In today’s post on the Bipolar Beat entitled “Increasing Rates of Bipolar Diagnosis: Pros and Cons,” I discuss the benefits and drawbacks of the sudden and dramatic rise in the diagnosis of bipolar disorder over the past two decades. On the plus side, the increase probably means that more people who need help are getting it. On the minus side, it probably means that more people than ever (especially children) are being misdiagnosed and receiving the wrong treatment.

I address the pros and cons in more detail in that post. In this post, I’d like to address the reason why I think the bipolar diagnosis is becoming much more common, maybe too common. I think one of the primary reasons behind the rise in bipolar diagnoses is the birth of the bipolar spectrum – a concept that broadens the definition of and criteria for a bipolar diagnosis.

The primary differences of opinion around the diagnosis relate to what exactly defines a bipolar disorder and what constitutes a mood swing:

• Classic definition: The classic definition of bipolar disorder includes major depressive episodes that last at least two weeks and periods of mania or hypomania that last at least seven or four days respectively.
• Expanded definition: Over the last decade a number of experts in the field encourage expanding the diagnosis to include mood changes that are much different – moods that change quickly (within moments to hours) and that are often triggered by a particular stimulus. Some feel that this kind of mood regulation problem is related to bipolar disorder – and this has led to the birth of the “bipolar spectrum” concept.

The concept of a bipolar spectrum has taken hold with great strength in the world of child psychiatry. As a result, all kinds of angry and emotionally unregulated children have been diagnosed as having bipolar disorder, and more adults in this range have been included as well.

These types of mood regulation problems are real problems – with real brain wiring issues – and deserve to be carefully evaluated and treated. The problem is that many conditions and problems other than bipolar disorder can also cause these regulation problems. Families of children and adults with this clinical picture suffer greatly, but whether or not it is helpful to lump all of these people in the “bipolar spectrum” is another question all together.

The answer to that question really hinges on the risks and benefits of making the diagnosis broadly versus more narrowly. I believe that the potential risks of broadening the criteria for diagnosing bipolar far outweigh the potential benefits, because the medications used to treat bipolar disorder are high powered with many side effects to navigate. Other conditions that lead to mood dysregulation might be treated with different, potentially less harmful medications or even specific kinds of psychotherapy.

Being labeled with bipolar disorder, particularly as a child, comes with a lot of heavy baggage. I think we lose nothing by sticking to a broad formulation of severe mood dysregulation and holding off on the bipolar diagnosis until we see more classic “cardinal” symptoms of mania and depression. With this broader label, we are still targeting the specific problem but we are looking at it more comprehensively and not narrowing down in treatment options or labels and prognosis prematurely.

Remember: These diagnostic categories are artificial really – put together by doctors to try to organize our understanding of these symptoms and the best treatment plans. But people’s brains don’t read the “DSM IV” before developing symptoms.

It’s important for us to keep in mind that when we diagnose we are looking at a complex person who has a number of symptoms that we need to help relieve, whether or not the symptoms fit into our neat categories. Rather than jamming humans into these artificial categories and getting over- focused on defining the labels let’s look at the range of difficulties that can be seen in the mood regulation wiring system and understand that we don’t yet fully understand this spectrum.

With imaging and genetic studies, we will begin to define mental illness by actual brain pathology, but until then, we are working with just groups of symptoms that we have lumped together because they tend to happen together and tend to have similar responses to treatment. I think we lose a lot of diagnostic and treatment power when we narrow ourselves too quickly to “one size fits all” labels.