psychic and cognitive symptoms were more common amongst the upper classes.
Another answer might be that the bipolar disorder which many are diagnosed with today isn’t Bipolar I but Bipolar II. Bipolar II is less likely to be associated with psychosis which could make it more acceptable. In the past Bipolar disorder or Manic Depression was associated with a severe emotional disturbances, psychosis and a lack of treatment. No one wants a disease with no treatment.
A third possibility is that a small number of celebrities have been diagnosed with bipolar disorder and this could increase the popularity of the disorder. Catherine Zeta- Jones is one such celebrity who has been diagnosed with Bipolar II. She is obviously beautiful, popular and wealthy. Who wouldn’t want to be associated with all that? Moncrief who is a psychiatrist doesn’t think Bipolar II patients need drugs and even questions the diagnostic category. Here is an excerpt from an article she wrote:
Bipolar disorder has become the ‘fashionable’ mental health diagnosis – helped, no doubt, by the fact that many celebrities, including Catherine Zeta-Jones and Stephen Fry, have said they, too, are sufferers.
A fourth possiblity is that artists such as Silvia Plath have been diagnosed with bipolar II. Artists share the angst that is more popular among younger people and popular artists are associated with increased social status/wealth.
A fifth possiblity is that bipolar disorder is more unusual than other mental illnesses with a percentage of around 2% of the population. It is also respected as more severe than say depression which is known as the “common cold” among doctors. This combined could make the person feel more unique and respected.
A sixth possibility and the most likely explanation is that Bipolar disorder is now seen as existing on a spectrum by a few bipolar experts. Additionally the concept of a spectrum gave pharmaceutical companies a new market for many of their highest priced medications which they market to psychiatrists and directly to the public.
In conclusion, I think it is popular to be slightly mentally ill but not so much that it is associated with loss of productivity and poverty. Poverty and isolation are what we all are trying to avoid.
A recent study found that there are a number of factors that increase the chance of having bipolar disorder.
Having at least four previous depressive episodes, suicidal acts, cyclothymic temperament, family history of bipolar disorder, substance abuse, younger age at onset and male gender all significantly and independently differentiated bipolar from unipolar disorders in the study of 2146 patients who initially presented with a first episode of major depression.
After an average of 13 years, 642 (29.9%) patients were diagnosed with bipolar disorder and 1504 (70.1%) were diagnosed with major depressive disorder.
Further statistical analyses showed that differentiation of future diagnoses of bipolar from unipolar disorder was maximal when between two and four risk factors were present per person.
I, myself, have about three. A family history of bipolar disorder, a younger age of onset and suicidal thoughts. The list specifies “suicidal acts” but I think suicidal thoughts could possibly count as well.
Danish researchers have identified characteristics in people with psychotic depression that predict an increased risk for conversion to bipolar disorder.
The researchers analyzed data from several Danish registries to identify conversion to bipolar disorder among patients with an initial diagnosis of unipolar psychotic depression between January 1995 and December 2007.
Among the 8588 patients included in the study, 609 were diagnosed with bipolar disorder (defined as a new diagnosis of hypomania, mania, mixed affective episode, or bipolar disorder) during follow-up, giving a conversion rate of 7.1%.
Comparison of patients who did and did not convert to bipolar disorder identified a range of differences, seven of which emerged as significant risk factors in multiple logistic regression analysis.
These were: younger age at onset of unipolar psychotic depression (adjusted odds ratio [AOR]=0.99 per year of increasing age); recurrent depression (AOR=1.02 per episode); living alone (AOR=1.29); receiving a disability pension (AOR=1.55); and the highest educational level being a technical education (AOR=1.55), short-cycle higher education (AOR=2.65), or medium-cycle higher education (AOR=1.75).
Further analysis of the impact of age at psychotic depression onset found that, compared with people aged 20 years or younger at onset, the AOR for bipolar disorder was 1.64 for those aged 20–29 years, 1.58 for age 30–39 years, 1.80 for age 40–49 years, 1.36 for age 50–59 years, 1.19 for age 60–69 years, 0.85 for age 70–79 years, and 0.40 for age 80 years or older.
The researchers said that in comparison to previous studies the risk was underestimated in this latest study. Interestingly people in the age group (40- 49) appear to have a greater risk than younger groups. I was under the impression for some time that bipolar disorder developed much earlier. Perhaps a greater fluctuation in hormones levels might increase the risk as well.
This study was of interest because I have experienced depression since age twelve and also experienced psychotic depression around age 14 and at 39. Despite experiencing some characteristics of bipolar disorder my doctors didn’t think bipolar disorder was likely.
Joanna Moncrieff believes that psychiatrists are over diagnosing Bipolar disorder. Bipolar disorder used to consist of extreme mood swings, hallucinations, bizarre beliefs and dramatic changes in energy which all occurred over weeks to months but now many “normal” people are receiving the label.
The manufacturers of rare antipsychotic medication have set about changing the meaning of this once rare and distinctive condition, expanding its boundaries beyond recognition so that ‘bipolar disorder’ has become a label that can be attached to a whole myriad of common personal difficulties, who then become legitimate targets for antipsychotic treatment.
I tend to still favor the idea of a mood spectrum since many traits in nature tend to be distributed in a bell curve like fashion. Extroversion/Introversion is one example of this. In the Myers and Briggs indicator extroversion/ introversion preferences are being tested for and when researchers looked at distibutions of scores of various preferences, most had a bell curve distribution. In this distribution most people fall on the borderline and the test somewhat arbitrarily says you are either an introvert or an extrovert.
I can see mood disorders being distributed in a similar fashion except this time perhaps the dichotomy would be instability/stability of mood. Many people would fall in the middle with a mild mood disturbance. What is questionable though are those Bipolar II individuals who border the “normal” area and one tail of the curve. Moncrieff would like to absorb the Bipolar II individuals into the normal part of the curve which would make Bipolar all or nothing however nature is rarely this black and white.