Tuesday, January 4, 2011

Bipolar Disorder and the Psychiatry War of the 20th Century

I'm going to start with a little history of psychiatry in America and the DSMIV.  Up into the 60s and 70s, psychiatry in America was heavily influenced by psychoanalysis - Freudian stuff (patient is on a couch free-associating, and the therapist is a "blank screen" - theoretically, though it hardly ever worked out like that), primarily because most of the psychoanalysts fled Germany during WWII and set up shop in London and New York and Boston - these places are still hotspots of psychoanalysis today and the center of East Coast academic training in psychiatry.  Psychoanalysts spend a lot of time talking about rage and repression and the unconscious and the mind, all very interesting, if you like that sort of thing.  But psychoanalysis isn't exactly neuroscience, and when biological correlates to some of the major psychiatric disorders started coming out, psychiatry swung the other direction.

In some respects there is a lot to admire about psychoanalysis as a science - Freud, a Victorian, met his match in a young girl with symptoms of hysteria named Ida (he called her Dora), and he came up with all sorts of Victorian theories about repression and sexuality to explain her symptoms of not being able to speak, and some neurological hand problems.  The case is often studied in academic feminism as an example as to why psychoanalytic theory is patriarchal and misogynist.  And yes, it certainly was, because that was the prevailing idea of the time.  However, it is often missed that the whole reason Freud published Dora was to present a failure of his therapy.  He missed the boat, he knew it, as a Victorian he didn't quite understand why.  In that respect, Dora is a humble case study and real medical science circa 1901. Now we would get to the brass tacks that Dora at the age of 14 was by her account repeatedly sexually propositioned by the father of the children she babysat, and the children's mother was also the lover of Dora's father.  Such a situation would be difficult now - imagine when one could not speak of such things and would not have been believed in any event.

Well.  Dora has a lot of dream analysis in it, and maybe that was a Victorian indirect way to get to the truth.  In 2011 we prefer more direct methods - saves time.  And I certainly prefer to look at much of psychiatric pathology from a neuroscience perspective, as it seems only rational.  The analysts will say we have lost the art of listening and all the modern psychiatrist does is shove pills down people's throats.  The biologic psychiatrist will say that psychiatric illness has more causes than just mental distress and to ignore those causes is unscientific and unconscionable.  The analyst will say the biologist is "mindless," the biologic psychiatrist will say the analyst is "brainless."

The truth of the matter is that we cannot afford to lose our ability to listen to patients - that is the problem in all of medicine at this time, and psychiatrists may be the last bastion of listening.  On the other hand, we can't afford to base psychiatric treatment on medical science circa 1901 (I'm being a little unfair here - hardly any analysts are Freudian drive-based anymore, most use a mix of more modern theoretical concepts derived from attachment theory, relational therapy, and even chaos theory).  So into the fray between biologic sorts and analytic sorts came the DSMIII and IV.  These books were written to be atheoretical.  Causes (whether it be genes and inflammation or history of trauma and personality style) are left out, on purpose, I think in part due to the fight between the analysts and the biologic psychiatrists.  I came into training rather at the end of this "war" but apparently it raged for decades. (One of my teachers, an analyst, said of another, a biologic psychiatrist, "I don't think he even believes in the unconscious!"   Another teacher talked about how he was forced as a resident to give psychoanalysis to actively psychotic individuals in state mental hospitals, and when it didn't work, was blamed for his failure.)

The DSMIV is merely a recipe book of traits.  Have the traits, match it up to the diagnosis, and there you go.  Mostly it was intended for research - since we don't have lab tests to define psychiatric illness, psychiatrists in one research center needed to be studying the same disorders as in another center - thus a checklist of sorts.  And then psychiatrists in the field needed to be talking about the same sort of problem that the researchers were studying treatments for.  It all makes perfect sense, but the DSMIV is maddeningly boring and the atheoretical part makes it a lightning rod for critics.  Then managed care and insurance and services based on diagnosis came along and the DSMIV became way more important than it should have been.

But the DSMIV is what we have, and there are certain definitions for bipolar disorder.  Bipolar I is when you have a manic episode (a period of insomnia, hypersexuality, impulsivity, rapid speech, increased religiosity, irritability, racing thoughts, manic psychosis often with religious delusions or grandiose delusions, increased energy, and euphoria - you don't need all of these to be manic, just enough of them, and to be mania, it needs to be serious enough for you to be psychotic or hospitalized.)  Bipolar I people usually have major depressive episodes also, but they don't have to.  Some people are only manic.

Then there is Bipolar II, where people tend to be depressed most of the time but occasionally have hypomanic episodes - mostly insomnia, irritability, increased goal-directed behavior, impulsivity, euphoria - but not as serious as a full manic episode. Bipolar II is a little hard to sort from regular depression - most of the people who show up at your clinic will be depressed, and hypomanic symptoms are often forgotten about, even when you ask directly about them.  

Neither of these are the same thing as "moody."  Being moody and irritable does not make you bipolar, though if you are bipolar, you will likely be more moody and irritable than average during an episode.  In a lot of ways, bipolar disorder overlaps (and sometimes exists at the same time with) other disorders - substance abuse, personality disorders, anxiety, depression, ADHD, which makes it all the more controversial.

Bipolar symptoms also tend to be different at different stages in life.  Kids will tend to cycle very rapidly between mood states and could hit many in the same day.  Adults tend to stick with one for several weeks or more.  (Bipolar disorder in kids is a bit controversial - it's called bipolar disorder because the same criteria fit to describe the behaviors, and often kids with bipolar symptoms do grow up to be adults with standard adult bipolar disorder, so it seems to be the same animal.  It is also highly genetic.  However, every kid with a temper or a bratty streak is not bipolar.  Bipolar in kids tends to be very serious - these kids are often kicked out of school (or preschool) for behavior problems.)

In a lot of ways, bipolar disorder is poorly understood.  

Which brings me to the paper I'm blogging about today, "An admixture analysis of the age at index episodes in bipolar disorder."  In this study, researchers interviewed 390 people with bipolar disorder in Canada about the history of illness, threw a bunch of data into a number cruncher, and came out with some interesting correlates. 

First off, people with early onset bipolar disorder (average onset age 18) tended to be more likely to have a family history of bipolar disorder, and more likely to have psychosis, anxiety, suicidal thoughts and behaviors, and a chronic and rapid cycling course, and were more likely to have migraines.  People with late onset (usually starting around age 33) disease were more likely to also have diabetes.  Typically, bipolar disorder begins with a depressive episode, and often earlier in women than in men (which would match up with women's greater vulnerability to mood disorders in general).  I can add further speculation that the later onset bipolar being more associated with diabetes would suggest that it is possibly part of metabolic syndrome in certain vulnerable people.  Early onset bipolar disorder may be more it's own animal.  I do think in both cases, inflammatory Western diets may be contributory, and there is some (bad epidemiologic) evidence that doesn't dispute that speculation.  Also interesting is the connection between bipolar disorders and migraines - both can respond to medications for epilepsy and theoretically from a ketogenic diet

A modern psychiatrist is hamstrung without time to get a good history and the psychological savvy to establish an excellent rapport with the patient and the understanding of basic human nature - but a modern psychiatrist is also crippled by a lack of knowledge of neuroscience, nutrition, and general medicine.  We need to pursue both threads in 2011.  It all comes back together for the betterment of everyone.


  1. Gary Taubes points out that the science of obesity was relatively well understood by the Germans and Austrians prior to WW2. However, American psychologists in the 60s deemed obesity a psychological disorder and ignored the science behind fat accumulation. Then again, I don't think it's been until recently that psychologists had any rigorous science or math training, and even now, I'm not sure how much.

    With nutrition making such an enormous impact on one's everyday health and well being, I don't see how any person in the healing profession can do a credible job without staying abreast of nutritional thought.

  2. Over at crazymeds.us, Jerod Poore (who says he's a textbook case of bipolar) has pointed out that bipolar has lots in common with epilepsy, and that anti-convulsant medications have been most effective out of all the things he's tried. And he's tried a lot of things, hence the site, whose premise is that since the pharmacos have no clue about what their drugs do, he and his friends have volunteered to serve as human lab rats and write up the results.

    Interestingly, a ketogenic diet is indicated as a very effective for childhood epilepsy (and probably adults as well).

    Having known a few people with bipolar disorder over the years, I have to say there's something qualitatively different about the condition from run of the mill depression. Many of them are brilliant and charismatic. And their suicide rate is tragically high.

  3. I would say the difference between psychoanalysis and biologic psychiatry is, in some sense, scale. I have always seen psychoanalysis as existing on a macro plane of meta-analysis. The individual qua individual is examined as phenomena and his/her mind's production as it relates to the social and cultural environment whereas the biological method must look at a person inasmuch as that person is composed on biologic systems, hormones, chemical productions and so on. It is but a manifestation of the old mind/body debate. Anyway, I was wondering if you think most of these modern psychological problems can also be seen as diseases of civilization? After all, one of the great criticisms of Freud is that his system is only applicable to Westerners.

  4. As a patient I can tell that it appears that psychiatrists and psychologists both are shooting blindfolded in a dark barn and declaring victory when they punch a hole in the wall.

    Would it kill you people to take genetic samples, record symptoms and work up a database so we're not subject to guesswork and diagnosis by prescription.

  5. Thank you for this.

    This helps me redouble my commitment to a low-carb lifestyle, for my mental as well as my physical health.

  6. "Then there is Bipolar II, where people tend to be depressed most of the time but occasionally have hypomanic episodes - mostly insomnia, irritability, increased goal-directed behavior, impulsivity, euphoria - but not as serious as a full manic episode."

    Uh-oh! After having been moderately depressed for about 6 months, I'm now a little, uh, hyper, though my sleep is fine. There were triggers for my depression & hypomania. Are bipolar II episodes spontaneous?

  7. Obviously I can't diagnose anything over the internet. For educational purposes, it is important to realize that "hypomanic" is generally serious enough to get you into some trouble. I think pretty much anyone can be hyper - sometimes supplementation of iodine/seleneium (thyroid stimulators) and fat loss can lead to feeling hyper. There is a biphasic lifetime incidence of first episode bipolar, however - usually late teens or early-mid thirties is the first episode. In women there can be a first episode at menopause. That doesn't mean it can't happen at other times, those are just the usual times.

  8. Hi Emily. Thanks for replying.

    I haven't got into any trouble as a result of being hyper, but I do feel very impatient and driven. I take Levothyroxine & Testogel due to pituitary dysfunction and have recently had an increase in my Levothyroxine dose from 100ug/day to 125ug/day. I may be overdoing it with the Vitamin D3 (I take 5,000iu/day all year round).

    The same thing happened a year ago and I was so driven that I got mum out of a crap nursing home into a better one. I kicked a lot of asses in the process!

    Maybe I just bottle-up frustration for too long and then "explode" when I reach the end of my tether.


  9. I am a 62 yr old female first diagnosed with bipolar II at age 41, but am quite sure I had iteven as a child but didn't know what it was..I have gone through so much hell with this illnessbut have faith that it will get better still, and at times it does, but I mostly keep to myself. Divorced before I was diagnosed after a 20 yr marriage, then worked with mania, crash, mania, crash, for 18 years loving the mania and so sick with the crash...nearly killed myself. Finally overdid it pushing a very large patient in a wheelchair and hurt my
    back. Forced to sit down was like death to me..
    My entire life changed forever, although my back is better and I can walk and move about,
    Thank God. I lost my high paying Radiology job though and had to retrain in other jobs..tried
    several but finally couldn't stick with any and
    was getting more restless..At the age of 58 I was fortunate to get my SS Disability Insurance
    on the bipolar alone. It wasn't easy..they put
    you through the mill and make it very difficult. I went through Binder and Binder
    though because I knew that I didn't have the
    strength to fight for it. They got it for me
    because they knew I had worked hard all my life
    and that I truly was an ill person with the
    documented medical hospitalization and visits
    to back it up. I am writing this to help others to see that true bipolar has no cure but there
    are options and help is there if you need it.
    Also, I have one problem that my doctor and I
    cannot seem to resolve. I am taking 900 mg daily of Lithium plus other meds is always low
    about .26 If I take more Lithium it makes me nauseaus like morning sickness, do you have
    any suggestions? I am going through the No Sleep phase right now and think it is because
    of low Lithium.


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