Nowadays, there is a myriad of psychiatric disorders that influence patient’s mood and bipolar disorder is among such ailments. According to the National Health Service (2022) (NHS), bipolar disorder is indicated by persistent emotional instability and severe mood swings. Yet, the type and scope of pathways involved in emotional regulation (ER) appear to be a significant element. It is obvious that the present diagnostic criteria should be improved and refined, however there is a requirement to include dimensions, possibly not as a replacement but instead as a helpful addition to categorization diagnosis. In this sense, when applicable, data from the laboratories, the family, and the clinical course should be routinely included into the diagnostic evaluation. Hence, diagnosis of bipolar disorder is not always scientifically valid and practically useful due to vague diagnostic metrics and ineffective nature in aspects of predicting consequences or determining the most appropriate treatments.
Bipolar disorder is usually considered within two frameworks, such as bipolar I and II. When evaluating patient records from hospital admissions at the National Institute of Mental Health in 1960s, it became clear that there existed three categories of individuals who had a history of mood disorders (Malhi et al., 2019). The first included patients who had only suffered from depression, the second included individuals who had been admitted to hospital due to episodes of mania and depression, and the third group included patients who had been admitted to hospital primarily for episodes of depression but had manic episodes (Malhi et al., 2019). The first two groups—unipolar and bipolar disorder, respectively—were previously classified in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), while the third category was not (Malhi et al., 2019). Bipolar II was created to identify this group of individuals who were in-between.
Consequently, bipolar II disorder used to be long acknowledged and mentioned but never considered a legitimate condition, until 25 years ago. Ultimately, in 1994, the DSM officially acknowledged bipolar II disorder (DSM-IV) (Gitlin and Malhi, 2020). All successive DSMs have maintained this acknowledgment while making only minor changes to its definition. In this way, when the new century began, it appeared that bipolar II illness had fully developed, received a diagnosis, and was now on level with other serious mood disorders like chronic depression and bipolar I disorder (Gitlin and Malhi, 2020). In addition, assessments of its incidence using an enlarged definition, namely, the bipolar spectrum, ranged up to 4.5% in one research and 10.9% in others with definitional adjustment (Gitlin and Malhi, 2020). Its standing was unquestionably secure. However, there has been some discussion recently regarding the usefulness and validity of the diagnostic categorization of bipolar II.
When it comes to the validity of bipolar disoder diagnosis, it is claimed that the presence of psychotic symptoms, which are thought to be a sign of the intensity of the episode, at some point during or after at least one incident of manic episodes, hypomania, or combined, which is typically but not always prompted or accompanied by a depressive episode, constitutes bipolar disorder. The DSMs have implicitly supported the notion that psychotic symptoms are a fundamental component of schizophrenic disorder but not bipolar disorder after the decision to omit psychotic symptoms from the diagnosis and relegating them to a simple predictor of dysfunction or severity was made (Koenders et al., 2020). Additionally, they have not fully used the potential utility of defining psychotic characteristics for discriminant validity vs schizophrenia.
Furthermore, there is no distinction between unipolar depression and bipolar depression in the DSMs’ description of significant depression. While some researchers continue to support the Kraepelinian theory of manic-depressive disorder, the DSM recognises the bipolar/unipolar distinction. This presents the issue that a manic, hypomanic, or combined episode must first occur before a diagnosis of bipolar depression can be confirmed (Koenders et al., 2020). Therefore, the method is presuming some lack of predictive accuracy in unipolar depression and broadening the idea of major depressive disorder while expecting some lack of predictive accuracy in bipolar depression (Koenders et al., 2020). In contrast, the idea of a combined episode is extremely precisely defined as the concurrence of a complete manic and depressed episode, leaving out many potentially helpful ideas like mixed hypomania and ruling out the likelihood that people with bipolar II disorder can experience mixed episodes (Koenders et al., 2020). The description of mixed phases highlights once more how challenging it is to translate dimensional principles into diagnostic groups. Specifically, the scientifically valid results can be inferred based on the fact that applied, basic, and field research types have been conducted on the subject matter (Koenders et al., 2020). Consequently, the distinction between the two conditions in question must be made and reflected in the guide accordingly.
As for the theories, the behavioral activation system dysregulation theory and the integrated cognitive theory are two different psychological theories that very effectively encapsulate the concept that difficulties in regulating emotional experiences constitutes an underlying cause of bipolar disorder. The BAS hypothesis focuses mostly on the (hypo-)manic episodes in bipolar patients. According to the idea, people with bipolar disorder are excessively sensitive to and responsive to goal- and reward-relevant impulses, which results in excessive approach- and reward-related drive and eventually causes manic symptoms (Koenders et al., 2020). There is strong evidence that these systems play a significant role in the onset of manic symptoms, at least for a subset of bipolar individuals. This hypothesis does a less satisfactory job of explaining the onset of repeated periods of depression, but it might be used to describe dysregulation of the behavioral inhibition system, which could be thought of as the BAS’s opposite (Koenders et al., 2020). In the overall population and people with “bipolar characteristics” (such as hypomanic character, symptoms of depression), the BIS motivates inhibiting and avoiding behavior patterns and is linked to depression, evasion, and higher susceptibility to non-reward. However, the BIS is less well researched in bipolar communities.
In turn, according to the ICM, the severe negative and positive evaluations of internal affective oscillations might be used to clarify the fundamental mechanism of both depressed and manic mood variations. Patients may have extremely favourable or negative opinions of stimulated states, for example, “when I feel energetic I am the best version of myself” or “when I feel energetic I lose all control” (Koenders et al., 2020, p.2). As a result, behaviour is determined by the appraisal’s substance. For example, there is a chance of acquiring a (hypo-) manic condition while participating in stimulating activities to help regulate the energetic state (Koenders et al., 2020). As an option, social disengagement to reduce this condition may have the unintended effect of worsening depressive mood. Negative emotional states could likewise be subject to these various assessment philosophies.
Lastly, when it comes to the utility of bipolar disorder diagnosis, it is noteworthy that bipolar II’s vague limitations have made it easier to diagnose and, perhaps, given pharmaceutical corporations an opportunity to capitalize. Pharmaceutical firms have worked diligently to propagate the concept that it is more detrimental to overlook a diagnosis of bipolar II rather than to overdiagnose those without the condition since the disorder was added to the DSM-IV (Malhi et al., 2019). The incidence of bipolar diagnoses has dramatically increased in the U.S., rising by as much as 50% in adult individuals from 1996 to 2004 and more than quadrupling in adolescents and children within the same time frame (Malhi et al., 2019). Antipsychotic drugs utilized in the management of bipolar disorders have seen an increase in prescriptions.
In the end, the diagnoses will continue to be at best vague, predicated on rather arbitrarily defined intensity and/or period metrics, and thus not always potentially effective in aspects of predicting consequences or determining the most appropriate treatments, until there is a biological or genetic foundation for people’s mood classification system. However, for the time being, the debate is on whether or not the difference between bipolar I and bipolar II disorders is clinically helpful and ought to be maintained (Gitlin and Malhi, 2020). In order to solve this, it could be helpful to look at an established example – the combination of autism and Asperger’s syndrome into autism spectrum disorder in the DSM-5 (ASD) (Gitlin and Malhi, 2020). This is an important illustration of how two illnesses have been combined into a single, more comprehensive dimensional category (Gitlin and Malhi, 2020). In that case, the theoretical coherence of autism as a condition that could be articulated on a spectrum overcame the rather artificial distinction between Asperger’s as a mild autism spectrum illness and more typical autism, in the opinion of the DSM-5’s creators.
It is crucial to remember that sometimes patients’ and their families’ concerns about identity are directly related to diagnostic classifications. This was undoubtedly the situation with ASD, when patients protested that they did not have autism but Asperger’s instead, and families objected to the name being used to describe the more severe illness (Gitlin and Malhi, 2020). Similar to the previous example, it is possible that many individuals would oppose the concept of having “bipolar disorder” since their enthusiastic so-called “manic” episodes are not as extreme as mania (Gitlin and Malhi, 2020). As a result, such patients can identify with bipolar II, the milder and purportedly slightly different version of the ailment, but they cannot identify with the label bipolar disorder, as it conveys a more serious, more harmful and dangerous, mania often characterised by psychotic symptoms.
The current framework for approaching the management of bipolar disorder might seem sufficiently robust and extensive. However, due to the skewed perspective on research that has been adopted consistently as a direct result of implicit biases within the healthcare system, the phenomenon of bipolar disorder, has been studied largely in White men (Sahota et al., 2020). The described approach has affected the quality of treatment offered to women suffering from bipolar disorder, particularly, women belonging to racial and ethnic minority groups (Sahota et al., 2020). As a result, the effects of proposed therapeutic approaches, as well as the impact of medications prescribed to women suffering from bipolar disorder has been inconsistent (Sahota et al., 2020).
Indeed, studies indicate that the management of bipolar disorder cases in women has been lacking appropriate adjustments needed to address the cause of the issue both in relation to biological and sociocultural factors. Namely, the problems pertaining to the identification of at-risk groups in relation to the development of bipolar disorder need to be resolved. Currently, risk factors to which women are subjected as a population category as far as the development of bipolar disorder is concerned are largely ignored when developing strategies and guidelines for bipolar disorder management (Sahota et al., 2020). Therefore, respective alterations must be made to the existing standards for BD identification and management in women.
Firstly and most importantly, adjustments in the understanding of how BD is developed in women as opposed to men need to be made to the current guide. As Table 1 above indicates, the current BD management guidelines do not specify that the subject matter fail to take specific factors making women particularly vulnerable to the development of BD into account. Specifically, the existing framework does not detail that women are more prone to the development of NBD and the related mental health issues than men (Sahota et al., 2020).
Additionally, the fact that women face sex-based oppression and, therefore, are significantly more prone to developing bipolar disorder as well as the associated mental health concerns, is absent from the current guidelines. Furthermore, the fact that women are more likely to develop suicidal ideation due to their oppression is omitted (Sahota et al., 2020). The described problem in the current NHS guide may lead to further confusion, such as female patients with suicidal ideations conflating their condition with BD or failing to notice tan early onset of BD (Sahota et al., 2020). Specifically, when being affected by suicidal ideation constantly and normalizing the specified issue, female patients are likely to fail to notice the early signs of BD (Sahota et al., 2020). As a result, the disorder may evolve to the point where managing it becomes a particularly complicated task (Sahota et al., 2020). Consequently, appropriate guidelines regarding the identification of BD in women and the significance of promoting patient education regarding the subject matter must be introduced.
Table 1. Parts to Be Removed and Replaced
|Current Text||Recommended Changes|
|Bipolar disorder and pregnancy (National Health Service, n.d.)||It is strongly advised that the specified section must be expanded by examining core factors associated with pregnancy that are likely to exacerbate BD in women or entail its onset. Specifically, it is suggested that the information regarding the likelihood of BD symptoms being amplified during pregnancy should be provided. Namely, the outcomes such as preterm birth must be identified in the guide, with the relevant suggestions concerning the treatment methods to be provided to healthcare experts. |
Additionally, the issue regarding diagnosing the concern in question and increasing the success rate of identifying instances of BD in women should be mentioned as one of the core concerns. Specifically, due to the presence of stereotypes and implicit biases toward women, behaviors and mood changes that are characteristic of BD may be dismissed as insignificant or pertaining to pregnancy-related mood instability.
|“Men and women from all backgrounds are equally likely to develop bipolar disorder” (National Health Service, n.d., para. 7)||Furthermore, the current guideline requires introduction of a more detailed description of signs and symptoms that can be particularly pronounced in women. The described change is required since the current set of criteria can be conflated with the presence of other mood disorders in women, particularly, during pregnancy (Sahota et al., 2020).|
|Ibid.||Another essential change that must be incorporated into the present NHS guide is linked to the patterns of BD development in women. Specifically, factors associated with seasonal mood disturbance need to be reflected in the current guidelines, therefore, allowing introducing additional measures for addressing the issue in the specified demographics.|
|Ibid.||Moreover, the issue of dosage needs to be explored as one of the major differences in addressing BD in men and women. Specifically, research concerning the effective dosage and the most appropriate medication for women with BD issues needs to be conducted, with respective changes to the guide being made.|
|Ibid.||Moreover, differences in how the existing medication and its respective dosage affects women of different ethnic and racial backgrounds must be reflected in the guide. Particularly, updated guidelines regarding the appropriate doses of the medication that produces the best effect on women of specific ethnic and racial backgrounds will have to be introduced.|
|Bipolar disorder and pregnancy (National Health Service, n.d.)||Finally, in regard to patient education, sociocultural differences in the perception of BD and mental health issues, in general, will have to be taken into account and expanded upon in the guide.|
Furthermore, the issue of the gender role dynamics needs to be considered when suggesting adjustments an amendments to the present guide for BD management and diagnosis. Specifically, the increased range of expectations that are presently placed on women, specifically, in regard to the necessity to manage their career and maintain the role of a homemaker, should be incorporated into the current understanding of the factors that may contribute to the emergence or exacerbation of BD in the specified demographic.
Moreover, cultural factors and the associated biases in representing the needs of women in handling the public health issue of BD must be integrated into the assessment. Specifically, it should be noted that, in a range of cultures, traditional perceptions of health management, specifically, health management in women, imply that mental health issues in the specified demographic are largely ignored (Sahota et al., 2020). The specified concern overlaps with the problem of health literacy and the related education opportunities, namely, the lack of access to the specified options, for women belonging to minority communities (Sahota et al., 2020). Namely, studies show that a substantial portion of the female population in racial and ethnic minority groups is denied educational opportunities and, therefore, the development of basic health literacy (Sahota et al., 2020). In turn, the specified lack of awareness concerning the threats of BD in women causes the latter to ignore the early warning signs (Sahota et al., 2020). Consequently, BD in women representing minority groups remains understudied and mostly undiscovered,
Due to the lack of focus on diversity and a clear understanding of the need of women, especially those from multi-cultural backgrounds, the current framework for identifying, diagnosing, and managing BD needs an urgent revision. Specifically, the guide designed for locating and managing BD in patients will have to incorporate instructions regarding the isolation of factors that women are specifically subjected to when examining the threat of BD. The specified perspective will require integrating sociocultural issues shaping the perception of mental health issues in women, as well as women’s own understanding for their mental health needs. Additionally, further research into the biological underpinnings of the development of BD in women and girls will have to be conducted, with appropriate updates introduced into the guide for diagnosing and treating BD in the specified population. Specifically, the issue of medication dosage and the associated concerns will have to be addressed. With the described alterations made to the current guide, a significant improvement in the management for BD as a public health issue is expected to occur.
Gitlin, M., & Malhi, G. S. (2020). The existential crisis of bipolar II disorder. International Journal of Bipolar Disorders, 8(1), 1-7.
Malhi, G. S., Outhred, T., & Irwin, L. (2019). Bipolar II disorder is a myth. The Canadian Journal of Psychiatry, 64(8), 531-536.
NHS. (2022). Bipolar disorder. NHS. Web.
Koenders, M. A., Dodd, A. L., Karl, A., Green, M. J., Elzinga, B. M., & Wright, K. (2020). Understanding bipolar disorder within a biopsychosocial emotion dysregulation framework. Journal of Affective Disorders Reports, 2, 1-14.
Sahota, P. K., & Sankar, P. L. (2020). Bipolar disorder, genetic risk, and reproductive decision-making: A qualitative study of social media discussion boards. Qualitative Health Research, 30(2), 293-302.