New and Better Ways to Falsely Expand the Definition of Bipolar Disorder

Angst redefines angst!

Blowing Hot Air

The Journal of Affective Disorders, which really should be called the Disordered Journal of Bipolar My A--, is helmed by one Hagop Akiskal, about whom I have previously blogged (A Stupid Study and an Even Stupider Headline, 2/1/2011). On its website, the journal describes itself thus: “The Journal of Affective Disorders publishes papers concerned with affective disorders in the widest sense.” I think they must mean the wildest sense.

In several previous posts, I have described how the authors who regularly contribute to this journal are constantly on the lookout for new and improved ways to re-label patients with depression, anxiety, chronic ongoing interpersonal strife, and, in particular, borderline personality disorder (BPD) as really suffering from some form of mania.  Any form of mania.  Their creativity in spreading this outrageous nonsense is truly impressive.

In a journal article described by my post of 3/6/12, Relabeling Depressive Symptoms as Manic Symptoms, authors suggested that the presence of something that they label as subsyndromal manic symptoms (that is, symptoms that they believe are the same as those that are usually seen in mania episodes, but which are “below the threshold for mania" - whatever that means) are seen in the major depressive episodes (MDE’s) that are also characteristic of bipolar disorder.  

As I stated in that post:

“They discuss how some other authors reported that “the most common manic symptom during bipolar MDEs was irritability (present in 73.1% of the sample), followed by distractibility (37.2%), psychomotor agitation (31.2%), flight of ideas or racing thoughts, (20.6%), and increased speech (11.0%). 

“Now, of course, they do not mention that these very same symptoms are also seen in the major depressive episodes of people who never have had or will have a manic episode. And who respond to antidepressant medication and have no response at all to lithium (which is highly effective in bipolar disorder). Back in ancient history (the 70’s and 80’s) we labeled depressed patients who show such symptoms as having an agitated depression.”

In another article described in my blog post of 8/13/2011, More Bipolar Disease Mongering in a Respected Journal, the authors found another way to create the fiction known as “subthreshold” mania – this time in another, major psychiatry journal, the Archives of General Psychiatry.

In this article, they introduced the term bipolarity specifier as if this were an established and valid measure.

As I described in the previous post, here's the definition:

“This bipolarity specifier attributes a diagnosis of bipolar disorder in patients who experienced an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR, associated with at least 1 of the 3 following consequences: (1) unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, (2) marked impairment in social or occupational functioning observable by others, or (3) requiring hospitalization or outpatient treatment. No minimum duration of symptoms was required and no exclusion criteria were applied.”

That last one, No minimum duration of symptoms was required and no exclusion criteria, is key. It means that any person who has a suddenly angry, agitated, or elated response to an environmental trigger (like a big fight with a family member or winning the lottery) could be labeled bipolar. This would also mean that if they had an episode of emotional dysregulation for the same reason, the reaction would be labeled a bipolar episode. This also makes almost anyone who has borderline personality disorder suddenly bipolar. The “research team” also included in their subthreshold category those patients who had experienced episodes of elevated or irritable mood triggered by antidepressants. Irritibility is a common side effect of drugs like prozac and may have absolutely nothing to do with bipolar disorder.

Some of my colleagues and I tore this study apart in a letter published in the Archives, and were answered with purposely misleading, phony “arguments,” as I described in my post of 6/19/2012,  Disease Mongering in a Respected Journal and Plausible Deniability.

Now comes another doosie of nonsensical research study, recently published online in the Journal of Affective Disorders, called Subthreshold bipolar disorder in a U.S. national representative sample: Prevalence, correlates, and perspectives for Psychiatric nosography by Hoertel, Le Strat, Angst, and Dubertret.  Jules Angst was also one of the authors of the Archives article as well.  I guess one could say that Angst is trying to redefine angst.

Jules Angst, M.D.

In this article they employ yet another brand new way to define “subthreshold” mania.  The criteria they used, in addition to the presence in a patient of an episode of major depression but who have not met the full criteria for an episode of mania or hypomania, is to include for purposes of the study anyone who answers in the affirmative to any one of three screening questions for bipolar disorder.

As I have mentioned many times in this blog, screening questions and questionnaires are purposely designed to cast a wide net, so that a lot of people who do not have the disorder are questioned further to make certain one way or  the other (false positives).  Their purpose is so researchers do not waste a lot of time questioning potential subjects who clearly do not have the disorder (false negatives). In other word, using screening questions to define a clinical entity is completely bogus by definition!

The reader can easily see why this is so by looking at the screening questions used in the paper:  1. In your entire life, have you ever had a time lasting at least one week when you felt so extremely excited, elated or hyper that other people thought you weren't your normal self? or (ii), In your entire life, have you ever had a time lasting at least one week when you felt so extremely excited, elated or hyper that other people were concerned about you? or (iii), In your entire life, have you ever had a time lasting at least one week when you were so irritable or easily annoyed that you would shout at people, throw or break things, or start fights or arguments?

Almost every patient with borderline personality disorder would answer at least one of these three questions in the affirmative.  Especially that third one.

The results of the study showed that people who met this screen for “subthreshold” hypomania (and who therefore had a "disorder" that had been merely defined into existence) were found, compared to depressed patients who did not, to be more likely to have been American born, and never to have been married. They were also less likely to earn more than $70,000 year.  They were more likely to have additional (comorbid) psychiatric disorders, especially personality disorders (other than borderline, interestingly, for which they mention later in the article they did not even bother to assess the subjects!) These included anxiety disorders, substance use disorders and dysthymia.

All of these findings are also true of patients with borderline personality disorder, which may have been what a significant percentage of these “subthreshold” manic patients had all along.

“But this sample of patients all were found to have had episodes of major depressive disorder (MDD),” you might protest. “So are you saying there is a sizable contingent of patients with borderline personality disorder who have co-morbid major depressive disorder?” Well, yes, that is true. But it is even more complicated than that.

The episodes of major depressive disorder seen in patients with borderline personality disorder are often qualitatively different from those in depressed patients who do not have this disorder.  These differences were described beautifully by my friend and colleague Kenneth Silk of the University of Michigan medical school in an article called, The quality of depression in borderline personality disorder and the diagnostic process, in the February 10^th 2010 issue of the Journal of Personality Disorders (24:1, pp. 25-37).

Ken Silk, M.D

He describes how MDD in BPD is less likely to be characterized by a full contingent of physical or vegetative symptoms (poor appetite, energy, slowing of thought and behavior, and so on), and less likely to respond to the earliest antidepressant medications (tricyclics).  Their depression was far more likely to be characterized by emptiness, loneliness, and desperation over their interpersonal relationships. Their depressive symptoms tend to be far more changeable (labile) and liable to come on suddenly in response to environmental events than patients with MDD without BPD. 

Patients with BPD are also most likely to be dysthymic, or chronically depressed, when they do not seem to be in the midst of a major depressive episode. In other words, as Dr. Silk says, “…these patients may suffer from chronic dysphoric mood that is being misinterpreted [by psychiatrists] as a [medication] non-responsive major depressive episode.”

The depression of patients with BPD is also much more likely to be characterized by high levels of anxiety. In fact, again according to Dr. Silk, their depression may stem from their exhaustion and demoralization from their unsuccessful battles with their overwhelming anxiety. Patients with an anxious depression are the very ones that will be labeled with subthreshold manic symptoms in articles such as the one under discussion.

By the way, these qualitative differences in the experience of certain patients with depression are not sorted out by the research diagnostic interviews and symptom checklists frequently used in psychiatric studies.  Imagine that.