Bipolar disorder (BPD) or what has historically been referred to as manic depressive disorder is one of the big 3 classic psychiatric disorders. Major depressive disorder (MDD) and schizophrenia round out this sad triad that has likely plagued humans since the dawn of mankind. The concept of bipolar disorder really didn’t take its modern form until the past 100 years or so. It shares with MDD intermittent episodes of severe depression but unlike classic depression, in bipolar disorder these episodes of depression alternate with episodes of manic psychosis.
Mr. Tuba Man
I still remember my first exposure to the disease in the 1970s when I was a resident at a large inner-city hospital in St. Paul, Minnesota. I was the sole clinician for a 60-bed acute care psychiatric unit and I distinctly remember waiting for an elevator when a middle-aged gentleman approached playing a tuba quite loudly. He did seem to have some skill with the instrument but he was alone and not part of any band or music group. The thought passed through my mind that I might be seeing more of Mr. Tuba man later in the evening. Sure enough, several hours later I received a call from the ER informing me that Mr. Tuba man was being admitted to the psychiatric unit for acute manic psychosis. He hadn’t slept or eaten in 3 or 4 days and he was convinced that he was the greatest tuba player on the face of the earth. He insisted that he was preparing to give a tuba concert to the Pope. Although at the time he was unable to give much meaningful history, a review of his medical records and discussions with his relatives revealed that he had severe bipolar disorder and he was in the middle of an acute manic episode.
Up until the past 50-60 years, we had only one type of bipolar disorder and it was defined by episodes of severe depression alternating with episodes of manic psychosis. In layman’s terms psychosis is more or less a complete separation from reality. People with acute psychosis are “looney” or “crazy” and their ability to function in the real world is markedly impaired. Manic psychosis differs from the psychotic episodes sometimes associated with MDD or schizophrenia. People with acute mania seem to be going 100 miles an hour, they need little sleep and they jump from one poor impulsive choice to another. They often have grandiose delusions and hallucinations and their ability to function is severely impaired.
A New Form of BPD Rather Suddenly Appears
Over the past 50 years we started to see a lot of folks with excessive mood swings interspersed with hypomania rather that acute mania. Hypomania by definition involves many of the characteristics of manic psychosis without any signs of acute psychosis. These folks may have rapid speech, poor impulse control, excessive spending and lack of sleep but they can still function reasonably well because they never become psychotic. The so-called experts at DSM who determine the criteria for all mental illnesses decided to call this form of the disease bipolar II and the original form associated with psychosis bipolar I. Over the past 40-50 years it has also been noted that the incidence of bipolar has dramatically increased to a lifetime risk of around 4% in the United States, but only 1% of the population meets the criteria for bipolar I. Therefore, almost all the increase in bipolar is in group II and this is especially true for children. The bipolar I form of the disease is almost never seen in children, but bipolar II is now experiencing a mini-epidemic in children and teenagers. This is especially troubling because the traditional treatment for bipolar disorder involves powerful and sometimes toxic anti-psychotic medications.
The Bipolar-Metabolic Connection
Another troubling and poorly understood aspect of bipolar disorder is its strong association with metabolic problems like obesity, metabolic syndrome and type II diabetes. It is estimated that up to 80% of those diagnosed with bipolar disorders have some degree of obesity. Obesity is what we consider to be a “gateway” illness in that it dramatically increases the incidence of the killer diseases like heart disease, hypertension, strokes and similar conditions. The bipolar/obesity issue is complicated by the fact that most medications used to treat bipolar are known to cause or accelerate obesity.
Another rather surprising aspect of bipolar II is that many people with the disorder view it almost as a gift. When they are experiencing hypomania, they are much more productive, social, outgoing and mentally sharp. They actually seem to miss these episodes once the hypomania subsides. Many extremely creative people have been diagnosed with BPD and it’s not unusual for them to attribute their success to their productive hypomanic episodes. Those with bipolar disorder I virtually always experience a sharp decline in productivity during their manic episodes. Many famous business founders have struggled with various mental disorders and some believe these disorders like BPD II actually increase the success of entrepreneurs.
Scary Bedfellows
BPD also seems to run with a scary crowd. In the National Comorbidity Study 95% of those with bipolar disorder met criteria for 3 or more lifetime psychiatric disorders. In the scientific community when we see such strong associations, we first look to see if there might be some type of connection between the disorders. This was the approach that Hudson and Pope took when they proposed their Affective Spectrum Disorder (ASD) concept over a decade ago. Their concept proposed that 14 common brain disorders were actually part of the same disease process. Because they never identified the triggers or pathology of the disorder, their concept never made it out of academic medicine.
CARB Syndrome: A New Disease Concept
In my over 40 years of front line clinical practice I made the same observations as Hudson and Pope that formed the basis of their ASD concept. I also determined that long-term exposure to highly processed food was the primary trigger of the disorder and I nailed down the basic pathology of the condition. Based on these considerations, I decided to rename the disorder Carbohydrate Associated Reversible Brain syndrome or CARB syndrome. What I find interesting is that Hudson and Pope included major depressive disorder (MDD) in their ASD concept but they did not include bipolar disorder. I suspect this is due to the confusion created by the subdivisions bipolar I and II.
The Clinical Mess of Bipolar Disorder
From a clinical perspective, I question whether bipolar I and II are in any way related to each other. As I have already mentioned, bipolar I is a rare condition that hasn’t increased in incidence over the centuries, whereas bipolar II has reached epidemic proportions in a few short decades. I propose that we solve this dilemma by accepting the concept that bipolar II is unrelated to bipolar I and all patients with bipolar II actually have CARB syndrome as their primary diagnosis. If we can accept this premise, then we can also dismiss the use of potent anti-psychotic medication in patients with bipolar II. They have proven to be largely ineffective in BPD II and they add to the obesity burden already associated with the diagnosis. Dr. Gordon Parker is a Psychiatrist who specializes in BPD and in this paper he discusses how bipolar I and II should be treated differently. He also suggests that bipolar II can often be managed with mood stabilizers and SSRI antidepressants without resorting to the use of potent anti-psychotic medication.
The Symptoms Tell the Tale
If BPD I and II are indeed completely different illnesses with contrasting treatment regimens, how do you tell the difference between these conditions? From a clinical standpoint, the easiest way to make this important distinction is to look for the 22 symptoms of CARB syndrome. People with bipolar 1 will usually have few or none of these symptoms whereas over time most folks with BPD II will develop most or all of these symptoms. Because CARB syndrome is a new concept not yet accepted by the medical community, you can’t walk into your physician’s office and expect to be diagnosed with CARB syndrome even if you have all of these symptoms. You likely will be diagnosed with multiple brain disorders and treated with multiple potent psychiatric medications that are unlikely to be helpful.
The Six Pillars of Treatment
To avoid this sorry fate, you will need to use these 22 symptoms to make your own self-diagnosis of CARB syndrome and arrange for your own treatment. In my opinion, this is a valid and ethically acceptable thing to do because all the treatments used for CARB syndrome are very safe, inexpensive and readily available. If the CARB syndrome model does include bipolar II, it makes sense that standard CARB syndrome treatments should work well for those with BPD II. In my over 40 years of clinical practice this has been my experience. I recommend including the following six components when treating anyone with BPD II:
- Eliminate high glycemic carbohydrates, excessive fructose mainly from added sugars and omega 6 fatty acids from your diet and eat a reasonable amount of real food loaded with healthy saturated fats and omega 3 fatty acids.
- When necessary, use low dose medications to control key symptoms and improve compliance. More information on this topic is available at my web site.
- Take supplements to enhance brain neurotransmitter levels and to maintain healthy brain function. I prefer using a fixed dose precursor supplement like CARB-22 that contains the precursors L-tyrosine and 5-htp in a ratio of 10 to 1. Julia Ross is the expert at using individual precursors to treat symptoms and I highly recommend reading one of her books. I also endorse taking a high-quality omega 3 supplement to get your AA/EPA ratio to between 1 and 3. This simple finger stick test is available through OmegaQuant. I also recommend checking a homocysteine level and if it is above 7, I used a combination of B vitamins to lower it into the ideal range.
- Exercise your body and mind.
- Get plenty of restful sleep.
- Maintain as many healthy relationships as possible.
The key to long-term health and wellbeing is to stay on top of these six simple and safe treatment elements over a long period of time. Unlike BPD, CARB syndrome is preventable, reversible and treatable. Yes indeed, when it comes to BPD II (CARB syndrome), it is possible to put the rabbit back in the hat!