Monday, February 1, 2016

Not Just Up and Down -- A New Map for Bipolar


Last week a friend told me she had just been diagnosed with bipolar.  I remember eight years ago when she told me she was finally getting treatment for depression.  I didn't say it at the time, but for the next several days my brain was screaming it: Really?  In 2016 people are still being misdiagnosed, and mis-treated, mistreated with meds that make them worse.  I mean, 


F*cking Really?!!

Lives are at stake here, people.  Careers, families, credit, and yes, lives. That is what people lose when their doctors get this call wrong.

Nancy Andreasen, world prominent researcher of schizophrenia and former editor of the American Journal of Psychiatry once wrote, Since the publication of DSM-III in 1980, there has been a steady decline in the teaching of careful clinical evaluation that is targeted to the individual's problems and social context and that is enriched by a good general knowledge of psychopathology.

What replaced careful clinical evaluation were the damned symptom lists.  The DSM was supposed to make it easier for researchers to talk with each other and check each other’s work.  But when clinicians, the people who treat patients, got hold of the lists, they stopped listening to patients and started comparing us to what we were supposed to look like.  Count the symptoms; assess severity; assign the diagnostic code.

As a consequence, the lists, which were actually rough drafts until DSM-III carved them in stone, turned into circular arguments.  They could never be significantly improved, because when the researchers wanted to learn more about bipolar, they went out and got a bunch of people who already matched what they thought bipolar was.  Deviations were excluded from studies, and so were not able to provide better data.
Downstream from the lab, patents became chained to lists.  We have to learn the language of the DSM, because that is the only language our doctors speak.  Unless we report what matches the lists, our complaints are not heard and not treated; our suffering is not known, let alone addressed.

How many times have I reported to a doctor that my body doesn’t regulate temperature well?  That might illustrate a pattern of difficulty maintaining homeostatsis, like any number of disregulation issues related to bipolar.  But it’s not on the list, and they really aren’t interested.

Shortly before DSM-5 was published, Thomas Insel, director of NIMH declared that treatments for mental illness were just not good enough.  He announced that NIMH wasn’t going to fund research anymore that depended on the damned lists.  It’s time to stop reading the list of features pasted to the car window and start looking under the hood.

Up steps John McManamy to say:
       Look under my hood!

In Not Just Up andDown, John tells the story of how medicine got to such a distorted view of bipolar – the very name of the disorder confuses doctors, patients, and public alike as to the nature of the beast.  He provides his own careful clinical evaluation.  And he proposes a different map to follow to connect the dots.

He tears up the book, looks at the patient, and finds a new way to explain what is going on, exactly what Insel says we need to do.  Finally!  Here is somebody paying attention.

Actually, John goes back to older books.  For thousands of years before DSM-III, people did pay attention.  Well, if you are not blinkered by your presuppositions, bipolar can be hard to miss!

From Galen and his four humours paradigm, through Jean-Pierre Falret with la folie circulaire (circular insanity) describing the continuous pattern of depression, mania, and 'normal' that he observed in his patients,


to Emil Kraepelin's"manic depression," which included the whole domain of periodic distress (including "recurrent depression"), and on to the whole posse of modern experts,





Frederick Goodwin and Kay Jamison who wrote the book, The Book, Manic Depressive Illness,






and researchers Nassir Ghaemi andHagop Akisnal, along with clinician Jim Phelps who all talk about the bipolar spectrum, these people developed their theories by paying attention to what was sitting in front of them, Nancy Andreasen's careful clinical evaluation.



Not Just Up and Down follows this long historical interpretive thread of a long observed malady, that of cycling. McManamy explains the train wreck of DSM-III, with its separation of unipolar  depression from bipolar.  He fails to explain how this radical departure from the observations of millenia (snuck in through a single university's rough draft of symptom lists) has persisted in opposition to the smartest names in the field, from DSM-III's publication in 1980 to DSM-5, thirty-three years later.  But the writers of DSM really need their own diagnostic code, different from the one on which John is working.  I have an idea what that code would be, and who would get it, but in the absence of a careful clinical evaluation...

The major contribution of Not Just Up and Down is the careful tracing of how all the parts under the hood connect to each other and in the lives of real human beings.  We need to start over, Thomas Insel has announced.  McManamy offers up his own map as a start, connecting trauma/stress, sleep, resilience, mood, thought, personality/temperament, energy, anxiety, seasons...

John is an expert patient. He has read all the journal articles, attended all the conferences, knows his science.  And he also knows himself. 

Know thyself has always been John’s mantra.  For those of us who have to live with this thing mis-named bipolar, it is how we can move from surviving to recovery to reclaiming our own most excellent selves.


Oh, and it’s a very funny book.

flair from Facebook.coim
photo of bible in public domain
photo of book burning by Patrick Correia, used under Creative Commons license
book cover from Amazon.com
photo of train wreck at Montparnasse, 1895 in public domain
photo of Socrates by John McManamy, used by permission

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