Burning the Bible

Let’s not replace one set of dogma with another.

Thomas R. Insel, M.D., Director of the National Institute of Mental Health, issued a sharply worded condemnation of the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM has long been considered the “Bible” of Psychiatry and has recently been under attack from many angles, but this announcement might be a game changer. It will be interesting to watch how it all plays out.

According to Dr. Insel, “it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”

One obvious problem is that the reliance on “objective laboratory measure” is also full of problems. In an attempt to turn real Psychiatric issues into “medical diseases,” there has been a widespread effort to claim depression and bipolar disorder a “chemical imbalance.” In “Psychiatry’s New Brain-Mind and the Legend of the ‘Chemical Imbalance,'” Dr. Ronald Pies said, “In the past 30 years, I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. On the other hand, the “chemical imbalance” trope has been tossed around a great deal by opponents of psychiatry, who mendaciously attribute the phrase to psychiatrists themselves. And, yes—the “chemical imbalance” image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients’ understanding. In truth, the “chemical imbalance” notion was always a kind of urban legend- – never a theory seriously propounded by well-informed psychiatrists.”

I have long argued that the definitions in the DSM regarding depression and bipolar disorder are not accurate. Basing assessments on a short list of symptoms is a huge part of the problem without also considering intensity, awareness, understanding, functionality, comfort, value, and length time it can be kept under control. But, abandoning any criteria because they have yet to find “biomarkers” for depression or bipolar disorder can leave real problems unaddressed. Depression and bipolar are dangerous conditions that destroy the lives of far too many people.

The bigger issue for me is the assumption that the “disease” includes the “symptoms” that are not in disorder. Any biomarker found in the future needs to recognize this fact before they throw the baby out with the bath water. Let’s assume that some day they are able to link bipolar to specific chemical reactions in the brain at specific regions. They will be able to tie the “symptom” of racing thoughts, for example, to a real difference in the brain compared to “normal” people. If they somehow eradicate the “disease” of racing thoughts by altering the brain, they destroy something that has moved mankind forward for millennia. They need to be extremely careful to separate the “disorder” of not understanding the racing thoughts from the in-ordered ability to function highly with them.

My proposal all along is to separate disordered bipolar from in-ordered bipolar. Bipolar Disorder means the condition is causing suffering and incapacitation, whereas Bipolar IN Order does not. Unless Bipolar IN Order is taken into account, using biomarkers to “prove” the condition an illness to be removed is a step backward. As I described in my article challenging the paradigm of remission; “With so many people thinking that remission is the same as ‘cured,’ the problem is all too real. They assume when I say Bipolar IN Order that they have achieved the same thing because they are not currently ill, but during the next cycle they are back in disorder while I am exploring yet another fascinating state with its own unique rewards. What they do not understand is that I, and the many others I have taught, are not ‘symptom’ free in the way commonly thought; we experience ‘traits’ every bit as intense as anyone in disorder, but we neither suffer nor are incapacitated by them. We are no longer in danger of relapse because we are already functioning highly at intensities that those without our understanding mistake for the illness.”

It is great news that the NIMH has decided to challenge the DSM. I hope that in rethinking “mental illness” they do not make the same mistakes in confusing what the “disorder” is.

Bipolar People Get Angry Too

When bipolar people get angry, the Bipolar IN Order concepts apply just as they do for most other states.

Bipolar in disorder combined with anger is a very dangerous mix. The disordered person tends to become very volatile and can explode into a rage with little provocation. It is best for the person to avoid anything that might trigger anger until the disorder is in remission, but even then an angering stimulus can trigger another manic or depressive episode with anger as one of the troubling elements.

Bipolar people who have their condition in order have learned important lessons that can be applied to most of our experiences. For example, since we understand bipolar so well that we can function highly during depression and mania, we can also handle more intense states of anger without losing control.Continue reading

The Elephant In The Bipolar Room

The “dis-abled”argument is central to bipolar disorder.

Stigma, medication, treatment options, recovery, patient rights, and physiological basis are some of the most discussed topics regarding bipolar. There are, of course, many other interesting aspects to debate, but it is hard to find any discussions about bipolar that do not include one or more of these central topics. While it has been very healthy to debate all of them, there is an underlying assumption that must be addressed too.

The paradigm that all of the above topics are based on is that we are incapable of remaining in control when mania and depression reach a certain intensity. We are therefore not responsible for our behaviors when manic or depressed. Because it is not possible in those states to choose better ones. This creates the goal of removing bipolar from our lives (at least at higher intensities) and the debate is about how it is best done. Much of the debate about medication, for example, is about alternative methods to achieve the same goal of reducing intensities of mania and depression.

But, what if we could be highly functional while manic or depressed?

Continue reading

What Depressives Can Teach Doctors About Grieving

Doctors’ inability to handle or acknowledge grief is negatively affecting care.

My daughter Kate is in her fourth year of medical school and is well on her way to becoming a very caring doctor. Her greatest gift is the ability to connect with people, which thankfully is being recognized in the hospital settings as an asset. She creates strong bonds with her patients and their families by communicating how much she cares about them. Among so many other admirable traits it is the one that makes me the most proud of her. It has been her greatest gift for as long as I can remember.

The ability to form strong emotional bonds is not without tremendous risks though. It hurts her deeply when a patient that she is involved with dies. It is a testament to her awareness, understanding, and strength that she can perform even on days when she sees the worst aspects of the medical profession; in spite of their best efforts, they cannot save everyone. Kate has grappled with that many times and come out the better for it.Continue reading

What Are Some of the Positives About Having Experienced Bouts of Depression?

Depression in self-mastery is often seen as a rich spiritual experience.

A recent question on our Depression and Bipolar Advantage LinkedIN Group brings up a point that needs to be addressed if we are to fully understand depression: What are some of the positives about having experienced bouts of depression? Since most people assume there are none, it is important to put it in perspective.Continue reading

Finding Value in Depression and Mania

Exploring the relationship between value and functionality in bipolar disorder.

Assuming you are not deeply depressed right now, try to remember the time when you were in the deepest depression of your life. Can you see any way it might have changed your life for the better? Did it make you more sensitive to the feelings of others? Are you better at helping others during their difficult times because you have had the experience yourself? Are there things you learned from being deeply depressed? Are you a better person because of the experience? What is the value in having been through it? On a scale from one to one hundred, how would you rank the value in having been deeply depressed?

These seem like unusual questions to some people. Wouldn’t we be better off trying to forget our depressions and get on with our lives? Can’t we just hope that depression remains in the past and we never have to face it again? Ignoring past episodes may sound like a better approach, but refusing to take a hard look at depression or mania leaves us ill prepared for the next time it comes. Unfortunately, if depression or mania happened before, it is likely to happen again.

Looking at how we value depression and mania is an important part of any assessment; a part that is sorely missing in most protocols. The laundry list of symptoms in most assessments belie an incorrect assumption that the items are all seen as negative.

We have been asking the above questions (and many more) for several years now and have learned a great deal about the role value plays in depression and mania. Although our data is not yet extensive enough to make final declarations, there are many surprising trends that are too important to delay sharing.Continue reading

Taking Measurement of Bipolar Comfort

Expanding the depression and bipolar comfort zone.

Understanding the role of comfort is critical for getting Bipolar IN Order. To do so, we must measure comfort at each level of intensity for both mania and depression. When we compare comfort levels to awarenessunderstandingfunctionality, value, and the time before escalation, we find the optimal intensities where bipolar is an advantage in our lives.

In any aspect of life, those who only seek comfort are consigned to mediocrity and boredom. Those who judiciously step outside their comfort zone and challenge themselves are the ones who learn and grow. This is equally as true with mania and depression.

The best growth, though, happens just slightly outside the comfort zone. Too far outside and the lack of comfort can cause you to shrink instead.

Too many times, bipolar people step too far outside their comfort zones and find themselves at an intensity of depression or mania that is far beyond their control. Many of them become so frightened by it they hide inside their comfort zone hoping to remain there the rest of their lives. They accept a diminished story of their lives because they believe they have no other choice. They fear one wrong step will rapidly escalate back to an uncomfortable and out-of-control state.Continue reading

Measuring Functionality In Depression and Bipolar Disorder

Many bipolar people say they are “high-functioning,” but most of them mean they function OK when in remission and cannot function when things get too intense. How well one functions during depression or mania defines the difference between Bipolar Disorder and Bipolar IN Order. At every intensity, functionality influences the comfort of everyone involved and whether they see value in the experience. Functionality should be the central focus of any approach to bipolar instead of simply trying to make it go away.

Many think intensity of depressive or manic episodes is the determining factor in functionality, but evidence contradicts such belief. Far more important are awareness and right understanding as outlined in the previous articles in this series. With enough education and practice, intensity becomes far less relevant to functionality than most people believe.Continue reading

Understanding Depression and Bipolar Disorder

Understanding Depression and Bipolar Disorder can take many forms. Functionality-based understanding is central to getting Bipolar IN Order.

When I first started putting together the protocol for assessing depression and bipolar disorder, I was working with a professor of Psychiatry to make sure the ideas were sound. His advice was to combine both awareness and understanding in the graph to keep it simpler. I am glad that I did not take the advice.

Awareness and understanding are different in ways that matter. Expertise might help someone understand why things happen, but does not necessarily lead to increased awareness. An expert on sex, for example, may be totally unaware that his wife is having an affair. It takes awareness (covered in the first article of the series) to know what is going on whether you understand the phenomenon or not.

It turns out that understanding is more related to functionality (covered in the next article) than awareness. You may be completely aware that you are sitting in a car, but unless you understand how to operate it you cannot drive.

Understanding is not just about knowing the physical, mental, emotional, spiritual, social, and career/financial aspects and their implications, it also includes knowing about the tools. You need to know how the tools work, have proficiency in using them, and understand which ones to use at each stage of bipolar – the disordered stages of Crisis, Managed, and Recovery, and the IN Order stages of Freedom, Stability, and Self-Mastery. I call this functionality-based understanding.

Too many people think those who cannot function are the ones we should be listening to. Those who only know bipolar disorder and have not created Bipolar IN Order in themselves or others have no understanding of what it takes to make it happen. They can learn, but many times their beliefs limit their willingness to do so. They keep insisting it is not possible to be highly functional with bipolar and refuse to consider the evidence that contradicts such beliefs.Continue reading

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