I want to respond to my esteemed colleague, Dr. Nassir Ghaemi, Director of the Mood Disorder Clinic atTufts University Medical Center, regarding the nature of both childhood and adult bipolar disorder. In his recent post, Dr. Ghaemi passionately disputes claims by fellow psychiatrist Dr. Stuart Kaplan and others here at Psychology Today that pediatric bipolar disorder does not exist. He makes the argument that since childhood depression does exist, which, in my opinion, is certainly and sadly so, and since bipolar disorder begins with major depression in most cases, that there is no reason to believe that bipolar disorder suddenly starts in adulthood, only after the age of eighteen, springing fully formed like Athena from the head of Zeus as it were. And he is right in this assertion.
The main problem I have with Dr. Ghaemi's and most similar current mainstream perspectives on bipolar disorder (historically known as manic-depressive illness), whether in children, adolescents or adults, is the underlying and practically unspoken, unquestioned, dogmatic, foregone conclusion that it is totally a genetically inherited, neurobiologically based and driven disease entity. Dr. Ghaemi and I debated this presumption briefly before in person while presenting a seminar here in Southern California last year on "clinical despair." (See my prior post.) And I have posted here previously on whether depression is a disease, similar to, say, diabetes. (More on that here and below.) But, for right now, let's focus more immediately on the matter of bipolar disorder: Is it a physiological or neurological disease? If so, when does it typically start? What causes it? And how should we define and treat it?
Bipolar disorder is, like most mental disorders, a pathological process occurring over time. But it is not a biologically destined ticking time bomb waiting to go off at some genetically predetermined moment. Bipolar disorder, like any other mental disorder, isn't something one just wakes up with one day, like the man in Kafka's The Metamorphosis turning into a cockroach overnight. It develops slowly and insidiously over time. In some cases, this process is practically imperceptible objectively until the first episode of mania or hypomania happens. (Until that time, there may be depressive symptoms, but the diagnosis of bipolar disorder requires the presence of at least one manic or hypomanic episode.) Given the reported concordance rates (the probability that a pair of identical twins will both have a certain characteristic, given that one of the pair has the characteristic).for bipolar disorder, up to 80% in identical twins for bipolar disorder, there appears to be significant temperamental disposition toward this syndrome. However, the true degree of this hereditary predisposition is debateable, since it is notoriously difficult to separate nature from nurture in scientific studies of siblings and twins. Many of these studies of genetically identical twins are flawed by the fact that the subjects were raised in in the same environment by the same set of parents, shared comparable life experiences, family dynamics and strongly psychologically identify with each other. Still, the tendency toward bipolar disorder is undeniably partially biogenetically based. But the degree of that biological influence (nature) in relation to psychological influence (nurture) remains murky.
Mania has psychological meaning. Psychodynamically speaking, mania or hypomania is a defensive, unconscious compensatory reaction against depression, an exaggerated and futile attempt to run from despair and deny the reality of depression. In the case of both adult and so-called pediatric bipolar disorder, depression eventually reaches a tipping point, turning into bipolar disorder. Mania in adolescents frequently includes psychotic symptoms, and is associated with poor academic performance, truancy, impulsivity, antisocial behavior or substance abuse, with such behavioral acting out often preceding the first full-blown manic episode. But the real problem here lies in how we define bipolar disorder phenomenologically, and how we view it etiologically. What really is "bipolar disorder"?
It seems to me that childhood bipolar disorder, and mania or hypomania specifically, tends to be diagnosed today based primarily on the degree and intensity of rage episodes present. Though irritability and anger can certainly be part of the clinical picture in adult mania or hypomania, there are typically more predominant symptoms such as grandiosity, decreased need for sleep, loquaciousness, poor judgment, flight of ideas, pressured speech and pleasurable activities likely to result in negative consequences, especially in the areas of impulsive spending, sex or thrill-seeking. It is important to note that, currently, there is no specific diagnosis for "Childhood Bipolar Disorder" in the DSM-IV-TR section titled "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence." Nor is there one for "Childhood Major Depressive Disorder" for that matter. Why is that?
Well, for one thing, depression, anxiety and possibly bipolar disorder tend to manifest differently in children and adolescents than they do in adults. For them, repeated (or, sometimes, even single) episodes of excessive and seemingly inappropriate anger or rage are enough for some clinicians to diagnose bipolar disorder. Are they depressed? Definitely. Are they anxious? Of course. But their anxiety and depression are expressed more behaviorally than in most adults. (ADHD, for instance, is in my opinion actually mainly a behavioral manifestation of depression, anger and, especially, anxiety in children and adolescents.) Moreover, because clinicians are reluctant to diagnose personality disorders such as Borderline Personality Disorder (see my prior post) prior to the age of eighteen, much of what is mistaken for bipolar disorder in both minors and adults is actually the early signs of Borderline Personality Disorder, which, by definition, is marked by self-destructive impulsivity, affective instability and inappropriate, intense episodic anger. (Bipolar disorder is quite commonly misdiagnosed in adults suffering from an underlying borderline personality disorder.) Or, in some child and adolescent cases, Conduct Disorder or Oppositional Defiant Disorder.
The point I want to make here is that these are all basically anger disorders (see my prior post), driven by repressed, suppressed or conscious rage which the child or adolescent is unable to constructively deal with. In my thirty-five years of clinical practice I have never seen a case of bipolar disorder that did not have a prominent core of unconscious rage. The same may be said of major depressive disorder, though it is typically only in mania or hypomania that this repressed rage finally surfaces. So the phenomenon bipolar disorder, particularly when defined by intense rage attacks, is very real in children and adolescents. But its cause is more psychological than biological in my view. And this is where the preconception of bipolar disorder as a biochemical imbalance or neurological aberration becomes so problematical in such debates. And in treatment.
According to the DSM-IV-TR, "there appear to be no laboratory features that are diagnostic of Bipolar I Disorder or that distinguish Major Depressive Episodes found in Bipolar I Disorder from those in Major Depressive Disorder or Bipolar II Disorder." (p. 384) "Approximately 10-15% of adolescents with recurrent Major Depressive Episodes will go on to develop Bipolar I Disorder." (p. 385) While some research suggests a "strong evidence of a genetic influence for Bipolar I Disorder" (p. 386), many of these twin and adoption studies are flawed and misleading. "Genetic influence" does not necessarily mean causation. It makes more sense to speak of genetic tendency or "predisposition" shared by first-degree relatives of individuals with bipolar disorder and major depressive disorder. But, the fact is that most manic or hypomanic episodes are triggered by some psychosocial or intrapsychic stressor, suggesting some significant psychological component to the illness. And it is that psychological component that becomes crucial to focus on, above and beyond genetic predisposition, when conceptualizing and treating bipolar disorder in children, adolescents or adults. The correct pharmacology is essential. But it cannot substitute for psychotherapy.
The vast majority (70%) of manic episodes happen right before or after a major depressive episode, closely linking mania with depression. So, to properly understand bipolar disorder, we need to consider the depressive pole as well. What is depression? Is it a disease? A mental disorder? Biochemical imbalance? A brain dysfunction? A psychological syndrome? An existential or spiritual crisis? Several of my fellow PT bloggers posted on depression recently. I want to discuss depression here as a clinical and forensic psychologist who has been practicing psychotherapy for more than three decades.
For me, the crucial question of whether depression (unipolar or bipolar) is a disease stems from the somewhat dubious application of the medical model to the theory and practice of psychiatry and psychology. What is the "medical model"? The medical model is the paradigm on which the practice of clinical medicine is founded: Symptoms are seen as manifestations of pathological physiological processes (disease) which are diagnosed and then treated with whatever methods available. The purpose of medical treatment is to eliminate, suppress or control the symptoms of disease. To, as much as possible, reduce suffering and prolong life. Physicians have been faithfully adhering to this valuable, honorable paradigm and practice since the time of Hippocrates.
The medical model is a particular way of viewing human suffering, decay, dysfunction and, ultimately, death. It is a paradigm, a lens through which physicians and others perceive certain abnormal or aberrant phenomena like leukemia, diabetes, and now, depression and many other mental disorders. But despite the immense contribution of the medical model in diagnosing and treating disease, its literal application to archetypal human experiences such as depression, psychosis and anxiety is limited.
There is no denying that those who suffer from moderate to severe depression are ill. Depression can be debilitating and, in some cases, deadly. Physical symptoms such as nausea, vomiting, fatigue, chronic pain, diarrhea, insomnia etc. are common concomitants to major depression. "Treatment," to use the medical terminology, is demanded. The real question is what form should that treatment take? The answer to this depends in part on how one understands the etiology or cause of depression and other major mental disorders such as bipolar disorder and psychosis. There are various theories as to the cause of depression, none of which have been unequivocally proven. These causal theories include biological, psychological, social and spiritual explanations. Research indicates the likelihood of at least some genetic predisposition to unipolar and bipolar depression, as well as (though less so) for psychotic disorders such as Schizophrenia and Schizoaffective Disorder. But, again, biological predisposition is not causation. Other (sometimes unrecognized) catalysts are required: loss, stress, isolation, trauma, meaninglessness, frustration, substance abuse, and chronically repressed rage can be, and frequently are, significant if not central contributing factors in these disorders.The newly discovered evidence that brain scans show a significant signature for bipolar disorder, cited by Dr. Lawlis in his post, is yet another phenomenon which, like biochemical theories, begs the classic question of chicken or egg: Could biochemical imbalances or aberrant blood flow patterns in the brain be additional symptoms rather than causes of depression? Physiological manifestations of underlying psychological conditions? Again, as every researcher knows, correlation is not necessarily causation.
But whatever the fundamental cause of depression, clinicians owe it to patients to provide the most aggressive and efficacious treatment methods currently available. The use of psychopharmacology in treating serious depression, despite its drawbacks, has been revolutionary and life-saving. Antidepressants and mood stabilizing drugs do something that psychotherapy cannot: they provide relatively rapid relief of the painful and debilitating symptoms of depression and stabilize otherwise dangerously labile mood swings. Does this prove that depression is primarily a biological disease? Not at all. It only demonstrates that we have fortunately found biochemical means to counteract and control the most acute symptoms of depression: sleep and appetite disturbance, lack of motivation, apathy, depressed or manic moods, anxiety, suicidality, etc. But as PT blogger psychiatrist Peter Kramer acknowledges in his previous post, even when the symptoms of depression are mitigated by medication, the underlying depressive condition evidently remains, rendering even medicated patients susceptible to future episodes. More than half of those suffering a first major depressive episode are likely to experience subsequent episodes at some time. The probability of recurrence increases dramatically (90%) after three such episodes. What is this underlying susceptibility? It seems to suggest the presence of something biochemical treatment doesn't resolve. What is this latently persisting vulnerability? It is the depressive core of the personality. It is repressed rage. It is the figurative heart of the Hydra.
Some mental disorders, including depression, can be likened to the legendary Hydra: a massive mythological monster with nine snake-like heads, each exhaling a lethal poison. Many patients suffer from myriad symptoms--e.g., anxiety, depression, chronic pain, irritable bowel, insomnia, fatigue, headaches, panic attacks, etc.-- which, after presumably being pharmacologically vanquished, return with a vengeance. The Greek hero Hercules had to do battle with the deadly Hydra. Luring it from its lair, he started lopping off the Hydra's serpentine heads. But no sooner had he done so, two more appeared in their place. Moreover, the hideous Hydra had one head which was immortal and indestructible. How did Hercules finally defeat the deadly Hydra? First, Hercules cauterized the decapitation cites with fire to prevent more heads from regenerating. Then he buried the immortal head of the Hydra under a massive stone in order to render it harmless. But because this head was immortal, the Hydra could never be completely destroyed. Only attenuated and subdued.
Major depression is a little like the Hydra. You can try pharmaceutically (or even apply electroconvulsive therapy in cases unresponsive to medications) to kill off its symptoms, but they tend to return. Can major depression be defeated? Not without getting to the heart of the Hydra. Depression's roots are, from my own clinical observations, more commonly basically psychological than biochemical--though one clearly affects the other. Often at the very heart of depression is repressed hatred, anger, rage, resentment. Abandonment. Betrayal. Discouragement. Unresolved grief. Meaninglessness. Nihilism. Loss of faith. Without aggressively attacking this psychological, spiritual and emotional core or heart of depression, it cannot be permanently dispatched. Only temporarily suppressed. Which is why pharmaceutical treatment of major depression by itself, while invaluable, is no substitute for real psychotherapy combined with psychopharmacology. Such an ongoing two-pronged attack on the Hydra of depression prevents or mitigates major setbacks, and can keep the dreaded Hydra in check. While the patient may always be biogenetically and/or psychologically predisposed to another depressive episode in the future, such psychotherapeutic treatment can empower the patient to nip such dips in the bud, in effect defeating the Hydra.
Can depression be cured? Should it be treated like any other disease? I think that depends. Some forms of mild to moderate and even severe depression are clearly situational responses to stress, trauma, loss and other life events. These so-called Adjustment Disorders or even major depressive episodes can be completely recovered from in most cases with adequate treatment, especially psychotherapy. Chronic and profound depression such as dysthymia, recurrent major depressive disorder, cyclothymic and bipolar disorders are more Hydra-like, requiring intensive treatment over prolonged periods of time. But even in these seemingly relatively intractable conditions, penetrating to the heart of the Hydra with psychotherapy combined with pharmacology can reduce both the severity and frequency of depressive and/or hypomanic or manic episodes. By psychotherapeutically improving the person's inter-episodic baseline, the frequency and severity of future episodes can be decreased. But whereas using only medications to fend off this Hydra tends to require increasing dosages and multiple types of drugs to keep it docile, psychotherapy of the sort I suggest in my book can actually reduce dependence on psychotropic medication, as the meaning of the depression and its psychological sources are therapeutically rooted out.
Thus, I submit that depression, both unipolar and bipolar, is not a disease that should be conceptualized and treated in the same way as say, diabetes (which itself is known in many cases to be stress-related). It is a biopsychosocialspiriitual syndrome requiring far more than pharmacological intervention. The unfortunate fact that most contemporary psychotherapy--including CBT--fails to penetrate to the heart of the Hydra in major unipolar and bipolar depression underscores the desperate need for more effective psychotherapy rather than proving a presumed biochemical cause for these devastating disorders. I believe that bipolar disorder as a formal psychiatric diagnosis should, for the most part, be reserved for young adults.(The average age of onset for both men and women is twenty years, though previously it was believed that manic-depressive disorder typically started later than schizophrenia, at closer to thirty than twenty years of age. ) But we need new diagnoses of anger disorders in children and adolescents under twenty. We are witnessing an anger epidemic across this country and beyond (see my prior posts), and our children and adolescents are especially vulnerable. Until we have more appropriate means of recognizing and diagnosing pediatric anger disorder, bipolar disorder will continue to be used as a convenient catch-all for clinicians. But a dangerously misleading one. And our children will continue to be inadequately or inappropriately pharmacologically treated for what is potentially a primarily psychologically-based and treatable anger disorder.
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