This post was edited and updated on June 24, 2013, to address comments received from readers. I thank them for their input.
. . . . . . . . . . . . . . . .
DSM-IV’s criteria for a manic episode are given below:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high potential for
painful consequences (e.g., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
D. The mood disturbance is sufficiently severe to cause marked impairment in
occupational functioning or in usual social activities or relationships with others, or
to necessitate hospitalization to prevent harm to self or others, or there are psychotic
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication, or other treatment) or a general medical condition (e.g.,
Note: Manic-like episodes that are clearly caused by somatic antidepressant
treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count
toward a diagnosis of Bipolar I Disorder.
The manic episode is an important part of the DSM system because it acts as the basis for a diagnosis of Bipolar Disorder. DSM lists several variations of Bipolar Disorder, each with its own specific criteria, but in general, if a person has had a manic or hypomanic episode, he has bipolar disorder.
Let’s take a look at criterion A. This criterion calls for a distinct period of abnormally and persistently elevated expansive or irritable mood, lasting at least a week… The DSM defines elevated mood as: an exaggerated feeling of well-being or euphoria or elation. Expansive mood is defined as a lack of restraint in expressing one’s feelings, frequently with an over-evaluation of one’s significance or importance. Finally irritable mood is defined as being easily annoyed and provoked to anger.
So the very basis for a diagnosis of Bipolar Disorder is either feeling particularly good about everything or feeling particularly grumpy and angry. How can the same illness manifest itself in such completely different ways? And bear in mind that these are not relatively trivial, incidental aspects of the so-called illness. These are the defining features. The very essence of bipolar disorder – according to DSM – is an episode of profound happiness or an episode of profound grumpiness and irritability. This is indeed a strange illness.
But let’s move on to criterion B. This provides a list of seven specific “symptoms,” three of which must be present for a positive diagnosis. (Incidentally, if the mood problem in criterion A is “only irritable,” then four items are needed from the list.)
This practice of providing a list of symptoms and specifying how many must be present in order to provide a diagnosis is very common in DSM and raises obvious difficulties. First is the arbitrariness of the number chosen. Why three? Why not two or four? The answer, of course, is because the APA says so. The second objection is that different groupings of three will generate very different presentations. For instance, a person meeting criteria 1, 3 and 4 will be grandiose, overly talkative, and somewhat scattered in his choice of topics. Whereas a person who meets criteria 2, 5, and 7 will be sleeping very little, very distractible, and will be maxing out his credit cards in unrestrained buying sprees. The notion that these two presentations are in fact manifestations of the same illness is untenable. This is particularly so in that the only justification for this position is that the APA say so.
A more important difficulty stems from the question: Why should these problems be considered indications of illness? Let’s look at each of the so-called symptoms in turn.
1. inflated self-esteem or grandiosity.
In this context it is worth noting that one of the “symptoms” of a major depressive episode is “feelings of worthlessness…” So if you haven’t got enough self-esteem, you’re depressed, but if you have too much, you’re manic. This raises the question: how much self-esteem is OK, and how much (or how little) is pathological? Who decides? In practice, of course, intake workers at mental health centers and hospitals make the decision, and the decision-making is intrinsically subjective and unreliable. In an informal way, we have all encountered individuals who are “full of themselves” to an obnoxious degree. Intuitively we attribute this kind of behavior either to an attempt to mask a marked sense of inferiority or to poor socialization training during childhood. The notion that this character trait is really a symptom of an illness is an extreme position for which the APA offers no proof. Indeed there isn’t even an argument. The APA simply says so.
2. decreased need for sleep…
This is a complex subject. A great deal has been learned about sleep but much remains unknown. Sleeplessness might well be an indication of some neurological damage or illness, but might on the other hand be simply a reflection of individual differences. There are numerous reports in history of prominent individuals who managed perfectly well on four or five hours sleep each night. Others need eight or nine. It would require a neurological examination to determine if a particular sleep pattern were pathological or a variation of normal. But even if a pathological condition were established, this would indicate a neurological condition, not a so-called mental illness. It is also worth noting that a “decreased need for sleep” very often is nothing more than excessive intake of caffeine or other stimulant drugs.
3. more talkative than usual or pressure to keep talking
We’ve all encountered individuals who talk too much – who hog the conversation. This phenomenon is best conceptualized as rudeness, i.e. a disregard for the normal conventions that direct social intercourse. This particular form of rudeness is usually the result of poor training during childhood. Small children sometimes talk excessively and try to dominate social relationships in this way. If steps are not taken to train them towards a more give-and-take approach to conversation, they often carry this trait into adult life.
4. flight of ideas or subjective experience that thoughts are racing
DSM defines flight of ideas as: “A nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli, or plays on words. When severe, speech may be disorganized and incoherent.”
It’s clear from this definition that the real issue here is not so much flight of ideas as flight of speech. Most people in fact experience flight of ideas on a fairly regular basis. It’s called stream of consciousness, and it flows like a babbling brook, swishing and eddying around twists and turns, over rocks and sand banks, endlessly changing and shifting. Even as I write these words, for instance, my thoughts have flitted to actual streams and rivers I have known. The problem is not that the person experiences a bewildering array of successive ideas, but rather that he puts these ideas into words. Most of us learn to censor stream of consciousness material at an early age and to confine our speech to items that have meaning and relevance for our listeners. A small number of poets and song-writers have managed to make a good living by dispensing with this kind of censorship, but most of us confine our verbal utterances to those ideas that have cogency and relevance for others. We call it discipline or self-control. Once again, it is lacking in small children whose early speech does indeed reflect stream of consciousness material. Proud parents are usually delighted with this initially, because it represents a major developmental breakthrough. Most parents, however, fairly soon begin the process of training and coaching that results in what we would call normal speech. If this training does not occur or is thwarted or frustrated for whatever reason, then the individual grows up without acquiring this skill. As with many skills normally acquired in childhood, it can be extremely difficult to learn in later life.
This facet of the manic presentation then is best conceptualized as a deficit in training and socialization, rather than a symptom of a medical condition.
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
This is essentially the same thing as the flight of ideas discussed above. The effect of splitting this phenomenon into two separate “symptoms” is to increase the likelihood of a positive “diagnosis.” Remember, it takes three (or more) symptoms for a diagnosis. If a person displays flight of ideas, he will almost certainly also meet the criteria for distractibility. So you get two hits for the price of one. The primary purpose of DSM is to generate business for psychiatrists.
6. increase in goal-directed activity (either socially, at work, or school, or sexually )or
Most people would probably see an increase in goal-directed activity as a good thing. Painting the garage or mowing the yard is better than vegetating in front of the television. But this is not quite what the APA has in mind by “goal-directed activity.” Elsewhere in the text they describe goal-directed activity that is “excessive” and as examples they mention: “ taking on multiple new business ventures…without regard for the apparent risks…,” “…calling friends or even strangers at all hours of the day or night…;”
“…writing a torrent of letters on many different topics to friends, public figures, or the media.”
It is clear that the real issue here is not goal-directed activity as such but rather irresponsible and inconsiderate activity. Once again, responsibility and consideration for others are attributes that we acquire during childhood through the normal methods of parental discipline, coaching, role modeling, etc.. When we see a person displaying a marked deficit in these areas the most parsimonious assumption is that his/her training and discipline in these areas was for some reason neglected or deficient. The notion that the person is ill is certainly not obvious. The APA offers no proof or even arguments for this position.
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g. engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Once again, what’s involved here is what most people would call irresponsibility: the kind of behavior we try to discourage in our children through the normal time-honored methods of discipline and example. The notion that these kinds of irresponsible and self-indulgent behaviors are in fact caused by a diagnosable illness is quite a reach. Bipolar disorder, like most of the other DSM diagnoses, is not something a person has, but is rather something that a person does. It is constantly presented by the APA, and by practitioners in the field, however, as something a person has (like diabetes) and something that is best treated with drugs.
I realize that many people reading this post will say that I’ve got it all wrong – that I’ve misrepresented the reality of the condition called bipolar disorder. They might say that people with this “diagnosis” are “crazy” – not just irresponsible or self-indulgent. And there is a measure of truth in this. Some of the individuals who are assigned this label do sometimes behave in a “crazy” fashion. But it’s important to note that in the DSM, this aspect of the matter – “psychotic features” – is included almost as an afterthought. It is not one of the defining features of a manic episode. Rather, it is something that may be present.
What the APA is doing here is trying to have their cake and eat it too. By including the possibility of psychotic features, they create the impression that this is a very serious matter; but by not making psychotic features a requirement, they manage to extend the diagnostic net to include people with relatively mild problems.
I will discuss psychotic features in later posts on the topic of “schizophrenia.”
The fact that lithium has a calming affect on individuals who behave in this manner is often cited as proof that the behavior in question really does stem from an illness. The logic is untenable. A couple of beers can be very effective in helping shy people overcome their inhibitions. Very few rational people would conclude from this that shyness is an illness and alcohol a “medication.” In addition, lithium has a calming effect on all people – not just those who carry a diagnosis of bipolar disorder.
Lithium carbonate is a salt – found widely in nature – and until 1949 was sold openly in the United States as a substitute for table salt. Besides having a salty taste, lithium salt has a calming effect on people’s behavior. With regards to the latter, the mechanism of action is unknown. There have been numerous proposed theories, but none has produced conclusive evidence or gathered much support.
In some respects the shyness/alcohol analogy mentioned earlier is even more apt. The chronically shy person can acknowledge his problem and take corrective action using the normal time-honored methods of effecting personal change. Or he can simply drink a couple of beers before every social situation. Either solution to the problem will work. Similarly the manically irresponsible person can acknowledge his problem behaviors and tackle them in the normal way – or he can take lithium carbonate. The latter is often quite effective in dampening the behavioral excesses, but like the alcohol, it also has some long-term side effects.
The central point of this and my earlier posts is that there are no mental illnesses. There are problems of living – problems that human beings encounter, sometimes resolve, sometimes live with. The so-called mental illnesses are an attempt to explain or understand these phenomena, but as explanations they are spurious, unhelpful, and indeed, counter-productive. They are merely labels.
A perfect analogy to the mental illness explanation of human problems is the phlogiston explanation of fire or the witchcraft theories of illness and crop destruction. The popularity of a concept is often independent of its validity. The phlogiston theory of fire is a good example. This theory, which held sway among scientists during the 1600’s and most of the 1700’s, maintained that combustible objects contain an element called phlogiston which was released when the object was burned. Non-flammable objects simply didn’t have this substance. Towards the end of the 1700’s evidence was gradually amassed to debunk the theory in favor of the oxygen-combination ideas of today. Many scientists, however, including Joseph Priestley (the discoverer of oxygen!), tried to cling to the older theory. Similarly, in former years, sickness and crop failures were often attributed to witchcraft. Here again, we have a spurious theory, i.e. that sickness and crop failures are caused by the actions of these so-called witches. Such thinking – back in the days – was very widespread, and witch-burnings were popular events. But the concept was nonsense, and today, thanks to science, we have a better understanding of the causes of illnesses and crop failures. Popularity is a very unreliable barometer for conceptual validity. Phlogiston doesn’t exist. There’s no such thing as witchcraft. And there are no mental illnesses. Fire, however, does exist. Crop failures and illness are realities. And human problems of living are real. People are complex and diverse and the problems we encounter on our journey through life are also complex and diverse. Some of the problems we meet are relatively minor and easy to deal with. Others can be truly overwhelming. Some are indeed medical problems and require medical help. Others do not.
The so-called mental illnesses are problems that do not require medical help. The medicalization of all human problems of living is as spurious as the phlogiston and witchcraft theories mentioned earlier. It is also counter-productive. Drugs are not an effective solution to life’s problems any more than the burning of so-called witches was a solution to crop failures or illness.
The medicalization of all human problems is about turf. The American Psychiatric Association is the psychiatrists’ trade union, and has as its primary agenda the promotion of its members’ interests. There’s nothing intrinsically wrong with this – all trade associations do the same. That’s why they exist. The problem with the APA, however, is that they have been so successful. At the present time one would be hard pressed to identify any problem of human living that is not covered by a DSM “diagnosis.” The purpose of these diagnoses is to legitimize psychiatric intervention and the prescription of drugs in any and every human problem.
At the risk of repetition, I am not saying that people should not use drugs. It is not for me to tell people what they should or should not ingest. These are decisions that people have to make for themselves. What I do object to, though, are the spurious notions that these pharmaceutical products are medicines, and that they are being prescribed to combat illnesses.