THE BIPOLAR SPECTRUM Diagnosis or Fad? Joel Paris http://www.routledgementalhealth.com/9780415891813 First published 2012 by Routledge 711 Third Avenue, New York, NY 10017 Simultaneously published in the UK by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Routledge is an imprint of the Taylor & Francis Group, an informa business © 2012 by Taylor & Francis Group, LLC The right of Joel Paris to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging in Publication Data Paris, Joel, 1940– The bipolar spectrum : diagnosis or fad? / by Joel Paris. p. ; cm.Includes bibliographical references and index. (hardback : alk. paper) I. Title. [DNLM: 1. Bipolar Disorder—diagnosis. 2. Diagnostic Errors—trends. WM 207] 616.89'5—dc232011043560 ISBN: 978–0–415–89181–3 (hbk) Typeset in Bembo by Swales & Willis Ltd, Exeter, Devon Printed and bound in the United States of America on acid-free paper. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the Routledge Web site at http://www.routledgementalhealth.com http://www.routledgementalhealth.com/9780415891813 CONTENTS Introduction 1 PART I Concepts 9 1 The Bipolar Diagnosis 11 2 “Diagnostic Creep” in the Bipolar Spectrum 23 3 Affective Instability 37 PART II Disorders 45 4 Differential Diagnosis of Unstable Mood 47 5 Bipolarity and Personality Disorders 57 6 Bipolarity and Childhood Behavioral Disorders 65 http://www.routledgementalhealth.com/9780415891813 viii Contents PART III Implications 73 7 How Psychiatric Fads Develop 75 8 The Impact of Overdiagnosis 85 References 91 Index 105 http://www.routledgementalhealth.com/9780415891813 1 THE BIPOLAR DIAGNOSIS Emil Kraepelin: The Pioneer It has been recognized since antiquity that some mental illnesses are character- ized by dramatic shifts in mood. This clinical picture was known to Hippocrates (Angst & Sellaro, 2000), but descriptions of a specific illness marked by alternating mania and depression only appeared in the nineteenth century (Healy, 2009). For modern psychiatrists, the pioneer and crucial figure in defining this illness was Emil Kraepelin (1856–1926). Serving as a professor at several leading German universities, Kraepelin was the most seminal figure in twentieth-century psychia- try (Shorter, 1997), and his influence continues to be felt today. Before Kraepe- lin’s time, the only meaningful distinction in diagnosis was between psychosis and non-psychosis. Within psychoses, classification was a confusing hodge-podge of overlapping syndromes. Kraepelin, although not a researcher in a contemporary sense, was a hero of systematic observation, and the first person to make sense out of mania. Kraepelin was the first psychiatrist to diagnose mental illness by delineating a specific course rather than diagnosing by symptoms alone. He reorganized the psychoses into two overarching categories. Schizophrenia (then called dementia praecox) had a continuous course that became steadily worse with time. In con- trast, manic-depression had a cyclical course in which patients could be normal, or at least near-normal, between episodes (Kraepelin, 1921). While these distinc- tions are not absolute, they remain crucial for classification. Kraepelin died in 1926, but his ideas never lost influence in Europe. In North America, during the period after World War II when psychoanalysis was dominant, Kraepelinian psychiatry went into a temporary eclipse (Shorter, 1997). In the United States, the classification of mental disorders was often seen as a dry http://www.routledgementalhealth.com/9780415891813 12 The Bipolar Diagnosis and unrewarding subject. This was reflected in a general lack of interest in earlier editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I and DSM-II). Psychoanalysts, as well as many other psychiatrists, viewed psychopa- thology as a reaction to circumstance, not as a biologically determined pattern. Recent decades have been marked by a sea change in the orientation of Amer- ican psychiatry. DSM-III was associated with the triumph of what has been called a “neo-Kraepelinian” school of thought (Klerman, 1986). Psychiatry took a U- turn away from psychoanalysis and rejoined the mainstream of medicine, becom- ing oriented towards neuroscience and psychopharmacology. As drug treatment advanced, it became possible to offer specific treatments for specific diagnoses. That is why classification gained importance. That is also why Kraepelin came back in a big way in the 1970s. Shorter (1997) has described him as the most important psychiatrist of the twentieth century. Under the influence of neo- Kraepelinian ideas, diagnosis became tied to family history, outcome, and the possibility of discovering biological markers of disease. Kraepelin was the first person to suggest the existence of a bipolar spectrum, which he envisaged as a dimension of mood disturbances ranging from psychotic illness to near-normal variants. As we will see later in this book, contemporary psychiatrists have resurrected and greatly expanded this idea. But since Kraepelin’s experience was confined to severely ill patients who were hospitalized, he might have been surprised by claims that 10% or more of the general population suffer from some form of bipolar disorder. Changing the Name For decades after Kraepelin, the concept of manic-depressive illness underwent little change. But under the influence of another German psychiatrist, Karl Leon- hard (1902–1988), the name was changed. The term “bipolar disorder,” intro- duced in 1957 (Goodwin & Jamison, 2007), was one of many suggestions made by Leonhard (1999) for reclassifying mental disorders, but the only one to be gen- erally adopted. Leonhard separated mood disorders into a unipolar type (depres- sion or mania but not both) and a bipolar type. While unipolar depression is com- mon, unipolar mania is very rare; however, almost all bipolar patients eventually suffer from both depressive and manic episodes. With time, the term “bipolar” came to replace manic-depression entirely. While the older terminology points to the necessity of manic episodes and sug- gests a severe illness, the newer label is more neutral. The term “bipolar” has made it easier to expand the boundaries of the disorder. Before and After Lithium Fifty years ago, bipolar disorder could often go unrecognized, particularly in North America. In the 1960s, a “New York–London Study” documented wide http://www.routledgementalhealth.com/9780415891813 The Bipolar Diagnosis 13 divergences in diagnostic practices between American and British psychiatrists (Cooper, Kendell, & Gurland, 1972). When presented with identical filmed interviews of psychotic patients, the Americans diagnosed most as schizophrenic, while the British diagnosed the same patients as having manic-depression. Ameri- can psychiatrists at the time had a very broad concept of schizophrenia, and almost anybody with psychotic symptoms, especially paranoid delusions, tended to get that diagnosis. Yet a few years later, the Americans came around to see things the British way. The reason was that bipolar disorder now had a specific treatment. Psychiatry had arrived in the age of lithium. Treatment with lithium carbonate was the most important event in the history of bipolar disorder. An Australian psychiatrist, John Cade (1949), was the first to report that this simple salt offered an effective treatment for mania. However his discovery was not followed up, mainly because lithium had been tried for cardiac patients and discarded due to side effects. The Danish psychiatrist Mogens Schou (2001) reintroduced lithium in the late 1960s. The results of this treatment could sometimes be miraculous (see the Introduction to this book). Before lithium, it did not make much difference whether a psychotic patient was diagnosed with mania, schizophrenia, or some other disorder. Either way, treat- ment, at least since the 1950s, had depended mainly on antipsychotic drugs. But these agents did not prevent recurrences of mania. If bipolar disorder responded specifically to lithium, and if many patients who were lithium-responsive could be maintained without antipsychotic drugs, the clinical advantage was enormous. With a lower threshold for a bipolar diagnosis, some patients who had not been recognized as having manic episodes were rediagnosed and given more appropriate treatment. But patients unlikely to respond to lithium (or other mood stabilizers) were also prescribed these drugs, sometimes for long periods. Most suf- fered from other psychotic conditions, particularly schizophrenia. If the original diagnosis was correct, these patients would not benefit. The problem was that it was impossible to determine if adding lithium to an antipsychotic regime was making any difference. This was the first indication that enthusiasm for a bipolar spectrum could create trouble. Variants of Bipolar Disorder Illness is not the same in every patient. That is most