Tuesday, February 23, 2010

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

Part I began issuing grades on the homework handed in nearly two weeks ago by the DSM-5 Task Force concerning its proposed revisions to bipolar. To recap:

Depression - “What were these people thinking? They weren’t.” Grade: F-minus.

Euphoric and Dysphoric Mania - “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 - “A very strong case can be made for lowering the diagnostic thresholds for hypomania.” Grade: Incomplete.

Hypomania as a Marker for Mania
- “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.

Moving on ...

Antidepressant-Induced Mania/Hypomania

The DSM-5 would recognize that flipping into mania or hypomania as the result of an antidepressant or ECT or other depression treatment  “is sufficient evidence for a manic or a hypomanic episode diagnosis,” but cautions that a mere one or two symptoms (such as irritability) should not be taken as evidence of an episode.

For a change, the DSM-5 Mood Disorders workgroup actually made what would amount to a significant change to the bipolar diagnosis. The catch is they buried it in the usual standard boilerplate which is suddenly not so standard. Trust me, if I failed to pick it up, the person you entrust your life to is not about to pick it up, either.

Grade: C-minus.

Mixed Episodes, Symptoms

In real life there are “pure” depressions and “mixed” depressions, “pure” manias and “mixed” manias. Successfully differentiating one from the other is crucial to treatment success. The current DSM recognizes mixed states only in bipolar I, when depression (with a capital D) and mania (with a capital M) rear their ugly heads together. Thus: DM.

Your best source of finding out what a mixed episode is like is listening to a patient who has been through it. Unbelievably, the DSM never bothered to turn in a description. (Short description: various forms of energized psychic distress, such as road rage, even when not driving.)

In by far the most significant change to the bipolar diagnosis, the DSM-5 would widen mixed states to include two or three mania symptoms (m) inside depression (D) or two or three depression symptoms (d) inside mania/hypomania (M). Thus: Dm or Md.

Presumably, this translates into symptoms strong enough to turn “euphoric” manias “dysphoric” and mind-numbing depressions “agitated.” The problem is the DSM leaves us presuming. Once again, what does a mixed state look like? Do we have to Google the answers, ourselves?

Grade: C-minus.

Mixed Episodes, Spectrum Considerations

The DSM-5 would acknowledge two types of mixed episodes: Predominately depressed and predominately manic/hypomanic, which would include for the first time those with bipolar II. The DSM-5 workgroup is undecided whether to include mixed states as episodes in their own right or as specifiers to depressive and manic episodes.

Inexcusably undecided is the workgroup’s position on mixed states in unipolar depression (see Part I to Grading Depression). Why would mixed depressions somehow be regarded as exclusive to the bipolar diagnosis?

Last but not least, why should a mixed depression or mania/hypomania require a full-blown episode? Think: how well are you truly when you have elements of both depression (d) and mania/hypomania (m) going on at once (dm)? Or, to put it another way, when is counting symptoms a substitute for evaluating functional impairments?

Grade: C-plus.

Bipolar III

Should the threshold for bipolar II be lowered to include patients with so-called “soft” bipolar? These are individuals whose depressions have far more in common with bipolar than unipolar and who do cycle “up,” though not necessarily as high or as long.

Or should a new category by created for them, such as bipolar III?

In other words, why should those who don’t dance on tables be overlooked? Especially if they continue to lead miserable lives treated as if for unipolar depression.

The DSM is considering reducing the time criteria for a hypomanic episode for bipolar II, but is holding the line on the symptom minimum.

Grade: D.

Recurrent Depression

As opposed to chronic depression, recurrent depressions come and go, typically in an up and down pattern. The current DSM includes recurrent depression as part unipolar depression and the DSM-5 would preserve the status quo.

Here’s the issue: If no expanded bipolar II diagnosis or no bipolar III, then why not put recurrent depression into service? Perhaps add new criteria as part of a new “highly recurrent depression” or “cycling depression” diagnosis. There are at least three advantages to this:
  • This would recognize the bipolar nature of these depressions without necessarily acknowledging them as part of the bipolar diagnosis. Clinicians would be encouraged to investigate more closely for these type of depressions before indiscriminately prescribing antidepressants.
  • Since this type of cycling depression would not be regarded as part of the bipolar diagnosis, a clinician need not find evidence of hypomania or mania to make the right call.
  • A cycling depression diagnosis would avoid the stigma of a bipolar diagnosis.
Mind you, for this to happen, the DSM-5 workgroup would have to put the interests of the patient above those who manufacture antidepressants or clinicians too lazy to ask the right questions or insurance companies who refuse to give clinicians time to do their job. I can well imagine the workgroup's deliberations: Explain the concept of patient interest to me ...

Grade: F-minus.


Strangely enough, true rapid-cyclers ride the roller coaster far too fast to be considered DSM-eligible as a rapid-cyclers, much less rate a bipolar diagnosis. Blame the current DSM for this mess, which demands the same “duration criteria” for episodes from everyone (two weeks for depression, one for mania, four days for hypomania).

According to an article in Psychiatric Times, even those responsible for the DSM-IV recognized the absurdity in their thinking. The question remains - can the DSM-5?

Grade: Incomplete.

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


Anonymous said...

is this based on any evidence, or just the your personal musings?

John McManamy said...

Hi, Anonymous. I would put it this way: My personal musings are based upon the evidence. :)