Is bipolar disorder just the latest diagnosis du jour?
By Carol Hall
I’m Bipolar. He’s Bipolar.
Sometimes it may seem as if everyone is bipolar. Is this a real condition—or just a fashionable diagnosis?
“It’s the diagnosis du jour,” declares geriatric psychologist Michael C. Smith. “It’s a fashion.” Dr. Alexander Lerman, a Westchester-based psychiatrist, couldn’t agree more. “It’s become an umbrella diagnosis.” You don’t have to be board certified to know that “bipolar disorder” is now part of the national conversation and part of the national diagnosis. Studies have shown that the number of people who have been diagnosed with it has risen dramatically over the past decade. It has become so au courant that hardly a week passes without another public figure being called “bipolar”—remember the off-the-cuff diagnosis of Britney Spears recently?
Children as young as four years old are now being diagnosed with the disorder, as are a growing number of elderly people (anywhere from 4 percent to 20 percent). Still, mental-health professionals uniformly agree that bipolar disorder, which was known as manic depression until 1980, is a very real, very serious condition. But many also agree that the label is being thrown around too liberally and that, as was the case with schizophrenia in the last century, it has suddenly become a catch-all diagnosis for a whole range of abnormal behaviors.
Estimates for the number of people in the United States suffering from bipolar disorder are all over the place. One book published in 1997 (Bipolar Disorder—A Family-Focused Treatment Approach by David J. Miklowitz and Michael Goldstein) estimated that 0.8 to 1.6 percent of the U.S. population suffer from bipolar disorder. But then a 2003 study by Drs. Hagop Akiskal and Lew Judd claimed that the figure could be as high as 6.4 percent. The most reliable estimate probably comes from the National Institute of Mental Health, which posits that 2.6 percent of the population aged 18 and up will have bipolar disorder at any given time (that’s 5.7 million people).
The disorder first was described in the late 19th century. “Over the past century and a half, the clinical descriptions of bipolar disorder have been remarkably consistent,” says
Dr. Mark Olfson, a psychiatrist at Columbia University. “It is one of the most serious, enduring, and life-threatening psychiatric disorders.” Still, Dr. Olfson questions the growing number of diagnoses. He is part of a team of researchers, including a doctor from the National Institute of Mental Health, who recently released the results of a study showing that, over a recent period, the number of children and adolescents diagnosed with bipolar disorder rose an astounding 40-fold. The study also tracked adult diagnoses over the same period; the number nearly doubled. Their study, based on data collected by the National Center for Health Statistics, examined 10 years of data from an annual, nationwide survey of visits to doctors’ offices over a one-week period.
Dr. Olfson cautions that the data should not be assumed to show that there has been an actual increase in the percentage of people with bipolar disorder. “Community surveys conducted over the past twenty-five years have found reasonably consistent rates of bipolar disorder in the general population,” he says. “We’re only finding increases in the rates at which physicians are diagnosing it, especially in young people.”
There are several reasons why so many more diagnoses of bipolar disorder are leaving doctors’ offices these days: one—the professional criteria for diagnosing the disease have expanded; two--the age group thought to be susceptible to the disorder has grown to include both younger and older people; and three--the explosive growth in the number of drugs available to treat the symptoms has encouraged more doctors to make the diagnosis.
“There is no question that bipolar disorder exists,” says Dr. Richard Gallagher, director of the Westchester Medical Center’s Comprehensive Psychiatric Emergency Program. “But in many cases, it’s being over-diagnosed. It’s not surprising that the public is confused about it.”
“I know this is très chic and over-diagnosed,” declares Lisa*, a furniture designer who lives in
Both Lisa and her 20-year-old son, Ned, have been diagnosed with bipolar disorder. Lisa has stabilized her life somewhat with medication. Ned, first diagnosed when he was seven, is still struggling. “Even in utero, Ned was so active it was like he was skateboarding in my stomach,” Lisa says. “As an infant, he screamed and never slept. I went down to about seventy-five pounds.” Lisa adds: “He had extreme separation anxiety. I would have claw marks on my chest that looked like they’d been made by a lion. If I was taking out the trash, he’d explode because I’d left the house.” By age seven, Ned was put on Depacote, a mood stabilizer, and, for a while, he improved.
“At school, he was brilliant and got excellent grades,” Lisa says. But in the fifth grade, his mom reports, Ned became deeply depressed and locked himself in his room, threatening suicide. “Some trauma had occurred in his brain,” Lisa says. At the age of 10, Ned was admitted to Four Winds Hospital, a psychiatric facility in Katonah, where he stayed for weeks. During the same year, Lisa checked into a similar facility, Silver Hill Hospital, in New Canaan.
Since then, Ned has been in and out of schools, hospitals, treatment programs, and jails. He has wrecked several family cars, devastated the family’s finances, has started dealing drugs, and has been coping with a heroin habit since he was 15. Their home has been robbed more than once by, his mother suspects, Ned’s acquaintances. When Ned is home, Lisa says, the family’s life is completely unpredictable. He may stay up half the night, or have explosive rages during the day. “We have no friends,” Lisa says. “We live under siege. When you try to explain all this to people, they don’t comprehend.”
Bipolar disorder can affect a person’s state of mind so radically that he or she can no longer function. A bipolar person will have a “cycle” of moods that features high (manic) and low (depression) “episodes.” There are times when the person seems almost normal. But at other times…
Dr. Alexander Lerman, a Chappaqua-based child and adolescent psychiatrist who is a clinical instructor at NewYork Presbyterian Hospital and also is on staff at Northern Westchester Hospital, recalls the mania of one patient in particular. He was an extremely successful executive, who had been brought into the hospital because “he was naked in the street, directing traffic.” When he was manic, “he was hysterically funny,” Dr. Lerman says. “He made Billy Crystal look slow, stupid, and boring.” Dr. Lerman says the man’s company tolerated his bipolar episodes for years because he was so effective at his job.
The depression associated with bipolar disorder can last for weeks, months, or, in severe cases, years—if the person survives; bipolar sufferers are 20 times more likely to commit suicide than the rest of the population.
No one is sure what causes the disorder. Researchers think that both genetics and environmental causes, such as emotional stress or physical trauma, play a role. The disorder seems to strike all races, income levels, and genders equally. However, women tend to have their first bipolar episode as an extended depression, while men usually have a manic episode first.
Susan, who today lives in Riverdale, had her first episode when she was 23, in the summer of 1987. Her sister had just died of a brain tumor, she was having difficulties at work, and a relationship was falling apart. She suddenly had trouble sleeping and became extremely religious (“hyper-religiosity” is a fairly common symptom, experts say). She fell in with the Harmonic Convergence movement, based on a New Age belief that is supposed to be the fulfillment of the prophecy of Quetzalcoatl, known as the Thirteen Heavens and Nine Hells. “I left everything and went to the Poconos,” she says. “I took one step from reality into this place where I felt I could save the world.” At that point,
Susan began living on the streets and, when her behavior became bizarre enough, complete strangers took her to a hospital. She continued to cycle over the years between manias and deep depressions, sometimes landing in hospital psychiatric wards. “In a mania, I am so elated,” she says, “but there is a total lack of social appropriateness. If I’m in the library and I want to sing, I sing. If I want to strip, I strip. I have no inhibitions and completely lose touch with reality.” Her hyper-religiosity continued. “One time when I was in the hospital, I thought I was going to have the Virgin Birth.”
Sam, who says he has been bipolar since the age of seven and today lives with his wife and son in Pelham, knows all about manic episodes. “The mania,” he says, “can be great fun. Some people will bring it on.” Many people can sense when they are about to begin a bipolar episode—they don’t sleep for days, or they are extremely creative and “up.”
Patients on medication can “bring it on” by simply not taking their meds. “People love how they feel when they are manic—you are more creative and energetic,” Sam says.
“But most people can’t control it. You keep going up and up, until you become irrational, hallucinate, and have delusions.” Over the years, he says, “the mania becomes much less pleasant.” Many patients experience what doctors call a “mixed state,” where elements of mania and depression mix. “That’s horrible,” Sam reports. “That’s when most suicides occur. All your deep fears kick in. The manias get more frightening each time.”
The manic phase is also when bipolar people are the most likely to do things that cause them great shame later and that can be detrimental to the future course of their lives. Melissa had her first bipolar episode when she was 15½. She fell into a deep depression after the death of an uncle and stopped going to school. “I hid at home or at my aunt’s house around the corner,” she says. “I felt everyone else was sick, that I was the normal one. I got super-spiritual and felt that I could heal with my hands. I gave money to people I didn’t even know.”
What the symptom list calls “poor judgment” often includes sexual promiscuity, and, by the age of 17, Melissa had a baby boy. “He was adopted out,” she says, “and that was harder than the illness. It was a good choice for him but a bad choice for me.” Today, in her mid-40s, Melissa is married and lives in Yonkers. She has been taking Lithium for 27 years and quit once, in an attempt to conceive another child. She experienced bipolar episodes and resumed the Lithium. She has made contact with her now-grown son and has told him about her illness. She has not had any other children.
It now is accepted that there are different kinds of bipolar disorder. The 1994 edition of the Diagnostic and Statistical Manual of Mental Disorders (known colloquially as the DSM-IV)—the bible of psychiatric diagnoses—greatly broadened the definition of bipolar disorder. In the DSM-IV, classic bipolar disorder is labeled Bipolar I, which is characterized by one or more manic episodes or mixed episodes plus often one or more major depressive episodes. It is joined by three more categories: Bipolar II (characterized by one or more major depressive episodes accompanied by at least one hypomanic episode); Cyclothymic Disorder (characterized by at least two years of hypomanic and depressive symptoms that do not meet the criteria for a major depressive episode); and Bipolar Disorder Not Otherwise Specified, a catch-all category for people with a smattering of bipolar-like symptoms. After the publication of the ’94 edition, the number of people diagnosed with bipolar disorder began to soar. “I don’t think there is any substantive scientific basis for the increase in the diagnosis,” says geriatric psychologist Smith, who is based in Brooklyn. “I think it’s just a matter of how the criteria have been interpreted.”
Still, nailing a psychiatric diagnosis can be very difficult. “It’s easy to diagnose severe mental illness,” Dr. Lerman says. “Research shows that concurrence on the diagnoses of severe mental illness among psychiatrists is eighty percent. But when you start getting away from severely mentally ill people, the rate drops to forty percent or less.” Is the rage a young child exhibits normal anger, or a serious mental illness like bipolar disorder? Is the depression in a teenager dealing with puberty and high school normal? Are the mood swings of elderly people living out their lives in nursing homes to be expected, or symptoms of bipolar disorder?
In time, new diagnostic tools, such as better brain-imaging tests and blood tests, will give diagnosticians more accurate information to add to what they rely on now—clinical observation. Over the past several decades, there has been something of a sea change in psychiatry, with the emphasis in diagnosis shifting from nurture to nature. More practitioners are looking more closely for biological causes of problems—be it a thyroid condition or a bad set of genes. Biological problems can be more readily treated with medication and are often deemed more acceptable to patients and their families. “Some psychiatrists believe that psychiatry is a neuroscience,” Dr. Lerman says.
It was around the time the ’94 edition of the psychiatric manual appeared that managed care and insurance companies came to dominate healthcare. They were less willing to reimburse doctors fully, if at all, for lengthy courses of therapy. So at roughly the same time a broadening of the criteria for bipolar disorder commenced, a corporate squeeze on treatment options began. Our healthcare system is increasingly set up to encourage doctors to make quicker diagnoses, issue prescriptions for more medications, and cut down on the number of office visits for therapy. It is less expensive to an insurer to have the patient referred to a social worker than a psychiatrist or psychologist. “The drug companies want us to use diagnoses that favor pharmacological treatment,” Dr. Lerman says. “That will increase their market penetration.”
Also around the same time that the DSM-IV was published, the prevailing view—that kids under 12 were never bipolar and that most cases emerged in young adults, 20 and older—began to change. In the early 1990s, Dr. Joseph Biederman, a child psychiatrist at
Infants, Dr. Biederman opined, could be bipolar.
“Dr. Biederman’s stance is we diagnose young, so we can fix it early,” says Dr. Candida Fink, a New Rochelle-based child and adolescent psychiatrist. “But there are a lot of pre-pubertal children who are being diagnosed without presenting the full range of symptoms. People have gotten into labeling these kids ‘bipolar’ when many of them are not.” Dr. Gallager of Westchester Medical Center reports that his emergency room is seeing roughly the same percentage of bipolar adults but “about fifty percent more kids.”
Diagnosing a child poses unique problems. Children tend to “cycle” through moods much faster than adults and can go through many severe mood changes in the course of a single day. Plus problems at home—from bad parenting to extreme sibling rivalry—rather than bad brain chemistry, may be at the root of some mood swings—a diagnosis that parents may not take kindly to.
“Over the past five years, I’ve seen more children referred to me with their parents asking, ‘Does my child have bipolar disorder?’” says Dr. Gabrielle Carlson, a professor of psychiatry and pediatrics at Stony Brook University of Medicine. “Most are not bipolar. What you do see is a lot of children having melt-downs.”
Perhaps the most astonishing indication that bipolar disorder is being over-diagnosed among adolescents is a 2001 study funded in part by the National Institutes of Health (NIH) and reported in the September 2007 issue of Archives of General Psychiatry. It found that nearly 50 percent of bipolar diagnoses in adolescent inpatients made by a community’s clinicians were later re-classified as having other mental illnesses.
Properly medicating a child for a psychiatric problem is difficult and potentially dangerous, and the drugs commonly prescribed to treat adults have had very, very little testing among children. “It takes much more skill to properly medicate a child because children are constantly changing,” reports Kenneth Gorfinkle, a child and adolescent psychologist with a practice in White Plains. “A four-year-old is different in four months. It’s like a moving target.” Doctors say that there is also an increase in geriatric patients being diagnosed as bipolar, though no one seems to be tracking this statistically yet.
Despite all the uncertainty regarding bipolar disorder, it’s important to emphasize that for people accurately diagnosed with the disorder, there is today a lot to be hopeful about. Successful treatment for bipolar disorder rests on two pillars—medication and therapy. With the right dose of the right medicine, a bipolar person can become
stable enough to function in the world, doctors say. Susan wasn’t able to work for a good 10 years. Now,
she has a part-time job and an apartment.
Therapy sessions can help sufferers learn how to monitor and tweak their moods and behavior, to identify the things that set off bipolar episodes. Margaret, for instance, is very careful to guard her sleep cycle. She promises her doctor not to start any project past 10 pm. ”Every person has his or her own set of triggers,” Sam says. “After a while you get good at it—it’s survival; you have to.”
Therapy is a lifeline for other reasons, too. “People with bipolar disorder will often burn out their personal resources,” says Dr. Robert Young, a psychiatrist at the Weill Cornell Institute of Geriatric Psychiatry. “They can wear out their welcome with their families, for instance. Talking can help them deal with such problems.”
In one important way, bipolar disorder’s newfound fame is helping its victims. “People are more able to say ‘I have a problem,’” Sam says. “That’s a good thing. When people are not ashamed of it, they can say, ‘Help me.’ When keeping quiet can mean suffering, and sometimes dying, that’s not a good thing.”
Carol Hall is a writer who lives in a writer lower Westchester and has written about other health-related topics for Westchester Magazine.