The rise in bipolar disorder is a myth

The apparent increase in bipolar disorder is largely due to a broadening of diagnostic criteria for the condition, say Phil Barker and Poppy Buchanan-Barker

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As recently as 1980, bipolar disorder was a rare psychiatric disorder. ?Manic depression?, as it was still known in the UK, was popularly associated with intellectual or creative types, given to swinging between energetic displays of creation and troughs of deep despair.

Van Gogh and Spike Milligan were iconic ?manic depressives?(1). The ?polar?, nature of these swings - from ?high? to ?low?-  led to the creation of ?bipolar disorder? diagnosis in 1980.

Over the past 30 years, what was a rare phenomenon has grown to near-epidemic proportions.  ?Manic depression? affected less than 1% of the population in 1980 and prior to that rates were even lower. An episode of severe mania, requiring hospitalisation, was usually necessary to confirm the diagnosis.

With the advent of ?bipolar disorder? the diagnostic criteria were softened and a ?bipolar spectrum? was created, which included more minor states, which patently were not ?polar? in nature. Geologically, the ?poles? are extremities. Mania and depression were recognised as analogues of such polar opposites. Today, the use of ?bipolar? in the context of the ?bipolar spectrum? seems ludicrous; rather like suggesting that the north of Scotland and the South of England, are ?poles?.

Today, 5% of the population is estimated to have a diagnosis of ?bipolar 1? ? classic ?manic depression?, where mania, depression and ?psychotic? features are evident. Over 10% of the population is said to meet the ?bipolar II? criteria, where depression and hypomania may be present, but mania and psychotic features are absent. Overall, almost 25% of the population is thought to lie somewhere along the ?bipolar spectrum? (2). Despite these scary statistics, rates of admission to hospital with mania ? once necessary for the diagnosis of manic depression - have remained largely unchanged.

A host of celebrities now talk about being ?bipolar?, blaming their relationship breakdowns, drug and alcohol problems or other wild excesses on this ?illness?. Others, in thrall to the cult of celebrity, even want a bipolar diagnosis applied to what may simply be aspects of ordinary misery (3). The ?bipolar? storyline has also appeared in television soaps. The BBC?s Eastenders won a MIND award for what was called its ?realistic? and ?responsible? bipolar storyline. However, almost every soap-opera character behaves in a reckless, explosive, antisocial or foolish manner, worthy of one psychiatric diagnosis or another. The Eastenders spotlight on ?bipolar disorder? may simply reflect its fashionable nature;  a dishonest way of trying to explain the recklessness and concomitant misery that affects so many people?s lives.

This ?bipolar? explosion is part of the epidemic of ?mental illness? documented by the award-winning American journalist, Robert Whitaker (4). Society at large and the medical community in particular have been fairly casual about accepting this epidemic as if it were inevitable. If any other rare, medical condition - such as epilepsy or cystic fibrosis - had shot off the statistical chart, serious questions would be asked about possible causes. Instead, our society appears to have swallowed the ludicrous idea that previously ?bipolar? disorder was ?under-diagnosed?. A comforting myth based on no reliable evidence.

The astonishing increases in bipolar diagnosis can be explained, in part, by the resetting of the criteria necessary to confirm the diagnosis, which began in the USA in 1980, with DSM III. Studies suggest that, as a result, rates of bipolar diagnoses in adults have increased by 56 per cent and over 400 per cent in children (5). In a recent interview, Allen Frances, chair of the DSM IV Task Force that further widened the diagnostic criteria in the mid 1990s, looked back with regret at his role in the development of the manual.  "We made mistakes that had terrible consequences... Diagnoses of autism, attention-deficit hyperactivity disorder, and bipolar disorder skyrocketed (6)? The epidemic of diagnoses among younger people is one of Frances? keenest regrets. The revised diagnostic manual facilitated these epidemics, fostering a tendency to attribute problems in living to some ?mental illness?, needing treatment with psychiatric  drugs.

This epidemic becomes even more worrying when one considers the history of recovery from manic depression in the early 20th Century. Few people, whether lay or professional, are aware that recovery from any form of ?mental illness?, was far better before the introduction of psychiatric drugs in the 1950s (7). In a 1929 study of 2000 people with manic depression, 80 per cent of the group recovered within a year and less than 1 percent needed long term care (8). A classic 30 year follow up study of 86 people admitted to hospital with mania, between 1935 and 1944, found that 70 per cent led normal lives - marrying, working and living in their own homes. Half of this group showed no symptoms of mania during this long follow up (9). Such findings led Winokur to conclude, in his classic book on manic depression, that: ?in a significant number of patients only one episode occurs? and as a result, it did not permanently affect those who suffered it (10). 

However, the indiscriminate or inappropriate use of the ?bipolar? diagnosis is only part of the story. For some time critics of the ?the chemical cure? have been concerned that the use of psychiatric drugs might have worsened outcomes, rather than improved them. Pharmaceutical companies have always been better at finding existing conditions to treat with old drugs, than in developing newdrugs to treat old conditions.

As a result, ?antipsychotics? are now used, routinely, as so-called ?anti-manic? drugs (11). However, these act as tranquillisers or sedatives, rather than in any ?illness specific? way. Antidepressants are also used routinely in bipolar disorder, and are thought to induce ?rapid cycling? and ?antidepressant-associated chronic irritable dysphoria?, both of which can endure for years (12).

Anticonvulsants were developed originally to control epilepsy, but have a new use as so-called ?mood stabilisers?. Like the promotion of antidepressants and antipsychotics as so-called ?anti-manic? drugs, the notion of ?mood stabilisers? appears to be little more than a way of making new profits out of old drugs. Despite the wide-spread use of ?mood stabilisers?, an important Welsh study showed that readmission rates were higher in the 1990s (77 percent) than a century ago (8 percent). Over 80 per cent of the discharges in the 1890s were described as ?recovered,? whereas this could only be said of 17 per cent for those a century later. The researchers concluded that such findings were: ?incompatible with simple claims that mood stabilising drugs ?work?? (13).

There is no doubt that many people today experience great distress related to a whole range of problems in their everyday lives. Many, perhaps the majority, turn first to psychiatric drugs as a means of resolving such problems. For millions of people, taking psychiatric drugs has become a ?normal? way of life (14). Contemporary life may be increasingly complicated but, as a society, we might ask how people recovered before the advent of psychiatric drugs. A growing body of evidence suggests that people can learn to manage the mood problems associated with ?bipolar disorder?.

However, the ?self-management? and social support involved today is probably little different from that practiced by bygone generations. If the source of people?s problems lies in their relationships and lifestyles, their energies and that of those seeking to help them, should be focused on managing the emotional fall-out from such problems in living.

Bipolar disorder remains a myth in that many people ? both lay and professional ? believe it exists and as result it exercises great symbolic power over and within people?s lives.

The myth may be helpful, by offering a pseudo-medical explanation of a person?s problems in human living. However, the same myth can also restrict severely, the person?s freedom to address the challenges of life, through exercising full human agency.

1. Jamison KR Touched with Fire: Manic-depressive Illness and the Artistic Temperament NY: Simon and Shuster, 1996.
2. Moncrieff J The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment. Basingstoke: Palgrave Macmillan, 2009.
3. Chan D and Sireling L. I want to be bipolar - a new phenomenon. The Psychiatrist, 2010; 34: 103-105
4. Whitaker R. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. New York: Crown Publishers, 2010.
5. Blader J and Carlson GA Increased rates of bipolar disorder diagnoses among US child, adolescent and adult populations, 1996-2004. Biological Psychiatry 2007: 62; 107-114
6. Greenberg G. Inside the battle to define mental illness. Wired Magazine 2010; 19 (1): 12-15
7. Healy D et al.Service utilization in 1896 and 1996: morbidity and mortality data from North Wales. History of Psychiatry 2005; 16(1): 27-41
8. Wertham F I. A group of benign psychoses: Prolonged manic excitements. American Journal of Psychiatry 1929; (9): 17-78.
9. Tsaung, M.T., Woolson, R.F. and Fleming, J.A. Long-term outcome of major psychoses: I. Schizophrenia and affective disorders compared with psychiatrically symptom-free surgical conditions. Archives of General Psychiatry, 1979:36:1295-1301
10. Winokur G. Manic Depressive Illness. St Louis: CV Mosby Company, 1969
11. National Institute for Clinical Excellence.  Bipolar Disorder. The Management of Bipolar Disorder in Adults, Children and Adolescents in Primary and Secondary Care. NIHCE; London 2006
12. El-Mallakh RS, Karippot A. Antidepressant-associated chronic irritable dysphoria (ACID) in bipolar disorder. J Affect Disord 2005; 84:267?272
13. Harris M S et al. The impact of mood stabilizers on bipolar disorder: The 1890s and 1990s compared. History of Psychiatry 16: 423-434
14. Rose N. ?Becoming neurochemical selves?. In N Stehr (Ed). Biotechnology, Commerce and Civil Society. New Brunswick, NJ; Transaction Pub. 2004.
    
    
    

    * Phil Barker is a psychotherapist in private practice and honorary professor at the University of Dundee. He was a mental health nurse for more than 35 years and the UK's first professor of psychiatric nursing practice. He is also professor of health science, Trinity College, Dublin, Ireland

    * Poppy Buchanan-Barker is a counsellor, advocate and director of Clan Unity International, Scotland.

    They have, between them, authored a number of books, including The Tidal Model: A guide for mental health professionals and Spirituality and Mental Health: Breakthrough

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Out-of-date

From: Michael Johnson, Counsellor, Canada
Date: February 10, 2011

You are out of date. Try reading the second edition of
Manic Depressive Illness by Godwin and Jamison

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If critical, be specific

From: Basil Miller, Head of Communications,
Date: February 10, 2011

Michael, you need to be more specific than this mere assertion.

B-B and B have marshalled 14 sources to support their argument, including one of your authors.

In what respects does Jamison and Goodwin's opus undermine our authors' argument? In what manner are they 'out of date'?

Are matters worse than they maintain, or are you arguing for the orthodox, and demonstrably failed and dangerous, approach?

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In love with diagnoses

From: Kim Sherrington, Clinical Lead/Manager, Orchard Therapy Unit, Avon and Wiltshire Mental Health Trust
Date: February 14, 2011

In my 32 years as nurse and psychotherapist in the NHS. I have witnessed this surge of diagnoses of BPolar.

I am frequently astonished at the lack of evidence for such a diagnosis even if I believed in it at a concept.

I feel that this is another example of a culture which has long been mesmerised by pseudo science which has in itself become little more than commercial endorsement for many products.

Of course the authors of DSm are 'got at' by the drug companies who look to increase their markets with little care for the greater good.

Geneticists will claim that we are totally enslaved by out chemistry and therefore also not responsible for the lives we lead and yet the age old chicken/egg question remains the mystery ie does our altered chemistry and 'faulty genes' cause or are a result of life problems?

We conveniently forget too how diagnoses have long been proven to be a subjective affair yet we remain in love with them.

Personally I understand Bi-p as just one of the many options of flight from an unsafe or undesired reality - this makes more sense to me than pathology.

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Life with someone bipolar

From: Mark Theron, Husband of a wife with bipolar disorder, Cape Town, South Africa
Date: February 21, 2011

Kim, until you live with someone with Bipolar, and see them in their up, down and normal states, cry with them during the bad times and savor the good ones, you have no idea.

Therapists and psychiatrists see patients for just a few hours of their lives - I have known my wife for 20 years and lived with her for 10.

Think before you call it "just one of the many options of flight from an unsafe or undesired reality".

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EastEnders' portrayal of bipolar 'insulting'

From: Nathan Blanshard, London, UK
Date: February 25, 2011

Having been diagnosed with Bipolar Disorder myself quite some time ago, I certainly understand the pain that people go through. It's hell. That inability to function properly, whether it's because my mind is moving too quickly or I can't get out of bed for weeks at a time, I can assure you that for genuine sufferers such as myself, the condition is very real and has a significant impact on people's lives in whatever they choose to do.

It has also come to light within the last few years, that Bipolar seems to have captured the imagination of the general public in a very self serving and altogether cynical fashion.

Whilst there was a time when people couldn't give a toss about us now Bipolar very much seems to be the MTV illness of choice, appearing on everything from american teen dramas to British soap operas. The most recent storyline in Eastenders is a case in point.

Whilst one might be tempted to say all of this recent awareness can only be positive for people with the condition, the reality is that no such awareness is being attempted.

People never go into the realities of the condition, instead choosing to depict Bipolar as some form of insanity,the kind who are generally dangerous and only allowed out on weekends or family holidays.

This was most certainly the case with regards to Eastenders, in which Bipolar Disorder was replaced with another fantasy illness, with both the character of Stacey Slater and her mother, showing signs of clear retardation and good old fashioned madness, as opposed to any of the real symptoms matching Bipolar Disorder, which to a large extent would never make great television.

The fact that the show received an award for it's depiction of the illness is all the more insulting to the real victims of this condition, and it deeply depresses me that the show's portrayal of the illness could be condoned at all, let alone be praised by a mental health organisation.

Which all leads me back to the opening quote. Such is the trivialisation of the illness in recent times, even people working within mental health are starting to question it's validity. This has to stop, as much for the real victims of Bipolar Disorder as anybody else. They are the people should really be left alone to tackle their symptoms, as opposed to having to deal with the persistent stigma attached to their unchosen condition.

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Narcissistic personlity disorder

From: Allan Honicker, Australia
Date: March 7, 2011

For many people this is real and you do need the drugs. I lived with someone with this diagnosis for 30 years and life with her was painful.

The reason bipolar disorder has become more common, I believe is because our society has become very narcissistic in nature. In fact many ambitious people at work, behave just like a person who rides on the high side of bipolar disorder.

In real life, when a bipolar person is on a high they do not use their heart to self-scrutinise behaviour because this would spoil the party. When depressed it is too painful to use the heart or any form of emotional inteligence. When moving between the two poles they are so full of guilt and doubt, they dare not use emotional inteligence to plan the next trip.

So it is they train themselves to function withut any emotional inteligence. They become very manipulative and tactless, cold and socially very clumsy. The words 'sorry', 'thanks' and 'please' are rarely used and never real and used only when faked for the purpose of manipulation.

This is essentially narcissistic personality disorder (NPD). So we have the good old 1% of people who are bipolar. Then there are the ones who have grown up to be narcissistic and behave the same way in anycase. When they get into enough trouble as they inevitably find the ground, out pops the diagnosis, which comes from the behavioural aspecst of their life.

The drugs are one thing, but in the flat period of normal brain function, its the growing up that is difficult. The development of empathy and the willingness to face off with the true self are the difficult tasks to manage.

Even when the meds are working perfect, most bipolar people are living through a false self, just as a person with NPD. This causes a nightmare for the one closest and is the most difficult and painful aspect of this life with a bipolar person or indeed, a person with a self denial personality disorder.

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Questioning diagnoses

From: Kim Sherrington, Clinical Lead/Manager, Orchard Therapy Unit, Avon and Wiltshire Mental Health Trust
Date: April 1, 2011

To Mark Theron - Dear Mark, I fully accept that you live with this and are therefore more qualified to comment upon the challenges you face with your wife's problems.

I see a great many with this diagnosis and I once worked in the old Institutions and lived alongside those also diagnosed similarly. As with all 'diagnosed' people the presentation is unique to them and there are a great many dynamics and reasons why peoples distress manifests itself in the way it does. I was simply commenting on the fact that this diagnosis has become epidemic in recent years and am curious to know why.

I know diagnoses do enjoy fashionable status having myself been around long enough to witness this. I also question the value of diagnoses full stop as I find them simplistic, subjective and ultimately unhelpful even to those who welcome them for they resign the receiver to being 'other' than the rest of us. Our profession is grossly arrogant and however dressed still is stuck with symptom diagnosis and relief equalling 'cure' as its foundation stone. This is an insult to the uniqueness of the human experience.

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