"sub-threshold bipolar disorder" posts

(I wouldn’t exactly call this high-quality – rather, I’d call it “strung-out after work” – but it puts together some of the issues that I’ve been thinking about lately.)

There was recently a news article about researchers finding that 2.4% of americans will have subthreshold bipolar disorder (as they defined it) at some point during their lifetime.

Check this post out, in which the author, whose bio states that he is an academic with clinical experience, starts with that article and works up to arguing that anyone who isn’t bipolar type I should not be receiving long-term medication because “there is scant if any research on what appropriate medication is for bipolar II and there is not a damn bit of research attesting to medication for SBD” (subthreshold bipolar disorder).

I do not think he is an academic with training on the research side of psychology. He also seems to have difficulty understanding that different diagnoses of bipolar disorder almost certainly involve similarities in etiology which are relevant to treatment.

A blogger called Furious Seasons links to “>this article, which says: “People with bipolar disorder not otherwise specified (BD-NOS), sometimes called subthreshold bipolar disorder, have manic and depressive symptoms as well, but they do not meet strict criteria for any specific type of bipolar disorder noted in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), the reference manual for psychiatric disorders. Nonetheless, BD-NOS still can significantly impair those who have it”.

Now, check out his later entry where he/she invites readers to rename SBD, in which he/she states that, in comparison to cyclothymia “SBD is like so totally better! Cyclothymia includes alternating periods of low scale hypomania and low scale depression. But SBD is skipping the depression altogether, so we can focus on people who are chronically productive and medicate them until they put on 100 pounds.”
Many of the people responding are equating hypomania to extra nice happiness, which it can involve, but it may also involve severe irritability, racing thoughts, and lots of other fun things.

There are some very interesting things in all this to write about, but they are not being written about well in the blogs I have seen so far. For example, some questions I’m thinking about (most of which I would answer “no”, but at least I’m still thinking about them):

Are our current, DSM-IV views of abnormality the ones that should define what is normal and abnormal? If not, should something else define them (such as, the subjective perceptions of normal/mentally ill that a particular generation on average grew up with)? Should our diagnostic definitions be open to research finding that a set of people formerly included in “normal” have persistent problems that resemble those of people who are currently included in a diagnosis, and bring that information to attention?

On a related note, should our current rates of diagnosis be the “right” ones? (Or, possibly, our rates from the 90s, or the 80s, or what…) Or should we look at population data to see how many people who would benefit from accurate diagnosis and treatment have not received either? (These issues come up all the time with ADD and autism, and to some extent bipolar II and bipolar disorder in general.)

Should people who don’t have “enough” (for whatever definition of enough) problems not receive diagnoses that will help direct them toward the treatment they need to handle those problems effectively?


Stuff like this makes me so angry – it’s often seems like a failure to admit that someone really could have severe problems, sometimes combined with a need to gatekeep diagnoses so that nobody less troubled can “get in.” It’s not an exclusive club, it’s a set of labels that can help people, but do not currently label all the people they can help.


10 Responses to "sub-threshold bipolar disorder" posts

  1. CL Psych says:

    Thanks for linking my post. I can see that you aren’t so hot on my conclusions. At this point, there really is no evidence that meds work for this so-called subthreshold bipolar disorder — I’m not making that up. I don’t believe there is much evidence of impairment caused by hypomania. Most of the problems in bipolar II occur during the depressed phase. Good luck with your blog.

  2. Stephany says:

    Crazymeds is a great site for med info, I’ve used it for years. One of the best mental health blogs written by a bipolar patient, journalist and mental health advocate is Furious Seasons. There’s nothing anti- med about that blog, and most commenters[like myself]have mental illness, and take meds; just open-minded enough to scrutinize, and want something more from the mental health system, than Big Pharma running most drug trials, or for instance–hiding information such as Eli Lilly and the Zyprexa scandal. [they knew it caused diabetes and didn’t report it].
    Interesting thread over at Crazymeds.

  3. resonance says:

    I’ve also used crazymeds for years, and remained at crazyboards.org for the same reason – not anti-meds, definitely pro-patient.

    Furious Seasons is one of the better blogs I’ve found, which is why I was sad to see him/her completely misunderstand SBD, and then see so many people there decide hypomania = happiness. (Part of the reason I like crazyboards is that they manage to maintain a pretty high level of education about [among other things] bipolar disorder.)

    cl psych: There is reason to believe SBD is related to the bipolar disorders we currently treat with medication, so I don’t think the default assumption should be that the same medications will not work.

  4. Mental illness is actually very easy to define. I can do it in two words: Impaired functionality. Actually, that’s pretty much the definition of any illness. You’ve broken an arm? Your arm’s functionality is impaired.

    Brains are very complex systems and the medical understanding of how they work is still at a fairly rudimentary stage. The systems of categorisations that psychiatrists have come up with so far are an attempt to deal with this complexity and paucity of hard information. The categories are useful, in that they give psychiatrists some idea of how to proceed with treatment, but they almost certainly don’t correspond on a one-to-one basis with the underlying physical reality.

    So, the criteria for any mental disorder to be recognised as such should be: Do the people involved feel their functionality is impaired? Are they capable of accurately estimating the impairment? Is this impairment measurable? And is the extent of this impairment outside the normal range of human experience? At that point, it’s up to the person involved or their carers to judge the risks and benefits of any proposed treatment. Arguing over terminology is a matter of politics and is largely pointless.

  5. resonance says:

    There are some measurement issues there (like not having estimates of average ranges and types of human suffering for most life situations), and there may be an issue with not being able to get treatment indicators if all you know is measure of impairment but not specific type of illness. But I agree, a lot of the argument is really just about “is this really for real impairment or are they faking/losers/whatever” – and that can be addressed by careful application of measurement of impairment.

    I think they have an axis for that in the DSM, but nobody ever uses it.

  6. Meredith says:

    I read this post before, but I just came back to it because I was thinking about hypomania. For me, it most definitely is an impairment. I’m shaky, irritable, my thoughts race, and I can’t sit still. I get occasional bursts of happiness, but I can’t focus my thoughts long enough to use all that energy. When that goes on for days on end, there’s a huge problem, and my work suffers, as does my personal life, because I can’t listen to conversations. Anyone who says hypomania is awesome is either not bipolar II (or I guess bipolar III or sbd) or lives in happy fun bipolar land, in which case, can I come live there too?

  7. resonance says:

    I think some people really do have the awesome hypomanias, and some people feel awesome but aren’t aware of how impaired they are and things kind of suck for them, and things just generally suck for everyone else.

    The new Goodwin and Jamison classic “Manic Depression” text has a really awesome chapter on mixed states I want to summarize at some point. Along with talking about non-mood symptoms like cognitive and memory impairment.

    I wanna live in happy fun bipolar land too. I bet they have roller coaster rides and stuff.

  8. […] you know what? I hate this. I hate it so much. As I posted in a comment at resonance’s blog Empirical Insanity, it is most definitely an impairment for […]

  9. resonance says:

    L.Rabbitgirl posted this on my previous blogspot version of my blog so I’m copying it over here:

    SBD really bothers me. Because I think it could be a whole lot of people misdiagnosed and that means trouble. I feel like in an effort to help the people that really need help, many are grabbing those that may not and pulling them into treatment because they have a crappy personality, bad spending habits, or general poor judgement. All of this can effect your life but there is a line and it needs to get drawn. There is human behavior and then there are symptoms and I think it’s inching toward the point where we are diagnosing simple human behaviors and bad choices, not necessarily the complexity of what a person presents. And crap I had something else to day but I really can’t remember now. Maybe I will later.

  10. resonance says:

    That’s a general problem with spectrum disorders, I think. As they shade into normal, there’s presumably a point at which normal human advice (buck up, pull yourself together, etc.) that’s useless and insensitive for more mentally ill people starts to actually have positive effects. So the issue might be less how impaired people described as SBD are (and they are impaired), and more what interventions work. They may be more toward ones that work for non-MI people or more toward those that work for MI people, but in either case you don’t want to just be ditching personal responsibility…

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