Forget Bipolar - We're Really Talking About Cycling Illness

I'm head down-ass up replacing my old bipolar diagnosis articles on mcmanweb with new ones. Following is an extract from one of my drafts ...

When I step out of the house, I go through the same mental checklist as everyone else - keys, wallet, phone, on and on. But I'm also performing a systems check on my brain. This sort of thing runs in the background all the time, but when I'm headed out the door the exercise assumes a quality of anal high drama, like a shuttle launch countdown ...

Make sure my head is screwed on right.

Ha! If people only knew. I live with bipolar. Most of the time I go about my life as if I don't have it, but that is only because I take nothing - including an operational brain - for granted. Breathe! I remind myself. All systems go. I'm ready to face the day.

It's Really All About Cycling

Bipolar is entirely the wrong term for my illness, your illness. "Cycling" is far more apt, suggesting the brain in perpetual motion - moods, thoughts, perceptions, everything - nothing standing still, everything shifting, nothing predictable.

But is there there anything up ahead I can at least anticipate?

Day slips into night, the moon waxes and wanes - my brain is a veritable I Ching. I may head out into the world cool, calm, and collected, but will my brain be working for me two hours from now when it really matters? I already know what I'll be like on the way home, a wrung-out dish rag, too spent to stop off at Trader Joe's. Is there enough food in the fridge?

Breathe! I remind myself. Breathe.

Way back in 1854, the French psychiatrist Jean-Pierre Falret came up with "la folie circulaire" (circular insanity) to explain the extreme mood changes he observed in his patients. The pioneering German diagnostician Emil Kraepelin coined the term "manic-depressive insanity" to describe what he saw as a much wider and more complex phenomenon. Nevertheless, cycling was a central piece to the puzzle. In the 1921 English translation to his classic "Manic-Depressive Insanity," Kraepelin describes the illness as including "the whole domain of so-called periodic and circular insanity."

What we call bipolar is an enormously complex illness, but strip it to its most essential element and what we're left with can be best described as a "cycling illness." Simply knowing that we have ups and downs is not sufficient. What we need to know is how these ups and downs relate, what is driving them, and what else is interacting with the dynamic.

Our "episodes" (depressed, manic, hypomanic, and mixed) only make sense in the context of the cycle that propels them. Is our hypomania (mania lite), for instance, a prelude to a crushing depression, or is it a warning that we are about to get swept up in a full tidal mania?

And what about the type of things that play havoc with our cycles, such as staying up all night to complete an assignment or cross-country travel?

In the second edition to "Manic-Depressive Illness" (2007), Goodwin and Jamison make it clear we are talking about more than one cycle, from the glacial pace of the shifting seasons to daily circadian rhythms. Kraepelin emphasized that there was a lot more to cycling than just mood, including intellect and volition, and not necessarily in sync. This would account for seemingly exotic but in fact fairly common variations to our moods such as "excited depressions" and "inhibited manias."

Let's rephrase: We are talking many cycles, not just one. Cycles within cycles, if you like. Throw any one of them out of whack and there goes your precision timing, your sense of being in control. Then life becomes a mad scramble, like juggling spinning plates. Inevitably, it happens - the plates crash to the floor. But always in a perverse slow motion that gives you just enough time to make the horrible realization - yet once again - that things have slipped away from you. And there you are, alone in the awful bitter aftermath, left to pick up the pieces.

The People’s DSM: My Alternative Bipolar (Cycling) Diagnosis - Part II

As opposed to depression, a highly-complex illness that clinicians dangerously over-simplify, one can make a strong case that bipolar is far more simple than it looks. Change the name to “cycling illness” characterized by “phases” rather than “episodes” or “states,” borrow what’s relevant from what we already have for depression, fill in the blanks with a little bit about what “up” looks like, and stop right there.

Indeed, my first installment did just that. When stripped to essentials, cycling illness is basically a pattern of down and up. And since we tend to be down way more than we are up, it’s fairly accurate to say that cycling illness is depression with speed bumps.

“Up” is anything that contrasts with down. You don’t have to be dancing on tables. “Normal” or “better than normal” will do, so long as it shows you have a depression that is not standing still.

Complex depression, simple illness. Simple, really.

Okay, “up” needs to be explained a lot better than what you find in the current and highly antiquated DSM mania/hypomania symptom list. You can have racing thoughts, grandiosity, pressured speech, and all the rest, but are you feeling great or feeling lousy?

The DSM doesn’t tell you. Can you believe it? Myth has it that we’re supposed to be feeling like Leonardo DiCaprio with Kate Winslet on the bow of the Titanic (or vice-versa), but too often we’re more like Kim Jong il on a bad hair day.

Depression with a power surge, in other words. “Dysphoric” mania/hypomania, as opposed to “euphoric,” which I laid out in full in Part I.

Another way of looking at it is our depressions and manias are mixed. Hence the need for this Part II exercise. Think of dysphoric mania/hypomania as the cycle gone crazy - out of phase, so to speak - with both up and down screaming for attention at once. One is crashing down the door while the other hasn’t yet left the building.

How much depression inside mania/hypomania do you need? Only enough to turn euphoric mania/hypomania dysphoric. No need to count symptoms. Simple. Do we even have to add the specifier, “mixed,” to dysphoric? No. It’s totally redundant. Then again, maybe we better, thus:

1. MANIC PHASE, DYSPHORIC (MIXED)
2. HYPOMANIC PHASE, DYSPHORIC (MIXED)

Meanwhile, over on the other side of the diagnostic divide, we already have “agitated (or mixed) depression with mania” (which we would include on this side of the divide, as well, without specifically having to spell it out). In some cases agitated depression may appear difficult to distinguish from dysphoric mania/hypomania, but, hey, this is life in the real world. Depression and mania co-exist on the same spectrum, and, contrary to what the current and future DSM would have you believe, the two overlap. One bleeds over into the other. They don’t separate for the convenience of clinicians in a hurry.

Finally, what about situations involving say just two symptoms of mania combined with just three symptoms of depression? Going by official DSM criteria, you are healthy. Except for the fact that you are feeling rotten. Fortunately, The People’s DSM is not anal about symptom counts. Problem solved.

Dare we get more complicated?

Coming soon: We get more complicated. In the meantime, your feedback is strongly encouraged. Comments below ...

Trick Question: Bipolar vs Cycling

The term, bipolar disorder, is used to indicate the duality of the illness: depression at one end and mania at the other. True or false?

True - uh false. No true. Maybe. Never mind. No, wait ...

In the second edition to "Manic-Depressive Illness," Goodwin and Jamison point out that while bipolar is useful to help explain "the coexistence of opposites," just as important (perhaps even more so) is "cyclicity."

A major drawback to the "bipolar" way of looking at things, the authors point out, is that we tend to separate out the dimensions of the illness with no attempt investigate how they tie in together.

Cyclicity is all about the dynamics of the illness, how two apparently unrelated features - depression and mania - relate. In 1854, the French physician Jean Pierre Falret coined the term, "la folie circulaire," in recognition that depression and mania were not separate illnesses, but different manifestations of the same underlying circular phenomenon.

One state, in effect, predicted the other, and back again.

A cyclic view encourages clinicians to investigate their patients over long periods of time and thereby help predict the future course of their respective illnesses, with a view to improving the outcome. For instance, a clinician treating depression needs to anticipate the likelihood of mania, and vice-versa.

In short, it is probably more useful to treat the cycle rather than the symptom of the day.

A few weeks ago, I had a conversation with a brain scientist at the American Psychiatric Association annual meeting in San Francisco. She told me that they do not have an animal model of bipolar. In other words, they have yet to figure out a way to get a lab rat to behave like a bipolar patient.

Wait a second, I interrupted. We can give rats methamphetamines to make them manic and psychotic. We can give them forced swim tests and foot shocks to induce them into learned helplessness (roughly equivalent to depression).

Yes, she said. But we can't do it in the same rat.

Oh, I said.

Technically, we can induce learned helplessness in the little guy before we feed it meth, but that's not going to teach us how we (humans, that is) cycle from one extreme to the other. We have yet to come up with a way of making the rat cycle. And cycling is the key to understanding bipolar, she informed me.

You know, I knew this all along, but suddenly the light bulb went off.

Oh, I said again, or something equally intelligent.