What Are the Bipolar Disorders?

Once upon a time, there was manic depression. Everybody knew what that was. Some people went from the depths of despair to the heights of uncontrolled joy, and back again. Sometimes, they were 'normal' in between these extremes. It was a diagnosis that was used sparingly, and those so labeled generally displayed extreme behavior at both ends of the mood swings. At least the diagnosis was used sparingly in the United States. When epidemiological comparisons were made, it was notable that the different parts of the world all seemed to have similar rates of what were considered psychotic (severely impaired) behaviors, but the diagnoses themselves were significantly different. In Great Britain, for example, there were many more manic depressives and, interestingly, a roughly equal number fewer of schizophrenics. If you added the two diagnoses together, the rates were very similar to those In the United States, but more people In the U. S. were labeled schizophrenic and correspondingly fewer were diagnosed with manic depressive Illness. As virtually no one believed that there was a real difference In the populations, It was fairly obvious that much of what the United States was diagnosing as schizophrenia, would have been diagnosed as manic depressive illness In Great Britain.

Did that difference matter? Did anything result from that discrepancy aside from labels? Yes, treatment decisions were based on the diagnoses. Schizophrenics were treated with one type of drug and manic depressives with quite another. Then, as now, the 'gold standard' treatment of manic depressive illness was lithium salts, which, in most people afflicted with manic depressive illness can control the symptoms to a major degree. Lithium, on the other hand, does nothing to alleviate the symptoms of schizophrenia. In short, what the British psychiatrists had noted was that there were a lot of people that did not fit the strict diagnosis of manic depressive illness who responded well to treatment with lithium. It was, therefore, practically useful to use criteria for the diagnoses that were closer to those used in Great Britain than those used in the United States. Treatment decisions had better outcomes.

Partly as a result of the fact that criteria for the diagnosis of manic depressive illness were being broadened to include many people who did not display the classic symptom pattern, the name, 'manic depressive illness' was dropped from the official manual of diagnostic criteria (now the DSM-IV TR) and the new category of "bipolar disorder" was introduced in its place. Incidentally, DSM-IV stands for "Diagnostic and Statistical Manual of Psychiatric Disorders" (of the American Psychiatric Association), fourth edition.* This manual specifies diagnostic criteria that must be followed. It is a largely successful attempt to standardize diagnoses across time and place so that epidemiological studies and comparisons can be made. In this manual, the very complex, multiple sets of criteria are specified for the bipolar disorders, of which there are several types. These criteria are adhered to by psychologists and psychiatrists across the United States and followed fairly closely in many other countries. It is well beyond the scope of this article to discuss the formal criteria, but there are some general similarities across the types of bipolar disorders that are important to mention.

Of course, the entire category falls under the broader rubric of "mood disorders." To criminally oversimplify, in all of the bipolar disorders, there are a widely varying 'swings' in mood from depressed (see associated articles) to excessively cheerful and ebullient, often grandiose and, at extreme, very disruptive, scattered, self damaging behaviors that can include grandiosity of even delusional degree. Sometimes, the manic presentation can be one of extreme irritability, even mixed with unwarranted cheerfulness. Usually, there are periods of normal behavior in between the mood swings. If there is a pattern of mood swings to a marked degree, but never so severe that functioning is impaired, it is diagnosed as "cyclothymic," rather than bipolar. In all manic episodes, there is a reduced need for sleep, and, at the high end, a severely impaired attention that cannot stay focused on one thing at a time.

How common is bipolar disorder? Official estimates have ranged from 0.4 to 1.6% lifetime prevalence. That is, studies have averaged out to suggest something In the vicinity of 1% of the population will be diagnosed with bipolar disorder at some time in their lives. That is the official line; it is my belief that it may be more common than that, and when cyclothymia (the less severe form) is included, I suspect it reaches several times that figure. It is extremely important, however, to realize that being diagnosed with cyclothymia or even bipolar disorder is not a sentence to a terrible and unproductive life. For one thing, there are very successful treatments that can control the symptoms, but there is another observation that I believe is extremely important.

Many highly successful people, a disproportionate number of artists, composers, writers, scientists, creative people of all kinds have been bipolar, or retrospectively diagnosed as bipolar. For example, Robert Louis Stevenson, Mark Twain, Winston Churchill, Napoleon Bonaparte, Art Buchwald, Tim Burton, Agatha Christie, Francis Ford Coppola, T. S. Elliot, Ralph Waldo Emerson, Drew Carey, Jim Carrey, Abraham Lincoln, Samuel Johnson, Isaac Newton, Edgar Allen Poe, F. Scott Fitzgerald, Tennessee Williams, Robert E. Lee, J. C. Penny, Victor Hugo, Walt Whitman, Alfred Lord Tennyson, Robert Blake, (some think) Sigmund Freud and many, many more famous and accomplished people. This is not an accident. During what is called the hypomanic state, high, but less than fully manic, people are filled with energy, driven to create, optimistic, enthusiastic and, sometimes, highly productive. Even in severe bipolar disorder, there is a period of time in which the person is on the upswing and not yet fully manic. During this time, intelligent people can be very productive and creative. In full mania, it becomes impossible to concentrate and focus enough to finish projects, but the time before the manic peak can be very productive. Some bipolar people refuse medication despite feeling extremely uncomfortable during depressions and at the top of manias, because of the productive, creative, and satisfying period of time on which they rely for their achievements.

It is not true that one needs to be 'crazy' to be a productive 'genius'. But consider this: how many people who are well adjusted, happy, and contented with their lives are really driven to great achievement? It takes more than intelligence or talent to accomplish great things. It also takes motivation and drive. Adjusted people can be happy, productive, and contributing citizens; they are rarely the ones who produce greatness. Some would choose greatness over contentment.
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* The "TR" stands for "Text Revision" which constituted the thinnest veil of an excuse for publishing a new volume I have ever seen. "Text revision" refers to the fact that nothing of substance was changed from the previous manual, only a little text, very little.