Should we be “Carving Bipolarity with a Lithium sword”?

There was an editorial in the British Journal of Psychiatry this month entitled – Carving Bipolarity with a Lithium Sword. This piece is written by some extremely eminent psychiatric researchers. In the article the authors claim that the diagnostic classification of mood disorders is severely limited and in need of reform. I would personally agree with this. For example the authors state that the experience of depression in bipolar depression is indistinguishable from that in unipolar depression, but that differing treatments are required, presumably the authors are referring to concerns of misdiagnosing bipolar as unipolar and then prescribing ‘unopposed antidepressants’.

“The categorical classification of mood disorders has proven to be problematic. For example, clinically an episode of depression within major depressive disorder is indistinguishable from that within bipolar disorder, but their treatment responses differ.”

The authors then propose a change of emphasis:

“Yet we can probably do much better if we move away from clinical assessment based on retrospective anamnesis and towards detailed, prospective measurements using the big data delivered by pervasive modern communication technologies and wearable devices.”

One such change in emphasis that the authors propose is that we look again at the difference between ‘responders’ and ‘non-responders’ with respect to Lithium therapy – referring to this as an alternative to the traditional approach of assessment:

“Traditionally, psychiatric disorders have been diagnosed according to signs and symptoms on the assumption that these form relatively homogeneous groups, which lend themselves to systematic investigation.”

They propose that we adopt a ‘reverse translation’ approach, defining subtypes of experience according to treatment response. This is not a novel proposal, indeed one of the ‘bipolar spectrum’ classifications is for Bipolar Disorder III – defined by the ‘unmasking’ of hypomania through antidepressant treatment.

I personally have quite a significant difficulty with this type of approach – and it is partially represented by the need that authors describe to move away from ‘clinical assessment based on retrospective anamnesis’. By defining peoples experiences in terms of treatment response I fear that we rob them of something quite important – the significance of their own, unique, psychosocial experiences.

This argument is summarised in the Lacanian analyst Darian Leader’s book – Strictly Bipolar. At only 90 pages long this is a stunning piece of writing that in my opinion ought to be read by almost anyone with any form of interest in the experience of mental distress – which, to be honest, should probably simply be anyone.

In this monograph Leader approaches the experiences of individuals with experience of mania, and manic-depression, drawing on examples from his own analytic practice and the writings of memoirs by those who have also received diagnoses of bipolar disorder. Leader demonstrates core patterns to the experiences described, linking them closely with early life experiences that the participants reveal and ends his book with a powerful call that we:

“…return to an earlier, more humane, approach; one which attends to the particularity of each case and offers the manic-depressive person the chance to assume – however slowly, however painfully – what can be assumed of their history, and to find a way to live with what can’t”

He cautions us that:

“If the constellation of the manic-depressive includes within it a basic fault line here – an impossibility or even a refusal to inscribe oneself in some aspect of one’s history – society’s neglect of this dimension can only exacerbate their problems.”

This to me is the problematic truth – modern psychiatry adopts a position that all disorder is at its root biological. And, given that we are biological entities, this is undoubtedly true. Yet there is an issue with this – as no research has as yet identified these root causes, or excluded the strong influence of social and psychological experience. Is there not a risk in ignoring these factors? As we continue to strongly adopt the seductive message that all ills can be conceptualised as illness and met with pharmacological panacea we risk losing something – the ability to approach these difficulties from a position of broader understanding. Frankl argues for a form of existential analysis, or logotherapy, arguing that what makes us human is the drive to move beyond mundane understandings to seek something greater – the Will-to-meaning (Frankl, V. E. (1959). The spiritual dimension in existential analysis and logotherapy. Journal of Individual Psychology, 15(2), 157–165.), when this will is disrupted, we experience distress and this must be recognised within our approach to psychic distress or we risk losing something crucial from human experience.

Leader as a Laconian analyst is no doubt far wiser, and more articulate, than me, as are the esteemed authors of the BJP editorial: – but please do yourself a great service and read both, if you can, but particularly Leader’s book-  £5 (no doubt less from your local tax paying online-retailer), 90 pages… there is little to lose, even if you end up disagreeing with the argument.

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