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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