The Bipolar Spectrum

John McManamy Health Guide
  • The term, manic-depression, was coined by the pioneering diagnostician, Emil Kraepelin, back in the early twentieth century. There is a common misconception that manic-depression is simply the old fashioned term for bipolar disorder, but Kraepelin applied that term to plain vanilla depression, as well.

    In Kraepelin's mind, depression and what we now call bipolar were merely slightly different expressions of the same phenomenon. Think of unipolar merging into bipolar the way colors of the rainbow blend into a spectrum. There is nothing black or white about our illness. It's all about subtle shading.

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    In a Feb 2008 supplement to the journal, Bipolar Disorders, a panel of experts had a crack at breaking down our diagnosis with more precision. Part of that exercise included an overview of the spectrum.

    Jim Phelps MD (author of "Why Am I Still Depressed?") led the workgroup dealing with the bipolar spectrum. According to Dr Phelps and company, categories are useful to a point, but intermediate cases suggest "a continuous spectrum of bipolar disorders" stretching from unipolar depression to bipolar I.

    There are a number of different (but hardly conflicting) ways of conceptualizing the spectrum. For starters, think of manic-depression as a cycling illness that also includes recurrent depression. Recurrent depressions come and go while chronic depression tends to hang around forever.

    People, in effect, cycle in and out of recurrent depression. They just don't happen to cycle up into mania or hypomania. There is strong evidence to suggest that antidepressants don't work well for recurrent depression. In fact, they may worsen the depression to the point that they turn depressives into true bipolars.

    So the question here is not whether or not you may have bipolar, but "how much" bipolar you may have. This opened the door for Bipolar II (with hypomania as the "up" threshold) to be included in the DSM in 1994. These days, people talk about "soft bipolar," in effect, depression with speed bumps.

    The spectrum can also be interpreted to include pure states bleeding into varying degrees of mixed states. Think of depression with a capital D and mania with a capital M. Now think of some depression and mania symptoms in terms of small d and small m. Now think of these varieties: D, Dm, DM, dM, M.

    In effect, we are talking of depressive symptoms in mania or hypomania, and manic or hypomanic symptoms in depression. So instead of feel-good (euphoric) manias and hypomanias, we are talking feel-lousy (dysphoric) manias and hypomanias. Instead of plain vanilla depression, we are talking about agitated depression. Whether mixed depression or mixed mania, we are referring to states that resemble road rage.

    Kraepelin made a clear split between manic-depression and what he termed dementia praecox (later changed to schizophrenia). These days, although not a mood disorder, schizophrenia may be conceived as occupying a place on the spectrum. The connecting link is psychosis, a state common to both bipolar and schizophrenia, as well as (less commonly) in depression. In addition, people with bipolar may have difficulty thinking clearly, even when not exhibiting mood symptoms. Conversely, depression is common to those with schizophrenia. The controversial diagnosis of schizoaffective disorder may be regarded as a hybrid, bridging the gap between the two illnesses.


  • As well, the spectrum may be viewed as illness meeting temperament, or state meeting trait. At what point, for instance, does a naturally upbeat disposition become a pathological mania? And what happens when an upbeat individual gets depressed? Do mixed states result?

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    Unfortunately, the DSM-IV does not take the spectrum into consideration. It is totally clueless regarding the fine points of cycling and mixed states. The DSM lumps recurrent and chronic depression together into a unipolar entity, instead of merging recurrent depression into bipolar. Moreover, it only recognizes mixed states where full-blown depression meets full-blown mania, totally ignoring the reality of mixed hypomania and other variations.

    As for schizoaffective, confusion reigns supreme.

    If your psychiatrist or therapist mistakenly treats the DSM as the bible, then he or she may not have accurately dialed in your diagnosis, with profound implications for your treatment. A new edition of the DSM is scheduled for 2012, but there is no guarantee that this installment will get it right.

    "Know thyself." Now, more than ever, your life is riding on it.

Published On: October 01, 2008