Where does the Bipolar spectrum begin and end?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Person with masks

Bipolar.
Photo courtesy of Pixabay.com

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.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

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For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

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Is Dysthymia better in the morning or worse?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

Depressed person

Depression.
Photo courtesy of Pixabay.com

Which depression is worse in the morning? – Morning Question #14

Having more depressive symptoms in the morning is a characteristic of “Atypical features” of a mood disorder. Atypical does not mean unusual it means “not melancholy.”

Atypical features include the hibernating-like-a-bear symptoms, overeating, sleeping too much and being tired and grouchy in the morning. With atypical features, the person may be able to feel better temporarily if something they really like happens, but the happiness does not last long. They may also feel better in the evening but by morning the depression comes back.

Atypical features can occur during episodes of Dysthymia, Bipolar one or two Disorders and Major Depressive Disorder. In practice, the only time I remember seeing this on a file is as part of the diagnosis of a Major Depressive Disorder but having atypical features increases the risk that this will eventually turn into a Bipolar disorder.

If your mood is customarily worse at a particular time of day, make sure you are eating and sleeping well, that there are not environmental problems like relationship issues that are causing this and then seriously consider consulting with a medical doctor or psychiatrist. If the doctor rules out any medical problems then some counseling should help.

Staying connected with David Joel Miller

Three David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

SasquatchWandering through a hole in time, they encounter Sasquatch. Can they survive? The guests had come to Meditation Mountain to find themselves. Trapped in the Menhirs during a sudden desert storm, two guests move through a porthole in time and encounter long extinct monsters. They want to get back to their own time, but the Sasquatch intends to kill them.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Books are now available on Amazon, Kobo, iBooks, Barnes & Noble, and many other online stores.

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.