Dr. Grossi's Blog
I continue to be challenged by patients when the diagnosis of bipolar disorder is made. For this reason I have decided to write another blog regarding this subject. This is a bit like standing alongside a carousel and trying to draw a picture of a horse on the rotating carousel. Each time the horse passes you draw a line. After fifteen or twenty passes, you have a picture of a horse. After fifteen or twenty blogs, we will have a complete picture of bi-polar disorder.
The bipolarity index takes into account a number of dimensions that are not included in the DSM. It contributes to the idea of bipolarity not as a "do I have it or don't I have it", a yes or no phenomena; but, rather as a how much of this do I have. I always emphasize that my diagnosis at the first interview should be viewed as a statistical probability and that the proposed treatment should be viewed as an empirical test, i.e., does it produce the result desired. This is a bit like dating. You don't ask someone to get married on the first date and start a family. That can occur over a long period of time and shared experience. Treatment is the same.
The Bipolarity Index, developed about seven years ago by Gary Sachs and his colleagues at the Harvard Department of Psychiatry, includes ratings in five dimensions and each dimension is given point scores from twenty to two points. The five dimensions are 1) episode characteristics, 2) age of onset, 3) illness course and other features, 4) response to medications, and 5) family history.
With regard to episode characteristics, most points are awarded for manic symptoms especially euphoria, grandiosity, and expansiveness. The next most points for symptoms of mania with dysphoria and/or irritability. Following those is hypomania or mania following use of an antidepressant. With regard to age of onset, the most points are awarded for onset between 15 to 19 years of age; the next most for age of onset between 20 to 30 or below 15 years of age. Less points are awarded for onset between 30 to forty and even less for onset over 45 years of age. With regard to the illness course, most points are awarded for manic episodes separated by full recovery, less points are awarded for incomplete recovery between manic episodes or hypomania with full recovery between episodes. Less points are given for incomplete recovery between manic episodes or substance abuse, or psychosis during mood episodes or legal problems associated with mania. The dimension of response to medications awards the most points for full recovery within 4 weeks of treatment with mood stabilizers. The next most points are given for full recovery within 12 weeks of treatment or relapse within 12 weeks of stopping mood stabilizers or switch to mania within 12 weeks of starting an antidepressant. The dimension of family history awards the most points for having a first degree relative (brother, sister, parent, child -50% identical DNA) with clear bipolar disorder, the next most points for second degree relative with bipolar disorder or first degree relative with unipolar disorder.
Please note that the above includes the most important aspects of the bipolarity index. For those interested in examining it in complete detail, please search for it on the web where it is easily found. Using the bipolarity index to score patients with a number is an error as the points meaning has not been worked out, although, most bipolar I patients score above 60.
Several years ago Malcolm Gladwell wrote a book entitled Blink. In this book he discussed research on the quick inferences from snippets of behavior, biases in judgment and the differences between automatic and controlled processes in perceptions and attitudes. He described how people filter complex information and come up with snap judgments. This can be a huge impediment to good judgment. The Gladwell book left a lot to be desired in terms of explanations and ramifications. Daniel Kahneman's book, Thinking, Fast and Slow is a much more comprehensive text.
Kahneman, who won the 2002 Nobel Prize in economics, challenges the idea that individuals are rational and shows that fear and love explain many of the departures from rationality. He also shows that luck plays a major role in our successes or failures. Early in the book Kahneman introduces the two major players whom he calls System 1 (S1) and System 2 (S2). S1 is fasts acting, can't be turned off, has little if any understanding of logic, operates automatically, effortlessly and without conscious control. S2 is rational, diligent, compares and contrasts, weight pros and cons, plans and tries to control our thoughts and behaviors emanating from S1. S1 is gullible, S2 is forever doubting. It is the interplay between these two forces that determines our success or failure in out perceptions and judgments.
Kahneman discussed Bayesian theory, regression to the mean, loss aversion (losses are more important than gains), and the operation of heuristic principles such as anchoring, representativeness, and availability. He also discusses prospect theory ( how losses and gains are represented).
We would all like to be better decision makers. After reading this book I was left a bit frustrated because experts repeat their mistakes just as novices do and the effort to overcome biases is extraordinarily labor-intensive with lots of self-monitoring and self-control. One will need to know when to activate S2 to correct biases generated by S1 and furthermore to know when to activate S2 to correct the perceptions and judgments of others. I learned a lot by reading the book and I became even more aware of the pitfalls at hand and in the future.
ADHD, a major public health issue, affects 9% of all children with a sex ratio heretofore of male to female of 2:1. Diagnosis of ADHD has increased in recent years with the diagnosis in females increasing more rapidly than in males. Recent large epidemiological studies by Froehlich et.al. found 8.7% met criteria for ADHD of which 51% were boys and 48% were girls. Adult ADHD reveals a higher incidence in females than males suggesting a delayed onset which in turn suggests differential brain maturation rates in the two sexes. Girls show a more rapid neurobiological, cognitive, motor, and social development. During the onset of puberty increased estrogen and dopamine receptors may lead to increased symptoms in adolescence.
Barkley, RA et.al have reported that those with ADHD are less likely to finish school, have few or no friends, exhibit more autistic social behavior, drive faster, have more accidents, have a higher rate of STDs, and are at increased risk for other psychiatric conditions in adulthood. Mick, E et.at. found that 16% of females with ADHD showed adequate social adjustment compared to 86% of females without ADHD. Females who met criteria for ADHD at 16 years of age showed a persistence of the condition into adulthood of 71% with deficits in executive function especially prominent. Earlier studies showed males as more impaired but they are likely in error because of failure to correct for ADHD subtypes. Current studies point to equal impairment in the two sexes.
The diagnosis of ADHD in girls is more complex and difficult than in boys because of the age of onset, more subtle clinical findings and problems problems associated with the criteria as set out in the DSM-IV as well as a variety of ratings which are tilted to the male presentation. Also, mental health professionals tend to have a bias toward more diagnosis in boys. In addition, boys have a delayed developmental maturity especially in self-control processes which likely contributes to over-diagnosis.
Males have brains that are 8-10% larger than females; however, female brains mature earlier and follow a different developmental course. Females are about three weeks ahead of males in physical maturation at birth and are often about one year more mature by the start of school at 5 years old. This is important because different maturations are associated with different patterns of cognitive skills. Total cortical volume is reached in females by 10.5 years and in boys by 14.5 years. This is also true for brain areas considered of importance in ADHD pathology. These areas include especially the frontal lobes and basal ganglia.
To summarize, sexual dimorphism in human neurobiological development extends to patterns of behavior along the developmental course of ADHD. Current research supports the equal prevalence in males and females. Previous cross sectional research is flawed because comparable ages in males and females did not take into account the differential developmental trajectory of the two sexes. Future studies will undoubtedly nail down the differences more clearly.
(Jump to a related post ADHD across the Lifecycle.)