Posted by Scott L. Schofield on March 23, 2000, at 7:47:37
In reply to Re: Me? Bipolar III citations for Sherry, posted by Blue Cheer on March 22, 2000, at 9:24:56
> No psychopharmacologist is going to let vague descriptions of what does or doesn't constitute bipolar disorder affect his prescribing practice. Hagop Akiskal is in love with nosology and does a disservice to bipolars with his broad 'bipolar spectrum' concepts. Dr. Akiskal and others have been expanding the diagnostic boundaries and definitions of bipolar disorder since the 1970s. They see bipolarity everywhere; anyone who shows the slightest degree of affective instability -- from histrionic personality disorder to hyperactive children may find themselves under the nosological umbrella of bipolar spectrum. In 1981, Dr. G.L. Klerman concocted no less then 7 subtypes of BD. Although Kraepelin lumped together his 400 cases as being manic-depressive, his own data showed that over two-thirds of them suffered from recurrent depression and the other third were bipolar. This inclusiveness lasted until it became clear that lithium was a specific treatment for mania, and bipolar disorder became accepted as a discrete entity. Since the 1970s, the trend has been to expand the bipolar concept and further blurring the distinctions among affective disorders, while cheapening the classic concept of bipolar disorder. Why is this a problem? Bipolar disorder is about as close to a 'disease' as there exists in psychiatry, and the federal government has recently granted the largest mental health award ever to support the study of improved treatment of bipolar disorder. Some of these 'bipolar spectrum' disorders have resemblance in their symptoms and sometimes respond to drugs used in bipolar disorder; however, since the pathophysiological mechanisms involved in these disorders are unknown, then it's important to focus on well-defined diagnostic criteria to obtain similar patients for studies. In other words, the better defined the phenotype, the better the chances are to identify the underlying mechanisms. Given the serious attention and money being committed to the study of BD, this isn't the time to be diluting the concept.
I like the concept of a bipolar-spectrum and the term “soft-bipolar”.
It seems that all of the local practitioners in my area see bipolar in almost any case where there is not an obviously chronic or stable depression. “Mood-lability = bipolar disorder.” It looks as if there is a pendulum effect swinging too far in the direction of bipolar diagnosis right now. If one were to accept the numbers of these cases diagnosed as bipolar as being accurate, it is far in excess of the generally accepted occurrence rate of 1%. However, I think the idea of expanding the diagnostic criteria for bipolar disorder is necessary to get more people well. The compendium of posts submitted on this board over the past five months demonstrates this quite well – at least to me. “Let me find what works first, and worry about how it works later.” For now, if doing so represents nothing more than accurately describing the various presentations of the same disorder, clinical practice advances. I don’t think the researchers in the lab will be persuaded to choose their targets of investigation based solely upon the empirical statistical definitions proscribed by a continually changing clinical manual.
The one example that comes to mind is the soft-bipolar presentation of cyclothymic-disorder. It does seem to be a prelude to unequivocal bipolar-disorder in a great percentage of cases. We know that early pharmacological intervention is critical in determining the future course of bipolar-disorder. Not having been defined as a bipolar-type disorder in the past, cyclothymia was often not attacked with the mood-stabilizers or other regimes that could have prevented its evolution into a more severe and less treatable bipolar presentation. I believe cyclothymia is one of the diagnostic presentations being considered as a separate category of bipolar illness. It seems to me that such would serve a useful purpose.
With all the myriad interactions occurring in a plastic brain of billions of neurons and a jungle of pathways, it does not seem unreasonable that a single enzyme polymorphism can be expressed in quite a few different ways. We’re not talking about peas here.
poster:Scott L. Schofield