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Bipolar Disorder

Response to my post "Bipolar Epidemic?"

Siri responds to comments from her previous post.

This post is in response to
Bipolar Epidemic?

I am very grateful for the thoughtful comments I have received about my small essay, “Bipolar Epidemic?” The surge in bipolar diagnoses in children is understandably a sensitive and controversial subject for many, especially those with children who are directly affected. My broader point, however—that whenever there is an explosion in a particular diagnosis, there is some cause for worry—seems not to have been fully understood. A few additional comments may help clarify what I had hoped to say before.

The great psychiatrist Emil Kraepalin (1856-1926) was the first to use the term manic depression and to distinguish it from dementia praecox, later redubbed schizophrenia by Eugen Bleuler, who refuted Kraepalin’s idea that the disease always led to deterioration of the patient’s mental faculties. Kraepalin classified hundreds of mental diseases through a close study of patient histories. Like many contemporary psychiatrists he regarded these illnesses as primarily genetic and biological and, as is maintained today, found that manic depression runs in families. Kraepalin, like his contemporary Freud, was confident that one day the genetic and neurobiological roots of these illnesses would be uncovered. For bipolar disorder, that day is yet to come. What this means is that unlike the measles, for example, which has a known cause, a diagnosis of bipolar disorder depends on a physician’s perception of symptoms or a pattern of symptoms in his or her patient. Its etiology remains unknown.

Perception plays a vital role in the diagnosis of bipolar illness. Symptoms are perceived through the categories of psychiatric medicine at a given moment in history, categories which continually shifting and being named or renamed. As Charles E. Rosenberg argues in Explaining Epidemics and Other Studies in the History of Medicine: “It is fair to say that a disease does not exist as a social phenomenon until is named.” It may exist as a biological phenomenon, but until it is named it is not part of psychiatry as an entity, as something that can be diagnosed, discussed, and treated. Every time the DSM prepares for a new edition, there are countless groups lobbying to get their particular mental illness recognized by the diagnostic manual. Surely, this is a social and cultural phenomenon.

There is abundant scientific evidence that expectation shapes human perception. Much of the time we see what we expect to see, and our perception of what we’re seeing is creative not passive. As the authors of the textbook Principles of Neural Science (2000) put it, “… the brain makes certain assumptions about what is to be seen in the world, expectations that seem to derive in part from experience and in part from the built-in neural wiring for vision.” Our experiences are manifold. We live in a world of shared cultural and linguistic meanings that are vital to how we understand our own lives. Psychiatrists rely heavily on their experienced perceptions of illnesses. When I taught writing classes to psychiatric patients, I met people whose stories of manic highs and immobilizing lows appeared to be textbook descriptions of classic bipolar disorder. I met other patients who had been diagnosed with myriad disorders. No doctor seemed to agree about what they actually suffered from.

One reader pointed out to me that there are European psychiatrists who have diagnosed bipolar disorder in children. I am sure this is true, and it is possible that the trend will continue and even expand. The fact remains, however, that the number of diagnoses on the continent is much lower than in the United States, and the disparity is so great it cannot be explained through genetic variations in the populations, which means there are cultural forces at work, just as there were when the country was beset with an epidemic of multiple personality disorder and recovered memories of horrific Satanic cults, a phenomenon that seems to have subsided considerably, if not totally.

None of us is immune to suggestion. We are social beings and live in a social world. Naming is essential to our conception of psychiatric illness, and that is surely why at least some diagnostic categories have become so controversial. Surely there are children afflicted with mood disorders and no doubt, part of their suffering stems from their inherited genetic temperament, but environmental factors also play a role. The DSM V will, to a large degree, determine how these disorders in children are classified. No doubt later editions will then reclassify them, especially if they continue to be controversial and if anti-psychotic drugs are found to be particularly damaging to young, developing brains and bodies. My cautionary stance can be restated: When it comes to psychiatric disorders that have no clearly identifiable pathogen, it is not always easy to know exactly what we are seeing or how much or how little of what we are seeing is founded on our expectations.