Not only that, but perhaps as much as, say, 80 percent of anxiety (or its syndrome) traits are diagnosed without a clue as to the true manic component, thus resulting in diagnoses that may treat anxiety but leave the mood swings labile and leave manic symptoms (often unreported and/or unexpressed in 20 minute visits) to do damage through unemployment, spending, gambling, drugs, what have you. Only when nosology relies ENTIRELY on *trait constellations* will diagnoses become reliable. Until then it's a crapshoot, I am sorry to say. What's worse, it seems to this observer that the psychiatric community is worse at diagnostics in this category than the general practitioners, who (in the U.S.) diagnose and treat the vast majority of all mental illness. Not a good way to sail the medical flotilla, frankly. I have spent several years developing an assessment tool that has proven successful in its initial employment (both patient and doctor acknowledged the necessity of the tool to identify previously undiagnosed manic components of obvious bipolarity not easily detectable in short interviews). There is a longer and a shorter tool described in the article linked below, and work proceeds on perfecting a scoring methodology to assist the practitioner. I should add also that the largest group of underdiagnosed bipolars are those who are successful enough to avoid detection either because the traits are thought characteristic or are not triggered in those having greater control over stressors. Poor folk make it far easier to discern symptoms because living in much higher mental and/or physical stress. See also my other comments in group neuroscience under the thread *stress*.

The Bipolar Spectrum: The Joy of Exposure, the Wisdom in Circumspection and the Danger of Isolation

http://ssrn.com/abstract=1652925

thanx a lot Charles Herrman, for your valuable input, to the topic. I have gone through your abstract, its fascinating. I will go though the whole paper in this week. Great you to know your work on developing tools for identification and the debate of categorical vs dimensional classification. Are DSM-v and ICD 11 working groups addressing this issue? Regards

Thanx a lot respected vanessa, INDIVIDUALITY of of a human being is definately very important. LABELLING helps sometime, but stigmatizes the PERSON. In our clinical practice we miss some cases of bipolar, keep treating those persons as only major depression. Your approach is laudible. I totally agree with you that putting persons into categories and giving labels and medicine/therapies to them is irrational. But it helps sometimes to detect some findings which will help in the future management of humans, albeit we keep giving them anti-depressants etc and forget the long term well being of the INDIVIDUAL and his/her whole life and family.

Thank you Vanessa for identifying the most important two reasons why clinicians are behind the 8-ball. I mean no disrespect here, but you must learn to think outside the box for a moment -- recall that in the U.S. it was only from the time of DSM III that correct approaches to diagnosis were finally appreciated as a general proposition. That is not a fact calculated to impress a philosopher. Especially a philosopher specializing in behavioral theory and who lectured college classes in neuroscience from the age of thirteen (true, by the way), and most especially a philosopher living his whole life with variations on severe mental impairment, starting with autism and ending with bipolar.

I know you mean well as a professional, but please allow that you might actually not be perfect. As a philosopher, I am not right simply because with my abilities I have thought a great thought. I am not right simply because I know I have done my best, and am not right simply because I believe my motives are unimpeachable. As a philosopher I am right -- and will justify myself as such -- only when the evidence is in, when empirical evidence and experience make plain that I am indeed right. Being right imposes a HUGE responsibility and can never be taken lightly. Here is a little something your patients may not have told you: clinicians tend to be a little too proud of themselves.

Now to the two points you mentioned, and which are really rather to the point in the discussion broached by Dr. Khan. The first was the matter of an apparent 'bizarre analysis'. And bizarre it assuredly is, Vanessa, for this reason -- the information giving rise to Khune's 'paradigm shifts' is always and necessarily 'bizarre'. Thus the book 'Shadow Syndromes' by Ratey and Johnson was not exactly a best seller in or out of the profession. And their term 'shadow', while an attempt to convey a potent meaning, so much attempts to avoid a 'label' as to be frankly misleading. Their point was my 'bizzarre point', namely, that many people exist undetected, in the sense that they present with 'subacute' symptoms. You might prefer to believe that such subacute symptoms are less undetected than undetectable for not being 'full bore' symptoms. You would be mistaken. The reason why is that we want to look for traits, NOT symptoms. Symptoms are composites of traits, and the reason why there is such a variety of symptomatology and of individuality in these states (bipolar especially) is specifically because there are no fewer than 350 identifiable traits that combine to form a still bewildering array of symptoms, many of which combine nosologically to offer the so-called syndromes of our diagnostic nomenclatures.

The second point you correctly adduce is that of 'labeling'. I am not certain whether you are more upset that I labelled you as uncaring (I did not) or ineffective (which I did, but as a comparative, not as an absolute) or whether I advocated honest labeling for the realm of mental illness. I barely even implied that, but as it is relevant I will deal with it here. We early-on changed from manic-depressive (the correct, true and honest variant) to bipolar (a correct and true, if a little less forthright, rendition). We must face a couple of facts here. First, labels are not always the problem, though they may also make an existing problem more difficult to deal with. Goffman of course took the lead, but here are some other additional matters to address. Second, once labels, originally of odor, are understood and acknowledged valid, and with familiarity, cease to be stigmas, hence, 'labels' in the pejorative sense.

Recall I am bipolar and have no problem with 'manic-depressive'. I have no problem with honesty in general, but then I am a philosopher, for whom truth does actually mean something. And those with whom I have conversed about these matters for years are now of a similar opinion: there is a way to be honest, truthful and straightforward without the worst issues attending stigmatizing labels. I refer in particular to a three-fold nomenclature: 1) Bipolar personality -- where traits we commonly associate with disorder or disease occasionally present in ways that permit a good clinition to identfy them as important characteristics of a person's 'personality'. Many redoubtable types fall into this category. Teddy Roosevelt was this type until some prescient clinicians realized he was well beyond merely 'redoubtable'. He is a perfect example of a guy who escaped notice and diagnosis for so long simply because in power and able to chalk up his antics to his 'personality'. On closer examination he is found to be in the second category 2) the bipolar disorder, in which there is evident potential for dysfunction and at least some empirical evidence of such, if less than a regular occurrence. Note that people in the first two categories are responsible for practically all the important inventions, discoveries and creations of mankind. No, that is NOT an exaggeration. These are TRAITS were are dealing with, and they are widely distributed in the gene pool, but as stress becomes more prominent in our genetic experience so these traits tend to coalesce in stress-coping formats over time. There is nothing wrong with having a bipolar personality. These are really great people, but they do have a propensity to have anger issues, can be haughty and arrogant, are often thin-skinned, and frequently exact horrible vengeance for wrongs done them. They are often divorced three or four times, often are the micromanagers, and on and on. While there may be a legitimate question as to whether they should be medicated, there can be no question as to the nosological features. The point is to get clinicians to recognize them for what they are and to tell patients what they are in an accepting manner. 3) the bipolar disease. You can do the math on that one.

One final remark that may, again, not settle well, but those 'stubborn facts' of William James do haunt us from time to time. I refer now to the Lakalai, a New Britton tribe that Valentine reported on back in 1963. In sum, they, these primitive people, living under constant stress (volcanic island, let alone the lifestyle), took note of a grouping of traits they found in a substantial segment, mainly of the male population. They just happen to be the five leading indicators of what DSM III finally reported to be diagnostic of bipolar disease. Imagine that. It takes a close observer with no training in medicine to detect what few in the modern profession could manage on a regular basis until the 1980's. So please be careful what you 'label' as 'bizarre'. I am not the one who is bizarre, but I am the one who will be proven correct.

The larger of two assessment tools I developed were established from an original 350 traits. The larger tool takes that down to 135, a minimum for proper diagnosis, especially of manic traits that commonly interfere with healthy functioning. How many manic traits can you throw out, just off-hand, Vanessa? Seems to me like we have a little learning curve here.

Again, I mean no disrespect, but my trade is facts, not impressions (except where they create phenomenological facts of import). Honor-based peoples do not believe in mental illness. We, a dignity-based people, are still, in our regular psychology, honor-based enough that we often enough refuse to so much as consider psychological (let alone psychiatric) intervention. That is the preeminent reason for the issue with labels. We need a national campaign of awareness, and that campaign will only be successful when we face the uncomfortable truths but face them in a way that is both accepting and realistic. Bipolar traits need not be stigmatizing, only their agglomeration into negative constellations that are otherwise considered 'symptoms' of disorder or disease.

I apologize for so long a comment, but you will appreciate the need to explicate at length on approaches that are off-center.

Thank you, Vanessa, your considerate and generous response demonstrates the attitude that will win converts to the paradigm shift in which all will breathe better and live happier, healthier and wiser. The highest perfection in any office, but especially of the professions, is accountability. Alas, it is but human nature that once ensconced in power, respect, position and pecuniary rewards, we do so tend to presume to *deserve* the emoluments granted for the purpose of compensating our devotion to the grantees of the office, the beneficiaries for whom these offices exist. The simple term nicely covering the ideal as also the cure for the present malaise is a pretty little thing: stewardship. I have spent a lifetime doing original theoretical work on this wonderful concept, and for that I count myself blessed.

The paradigm shift of which I speak is primarily one of education predicated upon a sincere devotion and desire to improve the lot of humankind. We must find the ways by which people can face, accept and consummate happiness within the context of reality. We must learn that labels have reasons and their dangers can be minimized without the sacrifice of the honesty necessary to face reality wisely. Otherwise, avoiding labels because they might "hurt" or "offend" can all too often become an excuse to avoid the difficult tasks of properly educating ourselves and our clients, patients, and citizens. The education we all need, professionals and lay alike, is that as creatures we possess marvelous mechanisms devolved to assist us in dealing with exposure, but which can in various ways present as disfiguring characteristics that may become patently dysfunctional and even dangerous.

We must also become less afraid of drug therapy without slackening our demand that pharmaceutical companies accept the normative stewardship of their allotted roles in society. They serve an indispensable function but when the executive ranks think they own the company or that they exist only for shareholders, they have announced the denial of stewardship. When they collectively refused to give notice that some neuroleptics might cause long-standing negative changes they were acting cavalierly, but felt themselves parental gods dictating that their products were so much the gift of a god that any sacrifice was too little thanks to these great people. What hogwash all this is.

And also how complex a morass is the task before us! Look at practitioners who cannot afford malpractice insurance. It is not really their fault as much as the politicians' and legalists'. We require a degree of tort reform so that people can exercise stewardship responsibilities with less fear of punishment, and yet where punishment is indeed the order of the day, it must fit the wrong and be just for all concerned. We live in far too litigious a society in which fear of liability is yielding absurd consequences that no one appreciates. Ignorance tends to result in the same, of course.

So I truly appreciate your help in all of this, Vanessa. Together we shall face up to our common challenges and present ourselves as the 'white knights' for our patients and professions. All of us, together, without condescension in either direction.

Thank you again

Dr. Khan, thank you for your encouraging remarks.

I have yet to look through the new DSM-V but the articles I have read regarding its development and aims do not offer solace, indeed suggest a step in the backward direction which I hope was merely negative thinking on the part of the reviewers.

I do also want to indicate that the article you will be reading is now just one year old and the assessment tool has been profitably modified. As it affected only one page in the paper I didn't go to the effort of a full revision which I intend to do at some point this year. Therefore, if you wish to see the present improved assessment tool with the latest considerations as to normative scoring methodologies, please indicate such (perhaps you have an email add. on this site?).

I look forward to your comments.

respected charles and venessa, thanx a lot for your time and valuable input to my knowledge. As a clinician I observed patients, some of the families even three generations are my patients. I observed that some of my patients of depression develop full maniac episodes, so was interested in learning. your observations on INDIVIDUAL and PERSON are remarkable. I learned today from one of my psychiatrist friend that DSM-v is a step backwards, you also mentioned that....is it so? regards

I have a little treat for you today, one that Rana and Vanessa will assuredly appreciate. It comes with lessons attached, which I shall briefly mention by way of introduction. The psychiatric community, especially in America, has nursed a rather regrettable disposition toward a know-it-all attitude that frowns on fringe theories and experiences, whence the very late start in accepting Kraepelin and then again to Meyer. Too many in today's trendy scholarship look condescendingly at work over five years old. Well, if you are in the one-upmanship business of gaining the latest advance in every detail, I suppose that is only fitting, but even so it renounces valuable observations by many gifted workers. Problem is, it takes true intelligence to determine what is worthy and what is not. I find that too few in the lofty professions actually possess the gritty intellect required to really handle what their professions properly demand. I offer you snippets from an OLD series edited by Flack. Each of the several volumes was a collage of articles individually published in journals throughout the eighties. All together it is a gem. Series title: Directions in Psychiatry Monograph Series.

From vol I., by Myre Sim "Psychiatric Diagnosis" --

Of one (of many) patient he records "was originally labelled as suffering from manic-depressive psychosis. Two days later he was hallucinating and showed the features of a well-established schizophrenic illness. A few days later he was again manic, joking and punning, very much in contact, and with an infectious sense of humor."

I mentioned that we want to observe TRAITS and not symptoms. Here is why. Who will be prepared to assert humor and punning and laughter as SYMPTOMS? No one. But in the context of mania, they are indicants and Myre correctly identifies them with an astuteness lacking in far too many of today's clinicians. Recall this is in the eighties! These are traits. Here's an eye-opener for you. Laughter and off-color jokes serve several functions not least of which is to modify exposure reactions by at once identifying AND distancing from them. Why do babies laugh and cry almost contemporaneously? Here you are. These traits are serviceable in dealing with EXPOSURE. They are conveniently categorized as confronting it, avoiding it or coping with it (the latter embraces a range of traits we typically diagnose as OCD, anxiety, panic and so on). And by the way, one indication that Lincoln was bipolar and not merely depressive is the large array of coincidental traits that together spell a VERY distinct and organized definition of MANIA. What was that about his reputation for bawdy stories??????? You have to use a brain and you have to escape from rigid conventions when and to the extent they rob you of your freedom to see and experience honestly. Be a philosopher in attitude and a professional in responsibility and you will likely be a godsend to your patients.

From vol. IV, by Louis Linn "Individual Psychotherapy for Schizophrenia"

"In general, it may be said that the solitary hunting mode seems best adapted to a jungle environment in which visibility is limited and large prey relatively scarce.... On the other hand, when it comes to hunting in the open plains...group hunting strategies work best and animals that are more sociable in their relationships are more successful here." He goes on to describe Jung's introversion-extroversion binary and also asserts (correctly) the 'cat people' v. 'dog people' cliche. He goes on:

"It is my hypothesis that, when the extroverted type becomes psychotic, he is more likely to manifest symptoms of the affective disorders, and that when the introverted type becomes psychotic, he usually manifests the symptoms of schizophrenia." I will add as well that I once remarked in liberal company with a child psychiatrist present that Asperger's would one day be recognized as the 'garden variety' of schizophrenia and he tried publicly to embarrass me. He should learn to respect his intellectual superiors. I have been proven almost totally correct if we accept the FDA-approved schizoid drugs as the treatments of choice. But let's go still further. While psychic episodes in Asperger's cases will be reliably schizoid, I have noticed even in books for the public that such individuals are frequently introduced and treated as full schizophrenics. In fact, let's allow room for theory here. Asperger's manifests general features of autism and was initially categorized as 'high-functioning autism. But autism is a mishmash, a manifesting stem cell, as it were, of both Asperger's and bipolar. This will be seen the moment we start treating the theoretical view as per exposure theory discussed above. One study suggested that some 40% of autistics turn out bipolar. It did not mention Asperger's but probably should have. Combine these tidbits with the first excerpt and we will observe in the Asperger's person what in ordinary behavior are a composite of manic and pre-emtive depressive traits. Treatment hinges on treating the schizoid base but also the comorbid mania, and psychotherapy is also very much advised in my opinion.

And a note of caution that only re-asserts a former admonition. Bright people often are bull-headed, wrong-headed and cocky. The good Dr. Sim was quite upset that DSM-III eliminated homosexuality and felt that PTSD was politically motivated - but did, correctly, indicate that its symptoms are a melange, which they are. They present together the dreamscape, the pre-emptive schizoid attack modes, and much of the manic spectrum.

And also I should add, just as a bit of humor, I am available for teaching abroad for extended periods. You could do worse, I assure you. Of course I expect laughter from any American school, but there are honor-based cultures that respect success and intelligence regardless the provenance and these may hopefully have escaped some of the institutional roadblocks imposed by the attempt to own content and escape from accountability. The school accepting me will get credible contributions in five fields. I suppose now I will be reprimanded for self-advertizing...

no respected Charles, you will not be reprimanded. This discussion and information has led to improve my clinical skills. today in the evening session I saw 15 patients. 5 with previous diagnosis of depression were showing symptoms of bipolar spectrum. rest with other illnesses. So it helped not only in theory, but also in the practical management of those 5 persons at least and the long term care. regards

A recent study has shown that up to 21% of the the cases of unipolar depression may turn out to be bipolar.............that leads us into a practical management dilemma

Well, I suppose there could be worse dilemmas...this at least holds out promise of improved diagnostics and treatment. My guess is that the percentage will be far higher than 21, btw. I will wager it is closer to 60 percent. The issue, however, for the clinician, is less that bipolarity is so common -- that is, the traits identifiable via an assessment tool -- as that the clinician and patient must find a way to determine whether and to what extent medications and/or non-drug therapies are in order. One of the fears I have of the large-scale plan to educate about the prevalence of these traits is the possible over-use of drugs which would not likely be warranted. In other words, clinicians require to be educated in dealing with this specific aspect of patient care independent of determination of treatment strategies. I want to write a book especially for clinicians to guide the way in which they approach patients about the question of whether and when treatment is advisable. As an opening salvo I wrote a paper (on SSRN) titled "How to Live Responsibly with Bipolar Ilness", which is oriented at both patients and clinicians. It has not, alas, been a popular download.

Another difficult issue is treatment where both aversion and confrontational dispositions are coexisting. Anger is a broad canopy terms which a theorist is apt to separate pre-emptive strikes on the avoidance side, and attacks consequent to frustration on the other (manic) side. Distinguishing which is which needn't be so very difficult once one is alerted to the basics, but that still does not resolve the difficulty facing any clinician who tries to attack the anger management through drugs. I myself have both issues but the latter predominates. Fortunately, I have been lucky to have doctors willing to work with me and experiment, but with no real success. I therefore do my own variation on psychotherapy intervention.

And I also wish to thank Dr. Khan for you informative and interesting posts. Always look forward to them.

regrets for the late reply, respected Charles,

I was too busy in re-scheduling my work, you know its fasting month here and my students were going on leave, patient timing are changed and so on.......

As regards the tool, that study I mentioned is from British journal of psychiatry July issue. I e-mailed the author but no reply, He has developed a scale hypomania checklist HCL-32 and bipolar spectrum disorder scale BSDS for use in primary as well as secondary and tertiary care, but these are not available to me, as I can not afford the subscription of the journal and my medical college is reluctant to pay for it.

any how, i find your valuable input to the topic very informative. the author says that patient of major depression when comes to you, if the patient is young, has psychotic symptoms, diurenal variation of mood, hyper-somnia, and depressive episodes of relatively shorter duration, the clinician should have high suspicion that in future, it may turn out to be bipolar.........Regards

Aha, very good points raised respected Vanessa,

Leaving aside drugs, psychotherapy research base, evidence base etc your simple approach seem very amazing, and a opens up a new horizon for me personally.

1. Re-connect with external world

2. To step outside the ME

wonderful observation and example of your grandfather, I wish I could live like him

just when i wrote these lines . one of my pts came. she was diagnosed with schizophrenia, I told her your 2 points. she really enjoyed it

Being healthy typically implies being productive and/or useful. Clearly, one is most useful in proportion as one goes outside of ME. But what counts for 'outside ME varies with circumstances and biology. To avoid aspects of stress that trigger major relapses or psychoses, or that trigger serious manic or depressive episodes, likewise varies by disposition and circumstance. Autistics, Aspies and schizoids and many with anxiety may, mood permitting, enjoy going outside ME by entertaining forays to parks, amusements, sports events, etc, only to get home exhausted and requiring 10 extra hours of sleep. Manic and/or depressive episodes are also frequently triggered. Going outside ME isn't always what it's cracked up to be, though it is true enough that too many depressives prefer to be victims rather than combat depression with activities (running and exercise are well known cathetics). There are reports that some with biologic high-intensity nervous systems are worsened by the usually benign and helpful catharsis of yoga and other meditative exercises.

As rules of thumb, your two points, Vanessa, are clearly well spoken and generally sound advice, but we should be careful of permitting a blanket approach -- not saying you were intending so, of course, just raising the issue since patients may easily take such advice as a blanket dictum, no?

There are, for example, two kinds of workaholics, the so-called type A in which overdrive is unhealthy, whereas bipolars typically thrive on overwork (or what normals consider such). Apart from the risk of exhaustion (Charles Dickens, a profound bipolar, died of this very thing) work is a release and vent for the natural energy welling from biological springs deep within. I am especially that way, and indeed for me work is a palliative even for depression and tends even to lessen disposition to depression. But when depression hits, I mean HITS, nature could care less of well-meaning locutions. When biology says stay clear of exposure, that's exactly what it means, nothing more or less. These patients (I am one) are best left to 'sleep it off'', for nature will go her course and the darkness will lift, just as morning listless and depression lifts with the day as much as by any activity or engagement.

Finally another biological oddity involves proneness to hysterical convulsions and similar seizure and seizure-like syndromes. Consider the classic seizure (including many migraines) where an aura announces (for those able to recognize it) the impending attack. The biological response is usually a heavy dose of sleep. I don't know of many clinicians who recommend other than sleep for these cases, and for good reason. Here, it was the inner equivalent of going outside ME that gets one into issues to begin with. As O. Sacks long ago observed, seizure disorders can be disorders of the arousal mechanism and reflect a misguided attempt of biology to convene sleep upon wakefulness or vice-versa. Many report that concentrative methods and hypnosis prevent seizures when initiated at the point of aura, and I can also personally attest to that both with clients and with myself. Indeed, as I had abdominal migraines (vagal stimulation so intense as to result in ulceration of the stomach), the aura was paroxysmal yawning, at which point I had to find a sauna or HOT shower within twenty minutes. Whole body MAJOR stimulation was the only thing to counter the internal flow. The usual antidotes of going outside of ME and so on are of course worthless and might even be positively harmful in these peculiar circumstances.

Btw, Vanessa, I classify bipolar traits, whether of subclinical or clinical manifestation, into a few handy categories as to displayed character: redoubtable (your grandfather), brooding, and hysteric. Most aspies as also 'angry' types also go into the brooding camp in this schema. t is frankly amazing how many bipolars are the hysteric type (yes, even men), but are diagnosed solely with anxiety disorders. Woman are especially misdiagnosed in this manner. I can not even imagine an hysteric not also frankly bipolar, for anxiety falls midway in the spectrum of exposure aversion and confrontation. These folks typically (but hardly always) report satisfaction with yogas and meditations but you will NEVER observe their bipolarity to be much improved on that account. After all, biologically speaking, there is 'soft-wired' that is amenable to non-drug modalities, and then there are the 'hard-wired' areas rarely impacted by ancillary methods, and for which drug therapy is a fist prerequisite even for subsequent successful ancillary treatments. People who are sure they can treat themselves or train themselves out of bipolar dusfunction are delusional and are by that very nonsense demonstrating the need for drug therapy. I have a student who refused for a decade to go to a psychiatrist. When I finally convinced him to go the the VA (he was military) they promptly misdiagned him. Fabulous. Meanwhile he has now for twenty years claimed at every juncture that he has discovered THE method. Right. He is no better now, in simple clinical terms, than ever, but has learned that fear can mediate beyond the soft-wired, so that military service actually did him some good. But apart from fear (an shame, be it noted) there are no excuses for a disease to go without normative treatments even if it has to be the extremity of drugs. To put it simply, the two points introduced by Vanessa are soft-wired oriented and work very well in that sphere and should indeed be advocated far more than at present, with the contraindications here mentioned. And drugs should be more utilized where required, as also not utilized where other approaches are necessary or more appropriate (usually these patients are not in the disease stage).

respected charles and vanessa

for the last two days I am reading your valuable detailed discussion on the topic again and again. It is remarkable knowledge that you both have and share, For me it is useful because i am working in a very remote area of the world, rural in the morning and a small city in the evening. there is no psychiatrist or anyone else here with whom i can discuss and gain knowledge to put into practice. If I geather my thoughts, I will write this,,,, rational use of medicine, psychotherapy and other meathods you both mentioned may be more beneficial to the person (patient, Individual, client) if used properly. regards

I am interested, Dr. Kahn, in the context of your remarks. You see many pts. most of whom are rural, and therefore more than likely 'traditional' - whence, like most traditional societies, there is a decided hesitancy to admit to mental issues unless somehow re-categorized. Do these people recognize 'traits' that they believe to be unsociable or otherwise unworkable? If so, how do they present and describe themselves? (or alternatively, how are they presented/described by those contacting you?)

Thanks as ever

Respected Vanessa and Charles,

Regrets for the late reply, firstly let me introduce myself to you and the context. I am a medical graduate,1998, means doctor, like MD in usa, then after internship in psychiatry and surgery, i chose, psychiatry for further studies and went though 4 years of training and then was included as Fellow in psychiatry 2004, by college of physicians and surgeon of Pakistan, the degree awarding institution here, like Amercan board or royal college of psychiatrists Uk, then i worked as consultant for 6 years and now teaching as asst professor in medical school/college here in my city and see patients too.

A.. Vanessa, as a doctor, we are trained to examin the patient, in four step,

1. inspection,,,look

2. palpation,,,,feel through hands, in psychiatry through heart and mind

3,,purcussion.....with hands to gain information inside

4...auscultation,,,,,listen through stethoscope, in psychiatry through ears

so order and methods may vary, but they are very similar to the 3 you mentioned, and i sometime change this order, varying from person to person, but LOOK is always first, and gives you a lot of information initially, then as you proceed in history taking and examination carefully, the person's case unfolds and you rightly mentioned , the healing process starts..............that builds a therapeutic relationship, and you go on and on with a journey with the person.

B. Charles. rural and urben, both patients are stigmatized by the society here too, and before coming to me, many go to faith healers or other alternative medicine rout, reaching me in the end, even after consulting their local doctors, who mostly fail to recognize the problem in such patients......why.....because most of them present with somatic or physical symptoms,.....and they describe their distress in somatic symptoms to me mostly, e.g, headache, weight on head, neck, shoulders, gastric discomfort, body aches etc. but as i follow the above mentioned steps, psychological symptoms and signs start to appear. so mind/body separation is here too, but gradually it disappears from the patient and then the family members who come along, patients become very compliant to treatment offered and the family too. mostly they become workable and then give me great knowledge about human feeling/emotions and lot more of the society as a whole. they are hesitant initially to admit mental illness, but when mind/body separation is removed, they feel just like any other person with any illness.

best regards to both of you

Resected Vanessa and Charles,

The discussion started from under-diagnosed bipolar disorder, but i am learning new and good things from you, Dont feel offended, i am here to learn, keeping aside my qualification.i just mentioned it to bring the context, in which i am working. not to pose myself as a big professor, i am still a student of learning, and your insights into persons (individuals) are very fruitful for my patients. who are mostly very poor. and you know what is the consultation fee, charged from them...... about 10 cents. or 1/10 th of a US DOLLAR.....and no fee on friday, so these people from rural and poor areas benefit a lot, from your feed back, as i add your advice and insights to examin and treat these rural people, who have no Psychiatrist, Psychologist etc in the vicinity of nearly 100 miles around them......you are helping them...regards as always

Many thanks for your gracious remarks. I for one don't get much of that over here, which is not owing to any disinterest at working with our institutions - rather, they tend to assume (all too often wrongly) that no one outside of professional circles has the mental muscle or clinical experience to be worth listening to. You are the picture perfect demonstration of a perfect attitude. So believe me, I respect you to the stars and always look forward to your remarks. And ditto for Vanessa, might I add.

I write on these areas but occasionally since my immediate project is the demonstration of the origin of the universal constants (pi, early roots, fine structure constant, natural logarithm, etc) and their inter-relations with one another and precisely what physical parameters they reflect. Am nearing an important point for developing a major article, so it keeps me busy.

By the same token, I recently purchased animation software because I intend to create a full course of lectures using funny creatures to explicate my full behavioral theory and the complete survey of the bipolar spectrum, assessment tool and all. The discussions here have material influence on the developmental methodologies to be used in that project, which makes me doubly pleased to have a couple sharp clinicians to toss about ideas.

And speaking of which, here is one such: the so-called "antisocial" personality. I am quite convinced that it is simply another collage of bipolar traits, where traits responding to stress with contempt aggression and rage predominate in the acute clinical picture. While we all acknowledge these are more difficult to treat, I firmly believe that the correct anti-convulsant and anti-depressent therapy can make inventive / innovative talk/depth therapies worth our while. I took on a severe case 20 years ago and the pt. himself told me I saved him from becoming a sociopath (others said I performed a miracle -- nonsense, I worked in accordance with good theoretical presuppositions -- of course it helps to know how to do good theory, whereat being a metaphysician has proven quite handy). So please understand me when I say it IS possible to make headway in difficult cases.

As ever

Respected Charles

amazing. anti-social and bipolar. what a wonderful observation you made. I find many similarites and traits, Many of my patients show very good response to mood stabliser ( anti-convulsants) mainly valproate and carbamazipine, and sometimes olanzapine or an anti-depressant. but mood stablizers are mostly used by me and other Psychiatrists in my country . Your observation is very astute one. very intuetive, and amazaingly similar to my clinical experience. We may not have the evidence base, but your method of work although different but is very useful and reveals things which normal or routine psychiatry or psychology and classification systems etc find it difficult to explain. but these are the things happening in real clinical practice. Evidence based practice is although still a gold standard, but practice base evidence has its own place. your methodology may seem DIFFERENT to some people. but it is really amazing .......regards as ever. today i felt such excitement by reading your response that my answer may show ....loosening of association. regrets for that. you amazed me.

I am gratified at your clinical findings. As they say, 'two pairs of eyes are usually better than one'. I also wanted to broach an aspect of identification of bipolar traits (i.e. traits associated with bipolar personality, disorder or disease, but which need not by themselves be a cause treatment but which should be a concern to clinicians for demonstrating a propensity to stress-based reactions that can be or become extreme if only in acute outbursts. Many in this category are bipolar personalities and, were it not for their positions of power would, especially if poor, become easily noticed for untoward behavior.

One way of studying these is as simple as looking through the biography section of any library. If a person is notable enough to have been the subject of a biography or related work (even i qualify on this one) you can bet your bottom dollar that this is a bipolar personality at the minimum. Here is an example from a book I purchased just today, of James Pierpont Morgan, the early 20th century titan of banking. Here is a single paragraph from the first page. It has everything ones requires to guide our clinical approach...

"Morgan has vision and surpassing imagination. Add to these incredible audacity, sublime self-confidence, unqualified courage, amazing virility of mind and body, and a personality that can only be described as overwhelming."

The first sentence nicely describes the expansive thinking that characterizes the bipolar (esp the redoubtable type). The second sentence details traits that by themselves can and are, in certain circumstances, the very best human traits -- yet, when combined and typifying the personality, these same traits effectively orient us toward a likely diagnosis of bipolar disorder if not disease. Think of what constitutes "normal" and ask if this combination has any remote relation to what defines 'normal'. These typified, for example, President Theodore Roosevelt, and only recently was he finally recognized as the bipolar he assuredly was.

It is NOT acceptable to relegate these combined features to the so-called 'forceful personality'. The simple fact of actual reality is this: these types will ALWAYS manifest associated negative traits that, together with those listed, delineate a pattern that clinicians simply must learn to identify and bring to the attention of their patients whether treatment is required or not. If the Lakalai of New Brittain could do it there is no excuse for modern psychiatrists to remain ignorant of these traits. I look forward to comments.

Here are a few additional reasons for under- and mis-diagnoses of bipolar disorder or disease.

1) Anxiety states -- in a majority of instances a careful examination will reveal sufficient evidence of manic traits to justify drug treatment which will also typically reduce the severity of the anxiety. Rarely is such an evaluation made, whence the under-diagnosis.

2) Depressive states -- Same as above, but with a twist. Depression can reflect a longing or frustration at being kept from a desire/need to confront exposure relations/stimuli, or it can be reactive consequent to over-exposure to negative stimuli, both of which come under the manic aspect of the bipolar spectrum. The so-called transference reactions (both the positive and negative) can usually be explained thereby. On the exposure avoidance side there are again two aspects. One is characterized by sadness and is normally a severe degree of frustrated longng/desire. The other is not so characterized and is probably related more to strict exposure avoidance observed on the far left schizoid section of the bipolar spectrum, also probably related to an additional biochemical disturbance, but still related to stress and exposure management.

3) OCD -- like anxiety and deptression, these are best viewed as biphasic, triggered either by exposure-confronting or by exposure avoiding mechanisms. Thus one may feel comfort or even dominance on the manic side, or relief / security on the avoidance-schizoid side. In either case there will be extensive, if perhaps low grade, manic traits requiring treatment.

4) Fibromyalgia, IBS, some seizure disorders -- These are frequently co-morbid with autism and thus also bipolar states in adulthood. These days anti-convulsants are being found helpful for fibromyalgia, and while they might not help in IBS it can be assumed that overstimulation is at work here. I knew someone with Crone's who knew he had been misdiagnosed regarding bipolar disease, which even he could discern and acknowledge. My paternal grandfather once asked me if I thought he should see a psychiatrist, at which I replied in the affirmative. Silly me. The good doctor, over-trained and under informed, sent him home with the diagnosis of hypochondriasis (correct enough, and it is a very frequent traits with bipolars of all categories). He missed the bipolar which led to suicide, and missed the fibromyalgia. Good job there, doc...

5) Expressive aphasias of all kinds -- This classification should be viewed as an aphasia *spectrum* and it should be included as a subset of the bipolar spectrum., since it shares the same polar etiologies of exposure confrontation or avoidance. These will be EXCESSIVELY common in those having gone through anything in the austistic spectrum in childhood, thus also frequently with adult bipolars. Consider dyslexia, whether visual or auditory. Exposure theory will postulate that the brain is anxious, fearful of mischaracterization of stimuli and offers a pre-emptive attempt to force the result, with all the predicted misadventures. Trying too hard or failing to force context will activate the confronting and avoidance, respectively. Despite the typically schizoid etiology, it is very prevalent in severe bipolars. Thus biographies demonstrate the matter, as for example Berlin's description of the man responsible for the Romantic movement, who was a raving bipolar who was killed in a scrape. His work could not be understood, but Goethe and Herder caught the sense of importance and both supported him. He simply could not express himself adequately. Ditto for the co-inventor of the steam engine, a Scott who wanted fame but feared it because he couldn't write a single correct sentence. He was weighted down with serious bipolar traits. I tutored a student who was from Haiti where stress is the order of the generations. Her son was severely autistic and she was severely bipolar but refused to acknowledge it and is still getting in trouble out of school and working for the government. Finally, I myself was incapable of correctly expressing myself until properly on medication. It was a sea change, the lucidity inviting me to revisit three cases of notebooks whose writings could not be understood by anybody but myself. Appears everyone else was right after all. I threw all hundred of the notebooks into a dumpster.

This is a brief list and the effort already too lengthy, but i hope this helps clinicians to be wary of pigeon-holing diagnoses along the symptom collages of the accepted syndromes. Such is a recipe for under- and mis-diagnosis. Doesn't matter what the IQ or level of experience (bad experience generates bad results, no?). One knows the traits or one doesn't. Ignorance of them will result in mis-dagnosis. It is the reason for two regrettable statistics: 1) psychiatrists have an unlovely ability to disagree with one anothers' diagnoses, and 2) the experience of the mentally ill is sufficient demonstration of rampant and massive ignorance of the attending clinicians. Matters have not improved terribly since the experience of my grandfather. Observing the traits and following good theory will rectify ALL such errors. It remains only for clinicians to understand that the avoidance-confrontational admixtures require an experimental approach and that pts should probably be made aware of the necessity.

Dear Charles

In the past few days, I was wondering, observing and recalling my clinical life and early part of it when we students used to sit in the corridor of hospital and guess personality and traits by just looking at the patients who came to the hospital and was recalling people whom biographies might be written, and watching relatives of the bipolar pts for the points you mentioned in the previous post. in the 2nd post you have made such a beautiful and wonderful formulation and analysis of the the bipolar spectrum that i am amazed how clear you are in your observations of so many kind of illnesses from anxiety to depression, ocd, expressive aphasia, fibromylagia, and what a beautiful analysis you have done of dominance/avoidance. and the practice of clinicians. your observations are really fruitful for any clinician. felt very sad to know about your grandfather, hope when people will like to improve the clinical skills and not consider their diagnosis or opinions as final and absolute. so that such sad events do not repeat over and over. Regards as always

This is a test for audiences receiving channel USA's new program SUITS. Explain why the character Trevor does or does not manifest sufficient traits of the bipolar spectrum to indicate the likely requirement of medication for bipolar disorder, in fact, explain why he should or should not be presumed to have bipolar disease rather than merely the disorder (the disease meets disability criteria, the disorder presents a disordered and/or troubled existence demonstrating potential for further aggravation).

We could play this game with lots of folks, such as O.J. Simpson or Charlie Sheen (hint -- his modal presentiment has next to nothing to do with drugs, but the real problem made him susceptible to addictive behaviors in general).

I will grade your responses openly, frankly, fairly and with a full explanation of your hits and misses. Any psychiatrists think they can one up-me? Here's your opportunity. And by the way, this is not, properly speaking, what the profession refers to as "diagnosis without license or in absence of the patient". It IS a considered judgment consequent to the identification of traits known to be associated with bipolar personality, disorder and/or disease.

Okay, so this is a bit of fun and not to be taken seriously unless you enjoy the nature of the challenge. What is serious is that any psychiatrist who can't argue the case that Trevor is to be presumed to have bipolar disease probably shouldn't be practicing the trade until mastering the basics. That is a rather lofty locution. It happens to be a valid one. Any takers?

Three simple formulas make the psychiatric challenge dangerous and costly. They are:

1) Neurotic worthiness (often at undetectable levels of so-called *grandiosity*) + neurotic deservedness (distinct from worthiness in presupposing *goodness* as a lead justification) = entitlement (as in the bipolar trait);

2) Entitlement (the trait) + scheming + contempt = narcissism;

3) Narcissism + need + opportunity = criminality

These formulas are a way of restating the argument in a paper I wrote called “Common Denominators in White-collar Crime” (http://ssrn.com/abstract=1319623), which was selected by a prestigious foreign publisher for inclusion in a collection of topic-related papers (awaiting publication). I want to highlight a specific example that makes these especially problematic for today’s clinicians, especially in light of the approaching advance in nosology requiring that we observe and identify TRAITS of the bipolar spectrum rather than the traditional (but grossly inadequate) symptom clusters of syndromes.

Within the bipolar spectrum the formulas introduced above are a heavy component in a subset of anxiety-depressive bipolars (and others, but they seem far more predominant in the selected category). Nosologically we can do still better, denominating the subset as the *hysteric* category of bipolar. Here is a brief, trenchant description of the type: The lead traits are four, namely, 1) anxiety-hypochondriac tendencies; 2) marked disposition to rely on *vicarious authority* to obtain neurotically inspired need for acceptance (the *needy* disposition remarked of by some commentators on bipolar illness) and respect (note that these two abnormal needs and abnormal methods employed to obtain them constitute a perfect description for all that Freud considered by the term “neurotic”, and it arrives only in light of a developed theoretical construct based on *exposure theory*); 3) a presentation of affected other-concern and altruistic motivation belying latent anger and contempt and rage consequent to the apparently unfulfilled neurotic needs above detailed, and 4) The constellation of behaviors that, for example, typify some of the new-age mentality that justly receives a good bit of mockery. Your “rock lovers” and the like help to identify a craving for psychological COMFORTS that sublimate the neurotic needs, whereas the vicarious authority compensates for the same, as when (a classic example offered in the literature), the pt determines to have a serious illness requiring hospitalization whereat there is now an effective vicarious authority compelling a target to display attentive cares and concerns, etc.

Have you ever noticed that those sharing some of these traits have a subliminal (until detected) habit of “getting” something, or, better stated, “getting away with something” every day or at every reasonable opportunity? This is a low-grade indication of a potential for the graver disturbances at the elevated trait expressions. A waiter seems somehow always to avert a duty; a spouse (which gender it is frequently culture-determined – cf. Mary Kingsley’s work in Africa) seems always prepared to needle the desired end via a scheming comprehension of the target’s needs and weaknesses; a new-ager (typically) lusts after anything and everything promoting psychological comfort, from otherwise useful things such as yoga and meditation, to rocks and specialty supplements, to identifying with important people or those in authority, to off-the-beaten-path spirituality, to addictive window-shopping and whole afternoons consumed in deciding which items are just the perfect compliment to a suave and health/spirit conscious good and kind soul.

The world is populated with millions of these clever devils. They frequently manifest many of the best and most noble traits, even of the redoubtable class of bipolar. But here is the cause for my alarm: it is predicated upon and highlighted by two recent instances in my own consulting practice in which this bipolar type took a new assessment tool that identifies manic traits almost always missed by clinicians, whereat they declare themselves bipolar for the purpose of obtaining government disability (one received it, the other is applying), whereat they then determine that they either aren’t bipolar after all, or simply do not require to take meds. In each instance, while I was not the authorized clinician, I was, however, the source of the effective assessment tool, hoping in each case that a respectable clinician would handle matters appropriately, which was not to be in the first instance and doubtless will not be in the second.

All of this because the profession currently favors an idiotic and outmoded methodology of nosological analysis, and because they refuse to be told anything by outside entities (except for the rare gems who know who they are, and praise be to them!). Note: failure to properly comprehend bipolar traits is dangerous in many unsavory if unwitting and inadvertent ways, and that even the improved approaches to diagnosis will only magnify our problems until such time as clinicians get real. The normative understanding of grounded and substantive theory and of the traits it presupposes is the only sure-fire way to avert these dangers and others that assuredly lurk about the horizon of our clinical experience.

A final matter, specific to the United States situation, concerns what society can do to instill the responsibility, if necessary through negative incentives, so that clinicians have teeth when determining access to treatment modalities and their efficacious administration. The many (and increasing) mass-killings indicate the obvious need to confront the problems implied by patients requiring prophylactic medication in the effort to protect the public.

Respected Charles

Here was the end of fasting month and the days of festival. After holidays A lot of patients and workload on me, so delay in response. One thing I noticed, many of my bipolars worsened and epileptic patients had seizures. Even patients of epilepsy, who were fit free for many months had fits over the Eid festival days. Wonder Why? What do you think, Is there any relationship of epilepsy with bipolar?

regards as ever

Two ways of approaching this, and both give an affirmative answer to your query. First, we recognize that when autism is the opening salvo, theory says it is a mix-and-match of avoidance-adient traits, and we observe that roughly 15 per cent of autistics present with one or more co-morbid peculiarities all too rarely remarked on by clinicians, to wit: bizarre allergies, peculiar GI disturbances and -- seizures. And we note that a very healthy percentage of autistics end up a bipolars. I myself had nearly all of the subset co-morbid aspects, lucky me! As for seizure activity, mine took the form of abdominal migraine (chief reference is O. Sachs Migraine: Evolution of a Common Disorder). And finally we observe that the core issue in the bipolar spectrum is over-reaction and/or over-stimulation, of which seizures are an example, whether or not local and/or specific in etiology.

The second approach deals with manic and/or seizure activity as compensatory over-reactions to exposure threats, real or imagined. With this undergirding biological disposition, simple excitement, even positive exposure, can incite seizures in those prone, as also manic outbreaks. Stress, after all is a generalized phenomenon and exposure is the requisite context in so much of life and its diseases. Almost all of mental illness is grounded in the need to deal with exposure. Seizures are thus related, and may fall into two classes, one genetically independent of bipolar disorder/disease, and the other simply another consequence of the excited states characterizing mania. In either case they are exposure dependent when not the result of an obvious lesion in an area not regulating reactions to exposure.

Dear Charles and Vanessa

In the end, I am glad we discussed the topic and I learned from you. Thanx a lot for your participation in the discussion.

Regards as ever and best wishes

Anyone else interested can join the discussion on this topic

Ditto. Would love to get more views.

ditto, glad to hear ans see you back. no contact for 3 weeks dear Charles,

Regards as ever

Ah, yes...that is mere confusion on my part. I sent you (via email) an answer to questions you raised and I was thinking, erroneously, that I should have awaiting your response! So forgive me, please. Anyway, I hope the explanations I offered to your questions (on number theory, scoring on assessment tool, etc. were acceptable). Again, feel free to conduct that type of thing via email as it is of questionable relevance here. On another semi-personal note, I have been occupied with my city's rendition of the Occupy Wall Street protest movement here in the States. I prepared an extensive examination of the movement's basis in the principles of stewardship. Today I am participating in the first day of the actual 'occupation' of city hall in Austin, Texas. So that has kept me as busy as much as out of trouble, heh heh.

Occupy and enjoy. i have 3 net connections to resch you. ha ha mania......charles

Indeed, but I am noticing there is almost an over enthusiasm in psychiatrists to diagnose patients as being on the bipolar spectrum. You could be bipolar I, II, III, IV, V, VI...Not everyone unresponsive to SSRIs and other interventions is bipolar. The patient could be a poor metabolizer of Cytochrome P450. Just thought I'd throw that in the discussion.

Thanx a lot Jessica

Glad to have another voice on the topic. This is a new dimention you pointed out. I never thought of it...., Can you please elaborate a bit more on it. It will be good and a new perspective for all of us to learn from your input. Feel free to express..

regards

Im just going to response the original author of this topic.

70% of bipolar disorder start as Major Depression Disorder.

10% of Mayor Deprresion Disorder turn tl Bipolar Disorder after 10 years.

This turn occurs in average at 32 years old, or after 2-4 episodes of Depression. It can occurs when patient is old too.

There are 10-20% of Bipolars, that remains "uni polar" or "pure mania", with out depressive episodes.

Hi Rana and Everyone in the is thread,

Cytochrome P450 comprises a bunch of isoforms that determine how you metabolize drugs. You can get genetically tested for your own particular profile by various private companies for around $1000.00. Most people do not get this done and physicians must choose meds based on an educated guess. But there is more of a scientific way of choosing appropriate medications based on the P450 profile. For example, I could be a poor metabolizer of Cytochrome CYP2C19. This means I do not metabolize certain drugs well such as citalopram. There is list of the enzymes and the drugs that are metabolized by them here:

http://www.healthanddna.com/Druglist.pdf

There is also a good article on Cytochrome P450 and its implications for metabolism of certain drugs:

http://www.aafp.org/afp/980101ap/cupp.html

I am advocating a more scientific approach to choosing drugs for patients rather than the sort of rush and roulette method that is the common current practice. The assumption that a patient is bipolar because they do not respond to the usual drugs does not necessarily follow. They may have unipolar depression. Of course, it should be investigated, but bipolar meds are pretty harsh. Many patients cannot stand the side effects of numerous bipolar medications. I am just saying that physicians should be careful when making assumptions and employ a scientific approach, if possible.

A little side note to Herman's response:

Just because 70% of bipolar patients start as MDD does not mean that 70%of patients with MDD are bipolar. Most bipolar patients do not seek medical help if they are in a manic state because they usually functional, if not euphoric. The patients usually present themselves because they depressed that they realize they need help. In fact, many bipolar patients do not want to lose their manic phase because they are accomplishing so much.

Welcome to the discussion Herman and Jessica. The investigation of CytochromeP450 is certainly in order and apparently the cost of the evaluation has come down -- at any rate I had expected a heftier price tag on that. I presume the reason there is an effort to diagnose along the bipolar "spectrum" is two things: first acknowledgment of some ignorance as the underlying etiology, and second, an awareness that whatever the cause(s) there appears to be a gradient affect. Both of these seem to me to possess merit.

I am sure that your experience with bipolars is all but universal. Lawyers and general practitioners will also agree I am sure (the lawyers get involved because so many bipolars come to a diagnosis only because a court requires an exam after arrest). At any rate, I am far less concerned with over-diagnosis along the spectrum and much more worried that a standardized theoretical structure is not guiding decisions. If any reasonably consistent theory was being used we could at least garner some guestimations as to what's what and why. As long as therapists refuse theoretical considerations it will remain a crap shoot, Cytochrome studies notwithstanding. I personally feel more and more that clinicians are little by little coming to realize that they are under-diagnosing as much or more than misdiagnosing, and the reason for that is inadequate understanding that it is traits we are wanting to observe rather than specified symptom constellations (that by their nature eliminate many diagnostically valuable traits).

I am very interested to see who has opinions on that score. I will say again here that I am happy to email anybody who is interested the assessment tool I have developed as an aid to identification of these traits. Further, it is based on forty years of work developing a sound theoretical foundation that may have yet to be proven by the scientists, but which works astoundingly well clinically, so far as it has been tried. It could use much more help and honing by those willing to extend the boundaries a little.

Good day to all...

Regrets to all for the late reply.

I was very busy with my patients for the last 5 days, but was reading the posts, comments and links provided by all of you on this thread, from my cell phone whenever I was free a bit from patients during the the last 5 days.

@Charles Herrman, Thanx a lot for your side of the input........as ever...

@Herman Figueroa, very true indeed, your figures are appreciable.

@Jessica. Your Input proved very helpful in clinical setting. As I see many Patients/day, average about 25. The number increases even more in certain days, Your new dimension in our discussion, of liver enzyme Cytochrome P450 was very helpful for many patients. Putting your Knowledge of biology in clinical practice worked well for some of patients who were not responding to their treatments. Input by a biologist in this discussion is very important and valueable. look forward to you further inputs, in my clinical setting more people with bipolar present in maniac state rather than depression. Its my personal observation of last 14 years, do not have an evidence base link to this point of mine at present. And I agree with you, that they say to me, ( Doctor! you have brought us out of our happy state, when they are in remission or in depressive phase) A little side note, Why i am always unable to remember the Cytocrhome enzymes list and their functions for the last 20 years, when I started my medical education?

It is an interesting note that the Cytochrome P450 was quoted to me, as an indicator of "Slow Acetylizing". (Unless it was P750). Anyway, if this is the case, it is entirely likely that there are co-morbidities in some enzyme reactions between bi-polar and diabetes. People who have "Slow Acetylizing" will tend it is assumed to have a different enzyme population in some of the Cytochrome enzymes, because those enzymes require the Acetyl group to be attached in order for a metabolic state to be approached. As a result, of Slow Acetylizing the same population will have insulin resistance (or so it is called) because Acetyl is critical to the Kreb cycle (The Glucose digestion to phosphorilation needed to create AMP, ADP, and ATP the power storage chemicals of the cell), and the production of these chemicals will no longer be rate dependent on the enzyme that creates Acetyl-coA, the co-enzyme that produces Acetylation activity. But because presumably the CoA enzyme is malformed, does not speed up the chemistry adequately to deal with the bodies needs, the rate will be limited by the slower chemistry, and will not respond to glucose supply as easily, and will tend to have byproducts only seen as a result of the slower chemistry, as well.

I have notice in my own case that both glucose levels and insulin levels can be high in "Slow Acetylizing" at the same time. This suggests that therapies that deal only with Insulin levels and "Blood Sugar" as an indication of insulin levels essentially fail to take into account the fact that the body may be experiencing high insulin levels, (Resulting in fat deposits etc) even when the blood sugar levels are high.

Without a comorbidity study, it would be hard to tell, whether the cytochrome P450 test is needed for diagnosis of comorbid bipolar and diabetes as a trait cluster, or whether the current process of separate diagnosis is adequate, but I suspect that there is a portion of both populations where comorbidity is to be expected.

While I have not had the time to read each of the comments on this particular entry I would highly agree that mono-therapy of an under-diagnosed bipolar disorder can often have a worsening effect. At the very least not an effect desired by the patient being treated. Though I have found dual-therapy treatment styles that seem to work extremely well.

A really good polor therapy which I have found works really well curing all all depression symptoms as well as great for getting the unfortunate friend or two off drug addictions is understanding the qualia or a recognizable feeling that is associated with low levels of each of the main neurotransmitters. with low dopamine you may not be depressed at all you may just seem tired. but low dopamine + stress causes signs of depression. so we know at the very least dopamine plays a role which has been semi ignored / really hard to regulate agaisnt abuse. Its unfortunate how far behind medicine is right now. I wish I had the time to write some text books :P.

Dear Adam j Clarke

Your input in the discussion is very valuable, I would like you to read the comments posted by all the friends above in this long but very fruitful discussion and give us your feed back. Here are the opinions of different but related fields, philosophy, sociology, biology, physiotherapy, psychology, Psychiatry and yours too. Regards

Personally, I think that the low energy state, is created by a feeling of fatigue.

In this model, I suggest that there is a dopamine level sensitivity, possibly in the Nucleus Accumbens or possibly in the Lower dopaminergic centers, (Those related to parkinsons) that is felt by the brain as a form of fatigue. (I suspect the higher area), the idea is that because Dopamine is usually rate limited in production, that when you use up your dopamine, you slow down, and give yourself a rest so that you will be able to replenish it.

It is entirely plausible to me that ADHD people may be so hyperactive that they motor on through their fatigue without hardly knowing it is there, with the result that dopamine gets too low, and they have problems related to it.

On the other hand ADD sufferers might instead have low Dopamine production, and thus, tend to use up too much dopamine during normal activity levels, with the result that they have problems with dopamine related processing similar to that of ADHD without the actual Hyperactivity.

Of interest to me, is the concept that the Nucleus Accumbens is critical for switching tasks midstream. Thus perseverance might be an indication that there is a low Dopamine level in the Nucleus Accumbens.

I guess that after 20 years of Hagop Akiskal's and Franco Benazzi's stink-raising about hip-shot mis-assessments of bipolars who tend to show up at the ER in the depressive tank, it would be more widely known that there are SOPs for making sure that bipolar is not mis-diagnosed. But, I still run into to regular examples of such stuff even now. Hey! Put that anxiety-soaked, mania-bent stimulus freak on some Paxil for a few years and see if he strangles some stranger in the post office parking lot. Call me jaded, but I just think CEU could do a little better here.

Not to mention hysteric bipolars who show up at the ER in the convulsive-Over-dose (or mix-and-match self-medicating)-cry-for-attention tanks. But I would favor lithium...

Bingo.

The issue of underdiagnosed bipolar depression "in favour" of major depression is a quite popular theme, yet no conclusive answer has been provided to date. In my opinion, this is mainly due to the fact that the treatment of "depression" still is "episode-centered" instead of being focused to the natural course of illness and the predictive factors/familial anamnesis of sub-threshold bipolar hints. Much more worringly, the fact that we use drugs labeled "antidepressants" (aiming) to treat inhomogeneous major depressive episodes, simply assuming that drugs genereally effective in the so-called "major depressive disorder" may be equally effective across different clinical entities characterized by "depressed mood". There at least two major implications: 1) the label "antidepressant(s)" (drug(s)) is derived by an "ex-adiuvantibus or ex-nocentibus" definition rather than a phenomenic, neo-Kraepelinian approach 2) different major depressive episodes may be perceived as "similar each other" if limiting our observation and clinical record just towards "mood" rather than mood+thought+motor patten, despite the original Kraepelinian and Wegandt's conceptualization of "mood" (but not only mood) disorders. As consequence, depressive mixed states, actually much more common in the clinical practice than the "pure unipolar" (manic or) depressive manifestations, are substantially misdiagnosed by limiting the diagnostic focus towards mood. Yet, antidepressants are "mood/thought+motor pattern" destabilizers, where for the better, where for the worse. 3) As major implication, this could also trigger not only mood (ideally shifting "depression" towards euthymia or even mania) but also motricity and thought (e.i. "suicidal thought"), possibly triggering suicialiy too.

I would recommend anyone interested in this perspective, to download my papers: "the argument of antidepressant drugs in the treatment of bipolar depression: mixed evidence or mixed states" and "could the underestimation of bipolarity obstruct the development of novel antidepressant drugs?".

Thank you for reading this, Michele Fornaro, MD.

In this paper I tried to answer this question, especially considering that despite the high number of "evidence" on the topic, no conclusive "evidence" has been provided in favor or in discharge of the practice of prescribing antidepressant drugs in the treatment of bipolar depression. Thank you.

Article The argument of antidepressant drugs in the treatment of bip...

In this paper, I tried to consider the clinical factors linked to overexposure to antidepressants in sub-threshold bipolar depressed patients and the factors potentially responsible also for precluding the development of truly effective "antidepressant" compounds for bipolar depression. Thank you.

Article Could the underestimation of bipolarity obstruct the search ...

Thank you, Dr. Fornaro for your interest in this topic. I have downloaded and will read both papers with anticipation.