Soft Bipolar
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Soft Bipolar:  Or a guide to the middle of the road.

In this article the some of the differences between the reasonably strict diagnostic guidelines found in the Diagnostic Statistical Manual Version IV (known as the DSM-IV) and the symptoms actually found in many bipolar disorder sufferers.  In fact Dr Jim Phelps, our wonderful help at Bipolar World will have a book out shortly on this particular subject that will be a must read for all of us!

But first, a bit of history,[1] although Sigmund Freud is commonly thought of as the father of psychiatry by many of the public, the real father of modern psychiatric diagnosis was Emil Kraepelin born 15 February 1856 and died 7 October 1926.  Kraepelin was a German psychiatrist who attempted to create a synthesis of the hundreds of mental disorders classified by the 19th century, grouping diseases together based on classification of common patterns of symptoms, rather than by simple similarity of major symptoms in the manner of his predecessors. In fact, it was precisely because of the demonstrated inadequacy of such methods that Kraepelin developed his new diagnostic system.

Kraepelin believed, unlike Freud, in an underlying biological or genetic mechanism to the many psychiatric disorders and vigourously opposed Freud’s view that all psychiatric illnesses were caused by pychological events or trauma.

Kraepelin is credited with the classification of what was previously considered to be a unitary concept of psychosis, into two distinct forms:

bullet Manic Depression (now seen as comprising a range of mood disorders such as Major Depression and Bipolar Disorder and
bullet Dementia praecox, which was later renamed schizophrenia by Eugene Bleuler.
Kraepelin was also a colleague of Alois Alzheimer and co-discoverer with Alzheimer of Alzheimers Disease.

One of the cardinal principles of his method was the recognition that any given symptom may appear in virtually any one of these disorders; i.e. there is virtually no single symptom occurring in schizophrenia, which cannot sometimes be found in manic-depression. What distinguishes each disease symptomatically (as opposed to the underlying pathology) is not any particular  symptom or symptoms, but a specific pattern of symptoms. In the absence of a direct physiological or genetic test or marker for each disease, it is only possible to distinguish them by their specific pattern of symptoms. Thus, Kraepelin's system is a method for pattern recognition, not grouping by common symptoms. (See footnote 1).


Kraepelin's great contribution in discovering schizophrenia and manic-depression remains relatively unknown to the general public and his work is little read, despite the recent widespread adoption of his fundamental theories on the etiology and diagnosis of psychiatric disorders which form the basis of all major diagnostic systems in use today, especially the American Psychiatric Association's DSM-IV and the World Health Organization's ICD system. (Footnote 1).

Dr Hagop S. Akiskal, Professor of Psychiatry and Director of the International Mood Center University of California at San Diego in a slide show presented at the 2nd Conference on Bipolar Disorder held in Pittsburgh in 1999 [2] argued for a partial return to the less restrictive broad concept of bipolar disorder as proposed by Kraepelin than as currently listed in the DSM-IV or ICD.

The slides below from that presentation indicate his views on the Soft Bipolar Spectrum.  That is bipolar symptoms that fall short of the classical Bipolar I and II and yet, in his view are still well with the spectrum of bipolar disorders.

Slide 1


Slide 2


Slide 3


Slide 4


Slide 5

Slide 6

He also indicated similar ideas in a paper called: The evolving bipolar spectrum. Prototypes I, II, III, and IV., in the [3]Psychiatr Clin North Am. 1999 Sep;22(3):517-34, vii.

So what does this really mean?  Well if you look at the figures on slide two – only 18 percent of those surveyed where in the classical Bipolar I category whereas 38 percent where in the Bipolar II-III or in that area before you came to those diagnosed with unipolar depression.

So at last it seems that recognition is being given to the majority of us with Bipolar who don’t fit neatly into the rigid DSM-IV categories but still have to live with the beast called “Bipolar”.

Graham Brown

26 August 2005


[1] From and; H. J. Eysenck in his Encyclopedia of Psychology.


[3] Psychiatr Clin North Am. 1999 Sep;22(3):517-34, vii.


The evolving bipolar spectrum. Prototypes I, II, III, and IV.

Akiskal HS, Pinto O.

Department of Psychiatry, University of California at San Diego, La Jolla, USA.

This article argues for the necessity of a partial return to Kraepelin's broad concept of manic-depressive illness, and proposes definitions--and provides prototypical cases--to illustrate the rich clinical phenomenology of bipolar subtypes I through IV. Although considerable evidence supports such extensions of bipolarity encroaching upon the territory of major depressive disorder, further research is needed in this area. From a practice standpoint, the compelling reason for broadening the bipolar spectrum lies in the utility of mood stabilizers as augmentation or monotherapy in the treatment of major depressive disorders with soft bipolar features falling short of the current strict standards for the diagnosis of bipolar II and hypomania in DSM-IV and ICD-10.


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