![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 25. This is the beginning of the thread.
Posted by SLS on September 5, 2008, at 11:15:08
The article is very long. Unfortunately, there is no URL link that points to it, thus the full posting. This is one of the most comprehensive summaries I have yet come across.
Does this article help to clarify your diagnosis?
- Scott****************************************************
Does the DSM accurately portray what is going on with your illness? A group of experts decided to investigate ...(Introduction, Mania and Mixed Mania, Bipolar Depression, Bipolar II, The Bipolar Spectrum, Mixed States, Rapid Cycling, Schizoaffective Disorder, Pediatric Bipolar, Final Word)
With this in mind, in 2004 the International Society for Bipolar Disorders (ISBD) convened a task force to identify areas of consensus and controversy, with a view to guiding the planned revisions of the DSM and ICD.The task force was headed up by Nassir Ghaemi MD of Tufts University, with eight subgroups assigned to specific areas. In 2006/2007, the task force subgroups submitted their respective articles to the ISBD Journal, "Bipolar Disorders." All but the work of the subgroup investigating mixed states survived the editorial approval and peer review process (see Newsletter 10#1).
The Feb 2008 Bipolar Disorders is devoted entirely to the efforts of these subgroups, with commentaries that might pique even Dr Lecter's interest. Without further ado ...
Mania and Mixed Mania
The authors in the pure and mixed mania subgroup included Frederick Cassidy MD of Duke University, Lakshmi Yatham MD of the University of British Columbia, Michael Berk MD, PhD of the University of Melbourne, and Paul Grof MD, PhD of the University of Toronto.
In their review article, the authors note that despite mania conjuring up the prototypic image of grandiosity and euphoria, more common "are manic patients displaying prominent irritability and psychosis." Psychomotor pressure is central to both pure and mixed mania.
Mixed mania may be thought of as a train wreck between depressive and manic episodes, but there also exists the possibility of "state" meeting "trait." Citing the pioneering diagnostician Emil Kraepelin and Hagop Akiskal MD of the University of California San Diego, the authors explain that mixed symptom patterns may result from the interaction between episode type (such as mania) and baseline temperament (such as dysthymic). Conversely, "pure" mania may result from mania developing over a hyperthymic temperament.
What little we know about the course of mania indicates that a history of mixed episodes may be predictive of future mixed episodes, though one study suggests that the earlier phases of mania may be characterized by elation and grandiosity, with dysphoric symptoms presenting later.
Gender in pure states is evenly divided, with females predominating in mixed states. Studies suggest that mania rates peak in the spring, though one study on a mixed population showed peaks in late summer/fall. Mixed states are more difficult to treat.
The DSM and ICD stipulate full-blown depression and mania for mixed manic states. Applying these thresholds, the authors note, results in much lower rates of mixed mania than in academic studies using less restrictive criteria.
Bipolar Depression
The authors in the bipolar depression subgroup included Philip Mitchell MD of the University of New South Wales, Guy Goodwin MD of Oxford, Gordon Johnson MD of the University of Sydney, and Robert Hirschfeld MD of the University of Texas Galveston.
The authors note that while elevated mood is the hallmark of bipolar, "syndromal or subsyndromal depression is now recognized to comprise the predominant cumulative effect over time."
Bipolar patients tend to present with depression first, with the age of onset earlier than for unipolar depression, and with more (and shorter) depressions over their lifetimes. There do not appear to be any differences in severity between bipolar and unipolar depression, but bipolar patients may experience more impairments, such as in memory and executive functioning.
Studies indicate that bipolar I depression is characterized by an admixture of melancholic (such as exaggerated worthlessness), atypical (such as weight gain and hypersomnia), and (less commonly) psychotic features, as distinct from "pure" melancholic and atypical depression.
According to a study by Gordon Parker MD, PhD of the University of New South Wales, patients with bipolar I depression were more likely to have had a past psychotic episode and to report worthlessness, anhedonia (loss of pleasure), restlessness, leaden paralysis, and hypersomnia than those with unipolar depression. Conversely, they were less likely to manifest tearfulness, anxiety, and to blame others. The most striking difference was that the bipolar group experienced greater psychomotor disturbances (such as slowing down in thought and movement, agitation, and cognitive dysfunction).
Studies on bipolar II patients conducted by Franco Benazzi MD, PhD of the Hecker Psychiatry Research Center (Ravenna) point to greater atypical features, but with no greater rates of psychomotor retardation.
An NIMH study found that four percent of unipolar patients graduated to bipolar I over 11 years. Nine percent converted to bipolar II.
Bipolar II
The authors in the bipolar II subgroup included Eduard Vieta MD, PhD of the University of Barcelona and Tricia Suppes MD, PhD of the University of Texas, Dallas.
The authors note that what is commonly regarded as "soft" bipolar is in fact "a severe pathology" that implies higher episode frequency, co-occurring ills, suicidal behavior, and rapid cycling than bipolar I. Compared to unipolar depression, those with bipolar II show a more chronic outcome and lower rates of recovery. Depression dominates over hypomania, by a ratio of 50-to-1 according to one study.
Not surprisingly, bipolar IIs tend to experience years of prolonged suffering due to misdiagnosis and improper treatment. One study found that 37 percent of bipolar patients had been misdiagnosed with unipolar depression at first presentation; another that only nine percent of bipolar II patients were accurately diagnosed. In a sample of patients diagnosed with unipolar depression, Dr Benazzi found that 45 percent actually had bipolar II.
The authors point out that standard diagnostic tools are deficient in picking up the full range of hypomanic symptoms. Moreover, individuals experiencing mild or moderate hypomania are not likely to interpret their condition as requiring help. Complicating matters is that dysphoric symptoms are often considered part of depression (often they are) rather than hypomania.
The authors make clear that hypomania is not just a light form of mania, as the DSM suggests. The DSM only recognizes euphoric hypomania, but this may not be its primary presentation. Patients manifesting the "dark" side of hypomania may show "dysphoric hyperactivity, anxiety, irritability, and depressive features emerging over a cyclothymic temperament." Mixed states may come into play (depression in hypomania), which may also apply to depression (hypomania in depression).
Bipolar II only achieved the same status as bipolar I with the 1994 publication of the DSM-IV. Prior to that, bipolar II was consigned to the dreaded NOS basket. The ICD does not recognize bipolar II.
The DSM-IV mandates at least four days of hypomania, but studies by Lewis Judd MD of the University of California San Diego lend credence to lowering the threshold to one or two days. In addition, Jules Angst MD of the University of Zurich has suggested that overactivity (such as goal-directed activity) may loom large in hypomania, despite any sign of obvious mood change.
Adopting broader criteria for bipolar II would raise current estimates of this population from one percent to three-to-six percent.
Studies indicate a genetic distinction between bipolar I and bipolar II. A study by Francis McMahon MD of the NIMH found that bipolar II sibling pairs showed strong linkage to the chromosomal region 18q21.
While bipolar I occurs with equal frequency in men and women, more women may experience bipolar II.
Citing a dearth of studies for treating bipolar II, the authors take issue with the FDA's position that what is good for treating bipolar I is good for treating bipolar II (but not the reverse), which discourages clinical trials for bipolar II patients.
The Bipolar Spectrum
The authors in the bipolar spectrum subgroup included James Phelps MD of Corvallis Psychiatric Clinic (Oregon), Jules Angst MD of the University of Zurich, Jacob Katzow MD of George Washington University, and John Sadler MD of the University of Texas Dallas.
The authors quote Socrates for the proposition that "we must only divide where there is real cleavage." Categories are useful to a point, the authors contend, but intermediate cases suggest "a continuous spectrum of bipolar disorders" stretching from unipolar depression to bipolar I.
The bipolar spectrum can also be taken wider and deeper to include: infrequent episodes and continuous cycling; pure states bleeding into varying degrees of mixed states; bipolar graduating into schizophrenia; and (more controversially) an overlap between bipolar and borderline personality disorder.
Last but not least, the spectrum can signify the continuum from normal to pathologic. The "lower border of bipolar II," for instance, has not been adequately addressed.
Various diagnostic schema for a bipolar spectrum include:
A cyclothymia-bipolar spectrum (Akiskal).
Bipolar subtypes along a spectrum (Angst).
Greater number of categories (Klerman, Akiskal).
New category of bipolar spectrum disorder (Ghaemi).
Add minor bipolar disorders (Angst).
100-point bipolarity index (Sachs).
Although these schema differ in numerous respects, the authors point to a commonality regarding:Individuals with hypomanic reactions to antidepressants. (Two long-term follow-up studies found that 100 percent of these patients ultimately manifested overt bipolarity.)
Subthreshold patients whose hypomania falls short of diagnostic cut-offs, but who clearly have more going on than simply major depression. (A recent National Comorbidity Survey reported a group of patients who did not meet bipolar thresholds, but whose disabilities equaled those of patients with asthma and diabetes.)
Patients with no history of hypomania, but who show other indications of bipolarity, such as recurring depressions, family history of bipolar, and/or early onset. (Recurrent depression goes back to Kraepelin. Recent genetic research indicates an overlap between unipolar and bipolar.)The authors suggest a "bipolar III" category that would include non-manic markers such as full major depression with subthreshold hypomania (accompanied by other indicators of bipolar). Alternatively, bipolar NOS could be widened to include bipolar III. Another option is "bipolar disorder without hypomania or mania." Another possibility is a "dimensional system" that would co-exist with the DSM categorical system.
The "categorical" view sees "nodes along a spectrum," which would call for more categories of the illness. The "dimensional" view sees the illness as a matter of degree, as in "how bipolar are you?" A further refinement to this is "probability," which looks at the question of likelihood (the bipolar depression subgroup took a "probablistic" approach).
Mixed States
The contribution from this subgroup did not make it into "Bipolar Disorders." Nevertheless, the obiter dicta from the above subgroups fill in some of the blanks, namely:
The mania and mixed mania subgroup, taking a cue from Dr Angst, would use the following notation to define a single episode: Full depression, "D." Full mania, "M." Some depression or mania or mania symptoms, "d" or "m," respectively. Hence these varieties: D, Dm, DM, dM, M.
The bipolar depression subgroup referred to "inside [major depression] hypomanic symptoms," including distractibility, racing thoughts, irritability, talkativeness, and risky and goal-directed activities.
The bipolar II subgroup mentions "dysphoric hyperactivity" and "some hypomanic symptoms embedded in depression," together with the proposition that "mixed and agitated depressions might be better ascribed to the bipolar spectrum."
The bipolar spectrum subgroup refers to a "possible continuum of mixed states."
In addition, the pediatric bipolar group (further below) raises the possibility of mixed states presenting as "chunks" of depression and mania in a way that may resemble very rapid cycling.The DSM only recognizes mixed mania, in the form of full-blown mania occurring with full-blown major depression.
Rapid Cycling
The authors in the rapid cycling subgroup included Michael Bauer MD, PhD of Dresden University, Serge Beaulieu MD, PhD of McGill University, David Dunner MD of the University of Washington, Beny Lafer MD of the University of Sao Paulo, and Ralph Kupka MD of Altrecht Institute for Mental Health Care.
The authors point out that rapid cycling is a fairly new concept, first articulated by Dr Dunner and Ronald Fieve MD of Columbia University in 1974. The number four for the threshold requirement of mood episodes in a year was chosen arbitrarily. Treatment with lithium and other mood stabilizers tends to be problematic with rapid cyclers.
According to various studies, rapid cyclers comprise anywhere from 12 to 24 percent of the bipolar population, with females predominating. There are indications that rapid cycling has become more frequent in recent years, possibly owing to the widespread use of antidepressants. Rapid cycling can be induced by stimulants.
NIMH data reveals that patients who initially present with depression who show a predominantly depressive course experience greater rates of rapid cycling. Rapid cycling tends to be transient in most patients, though it can persist over years.
The DSM-IV requires a minimum episode length of two weeks for depression, one week for mania, and four days for hypomania. Cycling patients often manifest much briefer episodes not recognized by the DSM - ultra-rapid cycling (over more than a day) and ultradian cycling (less than a day). The rationale for excluding more frequent cycling from the DSM has to do with Kraepelin's view that mood volatility was par for the course for bipolar.
Schizoaffective Disorder
The authors in the schizoaffective subgroup included Gin Malhi MD of the University of Sydney, Melissa Green MD of the University of New South Wales, Andrea Fagiolini MD of the University of Pittsburgh, and Veena Kumari PhD of Kings College.
The authors note that Kraepelin made an historic distinction between what he termed manic depression (an episodic, relapsing, and remitting illness) and dementia praecox (an unremitting and progressively dementing illness), but that "in practice, many cases fail to qualify for either of these two diagnoses."
Genetic studies lend credence to an overlap between bipolar and schizophrenia, with a clustering of both in family groups, and shared suspect genes in both illnesses (one example is the DAOA gene on chromosome 13).
Schizoaffective was coined in 1933. The DSM-IV maintains that schizoaffective is distinct from both bipolar and schizophrenia, but acknowledges that there are no "absolute boundaries." Schizoaffective is thought to occur in less than one percent of the general population (women predominate), but the patient population is much higher owing to clinicians making the diagnosis when they are uncertain.
Schizoaffective is distinguished by the simultaneous presentation of psychotic symptoms with affective symptoms (eg hallucinations with depression), but there is disagreement between the DSM and ICD as to what precisely constitutes "simultaneous."
In schizoaffective, "there must be a mood episode that is concurrent with active-phase symptoms of schizophrenia." This is different than a "mood disorder with psychotic features" or "mood symptoms in schizophrenia." Not that it's easy to tell. Is a psychotic feature, for instance, congruent (more likely to be mood-related) or incongruent (more likely to be schizophrenia-related)? And is any given depression a mood disorder phenomenon or schizophrenia phenomenon?
Confounding matters is the discomforting reality that schizoaffective is a moving target - the relative proportion of mood to psychotic symptoms may change over the course of the disturbance, not to mention over the long term. Not surprisingly, most patients who receive an initial diagnosis of schizoaffective are later diagnosed with something else.
With all this in mind, the authors offer two alternative concepts:
Schizoaffective exists as a co-occurring set of symptoms that is a byproduct of two separate disorders.
Schizoaffective exists at midpoint on the continuum between bipolar and schizophrenia.
In either case, the authors would eliminate the designation, schizoaffective, in its entirety and substitute it with additional specifiers to schizophrenia, bipolar I, bipolar II, and major depression. Thus, in addition to the current DSM specifiers, schizophrenia would include:With symptoms meeting criteria for mania or mixed features.
With symptoms meeting criteria for major depressive disorder.
And, in addition to the current DSM specifiers for bipolar I and II and major depression:With psychotic symptoms meeting Criterion A for schizophrenia (ie hallucinations or delusions over one month) and for at least two weeks without prominent mood features.
With psychotic symptoms meeting Criterion A for schizophrenia with consistent concurrent mood features.
Pediatric BipolarThe authors in the pediatric bipolar subgroup included Eric Youngstrom PhD of the University of North Carolina, Boris Birmaher MD of the University of Pittsburgh, and Robert Findling MD of Case Western Reserve University.
The authors note that the percentage of children diagnosed with bipolar has more than doubled in the past 10 years, fortunately coinciding with a surge of research. Disagreements abound, but "considerable evidence has amassed" supporting the validity of the bipolar diagnosis in kids.
Pediatric bipolar is associated with high functional impairment and low quality of life. The illness is identified with aggressive behavior, attention problems, anxious and depressed symptoms, delinquent behavior, social problems, withdrawal, and thought problems.
Irritability looms large as a symptom in kids. Although irritability (including aggression) is not specific to bipolar, its absence (unless other symptoms such as euphoria are present) may rule out a diagnosis. There is support for the idea that a state of chronic irritability may rate a diagnosis, even in the absence of obvious mood and energy swings, though the authors do not favor this view.
Other symptoms:
Some experts consider grandiosity a cardinal symptom, but this feature does not necessarily manifest in a good many youths with pediatric bipolar. Grandiosity may also be present in youths without bipolar. Nevertheless, fluctuations in self-esteem and grandiosity may be a dead giveaway.
Hypersexuality appears to occur in less than half the cases of pediatric bipolar, but it is rare (other than in cases of abuse) to encounter hypersexuality in other contexts.
Decreased need for sleep is also cause to consider bipolar.
One fifth of youths with pediatric bipolar experience hallucinations or delusions. Pediatric bipolar may be uncommon, but early-onset schizophrenia is even more rare.
Ultradian cycling appears to be the main point of departure from adult bipolar. Kids can literally switch from one extreme to another on a dime, but the authors note a distinction between cycling and an episode (which may encompass numerous cycles). In this light, kids may be seen as having mixed episodes, which may present as "chunks" of mania and depression over time (the "fudge ripple" effect).Viewed this way, pediatric bipolar may not be all that different from adult bipolar (where mixed states are common).
Kids with bipolar experience high rates of co-occurring ADHD (broadly consistent with the pattern in adults) and elevated rather of conduct disorder, substance use, and anxiety disorders (again, consistent with adult patterns).
The authors note that if pediatric bipolar may extend beyond strict DSM criteria, then so do many bipolar manifestations in adults (especially along a more broad spectrum). A lot of attention, they point out, focuses on apparent differences between the child and adult versions, but that "the growing expectation is that there will be considerable developmental continuity between pediatric bipolar disorder and adult presentations ..."
Final Word
In his introductory article, Dr Ghaemi points out that in the bipolar literature, treatment issues receive a lot more attention than diagnostic considerations. Yet, "in the practice of psychopharmacology, treatment decisions are often straightforward once diagnostic judgments are made."
Posted by Phillipa on September 5, 2008, at 12:27:22
In reply to Bipolar Spectrum: Very long but very accurate., posted by SLS on September 5, 2008, at 11:15:08
I guess that is one I can eliminate as need sleep. And have wished for a little mania to accomplish things. So does adolescent defiant behavior fit in these categories? Phillipa
Posted by Bob on September 5, 2008, at 12:56:22
In reply to Bipolar Spectrum: Very long but very accurate., posted by SLS on September 5, 2008, at 11:15:08
> Final Word
>
> In his introductory article, Dr Ghaemi points out that in the bipolar literature, treatment issues receive a lot more attention than diagnostic considerations. Yet, "in the practice of psychopharmacology, treatment decisions are often straightforward once diagnostic judgments are made."
>
Huh? Seems to be that this mood disorder bipolar spectrum issue might be one of the most challenging problems to solve in medecine, if not in the entire panolpy of human experience.Although one has to start somewhere, that article seems to leave more lose ends and open questions then ever. Even if all the myriad diagnoatic, sub-diagnostic, and sub-category/sub-diagnostic criteria are to be worked out at some point, I feel that the treatment options are anything but straightforward in many cases. In fact, it appears that in many cases, there is no idea how to proceed. Heck, we often don't understand what to do for people who are pure severe unipolar, yet completely treatment resistant. They even mention in the article that people who are BPII and/or rapid cycling very often don't improve with the introduction of Lithium or other mood stabilizers.
Posted by Toph on September 5, 2008, at 15:49:14
In reply to Bipolar Spectrum: Very long but very accurate., posted by SLS on September 5, 2008, at 11:15:08
I have a different reaction to this article Scott. When I started developing the symptoms of Bipolar I (then Manic-Depressive illness) 40 years ago, it was a relief to me when I finally realized that I had a distinct diagnosis with symptoms that were fairly specific, predictable and universal. The people whose mania required hospitalization like mine pretty much looked like me with their psychotic features of grandeosity, delusions, loose associations, insomnia, hyperkenetic behavior and the like. Upon leaving the hospital and in an attempt to transition back into society I tried a few public support groups for BP disorder. I rarely found in these groups anyone with similar symptoms as me. They were invariably dominated by depressed individuals or people who called themselves Bipolar Twos or rapid cyclers. I began to feel an identity crisis of sorts as I rarely ever had the opportunity to associate with people like myself outside of the psych ward. Don't get me wrong, it's good that people differentiate and accurately classify psychiatric disorders. It just feels like some of the people who share Bipolar disorder with me don't have my disorder at all. It peeves me at work when physicians lump all the Lewy-Body, Pick's, vascular, and pre-frontal dementias together with Alzheimer's as they present differing challenges for me and their caregivers. Anyway, I hate to sound like a Bipolar snob, but somehow my 5 stays in the locked unit of a psych ward has made me kind of sensitive to others using my diagnosis loosely. I wonder if anyone else feels little possesive about their diagnoses as I do. For me, different disorders should have different names - otherwise they should just call us all crazy.
Posted by Bob on September 5, 2008, at 16:16:30
In reply to Re: Bipolar Spectrum: Very long but very accurate. » SLS, posted by Bob on September 5, 2008, at 12:56:22
>
> > Final Word
> >
> > In his introductory article, Dr Ghaemi points out that in the bipolar literature, treatment issues receive a lot more attention than diagnostic considerations. Yet, "in the practice of psychopharmacology, treatment decisions are often straightforward once diagnostic judgments are made."
> >
>
>
> Huh? Seems to be that this mood disorder bipolar spectrum issue might be one of the most challenging problems to solve in medecine, if not in the entire panolpy of human experience.
>
> Although one has to start somewhere, that article seems to leave more lose ends and open questions then ever. Even if all the myriad diagnoatic, sub-diagnostic, and sub-category/sub-diagnostic criteria are to be worked out at some point, I feel that the treatment options are anything but straightforward in many cases. In fact, it appears that in many cases, there is no idea how to proceed. Heck, we often don't understand what to do for people who are pure severe unipolar, yet completely treatment resistant. They even mention in the article that people who are BPII and/or rapid cycling very often don't improve with the introduction of Lithium or other mood stabilizers.
>
>
I wanted to add that I too appreciate the effort to categorize and define disorders, but sometimes it seems to be like the treatment side of it is so far behind that it seems futile at times. Of course, you have to start somewhere and it does help to know what you're treating.
Posted by SLS on September 5, 2008, at 19:59:45
In reply to Re: Bipolar Spectrum: Very long but very accurate. » SLS, posted by Bob on September 5, 2008, at 12:56:22
>
> > Final Word
> >
> > In his introductory article, Dr Ghaemi points out that in the bipolar literature, treatment issues receive a lot more attention than diagnostic considerations. Yet, "in the practice of psychopharmacology, treatment decisions are often straightforward once diagnostic judgments are made."
> >
>
>
> Huh? Seems to be that this mood disorder bipolar spectrum issue might be one of the most challenging problems to solve in medecine, if not in the entire panolpy of human experience.
>
> Although one has to start somewhere, that article seems to leave more lose ends and open questions then ever. Even if all the myriad diagnoatic, sub-diagnostic, and sub-category/sub-diagnostic criteria are to be worked out at some point, I feel that the treatment options are anything but straightforward in many cases. In fact, it appears that in many cases, there is no idea how to proceed. Heck, we often don't understand what to do for people who are pure severe unipolar, yet completely treatment resistant. They even mention in the article that people who are BPII and/or rapid cycling very often don't improve with the introduction of Lithium or other mood stabilizers.I understand your reaction. I think most of us are in agreement that bipolar disorders are difficult to treat, and that even the most accurate of diagnoses do not guarantee treatability.
I think the premise of the article is sound; that there are indeed different subtypes of bipolar disorder whose presentations show an interindividual consistency in the aggregation of symptom clusters and biological traits. That a piece of literature opens up the opportunity to ask more questions is not a weakness, but a strength. Also, that the accepted treatment algorithm for a bipolar subtype is "straight forward" does not indicate that it is effective. It just indicates that there is a consensus as to how to best treat a particular presentation, even if the success rate is very low.
- Scott
Posted by Bob on September 5, 2008, at 22:35:19
In reply to Re: Bipolar Spectrum: Very long but very accurate. » Bob, posted by SLS on September 5, 2008, at 19:59:45
> >
> > > Final Word
> > >
> > > In his introductory article, Dr Ghaemi points out that in the bipolar literature, treatment issues receive a lot more attention than diagnostic considerations. Yet, "in the practice of psychopharmacology, treatment decisions are often straightforward once diagnostic judgments are made."
> > >
> >
> >
> > Huh? Seems to be that this mood disorder bipolar spectrum issue might be one of the most challenging problems to solve in medecine, if not in the entire panolpy of human experience.
> >
> > Although one has to start somewhere, that article seems to leave more lose ends and open questions then ever. Even if all the myriad diagnoatic, sub-diagnostic, and sub-category/sub-diagnostic criteria are to be worked out at some point, I feel that the treatment options are anything but straightforward in many cases. In fact, it appears that in many cases, there is no idea how to proceed. Heck, we often don't understand what to do for people who are pure severe unipolar, yet completely treatment resistant. They even mention in the article that people who are BPII and/or rapid cycling very often don't improve with the introduction of Lithium or other mood stabilizers.
>
> I understand your reaction. I think most of us are in agreement that bipolar disorders are difficult to treat, and that even the most accurate of diagnoses do not guarantee treatability.
>
> I think the premise of the article is sound; that there are indeed different subtypes of bipolar disorder whose presentations show an interindividual consistency in the aggregation of symptom clusters and biological traits. That a piece of literature opens up the opportunity to ask more questions is not a weakness, but a strength. Also, that the accepted treatment algorithm for a bipolar subtype is "straight forward" does not indicate that it is effective. It just indicates that there is a consensus as to how to best treat a particular presentation, even if the success rate is very low.
>
>
> - ScottI agree with all your points. Sometimes my frustration of the complexity of the whole mess gets to me.
- Bob
Posted by SLS on September 6, 2008, at 5:06:51
In reply to Re: Bipolar Spectrum: Very long but very accurate. » SLS, posted by Bob on September 5, 2008, at 22:35:19
Sometimes my frustration of the complexity of the whole mess gets to me.
>
> - BobI know. It can be very demoralizing. It breeds helplessness and hopelessness that we are at the mercy of medical ignorance, as competent as each physician may be.
- Scott
Posted by seldomseen on September 6, 2008, at 9:28:55
In reply to Bipolar Spectrum: Very long but very accurate., posted by SLS on September 5, 2008, at 11:15:08
scott,
what is psychomotor pressure?
Posted by SLS on September 6, 2008, at 10:43:03
In reply to Re: Bipolar Spectrum: Very long but very accurate. » SLS, posted by seldomseen on September 6, 2008, at 9:28:55
> scott,
> what is psychomotor pressure?Psychomotor pressure is the opposite of psychomotor retardation. Psychomotor retardation indicates a slowing of movement and speech. Psychomotor pressure indicates the need to stay in constant motion and rapid and voluminous speech (pressure of speech). This includes agitation.
- Scott
Posted by Larry Hoover on September 6, 2008, at 12:08:50
In reply to Bipolar Spectrum: Very long but very accurate., posted by SLS on September 5, 2008, at 11:15:08
A very complex and challenging issue, no doubt.
I remain concerned about the process, despite some progress, nonetheless. A patient presents at a doctor's office with symptoms, seeking treatment for those. The doctor makes a diagnosis, and treats accordingly. However, the treatment options all arise from the diagnosis, with all its defining characteristics, which match very few patients precisely. We just don't fit cleanly into the theoretical cubbyholes. That model works great for e.g. bacterial infection, or myocardial infarct, but mental illness? Blurring the boundaries (which is how I see this trend towards bipolar spectrum) *may* lead doctors to return to treating presenting symptoms. I only hope that it does.
BTW, I am an exception to what appears to be an absolute statement:
"Although these schema differ in numerous respects, the authors point to a commonality regarding:
Individuals with hypomanic reactions to antidepressants. (Two long-term follow-up studies found that 100 percent of these patients ultimately manifested overt bipolarity.)"
I suppose it is still possible that I might 'manifest overt bipolarity', as I ain't dead yet, but so far......nope.
Lar
Posted by Quintal on September 6, 2008, at 13:12:56
In reply to Re: Bipolar Spectrum » SLS, posted by Toph on September 5, 2008, at 15:49:14
>I began to feel an identity crisis of sorts as I rarely ever had the opportunity to associate with people like myself outside of the psych ward. Don't get me wrong, it's good that people differentiate and accurately classify psychiatric disorders. It just feels like some of the people who share Bipolar disorder with me don't have my disorder at all.
I feel the same way. What do you feel defines your bipolar I disorder as being seperate from bipolar II?
There are no support groups in my area, but the online ones I've gone to have mostly been dominated by bipolar IIs. For a long time that was my diagnosis, so I understand, but after it took this new turn (psychosis + enforced hospitalization) I feel like I have quite a different illness on top of the original mood disorder. It seems an awful lot like Schizophrenia to me. It's interesting that my mental health team has been split into 'affective' and 'psychosis' groups. My social worker has been assigned to the affective group, but I have been put into the psychosis group. I have a diagnosis of bipolar disorder, which I thought was primarily an affective disorder.
I'm confused by statements like this "Extreme manic episodes can sometimes lead to psychotic symptoms such as delusions and hallucinations." What happens if the psychotic symptoms occur without extreme manic symptoms? Does that happen often in bipolar I, or does it warrant a different diagnosis? It seems that since I crossed the line into manic psychosis I get psychotic symptoms fairly often even when I'm not manic.
>Anyway, I hate to sound like a Bipolar snob, but somehow my 5 stays in the locked unit of a psych ward has made me kind of sensitive to others using my diagnosis loosely. I wonder if anyone else feels little possesive about their diagnoses as I do.
I feel like I've earned it after years of having my self-reported symptoms invalidated! My psychologist wants me to give up mental illnes as part of my identity. She feels that so long as bipolar disorder defines my identity it will make recovery difficult. This isn't something new to me, but it's painful and irritating to have it shoved in my face like that. My old pdoc discharged me in 2006 as basically a malingerer. I had no treatment and gave up the idea that had any sort of mental illness, and people here were very cirital of that. Last October I became psychotic for the first time. In fact I think I was talking to you at the time! Bipolar does form a part of my identity because it's something I live with all the time. I'm as skeptical about the medical models as I am about the psychological theroies, but bipolar is real whatever it is, and it's still going to be there whether it's part of my identity or not.
Q
Posted by SLS on September 6, 2008, at 17:46:56
In reply to Re: Bipolar Spectrum: Very long but very accurate. » SLS, posted by Larry Hoover on September 6, 2008, at 12:08:50
Hi Larry.
> A very complex and challenging issue, no doubt.
>
> I remain concerned about the process, despite some progress, nonetheless. A patient presents at a doctor's office with symptoms, seeking treatment for those. The doctor makes a diagnosis, and treats accordingly. However, the treatment options all arise from the diagnosis, with all its defining characteristics, which match very few patients precisely.I was surprised at how accurate the descriptions of categories were as depicted in the summary article. They match very well what I have seen in myself and others with bipolar disorders. I disagree with the concept of treating symptoms without regard to defining the identity of the disorder being treated. Depression arising from hypothyroidism will not be well treated as a symptom by using antidepressants.
> We just don't fit cleanly into the theoretical cubbyholes.
This is just the point I was attempting to make. In my experience, the categorial schemas presented in the article described with unusual precision the various presentations of bipolar disorder that I have seen in myself and in others. It is unfortunate that so few clinicians even attempt to use such schemas more rigidly as they are defined in the article. I feel that great progress has been made in the diagnostics of mental illnesses compared to the state of the art as it existed in 1982.
I first presented with an ultra rapid cycling presentation of depression in the absence of hypomania or mania. I believe that my bipolarity would have been identified much earlier had my treatment team operated under the premise that any type of true ultra rapid cyclicity of mood state should indicate bipolarity. The absence of a bipolar diagnosis allowed the usage of antidepressants without the concomitant use of mood stabilizers; a treatment that eventually led me to a psychotic mania as the result of antidepressant treatment. The rest of the story is too long to describe here. However, let me say that I would never have appeared on Psycho-Babble had my doctor treated a disorder rather than a series of symptoms.
I believe my bipolar disorder would have been properly diagnosed were these diagnostic guidelines to be in existence at the time. As unusual as my case is, it can still be teased out using the diagnostic schemas described in the article.
The article does not propose a single diagnostic algorithm to be followed. Characterizing mental illnesses and applying it to diagnostics is a work in progress. Perhaps the key to choosing effective treatments is to be found in using microarrays to catalog gene activity. That is a hope of mine, anyway.
- Scott
Posted by Phillipa on September 6, 2008, at 19:31:55
In reply to Re: Bipolar Spectrum: Very long but very accurate. » Larry Hoover, posted by SLS on September 6, 2008, at 17:46:56
Scott so other than a thyroid med such as synthroid how would you treat me? Love Phillipa
Posted by Racer on September 6, 2008, at 19:33:56
In reply to Re: Bipolar Spectrum » Toph, posted by Quintal on September 6, 2008, at 13:12:56
> > Don't get me wrong, it's good that people differentiate and accurately classify psychiatric disorders. It just feels like some of the people who share Bipolar disorder with me don't have my disorder at all.
I understand that, although for different reasons. A million or so years ago, I majored in English Literature, and that sort of meaning-creep was always a topic. There are some perfectly good words out there going begging, while a word which should mean something else entirely are doing double duty. The end result is an impoverishment of the language, and difficulties in communication. It's a bete noir of mine, and it applies in this case as well as many others.
>
>
> >Anyway, I hate to sound like a Bipolar snob, but somehow my 5 stays in the locked unit of a psych ward has made me kind of sensitive to others using my diagnosis loosely. I wonder if anyone else feels little possesive about their diagnoses as I do.Actually, I feel a lot possessive about it -- and not only for the reason referred to above.
Depression and anxiety are often used conversationally, which does complicate trying to explain to others why there are periods of time when I can't clean the house, or have to be coaxed to go out to play, or any of the other things that go along with Major Depressive Disorder, or with Generalized Anxiety Disorder.
The Anorexia Nervosa, though, is a whole 'nother story. There are people out there who claim eating disorders as attention getting strategies. Or they make jokes about it -- "Oh, my cat is bulimic..." Or they use it spuriously -- "I'm just not hungry today, maybe I'm coming down with Anorexia," or "I've gained so much weight over the holidays, I wish I could catch Anorexia." Or use it as an insult -- "that b---h is just anorexic -- tell her to go buy a sandwich." All of those trivialize what I've gone through -- and continue to go through. I feel as though the various flavors of misery it's brought me are being discounted entirely, and I've been made a figure of ridicule.
But that's just me, and I'm sure I'm just nuts.
>
> I feel like I've earned it after years of having my self-reported symptoms invalidated! My psychologist wants me to give up mental illnes as part of my identity. She feels that so long as bipolar disorder defines my identity it will make recovery difficult.I gotta agree with your psychologist, though. Yes, you've earned your dx -- as I've earned mine, etc -- but I think she's saying something different. In fact, something I say regularly -- bipolar is part of your identity, but does it DEFINE your identity?
Wouldn't you rather be Quintal, a very creative, generous, nurturing, playful -- I don't know you, so I can't tell what works best for you -- who also suffers from bipolar with all the challenges that go along with it?
I don't even know if that makes sense, because I've tried to write this about six times now, but here's an illustration:
My dx includes MDD, GAD, and anorexia nervosa. I also have some physical dx, including severe arthritis in one hip. The pain from my hip is constant, although the intensity can vary; and I've lost range of motion. The depression/anxiety/AN are no less serious and no less chronic than the arthritis, and nor are any of them less variable in intensity, and all of them affect my life on a daily basis. I just don't want to BE any of them. I don't want any one of those to be the defining feature of my identity. I don't want to describe myself first and foremost as mentally ill, any more than I want to refer to myself as primarily an arthritic.
I think your psychologist might be referring to something like that, you know?
OK, I've tried to write this six ways from Sunday, but can't seem to manage. I'm going to send this out and hope that it has some sense in it somewhere... And I hope it helps, and ---
Quintal, I tried to revise that so that you wouldn't think I was trying to criticize you, because I'm not. I am trying to offer something helpful, an alternate way of incorporating the bipolar into your identity, without it becoming your identity. I really do hope that's clear to you, because I enjoy seeing you on here.
Posted by Quintal on September 6, 2008, at 19:58:14
In reply to Re: Bipolar Spectrum »Toph » Quintal, posted by Racer on September 6, 2008, at 19:33:56
Thank you posr posting this Racer. I took my zopiclone half an hour ago, so I'd best keep it short and quick.
>Wouldn't you rather be Quintal, a very creative, generous, nurturing, playful -- I don't know you, so I can't tell what works best for you -- who also suffers from bipolar with all the challenges that go along with it?
Yes, that's the way I see myself. I think my psychologist thinks I hold some sort of fixed idea of bipolar being me. She admits she can't see who I really am, but I know who I am, and it's not bipolar disorder. This is what irritates me - she jumps to conclusions. It worries me when people introduce themselves as "I am bipolar II, social anxiety disorder, fibromyalgia etc". So I see exactly where she's coming from, and I agree.
I do think she holds a naive idea though, that once I give up thinking about myself as having bipolar disorder the illness will go away. That's what really bugs me. For over a year I agreed with my pdoc's view that I was basically moody and there was nothing more to it than that, so the manic psychosis that followed at the end of that year seem to cast doubt over that theory.
I think I'll leave it there for tonight. More tomorrow.
Q
Posted by Racer on September 6, 2008, at 19:58:52
In reply to Bipolar Spectrum: Very long but very accurate., posted by SLS on September 5, 2008, at 11:15:08
Thank you for posting this, Scott. It's all very interesting, and I am always happy when I see the questions asked, the evidence revisited. And my little monkey brain says, "ooooh! Neat-o!"
My reservation about the issue is that study done by Rosenhans -- the pseudopatients who reverted to normal behavior after admission to a psych ward for "hearing voices" and were never identified as sane -- which makes me wonder if maybe having the bipolar dx might be sustained over time, even in the absence of confirming evidence.
That said...
You and I have known one another a long time, and you've certainly seen me try a few meds over time. Lately I've been revisiting the question of bipolar -- it's an OCD thing I do, by the way, it doesn't matter what evidence is offered against it, and my therapist and psychopharmacologist both say I'm not bipolar. And they've both seen me in the sorts of states that start me obsessing about it. I won't offer symptoms, because I'm not looking for a dx -- but I'm hoping I can attack the obsession from another direction...
So, Scotty me lad, let's say I am bipolar...
What medications would you think might be tolerable for me? I'm thinking you might be familiar enough with my med history -- not in detail, but the overall picture -- to suggest some options that might be tolerable. I'm happy to offer more med history, if that would help...
The OCD thing is partly general anxiety -- but it's actually based far more on fear of having to fight through finding a mood stabilizer as well as antidepressant. So, I know the obsessive bit is psychopathology -- but it's partly a fairly reasonable fear, considering some of my medication trials. And I have a very negative psychological reaction to the idea of taking certain meds, so I'm not asking for suggestions of what I should take -- only what medications might, if I am bipolar, be helpful. I really hope that made sense?
Anyway, speculate, my dear friend.
Posted by Racer on September 6, 2008, at 20:06:20
In reply to Re: Bipolar Spectrum » Racer, posted by Quintal on September 6, 2008, at 19:58:14
Quintal, I am so glad to hear that, because you are describing exactly what I meant, and what I think of as a very healthy way to see our various and sundry diagnoses...
And every so often my therapist also misses me -- I even walked out once because of it. We usually get back on track pretty quickly, but it's frustrating every time. (Especially since it tends to be things I see as very central to whatever we're dealing with.) I've finally learned to listen for clues that she's missed what I'm saying, and if it's really important, sometimes I'll even do the "what did you just hear me say?" That is often quite educational...
Have a good night's sleep.
Posted by JayMac on September 6, 2008, at 22:16:14
In reply to Bipolar Spectrum: Very long but very accurate., posted by SLS on September 5, 2008, at 11:15:08
> The article is very long. Unfortunately, there is no URL link that points to it, thus the full posting. This is one of the most comprehensive summaries I have yet come across.
>
> Does this article help to clarify your diagnosis?
>
>
> - ScottHi Scott,
Thank you for the article. It was an interesting read! I would like to possibly cite the article in the future, so how exactly did you find it? I understand you don't have a link, but I'm sure there must be a way to find the *original* source.Thanks so much,
Jay
Posted by SLS on September 7, 2008, at 4:35:01
In reply to Re: Bipolar Spectrum: Very long but very accurate., posted by JayMac on September 6, 2008, at 22:16:14
> Hi Scott,
> Thank you for the article. It was an interesting read! I would like to possibly cite the article in the future, so how exactly did you find it? I understand you don't have a link, but I'm sure there must be a way to find the *original* source.I copied the article from a free newsletter. I think it is worth subscribing to. I posted it on my website in its entirety, and it includes the information necessary to subscribe.
http://www.slschofield.com/medicine/bipolar_spectrum.html
- Scott
Posted by toph on September 7, 2008, at 7:58:29
In reply to Re: Bipolar Spectrum » Toph, posted by Quintal on September 6, 2008, at 13:12:56
I was glad to see you guys respond to my post. Sorry Scott if it is a bit of a diversion but it is my reaction to your article nonetheless. I have a hard time seeing BPD as a spectrum as if BPI is bluer than a reddish BPII. Not a biochemist, so I could be wrong here, but the psychosis of my mania separates me from identifying with my mood disorder bretheran. Okay so why on earth would I be proud of having a more serious disorder? I'm not happy about my illness but accepting it was such a huge part of learning to manage it. And seeing and identifying with other psychotic manics definitely motivated me to becoming compliant with it's treatment. Also, just because most people with either form of bipolar disorder benefit from mood stabilizers shouldn't necessarily mean they are the same disorder. I have always found it ironic that my illness with it's extremely severe manic and depressed episodes has been rendered into essential remission through a simple salt while others on the more begnign side of the spectrum struggle for relief with all variety of psychotropic cocktails. I think though while we all share a similar struggle that binds us as friends, we also tend to have our interest sparked by those with similar experiences and symptomatology as ourselves - be it OCD, eating disorders, depression, thought disorders or mania. I suppose its just that if I have to have a label that becomes some part of my identity, it better be an accurate one.
Posted by Larry Hoover on September 7, 2008, at 11:26:56
In reply to Re: Bipolar Spectrum: Very long but very accurate. » Larry Hoover, posted by SLS on September 6, 2008, at 17:46:56
> I was surprised at how accurate the descriptions of categories were as depicted in the summary article. They match very well what I have seen in myself and others with bipolar disorders. I disagree with the concept of treating symptoms without regard to defining the identity of the disorder being treated. Depression arising from hypothyroidism will not be well treated as a symptom by using antidepressants.
Allow me to clarify....I didn't intend to suggest that differential diagnosis has no value, but that the patient brings specific symptoms forward for treatment. The doctor decides that they cluster according to some diagnostic schema, but there tends to be a missing step.....taking that schema and determining which symptoms most trouble the patient, as a guide to treatment. If e.g. insomnia is the most troubling symptom of a putative BPII patient, providing treatment that fails to address that symptom will fail the patient, regardless of what other clustered symptoms are ameliorated by the selected treatment.
> I first presented with an ultra rapid cycling presentation of depression in the absence of hypomania or mania. I believe that my bipolarity would have been identified much earlier had my treatment team operated under the premise that any type of true ultra rapid cyclicity of mood state should indicate bipolarity. The absence of a bipolar diagnosis allowed the usage of antidepressants without the concomitant use of mood stabilizers; a treatment that eventually led me to a psychotic mania as the result of antidepressant treatment. The rest of the story is too long to describe here. However, let me say that I would never have appeared on Psycho-Babble had my doctor treated a disorder rather than a series of symptoms.
Scott, I would say that your experience is a perfect example of what I am suggesting remains a weakness of the mental illness treatment paradigm. Your caregiver(s) cherry-picked depressed mood symptom(s) and ignored other presenting symptom(s), the ultrarapid cycle. I do agree (and never questioned) that this diagnostic schema for bipolar spectrum is a vast improvement, but it too must be applied with the same caveats as I'm suggesting don't often occur. For this specific patient, what symptoms cluster within a category, and what symptoms are outside of it? What symptoms trouble this individual the most? Although more tightly circumscribed than early schemas might allow, even a specific diagnosis like "ultra-rapid cycling bipolar type II with mixed states" does not mean that appropriate treatment will be the same for each subject found to correspond therewith. In other words, a greater number of smaller cubbyholes is progress, but the symptoms are what matter to the patient.
Medical schools teach, and most doctors perhaps unwittingly follow, that once diagnosis is made, treatment is selected to fit the dx. In the case of mental illness, the patients' focus on sx, and the doctors' on dx, leads to a disconnect that led to serious problems for you, and me.
Lar
Posted by ricker on September 7, 2008, at 15:16:10
In reply to Re: Bipolar Spectrum: Very long but very accurate. » SLS, posted by Larry Hoover on September 7, 2008, at 11:26:56
Not sure if this site has been refered to. Here's the link.
http://www.psycheducation.org/index.html
Sorry if it's already been posted.
Rick
Posted by SLS on September 7, 2008, at 18:56:20
In reply to Re: Bipolar Spectrum: Shoot! Forgot to ask... » SLS, posted by Racer on September 6, 2008, at 19:58:52
> Anyway, speculate, my dear friend.
Given your less than amorous relationship with a plethora of drugs and a need to avoid others not yet tried, I would start talking about things like combining Trileptal and Klonopin. If you can tolerate Lamictal, it might also be considered. Have you spoken to your doctor about using memantine (Namenda) for OCD traits? It might also foster a longer period of responsivity to stimulants.
There. I managed to avoid reuptake inhibitors and MAOIs. I do forget, though, whether you have tried Geodon or not.
Feel free to reply. I am really curious to see how thinking outside the unipolar box might be an advantage to you.
- Scott
Posted by Marty on September 13, 2008, at 23:46:35
In reply to Re: Bipolar Spectrum: Very long but very accurate. » Larry Hoover, posted by SLS on September 6, 2008, at 17:46:56
> Perhaps the key to choosing effective treatments is to be found in using microarrays to catalog gene activity. That is a hope of mine, anyway.
---
It will be the key to the next evolution step in Psychiatry in the next 30 years OR it will be the revolution of psychiatry: a new medical domain will overlap and will end up displacing Psychiatry, just like Psychiatry somehow displaced Psychoanalysis and Psychology because it was more efficient.I thing THE key is to being able to make sense of what's going on in the brain IN REAL TIME. Based on the genopsychanalysis (made up word. Read 'gene analysis') results and the psychiatry (symptoms, history etc), a computer will determine what is of interest in the brain of the patient (regions, pathways, receptors, neurotransmitters etc). Then the patient will have his brain recorded ("taped"), at the determined and limited targets, in real time with a (yet to be invented) scanner. Later, a computer analyze the data and propose a treatment OR determine new targets to study, leading to another brain recording. Depending on the outcome of the treatment or the course of the illness in term of symptoms, the patient will eventuantly have his brain reanalyzed.
That was THE key for improving diagnostic and treatment prescription. But ultimately, as (I think) we already talk about together, the most important key in the future will be genetic therapy. Meanwhile I wouldn't say no to have an intermediate step between the 'Brain Analyzer' and genetic therapy: Based on the results of the brain analysis, the computer determine (analysis/simulations) the best molecules to treat the patient and send the molecules formula and synthetising step to a personalized pharmacology labs. :) .. which, hopefully, are so technologically advanced that they look at the 2000's pharmacological engineering tools with desdain and see nothing more than amateurish chemistry kits for kids. And so it doesn't cost you 50,000$ for your personalized drug.
Think it's science fiction ? In the computing science field, respected experts estimate that by 2035 we'll develop 'electronic brains' (read: computers) that will be as powerful as the human brain. By 2050, helped by those electronic brains, we would have electronic brains about 1000 time more powerful than our brain... put a couple of those to work together and you have something able to analyze about 1/10 of the brain at the molecular level at the speed of 1 minute of analysis for every second of brain activity..... maybe not exactly like that.. I just made up that part ;) but I'm sure that's not -THAT- far from what it could be.
Enough rambling.. Hope you're doing well Scott. Btw, what do you think of the DAOA thing ? I didn't research it a lot yet, but if you did I'd like to know if there's a rationale for trying to inhibit DAO, increasing DAO synthesis/effiency or neither of those strategies ... I think in the case of Schizophrenia they saw TWICE DAO activity than normal people, but I don't know for bipolars: hyperactivity, hypoactivity or aberant activity ?
/\/\arty
This is the end of the thread.
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