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"Aufheben": A Dialectical Approach to Bipolar Diagnosis

"Aufheben": A Dialectical Approach to Bipolar Diagnosis

Dichotomies are useful for education, communication, and simplification. Unfortunately, simplicity is useful, but untrue—whereas complexity is true, but useless.
—Vieta and Suppes, 20081

This essay begins an ongoing series on bipolar disorder focused on clinical utility. From the point of view of psychiatrists seeing patients every day, I’ll examine treatment options, such as N-acetyl-l-cysteine and supraphysiologic doses of thyroid hormone, that appeal to patients but are inadequately researched.

I'll look at common problems in differential diagnosis as well as at specific challenges, such as pregnancy, and big-picture issues, such as the effect of socioeconomic factors on outcomes. In each case, the goal is to bring insights from research—and sometimes from history, philosophy, and social sciences—to the daily practice of psychiatry.

Let us start with the dilemma posed by Vieta and Suppes.1 As elsewhere, controversies in psychiatry commonly revolve around dichotomizing a complex issue, eg, do anti­depressants cause suicidality, or reduce the risk? Are antipsychotics just too risky for young children, or does delaying treatment worsen the long-term picture? Is your patient’s depression unipolar or bipolar in origin?

Turning complex issues into simple questions makes them easier to consider and sometimes easier for patients to understand (in less time). Moreover, treating patients often requires making judgments in the face of overwhelming complexity: Is this depression due to circumstance? Does the timing really suggest causality? Or is this an endogenous mood shift that suggests “cycling”? How can this be teased out in the face of his financial problems, his job loss, his relationship struggles, and the difficulties his children are experiencing?

Sometimes one must simplify in the name of action. Take, for example, a 30-year-old man who does not have access to cognitive-behavioral ther­apy, whose diagnosis could be generalized anxiety disorder (GAD) with a history of multiple episodes of MDD, but who may also be regarded as having bipolar II (BP-II)—depending on how you interpret his agitation, insomnia, distractibility, irritability, and impulsivity. Are you going to prescribe an antidepressant or a mood stabilizer? Temporizing and gathering more data, to gain more insight into this patient’s problem, is appealing; but he is suffering and wants help as soon as possible, preferably today.

However, in psychiatry, making things simple, as in the statement “you have generalized anxiety disorder,” is frequently an oversimplification. Comorbidity is the norm, not the exception. DSM diagnoses overlap to a tremendous degree, with the bipolar/GAD overlap one of the most striking, as shown in the Table. (The DSM-intercommittee conversation that didn’t happen: “You have all those on your list too?”)

Table

DSM-IV criteria: overlap of symptoms in bipolar disorder and generalized anxiety disorder

Narrowing one’s focus to arrive at a formal diagnosis risks premature closure: what looks like “cycling,” suggesting bipolar disorder, could be the chaos of the patient’s life. Treatment with a mood stabilizer might have no benefit, but it may subject the patient to risks such as Stevens-Johnson syndrome (divalproex and carbamazepine as well as lamotri­gine) or hypothyroidism (not just lithium; quetiapine also carries this risk to some degree2,3). On the other hand, patients frequently do not recognize subtle hypomanic symptoms and focus instead on the dysphoric aspects of insomnia, disorganized thought, and agitation (often referred to as anxiety). Starting treatment with an antidepressant could precipitate a mixed state, which may be a greater concern than precipitating a frank manic episode, because mixed states are associated with suicide.4

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