Where does the Bipolar spectrum begin and end?


By David Joel Miller.

Thoughts on Bipolar spectrum.

My understanding of the Bipolar Disorders, like many other “mental illnesses” has changed over the time I have been involved with this field. Not all professionals agree on some of these things so it is only fair I tell you some of my biases first.

When I first learned the technical part of diagnosis we had to study the diagnostic manual (the DSM.) The assumption here is that a really good clinician can distinguish between those with a mental illness and those without and further that those with a mental illness are in some specific way different from the normal ones.

Neither of those assumptions is necessarily true.

In school it was really important to learn to distinguish the niceties of the diagnosis. I spent a lot of time on things like the differences between Schizophreniform disorder, Schizophrenia and Schizoaffective disorder. This is very important in school and in taking your exams for licensure. In the real world it is not so important. Both the meds and the talk therapy are likely to be the same for all of these.

Some of our view of the “Bipolar disorder spectrum” is distorted by the need to rule people in or out and to state which things are normal and which are diagnosable. The ruler you use can alter the results. Our venerable rule books on diagnosis in the mental health field fluctuate between the categorical approach, putting people into pre sized boxes, and the continuum approach where we line them up from well to sick. Here are my beliefs on this.

1. There are NOT two groups, the “normal” and the “mentally ill.”

With some medical disorders you either have it or don’t. Mental illness is not like that.

We are coming to recognize that there are not two distinct groups, the well and the unwell, but in fact there is a continuum between being well and unwell. Something bad happens to you, then you should be sad or anxious. All of us have some days we feel better and other days that we feel less well.

Most of the things we count as symptoms are in fact normal human behaviors. It is just that the unwell person has more symptoms or more severe symptoms than the less unwell person. When the symptoms add up to enough to make a diagnosis is largely a judgment call.

People do not move directly from a healthy weight directly to obese. The move comes on slowly one ounce at a time. The same thing happens with mood disorders. It is not just the number of symptoms but also the severity of symptoms that cause a professional to assign a diagnosis. Two different professionals and you may get two different diagnoses even in research studies using “strict diagnostic criteria.”

2. Counting symptoms is not an exact science.

Each mental health disorder has a list of symptoms that are believed to make up the disorder. The client needs to have some number of symptoms to get the disorder. Say a disorder requires the majority of the list of symptoms, 7 of 13 possible symptoms, look at all the ways we could add this up. The mathematicians among us will recognize this as a factorial problem, the number of outcomes of 13 things taken 7 at a time. Email me if you do the math and get a number. Take my word for it the number of combinations is huge.

So as the clinician talks to you he considers, do you have enough characteristics of a symptom to count that one? Then he adds them all up and if you get enough you win the diagnosis.

Lots of judgment calls in this process.

So what about the spectrum of Bipolar disorders?

I think this is a long spectrum and a lot of it does not deserve a diagnosis. The most severe cases can and should be diagnosed because if you have that many symptoms you need help.

Are birds Bipolar? Are other animals? I think they are a little. Every spring the days get longer, there is more daylight and they are awake more. They become interested in the opposite sex. Here in the northern hemisphere birds start looking for mates by Valentine’s day in February and by Easter they have bred, created nests and are hatching out chicks. People do this same thing.

We humans tend to fall in love in the spring and marry in the summer. It takes a little longer for the children, but not that much longer.

There is also a seasonal decline in activities for all animals in the winter. Bears eat all they can and then go sleep for the winter. In humans we call this atypical depression. So some change from active, even hypomanic behavior occurs naturally with the seasons. These mood changes are normal human behavior.

We probably should not give every teenager a Bipolar diagnosis, though most of the time their parents are sure that their preoccupation with sex and their moodiness should qualify.

People who have diagnosable Bipolar disorder do not really have different symptoms. What they have is a difference in the severity of symptoms. They also have different outcomes.

With all spectrum disorders we should not make our decision based on the presence or absence of symptoms, which alone is not enough. The key factor is what effect do those symptoms have on the person.

If the increased interest in sex during the manic or hypomanic phase damages their relationships, gets them fired for sexual harassment of causes other disruptions in their work and relationships then they get the diagnosis. Also if the symptoms of the mood swings become unmanageable and they upset the person with those symptoms, then they should be treated.

So yes there is a spectrum of Bipolar like symptoms from almost unnoticeable to debilitating severe. The thing we professionals should be looking at is not our judgment of the severity of the symptoms, but how are these symptoms, these problems in living life, affecting the client.

If the problems interfere with having a happy life then it has become severe enough we need to give it a diagnostic label and begin treatment.

Personally I think there are a lot of people with less severe mood swings than what would be diagnosed as a Bipolar spectrum disorder that would benefit from some counseling. But as long as they can maintain the choice is up to the client.

Thanks to reader Dr. Charan Singh Jilowa for suggesting this topic. For more on this topic check the list of posts to the right or the post list on Bipolar disorder and mania.

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13 thoughts on “Where does the Bipolar spectrum begin and end?

  1. I have “suspected bipolar disorder” although I haven’t been formally diagnosed because my treatment team are unclear as to whether it’s BPD instead. They’ve given me “drug trials”, and seem to be assessing my diagnosis on how well I do with certain medications… I currently take seroquel, and although still experience mood swings, I am a lot more stable when I was. When manic I would destroy, unknowingly, my relationships, spend all my money on useless “junk” and wouldn’t sleep for days because I didn’t need to sleep (along with less worrying symptoms like talking too much, racing thoughts all that stuff).
    Therefore, I don’t know if me having a diagnosis is that important because I am more stable now on Seroquel. I think, personally, a diagnosis would only benefit me in being able to tell other people, “Yes, I have bipolar” instead of “I have suspected bipolar” because the latter seems to get the reaction of “Well it cant be that bad if they only suspect it” despite becoming suicidal and in a crisis when I get into the “down phase” of my mood.

    Anyway, just thought you might find this interesting.

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    • Thanks for sharing that about yourself. I don’t have a clue what “suspected bipolar disorder” is. You described a manic episode pretty well and if someone has EVER had a manic episode that sounds like some kind of bipolar. There are only a very few other conditions that might be like mania.As you have found out we do not yet have different meds for each of the diagnosis. So what ever you have work with your doctor and therapist on managing your symptoms and having a happy life. It is also very possible that you have 2 or 3 illnesses. You can have diabetes, high blood pressure and a cold all at once. Lots of people with a mental illness have more than one diagnosable condition. Some problems are likely to be larger and more in need of treatment than others. Again thanks for being a reader.

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      • Yes, I have been formally diagnosed with OCD and PTSD and am currently in recovery from an Eating Disorder. Guess I’m working my way through the DSM.
        Since recovering from an Eating Disorder, I’ve been really interested in mental health and helping others, for this purpose I find your site extremely helpful. Thank you.

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  2. When I was first diagnosed with Bipolar 2, OCD, BPD, Anxiety and mood disorder, I didn’t want to accept it! When I finally stopped fighting the diagnosis, that’s when I started to get better😃 I’m so much better since taking the Seroquel. I won’t take medication for the other things as I try controlling them myself. I can’t stand medication. I shouldn’t have that attitude, I know! But it’s true! I ruined so many relationship because of my reckless behavior. That whole sexual thing was me too! Even now when my mood swings, I could go off and not give a damn about anyone’s feelings. After its all being said and done, I’m sorry! But it’s too late. Sometimes I’m so cold and can just switch off from the rest of the world. Yet I’m really loving on the other hand! *its strange*. 🎄🎊🎉🎆🎁

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  5. Are you saying that bipolar emotions are simply magnified normal emotions? If so I strongly disgree. I have lived with this illness for most of my life (34 years). When I am depressed I feel extremely guilty which has lead to suicide attempts in the past. THIS IS NOT “MAGNIFIED” NORMAL GUILT. This is clearly pathological.

    Add to that the fact that I have become paranoid, delusional and have had halluciations I cannot follow your logic at all. In fact at one time I believed that God Himself wanted me to kill myself.

    Perhaps I am not understanding the purpose of your article, but for me I feel that you are minimizing the experiences of people who have serious mental illnesses. One of the biggest stigmas that we have to deal with is the idea that since normal people get depressed at times that somehow we are supposed to be able to “snap out of it” THE FACT IS CLINICAL DEPRESSION AND BIPOLAR DISORDER ARE NOTHING AT ALL LIKE WHAT NORMAL PEOPLE CALL “THE BLUES.” THEY ARE NOT PSYCHOLOGICAL BUT RATHER BIOLOGICAL. I would think as a mental health counselor you would know that.

    Many people who have serious problems with depression or bipolar have to live with the misunderstandings of others who think that they are just feeling sorry for themselves. No, they are in the grip of a disorder that robs them of all joy and then they have deal with feeling guilty for being sick on top of it?

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    • Thanks for your comment. Clearly your illness has caused you a great deal of suffering. I think you are reading into my post a lot that is not what I intended. Let me try to explain.
      The old view was that there were two kinds of people normal and “crazy.” We no longer believe this. If we lined a hundred humans up we would find a range of feelings from happy to extremely, suicidal depressed. Any one person can move on that continuum. Sometimes their symptoms are better or worse than others. The most severe form of depression we would call major depressive disorder, recurrent, severe with psychotic features. You describe the psychosis of severe depression well.
      Think of this like having a temperature. A “normal temperature is 98.6 F. Someone with a temp of 99 is warmer. Someone with a temp of 106 is running a fever and is seriously ill. That temp of 106 might be brought down to 101 but we would still think that they are ill.
      Guilt is a whole other thing. You can have that with or without depression or Bipolar Disorder. Psychological problems are biological. You can’t have a thought without a change in the neurotransmitters in your brain. So every change in thought can change your biology. That is the reason counseling might help someone with depression even when meds are ineffective. You can’t separate the mind and the body that easily.
      The current understanding is that mental illness is an illness and you can’t “snap out of it at will any more than you can snap out of a 106 degree temperature. Some people with the “blues” find they are unable to snap out of it also. That inability to feel happy is a diagnostic feature of depression whether it is mild, moderate or severe.
      Half of all Americans will experience a mental illness in their life time that is severe enough that it is not normal and needs treatment. There should be no shame or guilt in deciding you need help for a mental illness any more than for having a temperature of 106.

      Liked by 1 person

      • Sorry it has taken so long to respond. I couldn’t remember where I had posted this! Thank you for your explanation and please forgive me for my outburst. It is just that a lot of people seem to think that bipolar or major depression are made up diagnoses. There is a great deal of misunderstanding about taking medications. People think they are “happy pills.” I have enountered people in my own life who will not acknowledge that I have a serious mental illness. They make my taking medications into a moral issue. There almost seems to be a stigma against those who are “high-functioning” which is if you get better then you must not have been sick in the first place!
        I know that is not what you are saying so again please accept my apologies.

        Liked by 1 person

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  8. Mary, Thanks for you comment. No need to apologize. There is so much stigma around mental illness and lots of people still want to deny it because that makes them feel safer. If they can deny it then they think they won’t catch it. Best wishes on your recovery.

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