Shirah Vollmer MD

The Musings of Dr. Vollmer

Bipolar II

Posted by Dr. Vollmer on July 24, 2015


Pathologizing mood states is a justified criticism of modern psychiatry. Bipolar II is a good example. This is a diagnosis which implies that the person has pathological mood swings which vary from hypomania (which could be a desirable mood state) to mild or more severe depressive states. The treatment is a mood stabilizer, such as Lamictal, which often helps because Lamictal is an anti-seizure medication, and as such, it quiets brain activity. Once again we are in a place where the benefit of a medication does not, or should not, give rise to a diagnosis. In this case, the Lamictal helps with symptom relief, but that does not mean that the person is mentally ill. It would be the same as saying that if I take tylenol for my headache, and my headache subsides, then I have a “headache disorder”. Symptoms can be transitory, and hence, not speak to a prognosis or long-term course of the illness. Mood swings can be frequent or infrequent, like headaches, without casting a shadow of a mental illness on the patient. By contrast to Bipolar I, where the disease has serious implications for biological family members, and the course of illness is known, Bipolar II gives us no information about either genetics or the future course. We have returned to this line in the sand where there is a great controversy over when a patient has symptoms, but no diagnosis, as opposed to a diagnosis. The majority of my patients have symptoms, but do not meet criteria for a diagnosis. As such, I advocate for a deeper honesty about our tool box. We treat symptoms, and we do that well. Diagnoses, on the other hand, we need to improve.


“What makes her Bipolar II?” I ask my student as he presents a case. She gets irritable and she sleeps poorly. “Maybe she is going through a rough patch and she is unsettled,” I respond. “Maybe she has her panties in a knot:,” my new favorite expression. “Yes, yes,” my student agrees, as we both acknowledge that there is the language of training programs which forces diagnoses on people, and there is a language in the outpatient setting, which sees patients on a spectrum of coping skills. Students learn to be bilingual, in this way. Mostly, my students take this disagreement in stride. I, on the other hand, feel rage. I am deeply concerned about what these labels mean to patients. How do patients cope with getting a diagnosis, which might only apply to this particular period in their lives, and yet the diagnosis implies a long-term course? How do family members see their loved ones, when they carry a diagnosis of a “mental illness?” By labeling these patients Bipolar II, we strip them of the embracing the common human experience of stress, internal discomfort, and dis-ease. We teach them that the answer to their problems is embracing the sick role, rather than empowering them to learn to cope. Sure, coping skills are part of the treatment of Bipolar II, but it is different if there is a psychiatric label, as opposed to normalizing it as the stress of maturation, and coping in a world filled with uncertainties and pain. Once again, I conclude, Psychiatry has lost its way. Medications can help, but diagnoses for non-psychotic illnesses, at least most of them,  do not.

2 Responses to “Bipolar II”

  1. Shelly said

    Are you saying that Bipolar II is not genetic whereas Bipolar I is? When you write, “…the majority of my patients have symptoms, but do not meet criteria for a diagnosis,” why is that? Don’t insurance companies require diagnoses in order to pay? Is this another way to make your patients feel good about themselves or shield them from the stigma of a long-term mental illness, i.e. “You are not your diagnosis,” or if you don’t give them a definite diagnosis, then they don’t have a disorder? If you see a patient with a history of severe mood swings, would you say that the patient only has a collection of symptoms but no diagnosis can be made? Are you stating that only patients who show psychoses should get diagnoses? And one more thing: Do you really think speaking about a patient like that (“Maybe she has her panties in a knot?”) is appropriate, even while speaking to fellow professionals? Patients may wonder what their physicians really think about them and how they may talk to others in the field about them–this may just increase the fear.

    • Yes!
      Our diagnostic system is very flawed. It does not distinguish between symptoms and disorders very well.
      Yes, insurance companies require diagnoses before they pay.
      It is not about making patients feel good, but it is about sharing our ignorance that most of the time, we really do not understand things very well.
      Yes..psychosis is a different ball game and yes, a diagnosis is useful to those patients and their families.
      Yes, language is critical to understanding and for some, “panties in a knot” may not be helpful, but for others, it is a descriptive for internal distress.


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