[Content note: brief discussion of suicide]
Weekly series! As per previous discussion, I will be published a big information blog about a specific mental illness on each Friday.
I know, today is not Friday. I’m publishing early because I’m excited, and also I want to get lots of feedback. Tell me what I’m not including, what other things you want to know, etc. If there’s enough questions, I’ll do a second follow-up post. Lastly, tell me if there’s terms I’m not defining that I should be. I really really don’t want to get wrapped around jargon here–it helps nobody.
The idea is to talk about what the diagnoses are and aren’t, common misconceptions, what treatment and outcomes look like, and so on. Though not all therapeutic orientations (the theory and approach behind a course of treatment) depend on or use diagnoses–and there’s some very good arguments against using the medical model of diagnosis–we do use labels to conduct research, and it’s worth learning what a mental illness is. I’m going to try to include any changes to diagnostic criteria as well as current debates.
This post is massive and organized in informational sections, so I’ve put it behind a jump.
Words of Note:
DSM: The acronym for the Diagnostic and Statistical Manual of Mental Disorders, a five axis classification system. We’re currently on DSM-IV-TR (TR being ‘text revision’). The DSM is atheoretical–it proposes no reasons for development of disorders, only means of identification. The DSM5 is predicted to be released in 2013, but it’s been put off so many times that it may change. More information here.
Comorbidity: A second disorder appears together with the initial diagnosis. For instance, depression is highly comorbid with anorexia nervosa. High levels of comorbidity can actually be a sign that the diagnosis is less accurate than it could be. To use the previous example, what if we’ve just misdefined anorexia? What if anorexia actually is a disorder that usually includes features that look like depression, but isn’t a wholly separate mental illness? Genetics and neuroscience research can come in handy here, and disentangling these things contributes to some of the reason we revise the DSM.
Bipolar disorder used to be known as manic depression or manic-depressive disorder. It is similar to depression in that in both cases, major depressive episodes are present. However, just the presence of a single manic or mixed episode results in a diagnosis of bipolar instead of depression.
Also like its unipolar counterpart, BD is highly heritable, meaning that genetics play a large role in the development of the disorder. Twin studies have been fairly small scale, so we can only estimate exactly how much, but it’s roughly 70%. There’s also some evidence that the manic and depressive aspects of the disease are inherited separately. This is born out in that children of parents with BD may inherit, with approximately equal risk, bipolar or unipolar depression. [More information here]
I also want to note here that just because there’s both mania and depressive episodes in BD does not make the lows somehow less distressing than in depression. I’d suggest viewing the disorder as having depression and having mania. Secondly, please remember that it just takes a single episode of mania or hypomania to receive a BD diagnosis–it’s possible to have BD and spend the majority of your time with major depressive episodes.
Bipolar Disorder Subtypes:
Cyclothymia: could be described as ‘mild’ version of bipolar. Moods never meet full criteria for mania, or major depressive episodes, but come close to both.
Bipolar I: Include at least one fully manic episode and major depressive episodes, each lasting at least seven days.
Bipolar II: Like BD I, but without reaching full mania or having mixed episodes. Both subtypes have equal rates of suicide attempts, though there’s research indicating those with BD II use more lethal means in their attempts (such as guns). [Note from twitterer Ally--because there's no distinct mania, BD II can easily be misdiagnosed as depression.]
Bipolar Not Otherwise Specified (BD NOS): The client doesn’t quite meet criteria for any other subtype, but is experiencing clinically significant distress that aligns most closely with BD. For instance, a client who experiences manic episodes that last four days at most, and meets criteria for having depressive episodes.
Rapid-Cycling: Any of the previous subtypes can carry this secondary label, which means having more than four episodes per year. That’s considered to be a higher-risk indicator, because of the constant polarity of mood.
Things Bipolar Disorder is Not:
Having a ‘mood swing’. Nope. It’s just not. Mania and depression are both incredibly distressing to experience, and it’s trivializing to compare that to a simple mood swing.
Changing your mind. “I can’t decide what I want! I’m so bipolar!” *Facepalm.* Don’t do this.
Schizophrenia/ADHD/Dissociative Identity Disorder. Apparently this is a common misconception. Those are all other diagnoses, and not even in the mood disorders category. Other things BD is not: the color blue, strawberry marmalade, and feeling happy and sad in the same day.
Mania, Hypomania, & Mixed Episodes
Mania & Hypomania: Bear with me here, because mania seems a touch like pornography–you know it when you see it. It’s basically a combination a large number of any of the following: restlessness, impulsive behavior particularly with things considered “high risk” such as sex and spending money, beginning projects, sleeping little, racing thoughts, and irritable mood. I want to emphasize that it has to be at clinically significant and distressing levels to qualify as mania. Sometimes we all bite off more than we can chew or feel restless. This is an overarching pattern of behavior outside of one’s control. People who have experienced this are welcome to speak up in comments.
Mixed Episodes: Mixed comes from the combination of depressive and manic symptoms. The two most definitely don’t cancel each other out, and mixed episodes are actually considered the worst. Take this easy example: Suzy has trouble with suicidal ideation. During mixed episodes she feels depressed, but also has lots of motivation and energy…which actually makes her more likely to follow through on a plan. Having had non-clinical levels of mixed feelings, I can assure you it’s horribly unpleasant. You feel awful, but you also can’t sit still or fall asleep or stay away from people. I want to crawl out of my skin.
Diagnostic criteria for Bipolar I Disorder
[Edited slightly--the DSM actually has criteria for Bipolar I divided out by most recent episode type. However, they're almost entirely identical]
A There has previously been at least one Manic Episode or Mixed Episode.
B. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
D. The mood symptoms in Criteria A and B are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
Diagnostic criteria for Bipolar II Disorder
A. Presence (or history) of one or more Major Depressive Episodes.
B. Presence (or history) of at least one Hypomanic Episode.
C. There has never been a Manic Episode or a Mixed Episode.
D. The mood symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Mood stabilizers such as lithium, anticonvulsants (which may carry a risk of increased suicidal thoughts), and atypical antipsychotics (also known as second generation antipsychotics). Oddly, there’s been no evidence to suggest that anti-depressants are any more effective than mood stabilizers in treating BD. (citation) It’s also of note that St. John’s Wort, which is sometimes marketed as an herbal antidepressant, might actually cause an increase in mania, as well as cause other medications to stop working (It can also interfere with hormonal birth control–alt med is not harmless). (NIMH)
An Unquiet Mind: A Memoir of Moods and Madness
If any information is incorrect, please note it in the comments! However, I am going to ask for citations. I have access to journals as a student, so no worries if it appears behind a paywall. Also, please chime in with your own experiences, misconceptions, myths you’ve heard, and any book suggestions!