Doctor Z
Bipolar Disorder
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Bipolar Disorder, formerly known as Manic-Depressive Illness, has become another popularized psychiatric diagnosis in recent years. Lately, I've seen an increasing number of patients who have been tagged with this label from prior psychiatric hospitalizations. Uncharacteristic of most manic-depressives whom I've encountered, these patients often present with a ready, sometimes proudful, admission of their newly discovered psychiatric diagnosis. Proclamations of "I have Bipolar Disorder" or more discrete offerings such as "I'm a Bipolar Disorder, Type 2", are quite typical. When pressed for additional communication beyond psychiatric verbiage, many are at a loss for even basic descriptions of underlying personal issues that may have played a role in their hospitalizations. If any information is elicited, it's usually quite superficial in content and devoid of psychological meaning; e.g. "I was having bad mood swings, and my doctor said that I had Bipolar.". Occasionally, a marginally insightful patient might further describe a "mood swing" in the following manner: "One minute I'm feeling great; and the next, I may go off.". This presentation seems to be the rule rather than the exception in our clinic, and quite a contrast from my understanding of this disorder during residency training days. Today, the clinical spectrum of Bipolar Disorder is so wide-ranging that some forms of the diagnosis bear little if any resemblance to the classic and time-honored descriptions by Emil Kraepelin, the brilliant German psychiatrist.

What is "classic" Bipolar Disorder, anyway? Essentially, the hallmark of this diagnosis is a heightened state of arousal characterized by a sustained elevation of mood, activity level, interests, cognition, and speech--a naturally occuring "high", likely influenced by an underlying neurobiological malfunction. If this change occurs gradually, as is often the case in the first episode, affected individuals may realistically perceive themselves early on as being more productive than ever before. This presage, referred to as hypomania, inevitably evolves into an uncontrollable state of excitement known as mania. Objective signs may include extreme euphoria or irritability, hedonistic pursuits, grandiosity/paranoia, garrulousness, and associated severe impairment in social and occupational functioning with a high potential for dangerous consequences. Ultimately, the episode culminates into a state of physical exhaustion from lack of sleep, frequently requiring lengthy hospitalization. Mood stabilizing agents including Lithium and Valproic Acid, antipsychotic medications, and benzodiazepines, make up the standard pharmaceutical armamentarium employed to combat mania, and often restore the patient to a baseline mental status--at least temporarily. Melancholic depression typically precedes or follows mania in a cyclical pattern that increases in frequency with successive episodes of either mood state, particularly in untreated or noncompliant cases. Commonly, the latter situation is influenced by psychological denial or intolerance to medications.

In recent years, our understanding of Bipolar Disorder has expanded to include reasonable deviations from this theme--so called "mixed" states (coexisting manic and depressive symptoms), "rapid-cyclers" (4 or more episodes of mania and/or depression per year), and numerical subtypes such as alternating major depression with hypomania ("Type II"). Such variants appear to benefit less from treatment with Lithium, in comparison to the classic type.

What's troubling to me is the most recent tendency of some clinicians to hastily brand patients with chronically maladaptive personality styles as bipolar disorders, without consideration of more plausible, well-researched diagnoses. Foremost among these, Borderline Personality Disorder is a relatively common mental disorder characterized by dramatically reactive mood swings, though rarely lasting longer than a few days. Unlike in Bipolar Disorder, its origins are consistently associated with repeated, unresolved, psychosocial trauma in the early developmental years. Medication management as a primary treatment intervention in Borderline Personality Disorder is woefully inadequate, though seemingly indicated if this condition is mistakenly diagnosed as Bipolar Disorder.

What factors have brought about this philosophical shift? Apart from unscrupulous practitioners pushing the envelope with equally profit-oriented insurance companies, there appears to be an underlying insecurity driving this pseudoscience. Those of us who are honest about our limited knowledge in this field recognize that disorders of the mind do not easily lend themselves to an Oslerian elucidiation as do diseases of concrete body parts, an obvious concession needing no apology when considering the very abstract and complex nature of the mind itself. As in nature, Medicine abhors a vacuum, which is periodically filled by doctrinaire explanations for confounding syndromes. Psychiatry seems perfectly susceptible to this phenomenon, sometimes to the point of throwing the proverbial baby out with the bath water. Accordingly, I often liken Psychiatry itself to a metaphorical personality disorder, struggling with an inadequate ego, ineffectively defended by impulsive identity shifts between psychodynamic and neurobiological extremes. Today, the latter orientation holds preeminent rank, indisputably reinforced by the highly visible pharmaceutical industry, ever tightening managed-care constraints, and a prevailing "quick-fix" mentality of society at large.

Critics of a psychotherapeutic approach in historically challenging patients with Borderline Personality Disorder will discount such efforts as fruitless travail, lacking "scientific, evidence-based" results. Actually, some promising outcome data from several published studies have demonstrated modest improvement in this patient population, utilizing a highly structured and supervised, cognitive/behavioral therapy protocol. Ironically, trendy attempts to universally classify and treat these clinical conundrums as bipolar disorder, may diminish the overall robust response rates to somatic therapies already realized in classic mania. Hmm...a scenario strikingly reminiscent of a time when Psychoanalysis, replete with such pretensions as the "schizophrenogenic mother", was the order of the day.

Scott Zentner

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