Commenting Philip Dawdy’s comments on bipolar II

April 12, 2009

Regular readers of Philip Dawdy’s excellent Furious Seasons web site will be familiar with his opinion of the DSM’s bipolar II diagnosis. In keeping with his idea of “a free market of ideas in the mental health world” I would like to contribute my opinions on this topic.

First, let me be clear: I admire Phillip’s work on Furious Seasons, have supported his fundraisers, and hope he keeps at it.

The opinion that causes some controversy is succinctly put in his interview with Christopher Lane in Psychology Today.

Here’s the quote in full:

I may be the only writer in America who thinks BP2 is controversial and I can hardly think of any doctors who do. For me, it’s a questionable classification and something of a cop-out by the DSM writers for a couple of reasons: One, BP2 isn’t bipolar disorder, properly understood. There’s no mania, there’s no hospitalization for mania, and there’s no one running naked down the street. The most prominent features of BP2 are depression (and that covers the vast majority of a person’s time who is diagnosed with BP2) and bursts of energy, broadly understood. To me, that sounds a whole lot more like depression and agitation than it does manic-depression.

Two, the minute someone gets hit with a bipolar disorder diagnosis of any subtype, then they are faced with a profoundly bad set of social assumptions; they get stigmatized by friends and family; and they lose their jobs. I know of multiple cases along these lines, including one of a sheriff’s deputy in King County, Washington who was fired from her job as soon as the brass learned she had BP2, even though she had a stellar track record as a cop and had done nothing wrong on the job. That hardly seems fair when we’re talking about a disorder that doesn’t involve hallucinations or psychosis and has none of the off-the-charts impulsivity of true manic-depression. While it’s nice of researchers and mental-health advocates to claim that we’ve got to end this kind of stigma, in the real world that would take generations and by then people with BP2 today will have reached the ends of their natural lives.


Why BP2 wasn’t called something else is beyond me, but the diagnosis has sure caused a lot of unfair social damage.

I have a BP2 diagnosis, the comical history of which you can read here, and Phillip’s description in the first paragraph doesn’t characterize my experience at all well. The reason I have a BP2 dx rather than BP is that I haven’t suffered “marked functional impairment” in any of my “hypomanic episodes”. If I had then DSM 4’s criteria would have me as BP.

Hospitalization is not a required criterion for diagnosis of mania or BP. Nor is running naked down the street. What I experienced included delusions (e.g. I once began planning to become Prime Minister), paranoia, demented spending (thankfully I had no lines of credit when the behavior was worst when I was younger or it would have been ruinous), crazy creativity with loss of my self-critical faculty, no sleep, ludicrous self-esteem and embarrassing incidents the memory of which make me wince decades hence. This is a bit more than a “burst of energy, broadly understood”. And there is suspicion of genetic evidence: my father’s odd behavior and suicide smacks of manic depression. I rather agree with my shrink that the criteria of mania and BP are met rather closely except that, because I never lost a job, got kicked out of school, got arrested or was hospitalized, it lacks “marked functional impairment”. In other words, I got away with it. Apparently that makes it BP2.

Nor is this behavior agitated depression. I have a lot of experience with that and it is entirely different. In agitated depression my mood is dysphoric, pessimistic and cynical but I can’t sleep, relax or let up with the negativity whereas in hypomania I am euphoric, self-confident, optimistic and at one with the world. There’s no way to confuse these states, in my experience.

On Philip’s second point, I don’t really disagree but the statement sounds a little sweeping. I’m sure some people have suffered negative and unfair social consequences but I’m not aware of any affecting me, at least not so far and certainly not within the first minute of diagnosis.

Whether or not a different name for this disorder would, on the whole, have been better for patients, I really don’t know. Would the social consequences for something called, say, Major Depression with Hypomania (with, as most new psychiatric disorders have, a three letter abbreviation, say MDH) be any better? I don’t find that very convincing but I honestly don’t know.

Moreover, I imagine there may be benefit to patients from the BP2 name. It seems clear from the reading I’ve done that it’s important to treat BP2 in basically the same way as bipolar, especially in regard to the dangers of antidepressants. I imagine that many (most?) physicians are aware of these concerns in bipolar. My own GP refused to prescribe an antidepressant because of his suspicion of bipolar. He sent me to a psychiatrist who refused to prescribe an antidepressant without first a robust mood stabilizer. It took two years to get that right before I was given the antidepressant. According to, for example, Husseini Manji, this is the safest approach. (He even prefers in cases of MDD that are familial.)

If BP2 had instead a name that failed to make the association with bipolar, I wonder if some physicians, especially those who aren’t psychiatrists, might be less likely to recognize these risks. Given that most BP2 patients present with depression, the association with the bipolar word may spare them some risk.

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