Friday, February 08, 2002 - No Simpler than this' Thoughts Archive - like it or not, we're all in this together.

[Follow Me Here] 11:09 PM ... this is important and i'm going to snatch elliot's whole post. theory has it that we're seeing an organic rejection to how we live today filtering through these temporary imbalances. like a pendulum not at rest, life as lived today is forcing things one way.. until the body comes and sets it right. "Doctor it hurts when I do this.. don't do it then"...

"Call me crazy, but it seems like everyone I know is manic-depressive." Friends in High Places: This writer from the San Jose MetroActive intersperses colorful anecdotes about bipolar (manic depressive) friends and acquaintances with reportage about why the illness is becoming more visible -- the lessening stigma to major mental illness, the increasingly accurate recognition and diagnosis of the disease, and the increasingly effective treatments for it that allow normalization of the life of its sufferers (which probably contributes to reason #1) -- even though it is probably not becoming more prevalent.

I think that, while this may be true, it is not necessarily the case that the increasing number of people among us who are 'out of the closet' with their manic-depressive diagnosis really warrant that diagnosis. One of the deplorable cultural trends shaping my environment as a psychiatrist has been the way in which the increasing medicalization of distress over the time I've been in the field has increasingly allowed people to adopt the bipolar diagnosis to explain (to others) and explain away (to themselves) other less palatable categories of labile mood and unstable behavior, especially borderline personality disorders (which, arguably, have become more prevalent in society from decade to decade). Increasing recognition of the disorder dates from around 1970, when the first medication with proven and dramatic stabilizing impact on manic depressive disorder, lithium, entered the pharmacopoeia -- because, arguably, one of the important reasons for diagnosis is to recognize something that you can do something about . Other comparably or perhaps even more effective medicines for bipolar mood swings have followed in the intervening decades, making this recognition even more important, but perhaps the diagnosis more circular (how do you know if it's truly a case of bipolar disease? if the medications that treat bipolar disease are effective against the case. What makes you think these are bipolar medications? They work on bipolars, of course!) But, in point of fact, mood stabilizing medications are non-specifically stabilizing to any cause of fluctuating or labile mood! Too much diagnosis is done by the 'walks-like-a-duck, quacks-like-a-duck" doctrine, which for the sake of empirical utility throws out almost all subtle depth-derived insight into the human process of a psychiatrically ill patient. Approaching a personality disorder as if it were an unstable mood disorder has profound and misguided consequences unless you believe that all there is to treatment is throwing medications at someone's life out of balance.

While I'm an adult and not a child psychiatrist, I can't help being similarly concerned about the last decade's 'recognition' of a hidden epidemic of childhood bipolar disorder. Lo and behold, the proponents of this message go through theoretical contortions -- not very convincingly, IMHO -- to explain that we never recognized childhood bipolar states before because, counterintuitively, they look nothing like manic depression in adults. Predictably, they resemble conduct disorders and oppositional-defiant disorder, childhood analogues and precursors of personality disorders which may not be neurobiological in nature at all. Calling these behavioral disturbances bipolar takes them out of the realm where treatment and training to enhance personal accountability and self-control are conceived as useful. This 'recognition' of childhood bipolar disorder is one of the reasons for the explosive growth in prescribing of psychoactive medications to children. The other source of this, of course, is the 'recognition' of the epidemic proportion of childhood attention deficit hyperactivity disorder (ADHD), which is now so prevalent in our school-age children that we could almost by current diagnostic practice label the modal behavior of the majority of kids in that age range with a disease! And, of course, being the good cultural materialist that I am, I can't help pointing out the economic advantages to the two big classes of 'winners' that sustain this 'medicalization of distress'. The pharmaceutical lobby, of course, wins big with the societal adoption of the meme that our emotional and behavioral distress can and should be medicated away. And members of the beleaguered psychiatric profession, struggling to hold onto market share in a managed care environment in which cheaper allied health professions increasingly displace them in conducting psychosocial interventions, do so by insisting they are the only ones who can take care of behavioral or emotional disturbances which are inherently medical or neurobiological in nature. 'I prescribe, therefore I am' ...