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Bringing bipolar into focus

Everyone's looks a little different

By Elizabeth Forbes, esperanza editor

Imagine a big museum filled with widely varied portraits. The shimmering figure in an ornate gold frame runs up his credit cards, cruises the bars and takes off on spontaneous trips every spring. Next to him is a monochrome image with just a splash of red—a man who mostly lives with depression but has a one-off manic episode in his past.

Over here is a woman photographed in vibrant color, reflecting the exuberant feeling of her hypomanic episodes. Facing her is a Cubist image which conveys an uncomfortable mix of twitchy energy, irritability and a kind of wired-up unhappiness. A tiny canvas represents symptoms that pass in days, while a mood that persists for weeks takes up a wall-sized tapestry.

In the Diagnostic and Statistical Manual of Mental Disorders (DSM for short), psychiatry has done its best to capture all those individual shades of experience and boil them down to a set of common criteria for bipolar disorder—or rather, bipolar disorders, because there are a handful of different diagnoses under the bipolar umbrella.

At the far manic end of the spectrum sits bipolar I disorder. Next comes bipolar II: depression with a helping of hypomania. Then there's cyclothymic disorder, which describes frequent mood shifts that never reach a full-blown episode of depression or mania, and a category previously known as "not otherwise specified," used for conditions that don't precisely fit the other categories.

Bipolar II is often seen as a milder or "softer" form of the illness than bipolar I. Not so, says Ellen Frank, a professor of psychiatry and psychology at the University of Pittsburgh School of Medicine and director of the Depression and Manic Depression Prevention program at the medical center's Western Psychiatric Institute and Clinic.

In bipolar II, she says, "the depressions ... can be so disabling and so long-lasting. The manias of bipolar I disorder are very dramatic and get people's attention and yes, people can do a lot of financial and interpersonal damage during mania, but we know how to treat mania quite well. We're not so good at treating either bipolar I or bipolar II depression."

Cyclothymia may seem milder yet, but by definition the diagnosis means that a person's stable periods don't last more than two months. "If you can't really count on whether you're going to be excessively energetic or optimistic or excessively pessimistic and not able to get anything done—if you can't count on that stability, it makes life extremely difficult," Frank says.

"By definition" gets back to those common criteria in the DSM, which is the standard reference clinicians use for figuring out how to label a set of symptoms—and thus how to treat the underlying illness. Unfortunately, life doesn't always play by the book. And when your particular portrait of bipolar disorder doesn't mesh neatly with the DSM descriptions, it can be harder to develop a treatment plan that will really help.

Revisions to the DSM take aim at that disconnect. Frank was part of a group tasked with updating the section on bipolar disorder in the DSM-IV (or fourth edition), which the American Psychiatric Association put out back in 1994. She says the new fifth edition, called DSM-5, tries to get closer to what clinicians see in actual practice.

She says the group set out to address several problems, including "the incredible time lag between first symptoms and an accurate diagnosis ... individuals who have bipolar disorder often wait 7 to 10 years for a correct diagnosis. That means they often wait 7 to 10 years for appropriate treatment."… [end of excerpt]

Read more from "Bringing Bipolar Into Focus."


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