April 29, 2008

Experts Weigh In On Bipolar Disorder

And they conclude there's a lot of bad information out there.  They try to set the record straight.

Bring a bottle.

From the article:

[The Diagnostic Guidelines Task Force of the International Society for Bipolar Disorder (ISBD)]  chairman S. Nassir Ghaemi, MD, MPH ... brought together some of the world's clinical experts on bipolar disorder and key researchers with the goal of having them develop a more systematic and coherent set of diagnostic guidelines.

In other words, what do the best minds in psychiatry have to say about bipolar disorder?  What says the latest data? 

Also expanded was the definition of bipolar depression, according to Ghaemi. "It is not just depression in someone who happens to have had manic episodes but rather specific kinds of depression with specific features," he said.

...Clinical features include early onset of first depression (before age 25 years), multiple (5 or more) previous episodes of depression, family history of bipolar disorder, atypical depressive symptoms (such as leaden paralysis), psychomotor retardation, psychotic features, and/or pathological guilt
That's based on the PET scans and the NIMH genetic studies which have so far cost a quadrillion dollars, right?  Well, here's a line from the actual Guidelines.  It's the kind of line that makes you, well, look upon the works, and despair:

The subgroup describes this as a 'probabilistic' approach to the differentiation of bipolar from unipolar depression, and offers a heuristic of operationalized criteria to be studied empirically. Areas of dissensus persist...

Got that?  No?  Good, it'll go down easier.  So it's soon to be official: Farewell, Depression.

What else does the team think?  Oh: schizoaffective disorder doesn't exist.

Most of the evidence, he explained, suggests that schizoaffective disorder does not represent a separate categorical disease entity; rather, it is "a variation on schizophrenia or a variation on mood disorder or co-occurrence of the two."  The subgroup recommended dropping the schizoaffective disorder diagnostic category altogether from DSM-V...
The question is, if the evidence has so far been indicating that schizoaffective is not real, why did we have to wait for the DSM to tell us it doesn't exist?  Why can't psychiatry simply make it happen? 

But the sleight of hand is saying that the schizoaffective is "really" a variation on a mood disorder (read: bipolar.)  It is equally plausible that bipolar disorder is a variation of schizoaffective disorder since neither one exist except synthetically. I don't mean the symptomatology doesn't exist, I mean the classification is completely empty.  We choose to call this thing schizoaffective, and now we choose not to.  We chose to call it depression, now we choose to call it bipolar depression.   It's not like you chose to call it a unicorn but later discover it's actually a rhinoceros.  A more accurate analogy is that you chose to call this a unicorn, and now choose to call it a ki-ran.  Wait-- what's a ki-ran, you say?  Exactly.

Or, you find an elephant's leg, and say, this is an elephant.  And next you find a horse's leg, so you say, this has much in common with an "elephant," same joint here, so this is an elephant also.  Which would be okay, except then we start making treatment decisions based on that logic: ah ha!   Antifungal cream is the mainstay of treatment for all elephant illnesses!  And meanwhile the elephant dies of throat cancer.  Does it make any sense that the best of our science suggests that the manipulation of four neurotransmitters is somehow involved in the treatment of every single psychiatric illness known, from anxiety to xenophobia?

What do we say to all of those patients diagnosed with schizoaffective disorder?  Oops?  Is it  any consolation to them, or their families, to hear that it's actually bipolar?  How about the criminal cases of schizoaffectives?  Should they get new trials?   Their new diagnosis of bipolar has more studies to draw from, it has more play in the legal system, and better known to jurors? 

As a final question, Ghaemi was asked if he believed bipolar disorder is being overdiagnosed. "While unipolar depression, personality disorders, and schizophrenia have each had periods of overdiagnosis, there has never been an era in which bipolar disorder has been overdiagnosed," he said, "no matter what skeptics claim."
He said that concerns about bipolar overdiagnosis are largely anecdotal, have not been empirically well-established, and ignore solid evidence of continued underdiagnosis.

And there's some more sleight of hand.  Empirically?  What's the test to see if it is actually bipolar or actually depression?  Especially when you have the power to change definitions?

The best is at the end:

The lack of focus on bipolar disorder has led to neglect and controversy, Ghaemi noted. "Our task force," he said, "is a step toward more consensus and less controversy."
Bipolar is the neglected diagnosis?  And this will cause less controversy?  Are you serious? 


Ah, great post. Too bad the... (Below threshold)

May 1, 2008 2:17 AM | Posted by Sally: | Reply

Ah, great post. Too bad there won't be coverage on the nightly news...I think "schizoaffective disorder" found (er decided) not to exist would be a pretty good story, but it won't fly. Society just likes labels too much, or is it something else?

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My view, as a patient, is t... (Below threshold)

May 1, 2008 3:11 AM | Posted by Anonymous: | Reply

My view, as a patient, is that treatment would be far better served if the subjective diagnostic features and diagnostic complexity of the DSM was thrown out the window in favor of an approach based on empirical biopsychiatric data connecting symptom sets to biological causes wherever possible. This would mostly cover mood disorders.

If someone's problems are caused by e.g. low serotonin, I don't see much benefit in drawing arbitrary boundaries between the multitude of symptoms that serotonin system disruption can cause. It's not hugely helpful to subdivide serotonin system issues into multitudes of subtypes except for niche stuff like psychoanalysis.

Under this system, the diagnostic criteria for psych disorders would look something like the diagnostic criteria for lupus--a shedload of symptoms that may or may not be present in any given sufferer but are all caused by the same underlying biological problem.

Adapting this system to deal with conditions that have no known biological cause is left as an exercise for the student.

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I think that your comments ... (Below threshold)

May 1, 2008 9:20 AM | Posted by Glen: | Reply

I think that your comments do a disservice both to the author and issue. Look at bipolar from a connectionist viewpoint and if one is to conceive of it as being waxing and waning periods of neurogenesis / neurodegeneration in the HC then why should be expect that manifestation of such will produce the same results. Unless everyone shared the same experiences (and genes)that shaped this and other brain regions, in the first place, is it logical to assume that changes in neural network morphologies would exhibit the same?

As to your comment;

"Does it make any sense that the best of our science suggests that the manipulation of four neurotransmitters is somehow involved in the treatment of every single psychiatric illness known, from anxiety to xenophobia?"

That does a great disservice to many researcher whom are working in this field. It may be the focus for pharmaceutical companies for a whole host of reasons, but is far from a general consensus.

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"Disclosure: S. Nassir Ghae... (Below threshold)

May 1, 2008 9:33 AM | Posted by Row1: | Reply

"Disclosure: S. Nassir Ghaemi, MD, MPH, has disclosed that he has received research grants from Janssen Pharmaceutica, Novartis, Abbott Labs, Eisai Inc, and GlaxoSmithKline, and has served on the speaker's bureau for Janssen Pharmaceutica, GlaxoSmithKline and Abbott Labs."

"I frequently give lectures locally and nationally. If you or your group would be interested in inviting me for a presentation related to any of my books, please contact my assistant..."

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Listen, DSM diagnoses serve... (Below threshold)

May 2, 2008 8:30 AM | Posted by Anonymous: | Reply

Listen, DSM diagnoses serve no one except the insurance companies. They are completely useless for any other purpose. When working with clients, I refuse to talk with them about their "diagnosis". When they ask what it is, I tell them but then ask them what that means to them. They usually have no comment. I then say "exactly" and proceed to explain the benenfit to insurance companies, etc etc.

Its much easier, in my experienec, to talk with patients, not about their "diagnosis", but the behavioral problems they are experiencing. THAT is what is real to them and that is what they can identify with.

The DSM either needs to be condensed, or in my opinion, flushed down the toilet. If the intention is to revisit and reclasify diagnoses, it is possible then, to collapse many of them into 2 categories (pediatric and "other") and then to maybe have 5-10 diagnoses.

I mean, if I wanted to, I could probably offer proof that their really is only one psychiatric illness that people suffer from, and that the differences we see in people are because it this one illness varies on a spectrum. I'll call it "My Life NOS"

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For me, he most telling par... (Below threshold)

May 4, 2008 10:41 AM | Posted by William Wrightz: | Reply

For me, he most telling paragraph in the Psychiatric Times "Task Force Proposes New Bipolar Guidelines" article was this:

"the subgroup recommended that the bipolar spectrum concept be added under bipolar NOS with 2 descriptors: subthreshold hypomanic episodes in the context of multiple other signs of bipolar disorder as well as multiple signs of bipolarity without hypomanic or manic episodes."

How better could they say that they want to diagnose a disorder with NO real symptoms?
-- "subthreshold hypomanic episodes" (Feels good sometimes?)
-- "bipolarity without hypomanic or manic episodes" SAY WHAT?!

Bring on the antipsychotics. There is a treatment for feeling.

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Pass the rum! oh brother! B... (Below threshold)

May 4, 2008 5:11 PM | Posted by Stephany: | Reply

Pass the rum! oh brother! BP is not over dx? what's that guy drinking while boarding over at CABF Child Adolescent Bipolar Foundation!? bp kids dot org is flourishing with new BP cases every day! and what about the 4000% increase in the last decade of bipolar diagnoses? That is not over diagnosed? and that is not anecdotal! Of course he speaks with a well funded pharma money smooth talk. I'm sick of these people! Yeah, let's just ask all of those SZ patients what they think of the discrimination they've had finding jobs or within the community, and tell them "oops" tell them it was all a mistake and make sure to look for the new DSM to prove it! So we now will have cut and dry dx without any overlap or "spectrums". That guy and Kiki Chang drive me nuts.

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The pharma-psyhhiatry busin... (Below threshold)

May 5, 2008 11:16 AM | Posted by Diane Abus: | Reply

The pharma-psyhhiatry business/mind-set,talk about blinders..the person never the "pseudo_science" here,investigation i.e. case histories of course assume that there are actually humans at both "ends" of the dyadal relationship.Pleeeze.

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oh goody! If they drop "sch... (Below threshold)

May 6, 2008 10:31 AM | Posted by mark p.s.: | Reply

oh goody! If they drop "schizoaffective disorder" from the DSM, I have to get a new psychiatric label/diagnosis for my collection! I started with paranoid schizophrenia, have about five others in between this first one and "schizoaffective disorder".

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Elegant, lively, wonderful ... (Below threshold)

May 7, 2008 12:33 PM | Posted by Anonymous: | Reply

Elegant, lively, wonderful writing. I wish someone like you were in the mainstream press to take a more skeptical look at all the hooey reported based on press releases and repeated by perhaps lazy medical journalists.

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I read this report with my ... (Below threshold)

May 12, 2008 4:52 AM | Posted by Anonymous: | Reply

I read this report with my jaw on the floor a couple weeks ago and stuffed it, the feelings that came up. I appreciate your writing this:

What do we say to all of those patients diagnosed with schizoaffective disorder? Oops?

Yeah. I spent the first ten years of my life in mental health treatment without labels or drugs, on a path of recovery from self-destructive impulses resulting from a dangerous and abusive childhood. In ten years not one on professional on my treatment team described me in terms of diagnosis, beyond ordinary dictionary words like trauma and depression, and my attention stayed where it belonged -- on my life, my mind, my progress in separating from what I grew up learning to do.

In the 11th year psychiatry entered into my treatment program, with all the language of psychosis, dissociation, conversion disorder and borderline/histrionic PD, but it was the "schizoaffective" diagnosis that told me I really am a lost cause, and the day I walked into the public library to research schizoaffective disorder was the turning point in the medicalization of what was once a narrative explanatory model of my behavioral and psychological complaints.

I sat in the library all day learning about my new identity as a "schizoaffective", telling myself I am going to have to accommodate this, there it is in black and white.

If not for the disdain of my therapist and my prior ten years working with a psychodynamic treatment team that focused on my phenomonology I would have completely succumbed to the schizoaffective identity. Instead it's been a constant struggle, one day you take it seriously, because that's what you're told and you want to be a responsible patient who works aggressively treating her very serious mental illness. The next day I try to dismiss it as just the usual bullshit. But the schizoaffective construct is always *there*, invasive, implicative, demanding my response, and informing the response of those who deal with me in any capacity. And now it's going to disappear? No harm, no foul, and down the road we go.
Fuck psychiatry.

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Bi polar not overdiagnosed?... (Below threshold)

May 25, 2008 8:01 PM | Posted by burnt out psych nurse: | Reply

Bi polar not overdiagnosed?, they should come to my hospital one day.its definitely the diagnosis du jour round my way. all my patients that used to have just boring old depression or borderline PD now have a nice whizz bang new label of bipolar, despite the fact that they have never experienced any episodes of mania and dont appear to meet the diagnostic criteria. however the drug companies are desperate the extend the licences on their crappy anti-psychotics and whadda ya know? suddenly zyprexa/seroquel et al are the new adjunct treatments for bipolar and a whole bunch of unfortunate patients get a new label and some expensive new drugs they cant afford, and some nice side effects too!.

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I would be so much happier ... (Below threshold)

June 4, 2008 5:19 PM | Posted by Anonymous: | Reply

I would be so much happier today if I could just get the label off my skin and get back to addressing the trauma that led me to cut into my thigh in the first place. I'd even take the meds with a little less aversion.

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loosing my dear husband had... (Below threshold)

June 23, 2008 12:32 AM | Posted by carol smith: | Reply

loosing my dear husband had left me in poor state of mind.i would not imagine that one day i will got out of it but thanks be to God i am free.
carol smith
Dual Diagnosis

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I would be interested in yo... (Below threshold)

July 15, 2008 7:48 AM | Posted, in reply to Row1's comment, by Anonymous: | Reply

I would be interested in your name and number. I am a therapist who is looking for a knowledgeable MD for medication evalution and follow-up for a client. I work in the Providence, RI area, but my client is willing to travel to Mass or Conn.

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Bipolar: Change or mood? I ... (Below threshold)

July 30, 2009 11:50 PM | Posted, in reply to burnt out psych nurse's comment, by rr: | Reply

Bipolar: Change or mood? I think it's people to afraid to mature or grow up that they create this episodes in their minds to escape for reality for a few moments, that would be dementia . Bipolar? Term use to create a new drug with side effects that will be pulled from the shelves in two years due to some rare disease. so, if someone is happy all the time, he has a the uninanipolar disease right?

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