Questioning Whether Bipolar Disorder is an Illness

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Several weeks ago, the British Psychological Society published a report online entitled "Understanding Bipolar Disorder."

Although the report doesn’t make any groundbreaking revelations, it does contain some important reminders, including the following:

• Everyone’s different. What works for one person with bipolar might not work at all or as well for another.
• Several non-medication therapies are helpful in maintaining mood stability. These therapies include mindfulness training, cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), family therapy, psychoeducation, family-focused therapy, and other relationship therapies.
• Learning to identify stressors and triggers and reduce or avoid them is sometimes helpful in preventing or mitigating mood episodes.
• A more accurate way of viewing the different types of bipolar disorder may be to imagine a bipolar spectrum that encompasses Bipolar I, Bipolar II, Cyclothymic, Rapid Cycling, and Bipolar NOS (not otherwise specified) and perhaps symptoms of other mental illnesses, including schizo-affective disorders.
• Everyone has the capacity to feel depressed or elated. The difference between those with clinical depression or mania is a matter of degree – those with bipolar experience extreme depression and/or elation (hypomania or mania).

What we take issue with in the report is that it diminishes the biological basis of bipolar disorder. The authors would probably argue that they did this intentionally to “restore the balance” that purportedly has been thrown out of whack by the predominant view that bipolar disorder is a medical problem, an illness, but we think it goes too far.

In the big picture, all of these factors are important – biology, psychology, relationships, work environment, and so on. Furthermore, psychology is biology. Emotional and behavioral responses are rooted in the wiring of and communication between brain cells. These patterns are formed by a combination of genetics and environmental effects that come together to create how a person feels, thinks, and acts.

To maintain an artificial duality, a false dichotomy, seems out of step with modern thinking. Everyone who knows anything about treating bipolar disorder is well aware that both medical and psychological therapies are helpful and often most helpful when used in combination. Psychological therapies still operate at the level of changing brain function – it is simply a different mechanism than medication.

We object to the view implied in the report that bipolar disorder may not be an illness. It is an illness – a serious medical condition that requires treatment. Viewing it as merely an extreme on a continuum and not as an illness has the potential of setting back the cause of reducing stigma and getting people to seek treatment and could even be dangerous in influencing people to stop taking their medications.

The idea that because something is part of normal function precludes it from being a symptom is a fallacy. We all breathe, and we all get short of breath sometimes for various reasons, but someone with asthma or emphysema has a lot more serious and frequent problems with breathing that can cause severely impaired function or even death.

Yes, as explained in the report, we all get happy or even very happy, and everyone has sad times, but at the extremes, when mood can’t be regulated adaptively, it becomes a medical condition requiring treatment. The data is increasingly clear that there are consistent and observable brain changes related to mental illness, including depression and bipolar disorder.

Furthermore, if bipolar is seen not as a medical condition, then the general population may see it as a character flaw or something that the person could control if she would just “try harder.” That can be just as stigmatizing as and perhaps even more so than having a bipolar diagnosis.

The mental health community, patients and practitioners, have worked hard to help clear up the idea that bipolar and other mood disorders are not something that people could just change if they would just try harder. Overemphasizing this idea that bipolar disorder isn’t necessarily a medical issue damages these efforts. Simply because the diagnostics are not always clear cut and the neurologic foundations are turning out to be very complex and difficult to characterize, doesn’t give one license to dismiss the fact that bipolar disorder and other mood disorders are illnesses that typically require medical intervention.