Manic depressive controversies

An interesting lecture from Nassir Ghaemi on the bipolar spectrum concept. According to him unipolar and bipolar used to both be encapsulated under the phrase "Manic Depression". "Manic Depression" meant someone who either experienced severe depression or mania. "Bipolar disorder" is defined by an individual having both depression and mania/hypomania. The two phrases differ only by a conjunction....something I hadn't paid attention to before. Additionally, according to Kraepelin, a well known historic authority on the topic, individuals displaying mixed states were more common than the ones who had more pure states of either depression or mania. This has been noted more recently by other researchers such as Benazzi who published a number of articles about people who experience mixed depression.

Prevalence of mixed depression, a combination of depression and manic or hypomanic symptoms, is high in patients with bipolar disorders. Controlled studies are needed to investigate treatment of mixed depression; antidepressants can worsen manic and hypomanic symptoms, and mood stabilising agents might be necessary

My experience with mixed depression

While my depression has been more chronic I have experienced periods of time when it lifted and I felt normal and productive. There has also been a pattern to some of these "remissions". They often occurred during my menses and when ever I altered my sleep schedule to a minor degree. These remissions weren't long enough by DSM standards to qualify for hypomania however as Ghaemi states, the threshold for hypomania is to a large degree arbitrary.

I have noticed as well that my depressions didn't seem pure. They often included good amounts of irritability, insomnia, racing/crowded thoughts, hypersexuality, and a little grandiosity. Somewhat interestingly these symptoms tended to occur in the late evening to the early morning hours. This has been noted by some researchers who study ultra rapid cycling in children. Many clinicians would probably categorize my experience as someone who is experiencing a pronounced diurnal variation but I am reluctant to think that since diurnal variation usually means a slight remission of symptoms throughout the day without hypomanic-like symptoms.

Manic-depressive insanity in the sense here delimited is a very frequent disease. About 10 to 15 per cent, of the admissions in our hospital belong to it. The causes of the. malady we must seek, as it appears, essentially in morbid predisposition.-- Kraepelin

Ghaemi's historical perspective different from DSM

Ghaemi's perspective much like Kraepelin is based on the big picture of evidence and history, not mainly on image. At the moment the DSM-V seems to be ruled by people who are primarily concerned with the public's image of them. They mainly don't want to appear like they are over prescribing and over pathologizing normal behavior. The fact that bipolar is no longer grouped with major depression under Mood disorders is one example of their over reaction to anti-psychiatry.

In conclusion Dsythymia not all that accurate

As someone who has experienced chronic depression with a moderate severity, I am tired of hearing how my so called Dysthymia is defined as mild and at one time in the past, a personality issue. Bipolar disorder has been generally viewed as more incapacitating and more endogenous while unipolar depression is more neurotic. Ghaemi and Kraepelin's theories make sense to me in light of my experience with depression. It has been for the most part, quite incapacitating, miserable and briefly quite pleasant.

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.

Why is bipolar disorder so popular?

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.