Comments on
Subthreshold Bipolar Disorder

By John M. Grohol, Psy.D.

Subthreshold Bipolar DisorderSubthreshold bipolar disorder is a set of bipolar symptoms that don’t quite meet the definition of bipolar disorder. Think of it as “bipolar lite.” There is no single, agreed-upon definition for this disorder. For instance, if you need 3 symptoms to meet the criteria for a manic episode, sub-threshold bipolar disorder might be met with fewer symptoms, or require that the symptoms be met for a lesser period of time.

In other words, it’s a way of characterizing people as having a potential mental illness — but who do not yet have one.

The DSM — the reference book that defines mental disorders — is under revision for a new edition to be published next year. One of the considerations is subthreshold bipolar disorder.

Yet Mark Zimmerman, MD points out that this is probably a bad idea. And I’d have to agree.

9 Comments to
Subthreshold Bipolar Disorder

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  1. Hi John, For my 2 cents, I will be happy when the day comes that the mental health academics finally decide to throw out the whole “illness/ disorder” which often leads only to the treatment of symptoms, approach and take a one based on pathology and treatment root causes. Why do they (we) feel this need to classify and then treat. It would be nice to see and approach that instead addressed every dysfunctional behavior and traced it to the historical causes.

    It would be nice if a medical professional could open a book and see, “Symptom: Cutting. Description: Patient finds some mental satisfaction in shallowly cutting and/ or hurting themselves. Possible causes: 1)Physical or mental abuse as a child in the form of making them feel they deserve punishment. 2)Caretakers that only showed negative and often physical reinforcement attentiveness. 3) survivors of traumatic events that are suffering from PTSD in the form of Survivor guilt.” This dictionary could be grown with every passing reiteration of document. Treat the behaviors, not clump people whose pathologies are all very unique into categories that never quite fit.

  2. Wow, did not hear about this travesty pending. And the APA continues to claim no agenda of being complicit with the pharma industry. Yeah, right! What is the purpose of labeling someone with an Axis 1 mood disorder? At least as a psychiatrist?

    I read at another site the APA is in debt this year, spending $25 million in the prep work for DSM 5, yet only paid about $5 million for DSM 4. Guess they are expecting a fat payoff after DSM 5 is published. Yet, with less than half of practicing psychiatrists as members, and my guess is half of active members are over 60, who is going to be supporting that organization in the next 5 to 10 years?

    A new concept: Suicide by publication!

  3. I was diagnosed bipolar II and medicated without ever having had a manic or hyper manic episode. I also have no relatives of any degree with bipolar I or II.

    It was diagnosed on the basis of insomnia and a recent bout of post partum depression, as well as the fact that the Effexor I was taking kept kicking out (I had done very well prior to that on Paxil but had to stop it because it caused a rash).

    I was diagnosed by a psychiatrist, and her thought process was that bipolar is a spectrum disorder, and that it was better to be safe than sorry. Apparently many of her patients have been given the same diagnosis and discovered later that it was incorrect.

    Considering the trajectory that my life took over the next 7 to 8 years on a cocktail of meds including anticonvulsants, benzodiazepines, antipsychotics, and antidepressants, I really, really wish that I had not taken her advice.

    When I finally managed to get off everything I found out that I am certainly not bipolar.

    A lot of damage had already been done though, and it took a long time to feel confident that I was not going to relapse into a condition I don’t have. My underlying depression, anxiety and trauma issues had worsened significantly, and still are being dealt with. My physical health was significantly impacted by medication side effects, and took a long time to come back in line. I feel tremendously lucky that I do not seem to have any neurological damage and that my family stuck by me during the time I was so incapacitated by the meds.

    My medical records still reflect this diagnosis, and I am confronted by stigma any time I encounter a new medical professional who has access to my history. It will never be removed.

    The worst part is that I have lost all faith in psychiatry. I was diagnosed by this dr originally, but three others upheld the DX because I reported it, and was on all the meds. None of them ever questioned it, and if I hadn’t been so desperately unhappy and ill from med side effects that I was willing to go against medical advice I would still be suffering.

    It is very difficult to have respect for a profession which has hurt me so much with so little evidence that they were doing the right thing. It horrifies me that the new DSM may further loosen the diagnostic criteria and I truly hope that it is not allowed to happen.

    • I feel your pain! I have spent the last year drug free and getting my life back. Sixteen years on psych meds from a wrong diagnosis. The medications made me look guilty by default. How many thousands of my dollars and tax dollars were spent hammering a wrong belief down my being. All of the labels can just be an excuse to not see a person who has survived like all of us to this point and now we have an opportunity to help. I am a survivor of trauma. I had a primal rage reaction to a huge situation crisis in my career after graduate school. In stead of compassion, I got a diagnosis and meds and countless people, professionals who told me who I was and what I needed to do! Depression was a normal response to a medicated mind, body, and spirit.

  4. After initially laughing over the title phrase “Bipolar Lite,” and its possible interpretation as a fad diet for the psyche, I read through the article and was left with a cold chill.

    To regard potential disorders on par with disorders puts me to mind of that science fiction movie about law enforcement’s prosecution of futurecrimes, because treatment — both psychiatrically and socially — would cross the border of fact into the realm of possibility. Medication could be given prematurely and needlessly. A person may be labelled as having a disorder they never would have actually developed. In all, overreaching paternalism would injure lives.

    Particularly in conjunction with advancing research in genetic markers of psychiatric disorders. DNA screening will put newborns into DSM classifications if an expanded set of merely potential disorders is adopted.

    To reinforce this concern about including potential disorders in the defined set of disorders for the basis of psychiatric treatment, consider how genetic markers and family history would just as conclusively support “leukemia lite”
    and other maladies.

    Arguments in favor of pre-emptively labelling and treating the potential for bipolar disorder could also analogously justify treatment and discrimination of potential physical maladies. Here too, physicians and insurers would be empowered to treat what doesn’t exist, and prejudicially deny insurance coverage.

    For I would wager someone with “potential bipolar disorder” would have a hard time getting an individual life insurance policy, as I do with bipolar disorder, and that someone with “potential leukemia” could also be marginalized in getting health coverage.

    There’s an inevitable and just degree to which our enhanced understanding of genetics and disorder symptomology enhance our effectiveness in managing our human variations. As humans, we’ll inevitably politicize what should constitute “effective management.”

    As someone who cherishes his and others’ liberty, I am alarmed about efforts to socially engineer the possible as if it were absolute. It’s simply too deterministic and illogical. ;^)

  5. Mindfulness meditation and psychotherapy set me free. Honor emotions: meditate not medicate.

  6. In my 27 years of experience as a licensed psychologist, Bipolar Disorder has become the most over-used and abused diagnosis, especially in children. In my cynical way of thinking, it is an easy diagnosis to make (especially with children); there is no cure, so you have a patient for life; there are a limited number of medications to utilize in treatment; and insurance always reimburses for it’s treatment. In this regard I am against the idea.

    On the other hand, my distain for mental disorder cookbooks is attracted to the acknowledgment of symptom spectrums. A person can have many problem behaviors, perceptions, moods, etc., but not meet the criteria for a formal diagnosis. Often our hands are tied by insurance companies, who demand a diagnosis or payment for services is denied (including some pertinent diagnoses that they just don’t like). Why are Mood Disorders only descriptive of Depression or Mania? What about anger, chronic irritability, shame, guilt, etc.? As long as we try to box in certain combinations of certain symptoms and consider that a “disorder” we will always fall short of the actual complexities that are involved in each individual, that are damned inconvenient for insurance reimbursement. Everything is complicated and everything matters, as I see it. That is why the manuals will always be part fiction.

  7. I think one element to this overdiagnosis of bipolar disorder is the sheer minimizing or plain ignoring of the role of Axis 2 disorders to a presentation of mood lability. And why, if this opinion had any traction?

    Insurers will not reimburse for a primary Axis 2 diagnosis. Which I do agree is NOT a diagnosis one should make on a first visit. Honestly, how many clinicians out there use Mood Disorder NOS in your eval to consider the role of Axis 2?

  8. To my view rapid developments in lowering the cost of sequencing will release terabytes of data. To this will be added the outcomes from millions of scans and attendant individual and family health histories.

    This will eventually generate reasonable risk profiles for the development of many disorders.

    Over time many errors will be eliminated as diagnostic variance narrows in systems directed by artificially intelligent expert systems.

    It would be interesting to see the reports from those people who hold that they have been misdiagnosed were they available today.

    We really have an inadequate state of knowledge in 2013 but not for very much longer.

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