Ultra Rapid Cycling Bipolar Disorder

OMG! Watch out for flying pigs!  DUCK!

Pigs in Spaaace

Something I have been harping about for years was finally correctly set straight in - of all places - a throwaway, drug-company supported, pharmaceutical-advertisement infested psychiatry journal - Current Psychiatry. Frozen hell!

In an article by Joseph F. Goldberg M.D., a clinical associate professor of psychiatry at the Mount Sinai School of Medicine in New York, the following summary was highlighted as a "bottom line: "Ultra rapid cycling [bipolar disorder] has not been validated as a distinct clinical entitiy, and frequent mood swings should not be used as a criterion for diagnosing bipolar disorder."

In the diagnostic Bible, the DSM, a rapid cycling bipolar disorder is defined as an individual who has four episodes of depression or mania per year, not per hour.  Yet the "bipolar disorder is everywhere" crowd has insisted for decades that there was such a beast as an "ultra-rapid cycler."  Thus anyone who was moody, had a sudden mood change no matter how brief, or had  the unstable emotions characteristic of individuals with borderline personality disorder, was suddenly "bipolar" and in need of medication for his "bipolar spectrum disorder." 

"Psychotherapy? What's that?" they seem to say.

The supposed existence of rapid cycling was advanced as an argument against using anti-depressant medication in bipolar patients having a depressive episode, because the drugs allegedly induced it.  This argument was even picked up by Robert Whitaker, author of Anatomy of an Epidemic, as a possible reason to be cautious about using antidepressants in general.  An argument based on a phenomenon invented by some psychiatrists that does not even exist!

Funny how after having practiced for 35 years in two states, with a wide variety of clinical populations, and specializing in the treatment of borderline personality disorder, I have never seen rapid cycling, with the possible exception of one case in which sudden episodes of psychosis (not mood changes) would come and go without warning.  Maybe I've just been lucky.  Or rapid cycling could be so rare as to be nearly non-existant.

When I first saw the cover of Current Psychiatry under discussion, I must admit was prepared for the worst.  "Oh no, not again,"  I thought. At least, I figured, I would have more material for a new post with another scathing attack on the whole bipolar spectrum craze.

Then I read the article.  What a pleasant surprise.

Meanwhile, in other myths-about-bipolar-disorder news, a new small study seems to contradict a bit of current conventional wisdom about the disorder: A study published in the January issue of the Journal of Affective Disorders (Baldessarini et. al.,136, 2012 pp. 149–154) reported: "Patients with bipolar I disorder show disease progression that is random or even 'chaotic.'"

After following 128 patients with bipolar I disorder for about six years to assess "inter-episode intervals (cycle length)," researchers found that "most current bipolar I disorder patients are unlikely to show progressive shortening of recurrence cycles."

In the past, the impression that bipolar patients had episodes more frequently as they got older, the authors believed, was a statistical artifact caused by a minority of patients with frequent recurrences!

As most of these subjects were being treated with medications, and were probably going on and off of them every so often as patients are wont to do, this is evidence that the treatments do not make bipolar disorder worse over time.

More B.S. About Bipolar Spectrum

A psychiatrist who works at the University of Texas Medical Branch in Galveston occasionally writes for a newspaper for psychiatrists called the Psychiatric Times, which is usually relatively unbiased in its coverage of the field despite heavy advertising from pharmaceutical companies. Dr. Wagner is, however, one of those “experts” who advocate labeling children who exhibit behavior problems with what I believe to be phony brain diseases like ADHD and then drugging them.

We know that true bipolar disorder is a real brain disease that has a significant genetic component. Earlier studies indicated that if you have a bipolar parent, your odds of developing the disorder are 5 to 10 times higher than the general population. Since the prevalence in the general population is about 1 percent, that means you have a five to ten percent chance of developing the disorder yourself. True bipolar disorder usually manifests itself in the late teens or early 20’s, most frequently with a depressive rather than a manic episode. Although rare, I saw one patient who had his very first manic episode in his 80’s!

Doctor Wagner wrote a column about a study by Birmaher and others (Archives of General Psychiatry 2009, vol. 66, pp 287-296) that allegedly studied the children of bipolar patients. Birmaher’s data is already suspect in my mind because a third of his sample of parents was diagnosed with something called “bipolar II” disorder rather than actual manic-depressive illness. In over thirty years of practice and teaching residents in both the public and private sector in two states, I have seen only two or three patients that actually meet the DSM criteria for this supposedly common disorder, and I suspect that these patients were all just mild cases of Bipolar “I,” because they all responded to lithium.

Bipolar II as described in the literature is said to rarely respond to lithium, most likely because it is not bipolar disorder at all. In my experience, many patients seem to endorse some of the criteria for bipolar II when asked about them by a psychiatrist because they really do not understand what the doctor is getting at. This becomes readily apparent if the doctor follows them closely for an extended period of time. As I discussed in a previous post, many patients with borderline personality disorder are misdiagnosed as bipolar II by doctors who use symptom checklists.

The children in Birmaher’s study, according to Wagner, were studied when they were on average about 12 years old. In truth, we rarely have any idea whether a 12 year old is going to eventually have a manic episode. Yet supposedly 10% of the children in the sample were diagnosed as bipolar! This means that they had to have some version of a manic episode, because you cannot tell if a depressed adolescent will turn out to have bipolar disorder or unipolar depression.

Of this group, the rate of Bipolar I in the children was stated to be about 20% of the supposedly bipolar sample. Some 12 year olds actually do have mania and are psychotic, but they are extremely rare. I doubt that the diagnoses of these young children were accurate. Another hint that the diagnoses might be bull was that about three quarters of the allegedly bipolar children were diagnosed with “bipolar NOS.” NOS means “not otherwise specified,” and is now used by those who believe that any moody, difficult or temperamental child has bipolar disorder. Bipolar NOS can be and often is applied to kids with “mood swings” or even temper tantrums that last for only a few minutes! The authors in the study toss out the “Bipolar NOS” term in the paper as if it were a well-validated and well-accepted psychiatric diagnosis.

The authors of the study claim at the beginning of the article that they evaluated the “family environment” of their subjects, but in the study methodology section of the paper, the only environmental factor mentioned as having been evaluated was the family’s socio-economic status. Nothing was said, of course, about the disciplinary practices of the parents.

Interestingly, the rate of post traumatic stress disorder (PTSD) from physical abuse, sexual abuse, witnessing death, or family violence was significantly higher in the “bipolar” children in the study than in the “normal” controls - 16% versus 3%. Now why would children with a supposedly biogenetic disorder like bipolar disorder have a higher risk of being abused? Could it be that a high percentage of the children in this study who were diagnosed bipolar came from dysfunctional families, and the source of their apparent mood swings was family dysfunction? Many of the parents were diagnosed with bipolar II after all, and could instead have severe personality disorders. Furthermore, family dysfunction has to be pretty severe to lead to clear-cut PTSD in a child, so perhaps the 16% feature was just the tip of the iceberg.

Some who want to explain this all away have argued that bipolar kids, being difficult, often create the very chaos that leads to both child abuse and marital conflict. Parents who are frustrated and cannot agree upon what to do with their child frequently do have angry interchanges, and punishment can get out of control. Talk about blaming the victim! Still, I must admit that it is probably true that a difficult child is somewhat more likely to be “punished” with physical abuse than an easy one. But how do the folks advancing this sort of explanation account for the childhood sexual abuse? How do we blame that on a rambunctious child? “She was driving me crazy, so I raped her.” I don’t think so.

Astra Zeneca free book

The drug rep from Astra Zeneca was in the University of Tennessee Department of Psychiatry office area today. In my mailbox, and in the mailboxes of all of the psychiatry residents (MD's in specialty training) was a free book. It was entitled, "Bipolar Disorder: Disease Management Guide."

Funny thing, there is no mention anywhere in this book of good old cheap, generic lithium, which is far and away the drug of choice for treating bipolar disorder. There was also no mention of the third choice, Tegretol, nor the fourth, Trileptal, nor "typical" (old and generic) anti-psychotic drugs - only information about brand-named atypical antipsychotic meds, Depakote ER, and Lamictal.

What is not discussed in this rather selective "guide" is of course entirely unsurprising. At least our residents have me to point out what this means.

The book also mentions the importance of screening patients for "subthreshold" presentations of the disorder, as well as for the diagnosis of "Bipolar NOS" (not otherwise specified). The book specifies that patients who have the latter diagnosis have hypomanic episodes that may last for only a few hours. Naturally, there is no mention of agitated depression, anxiety, interpersonal discord, or of the affective (emotional)instability characteristic of borderline personality disorder.

The existence of manic or depressive episodes that do not have to last for any significant amount of time is the party line for those drug company shills pushing for the diagnoses of pediatric (child) bipolar disorder, and "bipolar spectrum" in adults, which I like to refer to as B.S.

Let's medicate everyone with expensive, potentially toxic atypical antipsychotic drugs! After all, who among us has never had a mood swing?