My DSM-5 Report Card: Grading Bipolar - Part I

Last week, the DSM-5 Task Force turned in its homework regarding proposed revisions to the DSM. This week, I started grading its efforts. In my last three pieces, I broke down Team Depression’s term paper and issued the overall grade of F. Can Team Bipolar rise to the challenge?

First, some background:

Before there was bipolar, there was DSM-II manic-depression, which - believe it or not - included a “depressive type” that consisted “exclusively of depressive episodes.”

Bipolar made its official debut as a “mood disorder” in the DSM-III of 1980, with the diagnostic threshold set to full-blown mania. The DSM-IV of 1994 modified its restrictive stance with the inclusion of “bipolar II” and its less stringent “hypomania” threshold. But this failed to satisfy critics, who to this day contend that the DSM-II view of manic-depression was a lot closer to reality.

So, after all these years, are we finally going to witness the unveiling of “bipolar III?”

In the meantime, experts woke up to the fact that bipolar depressions could be very different from unipolar depressions. Plus there was a growing realization that bipolar had more in common with schizophrenia than once thought.

Now that we have set the scene, on with the grading ...

Depression

Mania gets all the attention, but depression is what clinicians need to be closely scrutinizing. The DSM calls for evidence of a previous manic or hypomanic episode to diagnose a depressed patient with bipolar, but what if the patient is unable to recall ever feeling good or feeling too good for his or her own good?

The current DSM criteria for a bipolar depressive episode is a straight copy-and-paste from unipolar depressive episode. We now know that patients with bipolar tend to manifest different features to their depressions and react far differently to antidepressants. Some clear red flags in the next DSM would put clinicians on notice.

Gary Sachs MD of Harvard likens depression to the pointer stars of the Big Dipper, offering navigational clues to the North Star that is mania and hypomania. Clinicians would still require evidence of mania or hypomania, but spotting anomalies within depression would help them with their detective work. The DSM-5 workgroup had no shortage of clear pointers to work with. Instead, the workgroup stuck with the copy-and-paste option.

Needless to say, this decision absolutely guarantees that the current unacceptably high rates of misdiagnosis (along the terrible suffering that involves) will continue unabated. What were these people thinking? They weren’t.

Grade: F-minus.

Euphoric and Dysphoric Mania

We tend to think of mania as feeling way too good for our own good. In reality, mania also has a way of manifesting as euphoria’s diametric opposite. These are your road rage states, your crawling out of your skin states. The DSM does acknowledge that mania can involve irritable mood, but this is nowhere near close to delineating night from day.

The DSM also recognizes mixed episodes, which the DSM-5 would widely expand, but even then there is no indication as to what mixed depression-mania actually looks like. Perhaps dysphoric?

All which makes you wonder. Is there a secret DSM with accurate information that only a privileged few are allowed access to? And a fantasy DSM for all the rest of us?

Grade: F.

The Mania Minimum Time Limit

Why seven days? Why not four? Who is truly counting the days when our life is in ruins? Don’t make me answer that.

Grade: D.

Hypomania as a Marker for Depression

Patients typically do not want to be cured of hypomania, but what does frighten them is what is likely to come next, such as crashing into depression. In this context, hypomania is more of a “marker” pointing to pathology rather than a pathology in its own right.

Why this is important is that depressions that cycle in and out (and up and down) are different animals than depressions that don’t. Often they need to be treated differently (such as going with a mood stabilizer rather than an antidepressant).

So, if all we are looking for is evidence of “up,” how high does up need to be? When triangulating depression, not high at all. Thus, a very strong case can be made for lowering the diagnostic thresholds for hypomania (say to two symptoms lasting two days). The DSM-5 says no to the former, but, pending further analysis, may say yes to the latter.

Grade: Incomplete.

Hypomania as a Marker for Mania

What separates hypomania from “normal” behavior is the individual’s own baseline. The operative DSM word is “uncharacteristic.”  Nevertheless, the individual’s functioning is not impaired. Turn up the heat to mania, however, and the picture is far different.

But how do we delineate “normal” (that include ups that are characteristic of a particular individual) from hypomanic from manic? Get it wrong and we will never find the patient’s treatment sweet spot. Needless to say, clinicians get it wrong a good deal of the time. It certainly doesn’t help that the symptom list for both hypomania and mania is exactly the same.

Consider: if the DSM does not regard hypomania as an impairment that interferes with normal functioning, then what is the justification for retaining the following symptom?

Excessive involvement in pleasurable activities that have a high potential for painful consequences ... (The DSM-5 would remove the modifier, pleasurable.)

As a symptom for mania, however, this could be a key differentiator. One simple adjustment. Are we asking for too much? Yes, apparently.

Grade: F.

Dysphoric and Euphoric Hypomania

The same arguments that apply to mania apply here.

Grade: F.

Much more to come. Stay tuned for Part II ...