When discussing bipolar disorder two reference points generally arise. The first relates to formal diagnostic categories and their associated symptoms and the second relates to personal narratives, that is, the lived-experience of people with bipolar. Often, one feeds off or informs the other, and gives rise to lively debates and occasional insights.
The passage of time, the frequency, duration and severity of symptoms are the bread-and-butter issues when formulating a diagnosis. They become the line in the sand and what separates ill from well, or normal from abnormal. Still, plenty of people actually experience bipolar symptoms yet do not cross the diagnostic threshold into bipolar disorder. So what’s the state of play with these people? Are they normal? Is a 72 hour experience of hypomania so very different from the obligatory minimum four days for diagnosis?
Ah, you’re maybe thinking, the DSM is really just a set of guidelines. It’s up to the clinician to use this as a tool and then to form a diagnosis based on their clinical expertise and judgment. How long have we got! Guidelines they may be but one of the key issues is that thing (or things) that makes bipolar distinct or different to other conditions. For example, at face value bipolar depression sounds very different to unipolar depression. Indeed certain distinctive qualities actually exist, but is it always so clear cut? You could, for example, easily have depressive symptoms for most of the time and have these punctuated with mood elevation so mild or so brief as not to merit a diagnosis of bipolar – but they are there.
The bipolar spectrum refers to a range of signs and symptoms that are linked in some way. Some of these associations are observed similarities, some are causation. Imagine the color spectrum of a rainbow. As we move from one color to the next the boundaries between colors become blurry. The bipolar spectrum is a little like this in that symptoms can easily fall into the spectrum but not sufficiently to be considered distinctive.
How often is the question, ‘am I bipolar?’ asked? Pretty frequently, I would suggest. Looking at some of the self-reported symptoms it is clear that many people worry about their mood changes, their low moods and sometimes even their confidence and optimism. In cases where symptoms might suggest a mild case of bipolar, should we extend the diagnostic category to include them? One possible danger of exclusion is that symptoms could develop later, but then again, they may not. Indeed the DSM has its own ‘Bipolar Not Otherwise Specified’ category that aims to sweep up some of these diagnostic anomalies.
There are suggestions that many people diagnosed with unipolar depression have symptoms that more readily fall into the bipolar spectrum. For example, if you feel flatness rather than sadness, or if your depression is associated with increased sleep and feelings of fatigue, you may well be a candidate. It’s a controversial area but there is nothing stopping people with these or similar symptoms possibly benefiting from treatment usually reserved for bipolar disorder.