Q:  Could Bipolar Mood Swings be a Symptom of an Imbalance beyond Neurotransmitters?

Dear Dr. Phelps,

First of all, thank you for the abundance of information you have provided on bipolar.

I cannot help but notice by reading books, websites, and blogs, that bipolar is often diagnosed along with other disorders that are physical/neurological. Put quite simply: please lead me to some more information about this.

Here is why I want to know.
After discovering that my thyroid is slightly overproductive (13.5) and that I have a nodule on my right thyroid, I have been investigating other causes for my moods, other explanations. My doctor is not convinced that the elevated thyroid hormone is enough to cause my mood swings and highly varied physical and mental symptoms.

It is a fact that I was raped and had a very emotionally charged home environment. Still, I have a resilient personality that has taken me places...full scholarship, working abroad fresh out of college...lived in a yoga ashram...teaching in a prison...etc.

After finally settling down and teaching in a public high school, I feel like a fifty year old twenty seven year old. I feel like my body and mind are sporadically giving out on me. I have a strong feeling that it is not just "histrionics" (so an insensitive "old school" male sergeon told me when evaluating me for a biopsy). I am starting to wonder if this complexity of symptoms is truly "bipolar" or something else entirely.

Could "bipolar" be a symptom?

I am taking my meds and seeing a therapist and psychiatrist...I have an endocrinologist and higher health care costs than any normal twenty something...

Thankfully, I have a good doctor who is on a quest to help me find any physical causes of these pinching and annoying pains in my body (and perhaps my spirit). I am getting an MRI and I am scared, because it may be MS. It may be temporal lobe epilepsy or a metabolic/endocrine disorder.

After being diagnosed with ADD, bipolar, hyperthyroidism, insulin resistance, and digestive issures (suggested IBS), I am sort of panicking and sort of pissed at the same time. What if they add this to my list of problems? What happens if it IS physical? These are rhetorical questions for God.

My question for you is, how do I find out more information on comorbid states? From your experience, how many people are diagnosed with all these things?

How do I find valid, scientifically, unbiased information on these trends that indicate that bipolar mood swings could easily be a symptom of physical disorder- an imbalance of something beyond neurotransmitters.

Are the doctors over prescribing and over diagnosing psychological disorders? Are we Americans in a frenzy to be labeled crazy and find some sort of sane pill? I will admit that I am resigned to the fact that I will have to take medicine my entire life to prevent myself from suicidal depression, but still I am a little suspicious that maybe being overmedicated CAUSED what ails me and exacerbates the symptoms of the innocuous thing that ails me.

(I want to go teach in France. I want to pursue my anthropology degree and travel and study, but now I am stuck to a job that is stable and has good insurance.)

Is the psychiatrist unconsciously trying to make me dependent on his meds? I am suspicious that if overmedicating a person with antibiotics can cause a more resistant strain of disease, that overmedicating the psyche can cause a more resistant bipolar.

I have read a book about the misdiagnosis of women (who have physical problems that cause psychiatric symptoms) on this topic, but I want to know more. My doctor seems to know about these connections so how can I find out?

How do I find valid, scientifically, unbiased information on these trends that indicate that bipolar mood swings could easily be a symptom of physical disorder- an imbalance of something beyond neurotransmitters.

Laura

PS. Sorry for the length of this response.

 

Dear Laura --
You are asking questions which are entirely justified; quite common; and very important.  For doctors, one of the questions you ask is "could you actually be making things worse, in your attempts to make things better?" We need to be very careful about that one.

So let's pick a couple of questions to focus on.  First, what is the difference between a mental illness and a physical illness?  That's easy, because the answer is fairly simple, at the most basic level: there is no difference.  Or, put another way: mental illness is a physical illness that happens above your neck.  But to be a little less glib --

Evidence is clear and overwhelming that bipolar disorder is no less a physical illness then pneumonia or rheumatoid arthritis.  I wrote a lengthy essay about the biological basis of bipolar disorder (subtitle: five mini-chapters on the brain chemistry of mania and depression) on my education website.  I have not updated that essay in a little over one year, and things are moving along, but the basic information there is reasonably up-to-date and accurate.  This should serve as at least one reference you are looking for, about the nature of bipolar disorder and its physical basis. 

However, you may have been asking a different question, wanting some reason to think that you're bipolar symptoms are not really "bipolar disorder", but rather are manifestations of some other underlying process, some neurologic condition perhaps, like multiple sclerosis (MS). I have "bottom line" for you there as well: even when mania clearly results from a brain injury, like stroke or head trauma, we still treat it just like mania. Even when depression clearly results from a neurologic process, like Parkinson's disease, we still treat it just like depression (aside from making sure that the Parkinson's disease itself is fully and well-managed). So even when there is indeed a "physical basis" for having mood symptoms, it really boils down to having mood symptoms, and needing to treat them. The label becomes almost immaterial

Your next question: Are the doctors over-diagnosing and then over-prescribing for psychological disorders? Here is one safeguard against that: to warrant a diagnosis, the symptoms in question should be messing up a person's life.  If she can't really function -- keep a job, keep relationships, keep a roof over her head -- then it is worth considering whether a brain illness like bipolar disorder might be the basis for that disturbance in function.  Mind you, it is just worth asking such a question, not having a foregone conclusion. 

Then, compare person A, who is struggling as above, with person B, who clearly has bipolar disorder (in other words, no one would quibble: person B has had a manic episode that was so severe, anyone could recognize it as being unquestionably "abnormal").  If there is a very strong similarity in these two people's symptoms, simple logic dictates that indeed, a mental diagnosis is one way to explain why person A is struggling so much in life.  This explanation should then be held up against other potential explanations, such as a spiritual crisis, or an unfortunate set of circumstances, and so forth.  The best explanation should win. In general, most scientists use "Occam's razor" to judge which explanation is best: the simplest hypothesis that captures all the data.

So much for overdiagnosing.  Now, what about overprescribing?  Well, I think most people would agree that non-medication approaches are usually preferable over medication approaches, if their effectiveness is equal.  For example, psychotherapy is as effective as medications for most kinds of depression.  Some of those psychotherapies are quite simple, and relatively brief, and offer much better long-term protection against recurrence than a medication approach does.  Evidence on this has been quite firm recently. (Interestingly, despite this, many people choose the pill instead of the therapy.  There are lots of reasons for this: time, money, but especially, stigma and fear).

However, when non-medication approaches have been tried; or when none of them has evidence for effectiveness equal to a medication approach; and when the symptoms are severe enough to really be affecting a person's function; and finally, when there is good evidence that a medication might indeed be able to diminish the severity of the symptoms and restore function; then I think most people agree that it is reasonable to use the pill approach.

In other words, I don’t worry too much about “overmedicating” when the person with the symptoms is in charge of deciding amongst treatment options (unless she/he is too fond of pills to make problems go away, which does happen sometimes; then it’s up to me to keep a lid on the number and type of medications we consider).

Many people have questions just like the ones you're asking in your letter.  I've picked out some that I think are the most important.  I hope these answers may prove useful to you and others.  I hope my knee didn't jerk too much.

Dr. Phelps

 

February, 2009