There is no umpire to rule something wrong, and the mere presence of the printed word, between two hard covers, and a pretty jacket, especially with the imprint of a large publisher, tends to have a weighty effect. (In contrast, in scientific journals, anonymous peer review occurs before publication, usually for better and sometimes for worse, challenging authors to substantiate their claims against opposing evidence). In the real world of public opinion, there are no referees of civility and evidence, and truth speaks softly.

The term «imperialism» is a sensitive one, flung around easily in some circles, often by those who never experienced it. As one who comes from that part of the world that got the short end of imperialism, I am sensitive enough to its meanings to realize that sometimes it is used incorrectly. So here is a first riposte in that larger world, where imperialism exists, but so does the freedom-seeking revolutionary. Indeed, since all action produces a reaction, the latter is perhaps destined to be denounced as the former.

I was attracted to a book, written by Dr Joel Paris, a prominent senior Canadian psychiatrist, which was said to be a critique of contemporary psychiatry. I knew the author through his work; like many outside the US borders, he recognizes some of the blindspots of American psychiatry, including, these days, an overly biological approach to psychiatry and overuse of medications; I agree with those criticisms. I found myself among those targeted in the book, however, for those flaws and this blog post is a response to his critique. (If indeed all publicity is good publicity, the author may not mind this posting.)

First, where we agree: Dr Paris wants to resist the overuse of medications for symptoms for persons who do not have bipolar disorder, but may simply have abnormal personalities. I concur, and have also strongly presented this view. Where we disagree: There are many persons who have bipolar disorder who do not receive the correct mood stabilizer medications because they are misdiagnosed with depression (antidepressants do not generally improve bipolar disorder) or borderline personality (where they receive mainly psychotherapies).

In flipping through the book, I came across my research, cited as part of the problem of what the author calls «bipolar imperialism.» The author was willing to grant that psychotic persons might have manic depressive illness, as in the traditional diagnostic systems of 100 years ago (the work of Emil Kraepelin in Germany), but the notion that non-psychotic persons – the walking depressed and anxious persons who populated the waiting rooms of the average psychiatrist and psychologist – might also sometimes have bipolar disorder seems unacceptable. Indeed this bipolar imperialism involves taking over territory that once was simply about depression or anxiety, or, in the case of the author’s own specialty, personality disorders.

As regards the science, the author presumes overdiagnosis of bipolar disorder, specifically ignoring the many studies show that bipolar disorder and manic depressive illness have been underdiagnosed for a century. His reference to one of my papers is to claim that bipolar overdiagnosis now occurs because the nonspecific use of «mood swings» has led to labeling bipolar disorder when individuals have borderline personality or simply anxiety/depression. I agree with that comment; in fact, my paper was written to provide a rationale for diagnosing the bipolar spectrum without using mood swings at all as a criterion.

While the science is questionable, the metaphor is weighty: Imperialism is about taking someone else’s territory. Some, like the psychoanalytically-disposed, want to protect their fiefdoms of personality disorders; others, like the depression and anxiety specialists, want to protect their huge continent of ill-defined mood; still others, the true imperialists one might say, want to free all those lands from the sway of the psychiatric profession altogether. There is one world here, and if the bipolar state expands, the others must contract; hence all the professional in-fighting and public derogation.

Postmodernists know that this must be the case: after all, there is no truth to the matter; there is no truly legitimate state of bipolarity, depression, or borderline personality. It is rather like the Israeli-Palestinian conflict; claims to truth seem hard to establish; hence no one compromises, and the conflict never ends.

But perhaps we can follow the metaphor in a truth-seeking mindset: who is to say that the boundaries of the bipolar state, as established by DSM-III in 1980, is the right one. How do we know it is not bigger? It is not metaphysically impossible for this to be the case; indeed, we can only turn to scientific research in diagnosis to tell us, and, I would hold, those studies support the view that a broader diagnosis, an enlargening of that state, is scientifically valid, and, in contrast, a narrowing of the nations of depression and personality disorder would correspond to what is scientifically true. (For instance, only about one-half of persons with severe mania have psychosis; thus to limit the diagnosis of bipolar disorder to only those with psychotic symptoms is to ignore half the population who has the illness). 

One can admit that if someone claims that bipolar disorder should be the only psychiatric diagnosis (though I know of no prominent researcher who has this view), in place of all psychosis or depression or anxiety or personality conditions, he is an imperialist. But short of that never-made claim, the question is one of boundaries: where do we put the limits between bipolar versus personality disorders or depression or schizophrenia? This is an empirical question, to be settled with accepted scientific standards, not one helped by a postmodern metaphor. Indeed it is hard to see how any fair reading of the scientific literature on psychiatric diagnosis until the last decade would come to any conclusion other than that bipolar disorder was the least diagnosed of all mental illnesses. Thus, rather than imperialism, perhaps the better metaphor is freedom, since the correct use of the diagnosis is a liberation to those misdiagnosed and mistreated for depression, schizophrenia, or borderline personality. (Repeated studies show that 40% of persons with bipolar disorder are initially misdiagnosed with these conditions; this does not mean that no one is ever diagnosed bipolar incorrectly, but the past, and continuing underdiagnosis, is an important fact that needs to be acknowledged when one is expressing concerns about overdiagnosis).