Firstly, sudden onset problems are a common feature of human existence. A great many of the mass shootings that have occurred in recent years would fall under this rubric. Similarly, temper tantrums are often described as having arisen “out of the blue.” And at the group level, prison riots have been known to occur at times when the facilities had seemed particularly peaceful.

Implicit in your question is the notion that if the problem arose suddenly, then it can’t be the product of deficient socialization during childhood. I don’t think this position is tenable. Consider the analogy of earthquakes. All reputable scientists today are in agreement that earthquakes are caused by the very slow gradual movement of the Earth’s tectonic plates. Yet the actual earthquake is a sudden, virtually unpredictable, event. Human beings are a great deal more complicated than tectonic plates, and in my view it is not only possible, but indeed likely, not only that sudden onset problems occur, but also that they might be causally related to the gradual processes of earlier learning.

Consider, for example, the case of a small boy whose parents indulge his every whim. He is raised to think of himself as a “prince.” He is not required to do chores or make sacrifices. All the good things of life come his way just for the asking. Then he goes out into the real world and encounters resistance, hardship, adversity, etc.. Now whilst it is not possible to predict the outcome of this encounter in individual cases, it is certainly easy to imagine that sudden onset problems might develop. But it is also easy to see that the problems didn’t really arise “out of the blue,” but were the likely outcome of the child-rearing policies of the parents.

The general question of small gradual changes over time resulting in a sudden major change is addressed in a mathematical system called catastrophe theory. This was developed around 1970 by Rene Thom (1923-2002), and was applied to social/psychological systems by Erik Christopher Zeeman (1925–) during the 70s and beyond.

Your question raises another implicit issue. And that is the quality of information. The mental health system is notoriously poor at gathering information. Almost all client information that enters the system is by self-report. So when a client tells a psychiatrist or other mental health worker that a problem arose “out of the blue,” there is a very strong tendency to believe him and to enter this “fact” as “data” for both clinical and research purposes. The reality, of course, might be quite different. With specific reference to the problem known as Bipolar Disorder, the presence of “mood swings” is generally considered definitive. This is typically assessed by an intake worker simply asking “do you have mood swings?” If the answer is yes, then a “diagnosis” of Bipolar Disorder is almost inevitable, though there is seldom any attempt made to elucidate exactly what the client meant when he said “yes” to this question. I have often explored this matter with clients, and in my experience, what they almost always had in mind when they said “yes” was the presence of frequent temper tantrums. Now in my view, temper tantrums are innate. I have seen very young babies develop extreme temper tantrums when their needs were not being met, and one of the great challenges of parenting is inculcating more moderate ways of dealing with the experience of frustration and of feeling attacked. The fact that society works as well as it does is tribute to parental success. But the fact that tragic outbursts of rage still occur quite frequently suggests that parents (or at least some parents) need more help/coaching. Within the mental health system, however, the only “help” given is a drug for the “patient.”

In writing the Bipolar post I was trying to show how the various “symptoms” are in fact behavioral problems stemming usually from some deficit in the child-rearing area. This is a sensitive topic. Most parents take their parenting responsibilities very seriously, and are sometimes irritated and even angry at the suggestion that their performance in this area was anything less than stellar. I think there is a great need in our society to lift this taboo, and to create more opportunities for parents to acknowledge their difficulties and deficits and to receive real help/support/coaching, etc.. I don’t believe that our present mental health system, dominated as it is by pharmaceutical and APA interests, is capable of providing this kind of help.

So, once again, thanks for your comment. I hope I have addressed your question adequately. If not, don’t hesitate to get back to me.

“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.”

And I wondered how this might fit with suddon onset symptoms? If, prior to the onset of the “manic episode” there were no problems with the “skills normally learned in childhood” – what then accounts for symptoms?

Curious as to your thoughts, and looking forward to your response!

One of the reasons that I find the whole mental disorder/illness model troubling is that it ignores the role that nutrition plays in everyday life. We are fundamentally biological organisms, and all of the higher functions are based on and sustained by biological structures and mechanisms, which in turn are sustained by nutrition.

Remembering, thinking, feeling, paying attention, etc. are all negatively impacted by poor nutrition. Yet this area is almost never explored in mental health assessments. In most mental health intake work a genuine exploration of the client’s problems and concerns is seldom addressed or pursued.

Once again, thanks for your interest and for the important work you are doing.

Also, are you familiar with the work of Tom Wootton? His soon-to-be-published book “Bipolar In Order” appears to me to have a number of parallels to your philosophy. His web site: http://www.BiPolarInOrder.com

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).

The implication here is that there are significant fluctuations in behavior and that these fluctuations constitute a major component of the “illness.”

What needs to be recognized, however, is that virtually everybody experiences fluctuations in behavior and reported mood. Think of any behavior whatsoever and ask yourself how often do you engage in this activity. Almost always, the answer will be: with varying frequency. Even avid golfers will occasionally take a day off – or even a week or two. Most heavy drinkers have bouts of abstinence. Career criminals don’t go out burgling every night. And so on.

Similar things can be said about mood. Very few people report feeling the same every day. Most of us have up days and down days and even up weeks and down weeks. But we conceptualize these mood and behavioral swings as a normal part of life – something that we just have to deal with.

The standard mental health response here, of course, would be that the fluctuations involved in the so-called bipolar disorder are much more extreme than the normal day-to-day fluctuations described above. This immediately raises the question of measurement. Now one can certainly envisage a behavioral protocol for measuring any particular facet of behavior or reported mood. (In fact, several such protocols exist.) One could use such protocols to measure/assess individuals who present themselves for mental health treatment. The difficulty, however, is that such measurements almost always produce an unbroken continuum of results. If, for instance, the rating scale yielded results between 1 and 100, it is likely that all possible scores will be represented and that the distribution will be more or less bell-shaped, i.e. bunched towards the middle, sparse on the edges. (Some behavioral measures yield dichotomous results, e.g. murderers vs. non-murderers, but most behavioral measures are continuous.)

Now we’re talking about fluctuations in behavior or reported mood. But the general concept is the same. The human population does not divide neatly into those who do experience fluctuations in mood and those who don’t. Rather, there is a continuum in this area as in others.

This is a problem with DSM generally – the shoehorning of continuous data into an overly simplistic yes/no format. It is a problem incidentally which the APA openly acknowledged in the introduction to DSM-IV (p xxii).

It was suggested that the DSM-IV classifications be organized following a dimensional model rather than the categorical model used in DSM-III-R. A dimensional system classifies clinical presentations based on quantification of attributes rather than the assignment to categories and works best in describing phenomena that are distributed continuously and that do not have clear boundaries. Although dimensional systems increase reliability and communicate more clinical information (because they report clinical attributes that might be subthreshold in a categorical system), they also have serious limitations and thus far have been less useful than categorical systems in clinical practice and in stimulating research. Numerical dimensional descriptions are much less familiar and vivid than are the categorical names for mental disorders.

Familiarity and vividity seem to me to be poor criteria for such a fundamental decision.

Anyway, to get back to your very interesting and thought-provoking question, my position is that:

1. Most behavioral measures (including all the “symptoms” of a manic episode) are continuously distributed in the population.
2. Most measures of reported mood are similarly continuous. (An exception would be: committed suicide yes/no.)
3. Fluctuations in behavior and reported mood are also continuously distributed.
4. Mental health practitioners are not usually objective. They have been conditioned by the DSM and by the terms of their employment and by their working milieu to find billable diagnoses. So they “see” what they need to see to stay in business and to maintain their professional status.
5. The problem behaviors listed by DSM under manic episode can be very serious problems. The extent to which individuals display these problems varies from person to person and, within a given individual, from time to time. Such fluctuations are normal. Behavioral output at any given moment is a function of antecedent events and the stimulus properties of the presenting situation.
6. In clinical practice temper tantrums are often considered to be instances of manic behavior. People who are given to temper tantrums usually are not raging uncontrollably all the time. They have periods of calm, interspersed with periods of rage. Usually they can identify the incident or event which triggered the outburst. In clinical practice this waxing and waning of rage is often cited as evidence of mood swings, which strictly speaking is accurate. The problem, however, is the raging, not the calm and not the fluctuations. And the raging is due, in my view, to poor socialization training during childhood.

Your question went to the heart of so many DSM issues. I hope I have addressed your question; if not, don’t hesitate to come back.

The history is interesting. Until 1850 or so there was relatively little scientific basis to the practice of medicine. Then the various insights and discoveries from the life sciences began to permeate the profession, and steady progress on a wide range of fronts was made for most of the 20th century. At some point (perhaps the 80’s?) the pharmaceutical companies began to exert influence on the field of medical research, and today I have become very skeptical of any finding published in a medical journal.

On a personal note, I have had serious health problems, including total kidney failure, and have been on dialysis for the past eight years. In that time I have encountered some physicians who were extraordinarily knowledgeable and skilled. Others were ignorant and arrogant. I quite literally owe my life to the medical profession, but I owe many of my current problems to medical errors. So I have become a skeptical consumer.

In America today medicine is a business and healthcare is a commodity. In my view, this stance underlies a great many of the problems we are discussing, and I doubt that we will see significant progress until the basic principles are re-thought and modified.

Once again, thanks for your comment. Your message is important, and I hope you will keep saying it.

They can do it if they want and if people are willing to pay for it (not out of shared funds). They just shouldn’t be allowed to call what they are doing “science.”